Annals of the Royal College of Surgeons of England (1991) vol. 73, 137-142
Amputations: statistics and trends A Gregory-Dean
MD Late Senior Medical Officer
DHSS Artificial Limb Services, Roehampton
Since 1955, the artificial limb fitting services in England, Wales and Northern Ireland have gathered statistics of all amputees referred for the first time. The information originally requested was basic: site of amputation, length and type of amputation stump (in inches), causes of amputation and the type of artificial limb supplied. In 1970, with the wider use of computers, much greater detail was introduced. In addition, an updating of information at 1 year after limb fitting and limb training was included, followed by a progress review at 2 years after the first attendance. If the amputee abandoned limb wearing for any reason, emigrated or died, this information was also entered into the computer. It should be remembered that the artificial limb services do not discharge their patients, therefore the young amputee becomes the responsibility of the Service for the remainder of his or her life. This responsibility covers the maintenance and replacement of the artificial limbs supplied (Fig. 1). Between 5000 and 5500 amputees are seen at the limb centres in England for the first time each year. A slight increase over the years is commensurate with the increase in the population of those in their 7th and 8th decades of life. Deaths of amputees in England each year number between 2500 and 3000, thus a small increase in the total population of amputees in England which remains between 60 000 and 65 000 thousand (1). In any study of statistics relative to amputations it is necessary to differentiate between amputation and amputee, inasmuch as one amputee may have suffered the loss of more than one limb. Likewise, it is not possible to correlate the number of amputations recorded in hospital operating theatre books because these may include minor digital amputations and reamputations on the same limb. Three-quarters of all amputees seen for the first time in England in 1986 (2) were over the age of 60 years and many were in their late seventies and early eighties (Table I). The ratio of male to female amputees is 2.5: 1, becoming closer to parity as age increases. Upper limb amputees are generally found in the younger age groups. The Correspondence to: Dr A A Gregory-Dean, 17 Fircroft Crescent, Rustington, Littlehampton, West Sussex BN16 3HP
6000rw
5000 No. of patients
4000
3000----
1961
1970
1980
1986
Figure 1. The gradual and sustained increase in the number of amputees referred to centres for the final time.
ratio of arm amputees to leg amputees is 1: 26 (Table II(a)). Figures for Wales and Northern Ireland follow very similar trends though numbers are much smaller, being quite compatible with the size of the population (Table II(b,c)). Peripheral vascular disease is by far the commonest cause of lower limb loss, including diabetes and metabolic diseases that are age related (Table III). Trauma as a cause of limb amputation is more common below the age of 60 years. Of amputees losing a limb because of trauma, 40% suffer this loss as the result of a traffic accident, and in four-fifths of these cases they were either the driver or the passenger on a two-wheeled motor vehicle. The number of amputees who lose limbs as the result of industrial accidents has decreased quite markedly over the last two decades, while the numbers losing limbs from accidents in the home or during recreational pursuits have remained fairly constant over the years. It has not been possible to establish any trend from the numbers of amputees who lose limbs through malignant disease other than that the numbers in the various age groups appear closer than they were a decade or so ago; osteogenic sarcoma and fibrosarcoma account for over 50% of amputations for malignant disease (Table III(a)). There has been a welcome trend in recent years for surgeons to ignore the dogma of 'ideal length of stump' in favour of a more pragmatic approach that allows for a space of not less than 4.5 in. between the end of the stump and the centre of the distal joint. This space allows
138
A Gregory-Dean
Table I. Patients attending limb fitting centres in England for the first time in 1986. Type of case by age and sex Amputations Single-arm Male Female Single-leg Male Female Double-arm Male Female Double-leg Male Female Other Male Female Totals
60-79
80+
35 13
22 16
3 2
203 51
563 169
1926 946
381 440
2
9 2
83 20
232 87
40 17
6
14
-
2
100
347
884
3231
All ages
0-9
10-19
20-39
40-59
123 57
1 2
14 4
48 20
3145 1628
15 5
57 17
4 2
1
370 128 22
5474
29
883
Table II(a). Total number of patients attending limb fitting centres for the first time in 1986 (a) England Total
Amputations
Male
Female
Single-arm Double-arm
(128) (3) 3145 (2961) 140 (223) (-) 230 (142)
57 (36) 1 (2) 1628 (1579) 51 (83)
180 1 4773 191
(-) (46)
(-)
(-)
307
(188)
Single-leg Double-leg Double-arm (previously single) Double-leg (previously single) Other cases Patientst Limbst Totals
123
77
(6)
(5)
15 (10) 3660 (3473)
(8) 1814 (1759)
7
(104)* (5) (4540) (306)
7 (11) 15 (18) 5474 (5232)
Figures in parentheses represent totals for 1985 referred for advice Patients t : Congenital limb deformities *
Table II((b) and (c)). Total number of patients seen in limb fitting centres for the first time in 1986 (c) Northern Ireland (b) Wales Amputations Single-arm
Amputations
Number 3
Single-arm
Number 7
Double-arm
Double-arm
Single-leg
190
Single-leg
95
Double-leg
10
Double-leg
7
Double-arm (previously single)
Double-arm (previously single)
Double-leg (previously single) Total
5
208
Double-leg (previously single) Total
4
113
Statistics and trends
139
Table III. Patients attending limb fitting centres in England in 1986-cause by age and sex All ages
(a) Disease Vascular insufficiency Embolism Thromboangitis Varicose ulceration Other Metabolic Diabetes Other Infective Gas gangrene Other Malignancy Neurogenic deformity Acquired Congenital Totals
(b) Accident Industrial Home Recreation Armed forces Traffic Pedestrian Road vehicle Two wheel Other Rail Other (unspecified) Totals
0-9
10-19
M
F
M
2064 130 20 29 52
1026 79 5 32 43
-
1 1
-
729 4
374 5
1
-
6 60 112
2 33 92
15 3251
9 15 1715
38 21 19 13
12 21 6 1
46
20
2
128 38 21 20 394
8 15 5
-
11 99
1 4
30
1
20-39 F
M
F
M
F
M
F
10 3 4 1 3
6 4 7
322 23 13 3 20
84 10 2 6 9
1420 91 1 20 22
618 46 2 17 20
312 12 2 4 5
317 19 1 9 6
9 2
1 1
159 2
44
488
263 3
72
66 1
1 1 1 17 4
1 10 25
1 10 27
4 20
2 37 38
2 15 32
1 2 5
-
3 19
1 5 11
5 10 83
1 4 46
2 2 584
1 2 182
7
3
1 1021 416
3 448
2
34 4 13 7
3 5 4 1
35 6 3 2
3 3 1
5
5
14
7
1
6
20 13 3 4 91
1 2
9 4 3 1 52
1 2 2 1 26
2 1
1 1
M
1
-
F
-
-
- -
1
1
- - -
4 7
6 26
- -
8 2 1
12 16
1
1 -
-
-
6
- -
1 2
80+
M
F
1
60-79
40-59
25 5 1 8 56
for the inclusion of a functional joint in the artificial limb without altering the joint level. This is particularly important where a knee joint is concerned, not only for cosmetic reasons, but also for better function. The preservation of the natural knee joint in any lower limb ablation is of prime importance to the degree of mobility that can be expected after limb fitting. A further consideration in the preservation of the natural knee joint in those who suffer the loss of a leg as a result of peripheral vascular disease, is the ever present possibility that the condition causing the first amputation may well, in time, demand the ablation of the contralateral limb which, because of the intervening time interval, may well mean above-knee amputation (Fig. 2). The number of below-knee amputations performed in relation to above-knee amputations has gradually increased over the last two decades, thus ensuring a much higher degree of rehabilitation over a wider age range than was possible in the past. Today, amputation is a form of treatment and not a purely life-saving procedure. The choice of prosthesis depends on the site of the
18 2 3 1 8
72 16 9 10 183
4 4 3 5 31
3 19
2126 9 6 2 4
4 8
2 2
-
-
9 17
-
4
1
-
1 8
11
Amputation
100
Above knee
Below knee
80
60
40
20 OR
_
.
I
I_,,,,_a
1961
1981
1986
Figure 2. Improving rate of below-knee procedures to aboveknee ablations.
amputation, the physical condition of the stump and the age of the amputee. The restoration of the body image and a return to an equal or even higher level of activity must be the target in amputee rehabilitation (Table IV).
140
A Gregory-Dean
In the case of the arm amputee, the patient's motivation is all important, but it is also necessary to provide a prosthesis as soon as possible after amputation before a 'one arm habit' has a chance to develop. The assessment of success of an arm amputee is judged by his or her ability to use the terminal device or artificial hand. Because it is more easily detected by onlookers, a good cosmetic appearance is necessary for the morale of the patient. While motivation is also important in the lower limb amputee, the desire to walk is also very strong. This makes the rehabilitation of the leg amputee more rewarding than rehabilitation of the arm amputee. Those who lose a leg early in life require leg length equalisation as soon as possible. They need a prosthesis that is functional, durable and cosmetically acceptable. Those who become leg amputees later in life have not dissimilar requirements though comfort and special features (eg stabilised knee, rotator, etc.; the rotator is a device inserted in the shin tube between knee and ankle so that a few degrees of medial and lateral rotation may be allowed, thus lessening the shear effect between stump and socket-very welcome by amputee golfers) may be required to allow the amputee to lead an active life. Those who become amputees over the age of 60 years require a prosthesis that is easy to put on and take off, that is light, very stable and cosmetically acceptable. Rehabilitation of a single below-knee amputee gives a very high degree of success even in the aged patient, many of whom become more active than they were before the loss of their leg. The higher the level of amputation the greater becomes the physical effort to walk, though good and active gait may be achieved in most single above-knee amputees. Where there is a loss of both legs, success is more often than not achieved in the double below-knee amputee, but far less likely in those who have one or more aboveknee amputations. Hence, the need to preserve the natural knee wherever possible, especially in the elderly amputee. Numbers and types of artificial limbs are listed in Table V, which refers to centres in England in 1986. The Modular Assembly Prosthesis, which came into use in
Table IV. Comparison of mobility levels of 1000 leg amputees before amputation and 1 year after limb fitting and walking training Activity Not known
Inactive
Moderately active
Very active
387 299 30 284 Before 133 693 164 10 One year after fitting Fully Transfers Independent Walks Mobility outdoors mobile indoors only
Table V. Limbs fitted in the year ended 31 December 1986 Arms Working arm Light working arm Dress arm Externally powered arm Other Total
18 68 33 7 31 157
11.46% 43.31% 21.02% 4.46% 19.75% 100.00%
5 781 222 807 2494 4520
0.11% 17.28% 4.91% 17.86% 54.18% 100.00%
Legs Wooden leg Metal leg Plastic leg Peg or pylon as permanent issue Modular assembly prosthesis Total
Table VI. Comparison of 'stump pain' and 'phantom pain' in patients attending limb fitting centres for the first time in 1985 and on review in 1986 Stump pain At first attendance
After
Pain
Yes No
Yes
No
Arms Legs
1 78
7 85
99 2551
23 589
Phantom pain
I year No Painful Painless phantom phantom phantom
1 68
16 537
7 218
the mid-1970s, and which has been greatly improved since then, has not only had the weight reduced, but more versatile joint mechanisms are now included. These modular limbs are endoskeletal and differ from the more traditional prostheses that are exoskeletal in that the former are soft to the touch where the latter are not and they can also be assembled in a very short time. No statistical comment on amputations would be complete without reference to painful stumps and phantom limbs. The figures for these conditions in England show that for amputees seen on review after 1 year of limb wearing, pain in the stump is an uncommon complication in lower limb amputees and a phantom limb has usually either disappeared or become painless (Table VI).
References 1 On the state of the Public Health. DHSS Annual Reports of the Chief Medical Officer-1969 to 1980. 2 DHSS-Statistics & Research Division. Amputation Statistics for England Wales and Northern Ireland-1975 to 1986.
Statistics and trends Appendix
Artificial limbs: uses and expectations
Comparative table of appliances Function
Natural hand
Split hook
Universal tool holder
Mechanical hand
Myoelectric hand
Pincer
+++
-
+++
++
+-I-+
-
-
-
+ ++
++++
+ ++
++
1. Arms
Peg Vice
++++ ++++ ++++
Single-arm amputees
Clamp
++++
In general, the earlier the arm amputee can be fitted with a prosthesis, the better the prognosis and the less likelihood of developing a one arm habit. (a) Forequarter ablation and through-shoulder disarticulation These prostheses have very limited practical function. They feel heavy, but they do restore the body outline. An elbow lock allows the elbow to be held in a flexed position at 900, permitting the carriage of light objects. An alternative is the shoulder cap with an upper arm section, which is lighter and preferred by some patients. It protects existing scars and restores shoulder girdle symmetry. (b) Above-elbow amputee These prostheses are functional provided there is adequate muscle power and a normal range of movement of the shoulder girdle. Working limbs (builders, carpenters, etc), light working limbs (cabinet makers, pottery, gardening, housework) and dress limbs are available. Dress arms are of the lightest construction but are the least functional. (c) Through-elbow disarticulation As (b) above, except that working and light working prostheses are more useful to the amputee. (d) Below-elbow amputation These are highly functional artificial arms, and they can be supplied with a large variety of terminal devices (appliances) which can be adapted to most occupations and hobbies from engineering to carpentry, photography and gardening. Self-powered and electrically powered (myoelectric) hands can be supplied, the latter especially for children. (e) Through-wrist disarticulation These prostheses are available, but are not widely used. They have less than adequate function and are not particularly elegant. (f)
One-piece dress prostheses These
also available for arm amputees. They are wellshaped, with natural looking hands with passively bendable fingers, soft cosmetic covering and cosmetic gloves. Those used for above-elbow amputees have an articulated are
elbow.
(g) All prostheses, except the purely cosmetic ones, have a wrist rotary into which a variety of appliances can be inserted and placed in optimum position (pronation or supination) for use. This rotary allows easy interchange of one appliance or hand for another. Power to operate these appliances is derived from shoulder movement and transmitted by an operation cord independent of the harness or suspension.
++
+
(h) Double-arm amputees The more distal the loss, the better in general is the prognosis. Many do very well indeed, provided the shoulder girdle is intact and the patient is given adequate arm training. For these patients, who are fortunately few in number, either gas powered or electrically powered arms are of great advantage. Myoelectric arms are suggested for the double below-elbow amputee. 2. Legs
Single-leg amputees Leg length equalisation, stable joints and good cosmetic appearance are prime factors in the successful rehabilitation of the lower limb amputee. With the new, improved modular assembly prosthesis, the new leg amputee can be given a cosmetically acceptable artificial leg within 2 weeks of his first visit to a limb centre. Metal or exoskeletal limbs are still made and supplied to those established wearers who do not wish to be converted to the modular endoskeletal type of prosthesis. In general, the new endoskeletal limbs are lighter than the crustacean limbs. (a) Hindquarter amputations and through-hip disarticulations These artificial legs are composed of a socket in which the patient sits; this socket is based on the tilting table principle, embraces both hips, and is self-supporting. The anterior hip joint allows the patient to sit on the level. A thigh section, knee mechanism, shin piece, ankle mechanism and foot complete the set-up. In order to avoid the mechanical problems inherent in a compound pendulum, the hip joint should have an adjustable hip limiter and the knee joint should either be lockable or stabilised, or both. The stabilised knee is usually fitted with swing phase control. A uniaxial or multiaxial ankle joint may be used with most types of artificial feet. (b) Above-knee amputation In order to take advantage of the sophisticated knee mechanism available, there must be 11 cm (4{ in.) between the end of the above-knee stump and the axes on which the knees bend. Sockets for this level of loss can be self-supporting (suction or total surface bearing) or suspended by belts and/or braces. There is a choice of materials from which the sockets can be made, eg metal, leather, plastic, or occasionally wood. A wide selection of knee units are available, from the simple bolt type to stabilised knees with either semiautomatic or hand-operated knee locks, to which swing phase controls and/or stance flex knee units may be added. The ankle joints and feet will be described below.
142
A Gregory-Dean
(c) Gritti-Stokes amputations and through-knee disarticulations Both are excellent surgical procedures, to be used when the knee joint cannot be saved or when the resulting stump would be too short to be of any value (less than 4 cm of tibia). Neither of these procedures is advisable in women unless the clinical condition precludes an above-knee amputation, because the prostheses are bulky and rarely acceptable to the patient. Furthermore, because of the need for an external knee joint or four-bar linkage mechanism, the shin piece is shorter than the natural leg, and unacceptable cosmetically unless trousers are worn. Both stumps are end-bearing and are an advantage to active, hard-working young men. Exoskeletal and endoskeletal limbs are available for these amputation stumps. In general, the exoskeletal limbs are preferred by patients, although the controlled knee mechanisms can only be used with endoskeletal limbs. Sockets can be self-supporting, if the more proximal circumference is less than that round the condyles. It is suggested that, when performing a through-knee disarticulation, equal lateral and medial flaps are used rather than a long anterior flap, which frequently has less than adequate circulation and results in delayed healing of the transverse posterior scar. The scar resulting from the use of side flaps heals well and retracts nicely into the intercondylar sulcus, giving an excellent end-bearing stump.
(d) Below-knee amputation Arguably the procedure to be adopted whenever it is clinically possible. Even very short and heavily scarred stumps have been successfully fitted with patellar tendon bearing prostheses. These are usually suspended by the use of an adjustable cuff that is fitted just above the femoral condyles. Supracondylar sockets which are selfsuspending can be used when the configuration of the distal part of the thigh permits. In women who wear suspender belts or corsets, suspension by elastic stockings gives a leg with unbroken contours. Strong elasticated sleeves covering the lower two-thirds of the thigh are often preferred for sporting activities. Invariably, modular limbs are prescribed for these patients; only when the amputation stump is unable to bear any pressure or tolerate any friction (split-skin grafting) is the older type of exoskeletal prosthesis with a thigh corset and side steels prescribed.
(e) Ankle mechanisms Ankle mechanisms for all the artificial legs mentioned above may be uniaxial, uniaxial with adjustable heel (for women), multiaxial, which allow a degree of inversion, eversion and rotation, or solid (no movement). These are prescribed according to the degree of activity required by the patient. (f)
Syme's amputation Wherever possible, an end-bearing prosthesis is provided, and if total end-bearing is not possible, a patellar tendon bearing socket is provided in leather or plastic and enclosed in a shin piece of either metal or plastic. These are self-suspending. Ankles are either uniaxial or solid. Occasionally, and for certain heavy activities, block leather sockets fitted into bifurcated steels with soft leather gaiters are demanded (eg farmers).
(g) Partial foot ablation Until fairly recently, the prostheses available for the Chopart, Lisfranc, and other partial foot procedures have been the least satisfactory of all, being too bulky to fit neatly into any but bespoke shoes or boots. Scars from these procedures are invariably thin and adherent to hard tissues beneath. They do not stand up well to friction, and when they do, callosities tend to form on the stump, despite all prosthetic efforts to provide soft linings, and pure wool socks should always be used. Nowadays, however, silicone-based moulded socks can be made which fit closely round the stump. These are soft lined and much kinder to the soft tissues. Rigid or semi-rigid footplates can be incorporated to improve stability. So far, these shoe or boot fillers have been found to be much more acceptable to patients, both male and female. (h) The artificial foot (i) The standard wood foot with uniaxial ankle shaped to fit the shoe provided by the patient has adjustable heel and instep rubbers to allow a plantigrade tread regardless of the height of the heel. There is also a toe rubber (varied densities) placed at the level of the metatarsal phalangeal joints that assists toe-off. (ii) The solid ankle cushion heel foot (SACH), used frequently when space between the end of the stump and ground is not sufficient, or when preferred by the patient. (iii) The moulded uniaxial foot, very similar in action to the standard wood foot, used exclusively by some manufacturers. If broken, it can be changed at one short visit to the prosthetist. (iv) The Multiflex ankle and foot. Today, this is the usual foot for all modular limbs manufactured in the UK. In addition to flexion and extension, it allows some inversion and eversion and fractional rotation. (v) The quantum foot. An interesting new concept in which the energy produced at heel strike and roll over is stored within the foot and used to enhance toe-off. This foot is very popular with the active and sporty young amputee.
It is uniaxial.
Walking for the single-leg amputee All single amputees walk within the limitations imposed by their age and general physical condition. The more distal the amputation, the better their chance of regaining complete ambulatory rehabilitation. No single amputee, regardless of age, health or level of loss, should be denied the chance to attempt to walk or, even in apparently hopeless cases, to learn how to transfer from one seat to another. Double-leg amputees Many double above-knee amputees learn to walk and be independent with a walking frame or two walking sticks, provided their general health does not debar them from this greater physical effort. Reduction in the length of the prostheses reduces the physical effort required. When one or, better still, both knees have been preserved, then the chances of independent mobility are good, and excellent when the person is a double below-knee amputee. Most young double below-knee amputees walk very well indeed. Light, cosmetic, non-weight-bearing prostheses can be provided for chair-bound double amputees, giving them a more dignified appearance.
Amputations: statistics and trends A Gregory-Dean
MD Late Senior Medical Officer
DHSS Artificial Limb Services, Roehampton
Since 1955, the artificial limb fitting services in England, Wales and Northern Ireland have gathered statistics of all amputees referred for the first time. The information originally requested was basic: site of amputation, length and type of amputation stump (in inches), causes of amputation and the type of artificial limb supplied. In 1970, with the wider use of computers, much greater detail was introduced. In addition, an updating of information at 1 year after limb fitting and limb training was included, followed by a progress review at 2 years after the first attendance. If the amputee abandoned limb wearing for any reason, emigrated or died, this information was also entered into the computer. It should be remembered that the artificial limb services do not discharge their patients, therefore the young amputee becomes the responsibility of the Service for the remainder of his or her life. This responsibility covers the maintenance and replacement of the artificial limbs supplied (Fig. 1). Between 5000 and 5500 amputees are seen at the limb centres in England for the first time each year. A slight increase over the years is commensurate with the increase in the population of those in their 7th and 8th decades of life. Deaths of amputees in England each year number between 2500 and 3000, thus a small increase in the total population of amputees in England which remains between 60 000 and 65 000 thousand (1). In any study of statistics relative to amputations it is necessary to differentiate between amputation and amputee, inasmuch as one amputee may have suffered the loss of more than one limb. Likewise, it is not possible to correlate the number of amputations recorded in hospital operating theatre books because these may include minor digital amputations and reamputations on the same limb. Three-quarters of all amputees seen for the first time in England in 1986 (2) were over the age of 60 years and many were in their late seventies and early eighties (Table I). The ratio of male to female amputees is 2.5: 1, becoming closer to parity as age increases. Upper limb amputees are generally found in the younger age groups. The Correspondence to: Dr A A Gregory-Dean, 17 Fircroft Crescent, Rustington, Littlehampton, West Sussex BN16 3HP
6000rw
5000 No. of patients
4000
3000----
1961
1970
1980
1986
Figure 1. The gradual and sustained increase in the number of amputees referred to centres for the final time.
ratio of arm amputees to leg amputees is 1: 26 (Table II(a)). Figures for Wales and Northern Ireland follow very similar trends though numbers are much smaller, being quite compatible with the size of the population (Table II(b,c)). Peripheral vascular disease is by far the commonest cause of lower limb loss, including diabetes and metabolic diseases that are age related (Table III). Trauma as a cause of limb amputation is more common below the age of 60 years. Of amputees losing a limb because of trauma, 40% suffer this loss as the result of a traffic accident, and in four-fifths of these cases they were either the driver or the passenger on a two-wheeled motor vehicle. The number of amputees who lose limbs as the result of industrial accidents has decreased quite markedly over the last two decades, while the numbers losing limbs from accidents in the home or during recreational pursuits have remained fairly constant over the years. It has not been possible to establish any trend from the numbers of amputees who lose limbs through malignant disease other than that the numbers in the various age groups appear closer than they were a decade or so ago; osteogenic sarcoma and fibrosarcoma account for over 50% of amputations for malignant disease (Table III(a)). There has been a welcome trend in recent years for surgeons to ignore the dogma of 'ideal length of stump' in favour of a more pragmatic approach that allows for a space of not less than 4.5 in. between the end of the stump and the centre of the distal joint. This space allows
138
A Gregory-Dean
Table I. Patients attending limb fitting centres in England for the first time in 1986. Type of case by age and sex Amputations Single-arm Male Female Single-leg Male Female Double-arm Male Female Double-leg Male Female Other Male Female Totals
60-79
80+
35 13
22 16
3 2
203 51
563 169
1926 946
381 440
2
9 2
83 20
232 87
40 17
6
14
-
2
100
347
884
3231
All ages
0-9
10-19
20-39
40-59
123 57
1 2
14 4
48 20
3145 1628
15 5
57 17
4 2
1
370 128 22
5474
29
883
Table II(a). Total number of patients attending limb fitting centres for the first time in 1986 (a) England Total
Amputations
Male
Female
Single-arm Double-arm
(128) (3) 3145 (2961) 140 (223) (-) 230 (142)
57 (36) 1 (2) 1628 (1579) 51 (83)
180 1 4773 191
(-) (46)
(-)
(-)
307
(188)
Single-leg Double-leg Double-arm (previously single) Double-leg (previously single) Other cases Patientst Limbst Totals
123
77
(6)
(5)
15 (10) 3660 (3473)
(8) 1814 (1759)
7
(104)* (5) (4540) (306)
7 (11) 15 (18) 5474 (5232)
Figures in parentheses represent totals for 1985 referred for advice Patients t : Congenital limb deformities *
Table II((b) and (c)). Total number of patients seen in limb fitting centres for the first time in 1986 (c) Northern Ireland (b) Wales Amputations Single-arm
Amputations
Number 3
Single-arm
Number 7
Double-arm
Double-arm
Single-leg
190
Single-leg
95
Double-leg
10
Double-leg
7
Double-arm (previously single)
Double-arm (previously single)
Double-leg (previously single) Total
5
208
Double-leg (previously single) Total
4
113
Statistics and trends
139
Table III. Patients attending limb fitting centres in England in 1986-cause by age and sex All ages
(a) Disease Vascular insufficiency Embolism Thromboangitis Varicose ulceration Other Metabolic Diabetes Other Infective Gas gangrene Other Malignancy Neurogenic deformity Acquired Congenital Totals
(b) Accident Industrial Home Recreation Armed forces Traffic Pedestrian Road vehicle Two wheel Other Rail Other (unspecified) Totals
0-9
10-19
M
F
M
2064 130 20 29 52
1026 79 5 32 43
-
1 1
-
729 4
374 5
1
-
6 60 112
2 33 92
15 3251
9 15 1715
38 21 19 13
12 21 6 1
46
20
2
128 38 21 20 394
8 15 5
-
11 99
1 4
30
1
20-39 F
M
F
M
F
M
F
10 3 4 1 3
6 4 7
322 23 13 3 20
84 10 2 6 9
1420 91 1 20 22
618 46 2 17 20
312 12 2 4 5
317 19 1 9 6
9 2
1 1
159 2
44
488
263 3
72
66 1
1 1 1 17 4
1 10 25
1 10 27
4 20
2 37 38
2 15 32
1 2 5
-
3 19
1 5 11
5 10 83
1 4 46
2 2 584
1 2 182
7
3
1 1021 416
3 448
2
34 4 13 7
3 5 4 1
35 6 3 2
3 3 1
5
5
14
7
1
6
20 13 3 4 91
1 2
9 4 3 1 52
1 2 2 1 26
2 1
1 1
M
1
-
F
-
-
- -
1
1
- - -
4 7
6 26
- -
8 2 1
12 16
1
1 -
-
-
6
- -
1 2
80+
M
F
1
60-79
40-59
25 5 1 8 56
for the inclusion of a functional joint in the artificial limb without altering the joint level. This is particularly important where a knee joint is concerned, not only for cosmetic reasons, but also for better function. The preservation of the natural knee joint in any lower limb ablation is of prime importance to the degree of mobility that can be expected after limb fitting. A further consideration in the preservation of the natural knee joint in those who suffer the loss of a leg as a result of peripheral vascular disease, is the ever present possibility that the condition causing the first amputation may well, in time, demand the ablation of the contralateral limb which, because of the intervening time interval, may well mean above-knee amputation (Fig. 2). The number of below-knee amputations performed in relation to above-knee amputations has gradually increased over the last two decades, thus ensuring a much higher degree of rehabilitation over a wider age range than was possible in the past. Today, amputation is a form of treatment and not a purely life-saving procedure. The choice of prosthesis depends on the site of the
18 2 3 1 8
72 16 9 10 183
4 4 3 5 31
3 19
2126 9 6 2 4
4 8
2 2
-
-
9 17
-
4
1
-
1 8
11
Amputation
100
Above knee
Below knee
80
60
40
20 OR
_
.
I
I_,,,,_a
1961
1981
1986
Figure 2. Improving rate of below-knee procedures to aboveknee ablations.
amputation, the physical condition of the stump and the age of the amputee. The restoration of the body image and a return to an equal or even higher level of activity must be the target in amputee rehabilitation (Table IV).
140
A Gregory-Dean
In the case of the arm amputee, the patient's motivation is all important, but it is also necessary to provide a prosthesis as soon as possible after amputation before a 'one arm habit' has a chance to develop. The assessment of success of an arm amputee is judged by his or her ability to use the terminal device or artificial hand. Because it is more easily detected by onlookers, a good cosmetic appearance is necessary for the morale of the patient. While motivation is also important in the lower limb amputee, the desire to walk is also very strong. This makes the rehabilitation of the leg amputee more rewarding than rehabilitation of the arm amputee. Those who lose a leg early in life require leg length equalisation as soon as possible. They need a prosthesis that is functional, durable and cosmetically acceptable. Those who become leg amputees later in life have not dissimilar requirements though comfort and special features (eg stabilised knee, rotator, etc.; the rotator is a device inserted in the shin tube between knee and ankle so that a few degrees of medial and lateral rotation may be allowed, thus lessening the shear effect between stump and socket-very welcome by amputee golfers) may be required to allow the amputee to lead an active life. Those who become amputees over the age of 60 years require a prosthesis that is easy to put on and take off, that is light, very stable and cosmetically acceptable. Rehabilitation of a single below-knee amputee gives a very high degree of success even in the aged patient, many of whom become more active than they were before the loss of their leg. The higher the level of amputation the greater becomes the physical effort to walk, though good and active gait may be achieved in most single above-knee amputees. Where there is a loss of both legs, success is more often than not achieved in the double below-knee amputee, but far less likely in those who have one or more aboveknee amputations. Hence, the need to preserve the natural knee wherever possible, especially in the elderly amputee. Numbers and types of artificial limbs are listed in Table V, which refers to centres in England in 1986. The Modular Assembly Prosthesis, which came into use in
Table IV. Comparison of mobility levels of 1000 leg amputees before amputation and 1 year after limb fitting and walking training Activity Not known
Inactive
Moderately active
Very active
387 299 30 284 Before 133 693 164 10 One year after fitting Fully Transfers Independent Walks Mobility outdoors mobile indoors only
Table V. Limbs fitted in the year ended 31 December 1986 Arms Working arm Light working arm Dress arm Externally powered arm Other Total
18 68 33 7 31 157
11.46% 43.31% 21.02% 4.46% 19.75% 100.00%
5 781 222 807 2494 4520
0.11% 17.28% 4.91% 17.86% 54.18% 100.00%
Legs Wooden leg Metal leg Plastic leg Peg or pylon as permanent issue Modular assembly prosthesis Total
Table VI. Comparison of 'stump pain' and 'phantom pain' in patients attending limb fitting centres for the first time in 1985 and on review in 1986 Stump pain At first attendance
After
Pain
Yes No
Yes
No
Arms Legs
1 78
7 85
99 2551
23 589
Phantom pain
I year No Painful Painless phantom phantom phantom
1 68
16 537
7 218
the mid-1970s, and which has been greatly improved since then, has not only had the weight reduced, but more versatile joint mechanisms are now included. These modular limbs are endoskeletal and differ from the more traditional prostheses that are exoskeletal in that the former are soft to the touch where the latter are not and they can also be assembled in a very short time. No statistical comment on amputations would be complete without reference to painful stumps and phantom limbs. The figures for these conditions in England show that for amputees seen on review after 1 year of limb wearing, pain in the stump is an uncommon complication in lower limb amputees and a phantom limb has usually either disappeared or become painless (Table VI).
References 1 On the state of the Public Health. DHSS Annual Reports of the Chief Medical Officer-1969 to 1980. 2 DHSS-Statistics & Research Division. Amputation Statistics for England Wales and Northern Ireland-1975 to 1986.
Statistics and trends Appendix
Artificial limbs: uses and expectations
Comparative table of appliances Function
Natural hand
Split hook
Universal tool holder
Mechanical hand
Myoelectric hand
Pincer
+++
-
+++
++
+-I-+
-
-
-
+ ++
++++
+ ++
++
1. Arms
Peg Vice
++++ ++++ ++++
Single-arm amputees
Clamp
++++
In general, the earlier the arm amputee can be fitted with a prosthesis, the better the prognosis and the less likelihood of developing a one arm habit. (a) Forequarter ablation and through-shoulder disarticulation These prostheses have very limited practical function. They feel heavy, but they do restore the body outline. An elbow lock allows the elbow to be held in a flexed position at 900, permitting the carriage of light objects. An alternative is the shoulder cap with an upper arm section, which is lighter and preferred by some patients. It protects existing scars and restores shoulder girdle symmetry. (b) Above-elbow amputee These prostheses are functional provided there is adequate muscle power and a normal range of movement of the shoulder girdle. Working limbs (builders, carpenters, etc), light working limbs (cabinet makers, pottery, gardening, housework) and dress limbs are available. Dress arms are of the lightest construction but are the least functional. (c) Through-elbow disarticulation As (b) above, except that working and light working prostheses are more useful to the amputee. (d) Below-elbow amputation These are highly functional artificial arms, and they can be supplied with a large variety of terminal devices (appliances) which can be adapted to most occupations and hobbies from engineering to carpentry, photography and gardening. Self-powered and electrically powered (myoelectric) hands can be supplied, the latter especially for children. (e) Through-wrist disarticulation These prostheses are available, but are not widely used. They have less than adequate function and are not particularly elegant. (f)
One-piece dress prostheses These
also available for arm amputees. They are wellshaped, with natural looking hands with passively bendable fingers, soft cosmetic covering and cosmetic gloves. Those used for above-elbow amputees have an articulated are
elbow.
(g) All prostheses, except the purely cosmetic ones, have a wrist rotary into which a variety of appliances can be inserted and placed in optimum position (pronation or supination) for use. This rotary allows easy interchange of one appliance or hand for another. Power to operate these appliances is derived from shoulder movement and transmitted by an operation cord independent of the harness or suspension.
++
+
(h) Double-arm amputees The more distal the loss, the better in general is the prognosis. Many do very well indeed, provided the shoulder girdle is intact and the patient is given adequate arm training. For these patients, who are fortunately few in number, either gas powered or electrically powered arms are of great advantage. Myoelectric arms are suggested for the double below-elbow amputee. 2. Legs
Single-leg amputees Leg length equalisation, stable joints and good cosmetic appearance are prime factors in the successful rehabilitation of the lower limb amputee. With the new, improved modular assembly prosthesis, the new leg amputee can be given a cosmetically acceptable artificial leg within 2 weeks of his first visit to a limb centre. Metal or exoskeletal limbs are still made and supplied to those established wearers who do not wish to be converted to the modular endoskeletal type of prosthesis. In general, the new endoskeletal limbs are lighter than the crustacean limbs. (a) Hindquarter amputations and through-hip disarticulations These artificial legs are composed of a socket in which the patient sits; this socket is based on the tilting table principle, embraces both hips, and is self-supporting. The anterior hip joint allows the patient to sit on the level. A thigh section, knee mechanism, shin piece, ankle mechanism and foot complete the set-up. In order to avoid the mechanical problems inherent in a compound pendulum, the hip joint should have an adjustable hip limiter and the knee joint should either be lockable or stabilised, or both. The stabilised knee is usually fitted with swing phase control. A uniaxial or multiaxial ankle joint may be used with most types of artificial feet. (b) Above-knee amputation In order to take advantage of the sophisticated knee mechanism available, there must be 11 cm (4{ in.) between the end of the above-knee stump and the axes on which the knees bend. Sockets for this level of loss can be self-supporting (suction or total surface bearing) or suspended by belts and/or braces. There is a choice of materials from which the sockets can be made, eg metal, leather, plastic, or occasionally wood. A wide selection of knee units are available, from the simple bolt type to stabilised knees with either semiautomatic or hand-operated knee locks, to which swing phase controls and/or stance flex knee units may be added. The ankle joints and feet will be described below.
142
A Gregory-Dean
(c) Gritti-Stokes amputations and through-knee disarticulations Both are excellent surgical procedures, to be used when the knee joint cannot be saved or when the resulting stump would be too short to be of any value (less than 4 cm of tibia). Neither of these procedures is advisable in women unless the clinical condition precludes an above-knee amputation, because the prostheses are bulky and rarely acceptable to the patient. Furthermore, because of the need for an external knee joint or four-bar linkage mechanism, the shin piece is shorter than the natural leg, and unacceptable cosmetically unless trousers are worn. Both stumps are end-bearing and are an advantage to active, hard-working young men. Exoskeletal and endoskeletal limbs are available for these amputation stumps. In general, the exoskeletal limbs are preferred by patients, although the controlled knee mechanisms can only be used with endoskeletal limbs. Sockets can be self-supporting, if the more proximal circumference is less than that round the condyles. It is suggested that, when performing a through-knee disarticulation, equal lateral and medial flaps are used rather than a long anterior flap, which frequently has less than adequate circulation and results in delayed healing of the transverse posterior scar. The scar resulting from the use of side flaps heals well and retracts nicely into the intercondylar sulcus, giving an excellent end-bearing stump.
(d) Below-knee amputation Arguably the procedure to be adopted whenever it is clinically possible. Even very short and heavily scarred stumps have been successfully fitted with patellar tendon bearing prostheses. These are usually suspended by the use of an adjustable cuff that is fitted just above the femoral condyles. Supracondylar sockets which are selfsuspending can be used when the configuration of the distal part of the thigh permits. In women who wear suspender belts or corsets, suspension by elastic stockings gives a leg with unbroken contours. Strong elasticated sleeves covering the lower two-thirds of the thigh are often preferred for sporting activities. Invariably, modular limbs are prescribed for these patients; only when the amputation stump is unable to bear any pressure or tolerate any friction (split-skin grafting) is the older type of exoskeletal prosthesis with a thigh corset and side steels prescribed.
(e) Ankle mechanisms Ankle mechanisms for all the artificial legs mentioned above may be uniaxial, uniaxial with adjustable heel (for women), multiaxial, which allow a degree of inversion, eversion and rotation, or solid (no movement). These are prescribed according to the degree of activity required by the patient. (f)
Syme's amputation Wherever possible, an end-bearing prosthesis is provided, and if total end-bearing is not possible, a patellar tendon bearing socket is provided in leather or plastic and enclosed in a shin piece of either metal or plastic. These are self-suspending. Ankles are either uniaxial or solid. Occasionally, and for certain heavy activities, block leather sockets fitted into bifurcated steels with soft leather gaiters are demanded (eg farmers).
(g) Partial foot ablation Until fairly recently, the prostheses available for the Chopart, Lisfranc, and other partial foot procedures have been the least satisfactory of all, being too bulky to fit neatly into any but bespoke shoes or boots. Scars from these procedures are invariably thin and adherent to hard tissues beneath. They do not stand up well to friction, and when they do, callosities tend to form on the stump, despite all prosthetic efforts to provide soft linings, and pure wool socks should always be used. Nowadays, however, silicone-based moulded socks can be made which fit closely round the stump. These are soft lined and much kinder to the soft tissues. Rigid or semi-rigid footplates can be incorporated to improve stability. So far, these shoe or boot fillers have been found to be much more acceptable to patients, both male and female. (h) The artificial foot (i) The standard wood foot with uniaxial ankle shaped to fit the shoe provided by the patient has adjustable heel and instep rubbers to allow a plantigrade tread regardless of the height of the heel. There is also a toe rubber (varied densities) placed at the level of the metatarsal phalangeal joints that assists toe-off. (ii) The solid ankle cushion heel foot (SACH), used frequently when space between the end of the stump and ground is not sufficient, or when preferred by the patient. (iii) The moulded uniaxial foot, very similar in action to the standard wood foot, used exclusively by some manufacturers. If broken, it can be changed at one short visit to the prosthetist. (iv) The Multiflex ankle and foot. Today, this is the usual foot for all modular limbs manufactured in the UK. In addition to flexion and extension, it allows some inversion and eversion and fractional rotation. (v) The quantum foot. An interesting new concept in which the energy produced at heel strike and roll over is stored within the foot and used to enhance toe-off. This foot is very popular with the active and sporty young amputee.
It is uniaxial.
Walking for the single-leg amputee All single amputees walk within the limitations imposed by their age and general physical condition. The more distal the amputation, the better their chance of regaining complete ambulatory rehabilitation. No single amputee, regardless of age, health or level of loss, should be denied the chance to attempt to walk or, even in apparently hopeless cases, to learn how to transfer from one seat to another. Double-leg amputees Many double above-knee amputees learn to walk and be independent with a walking frame or two walking sticks, provided their general health does not debar them from this greater physical effort. Reduction in the length of the prostheses reduces the physical effort required. When one or, better still, both knees have been preserved, then the chances of independent mobility are good, and excellent when the person is a double below-knee amputee. Most young double below-knee amputees walk very well indeed. Light, cosmetic, non-weight-bearing prostheses can be provided for chair-bound double amputees, giving them a more dignified appearance.
