Authors: Michael E. Kralovec, MD Matthew T. Houdek, MD Karen L. Andrews, MD Thomas C. Shives, MD Peter S. Rose, MD Franklin H. Sim, MD
Prosthetic Rehabilitation
ORIGINAL RESEARCH ARTICLE
Affiliations: From the Departments of Orthopedic Surgery (MEK, MTH, TCS, PSR, FHS) and Physical Medicine and Rehabilitation (KLA), Mayo Clinic, Rochester, Minnesota.
Prosthetic Rehabilitation After Hip Disarticulation or Hemipelvectomy
Correspondence: All correspondence and requests for reprints should be addressed to: Franklin H. Sim, MD, Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
Disclosures: Michael E. Kralovec and Matthew T. Houdek contributed equally in the preparation of this article. No disclosures of funding were received for this work from the National Institutes of Health, the Wellcome Trust, or the Howard Hughes Medical Institute. Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
0894-9115/15/9412-1035 American Journal of Physical Medicine & Rehabilitation Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/PHM.0000000000000292
ABSTRACT Kralovec ME, Houdek MT, Andrews KL, Shives TC, Rose PS, Sim FH: Prosthetic rehabilitation after hip disarticulation or hemipelvectomy. Am J Phys Med Rehabil 2015;94:1035Y1040.
Objective:
Prosthetic rehabilitation after pelvic-level amputation (hemipelvectomy/ hip disarticulation) is difficult, and because of this, many patients are never fit with a prosthetic limb. The objectives of the study were to evaluate the characteristics of successful prosthetic users and to determine what factors are associated with successful prosthetic fitting and use.
Design: The authors identified 43 patients who underwent hip disarticulation/ hemipelvectomy between 2000 and 2010 and were candidates for prosthetic fitting at the authors" institution. The medical records of these patients were then reviewed for pertinent demographic and medical characteristics to identify the profile of successful prosthetic users.
Results: Of 43 patients, 18 (43%) successfully used a prosthetic limb. The only preoperative factor associated with unsuccessful prosthetic fitting was coronary artery disease. Specifically, age, body mass index, other medical comorbidities, and demographic characteristics were not associated with successful or unsuccessful prosthetic fitting. Successful users wore their prosthesis an average of 5.8 hrs/day, and most ambulated with one or both hands free.
Conclusions: Successful prosthetic rehabilitation after hemipelvectomy and hip disarticulation is possible. Increased body mass index, advanced age, depression, and other comorbidities should not discourage prosthetic rehabilitation. Most patients that undergo prosthetic rehabilitation enjoy long periods of survival and wear their prosthesis for most of the day. Key Words:
www.ajpmr.com
Prosthetic Rehabilitation, Hip Disarticulation, Hemipelvectomy
Prosthetic Rehabilitation After Pelvic-Level Amputation Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
1035
OBJECTIVE Pelvic-level amputation (hip disarticulation or external hemipelvectomy) is a rare operative procedure performed for advanced malignancy, untreatable ischemia, or fulminant infection, with historic mortality rates exceeding 50%.1 Through advances in anesthesia and surgical care, the reported mortality rates after high-level amputations have dramatically been reduced to 0%Y10%.2Y5 Although the mortality rate has substantially decreased, these procedures continue to be associated with significant morbidity, with complications ranging from 50% to 80%.4,6 In a large study by Senchenkov et al.,6 more than half of the patients developed a postoperative complication, most notably wound infections and flap necrosis. After hip disarticulation or hemipelvectomy amputation, prosthetic training is a challenge. During the rehabilitation process, it is difficult for the patient to control the swing phase of gait, as well as stance, while attempting to stabilize a prosthesis.7,8 Because of these difficulties, some patients choose to function from a wheelchair base or ambulate with a one-legged gait using crutches or a walker. Although the use of a prosthetic limb is difficult, there is a select group of patients who choose to wear a prosthetic limb, some all day, whereas others prefer to combine use of the prosthesis with one-legged gait or wheelchair mobility. The aims of this study were twofold. First, the authors sought to identify the demographic features of patients who successfully use a prosthesis and compare them to patients who do not successfully use a prosthesis after hip disarticulation or hemipelvectomy. Second, the authors attempted to identify any preoperative risk factors that were associated with successful or unsuccessful prosthetic use in patients undergoing a hip disarticulation or hemipelvectomy.
DESIGN After the approval of the authors" institutional review board, the authors retrospectively reviewed their surgical database for patients who underwent a pelvic-level amputation over a 10-yr period (2000Y2010). Written consent was not obtained from each patient in this chart review. At the authors" tertiary, academic medical center, a total of 135 patients underwent hip disarticulation or hemipelvectomy over the study period. Ninety-two (68%) of these patients were excluded. Factors why patients were excluded were as follows: (1) patients elected to carry out their rehabilitation and follow-up care closer to home at another institution
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(n = 72, 53%), (2) patients did not live at least 6 mos postoperatively (n = 18, 13%), and (3) patients had a preexisting neurologic dysfunction on the contralateral side, that is, paraplegia (n = 2, 1%). After the exclusion of these patients, there were 43 patients included in this review. The sample was predominantly male (n = 33, 77%), with a mean age of 52.6 yrs (range, 14Y88 yrs). The most common indication for amputation was an oncologic process (n = 34, 79%). The medical record of each patient was reviewed for pertinent patient demographics, including age, sex, indication for amputation, level of amputation, medical comorbidities, marital status, and preoperative body mass index (BMI). The medical record and therapy notes were also analyzed for the maximum distance the patient was able to ambulate without stopping, the number of hours per day they feel they wear their prosthesis, and their main reasons why they like to use a prosthesis over other modes of ambulation such as crutches or a wheelchair. Prosthetic use was based off a review of the patients" medical records. Patients who were fit with a prosthesis after prosthetic rehabilitation and used a prosthesis at least three times a week for at least 1 hr/day at the time of their last clinical visit or physical therapy appointment were considered successful users. For the purposes of analyzing the data, the authors divided patients into two groups. Group 1 (n = 18 patients) was composed of those who successfully used a prosthesis (successful). Group 2 (n = 25 patients) was composed of patients who did not use a prosthesis regardless of reason. The clinical features of patients were analyzed for comparability by using Student"s t tests, Fisher"s exact test, and odds ratios. Survival estimates were made using the Kaplan-Meier survival method, with comparisons between the patients successfully fit with a prosthetic limb and those who did not use a prosthesis using the log-rank test. All statistical calculations were made using JMP version 9 (Statistical Analysis Software, Cary, NC), with statistical significance set at a P value of less than 0.05.
RESULTS Baseline demographic and clinical characteristics of the 43 patients are described in Table 1. Eighteen patients (42%) were successfully fit and used a prosthetic limb at the last follow-up. Twelve (67%) of the successful users underwent a hemipelvectomy, whereas six (33%) underwent a hip disarticulation. In the remaining 25 patients, reasons why a prosthetic limb was not used included the following: not offered prosthetic fitting
Am. J. Phys. Med. Rehabil. & Vol. 94, No. 12, December 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
TABLE 1 Demographics of patients undergoing pelvic amputations
Patients Men Women Mean age, yrs Mean BMI, kg/m2 Indications Oncology Infection Ischemia
Total Cohort
Hemipelvectomy
Hip Disarticulation
43 33 10 52.6 27.8
29 23 6 47.9 27.7
14 10 4 63.2 27.9
34 6 3
28 1 0
6 5 3
(n = 9), wound healing complications not allowing fitting (n = 6), deemed not medically stable for fitting (n = 6), and fitted with a prosthetic limb but chose not to wear it (n = 4). None of the patients who were not initially offered a prosthesis went onto a prosthetic fitting at a later date. One patient with wound healing complications was fit for a prosthesis at the 2-yr postoperative mark. The mean time from amputation to prosthetic fitting was 7 mos (range, 2Y24 mos). Group 1 patients wore their prosthesis for a mean of 6 hrs/day (range, 1Y12 hrs/day). All were able to ambulate with or without the use of gait aids for a mean distance of 158 ft (range, 100Y200 ft) between rest periods. Five (28%) wore their prosthesis longer than 8 hrs/day, 11 (62%) wore their prosthesis between 3 and 8 hrs/day, and 2 (11%) patients wore their prosthesis shorter than 3 hrs/day (Table 2). Nine patients (50%) were able to ambulate with either a cane, a single crutch, or no gait aid, leaving one hand free. In a review of the patients" preoperative medical comorbidities, the only statistically significant association of not being fit and using a prosthesis was the presence of coronary artery disease (CAD) (P =
0.001; odds ratio, 25.2) (Table 3). BMI, age, marital status, presence of contralateral lower extremity osteoarthritis, depression, cerebrovascular disease, diabetes mellitus, pulmonary disease (chronic obstructive pulmonary disease or asthma), history of previous orthopedic surgeries, and dementia were not significantly associated with successful prosthetic fitting. Over the course of the study period, the 5- and 10-yr survival estimates for patients fitted with a prosthetic limb had significantly improved overall survival (89% and 69%; P = 0.001), compared with patients who did not use a prosthetic limb, whose 5- and 10-yr survival estimates were 36% and 29% (Fig. 1).
CONCLUSION Previous studies on patients with pelvic amputations have shown high rates of morbidity and mortality, with a low incidence of successful ambulation or prosthetic fit.9,10 After hemipelvectomy or hip disarticulation amputation, prosthetic use has previously been shown to require more energy expenditure than walking with crutches or functioning from a wheelchair base.11Y13
TABLE 2 Ambulation characteristics of prosthetic users Prosthetic Users Average hours of prosthetic use 98 hrs/day 3Y8 hrs/day G3 hrs/day Average maximum distance ambulated, ft Gait aids None Cane Single forearm crutch Two forearm crutches Walker
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6 5 11 2 158 2 3 3 4 5
Prosthetic Rehabilitation After Pelvic-Level Amputation Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
1037
TABLE 3 Factors associated with successful prosthetic use Fit with Prosthesis Not Fit with Prosthesis Significance Odds Ratio (95% CI) Mean BMI Mean age Presence of condition CAD Previous orthopedic procedures Arthritis Cardiovascular disease Diabetes mellitus Dementia Married Pulmonary conditions Depression
27.6 47.1 Yes 1 1 1 1 2 1 11 5 5
28.1 56.7 Yes 9 7 5 3 4 2 16 6 2
Overall, less than half (42%, n = 18) of patients were successfully fit and used a prosthetic limb. Given the morbidity associated with this surgery, as well as the disease processes that prompt it, it is expected that some patients are unable to undergo successful prosthetic rehabilitation due to medical and wound healing complications.14 That being said, one of the more compelling findings regarding the group of nonprosthetic users was that they were never offered one. One in five patients were not offered a prosthetic limb and told they were not a candidate for a prosthetic limb or they would Bfunction[ better without one. As advances occur in prosthetic devices and rehabilitation, the criteria of who makes a good prosthetic candidate should be constantly reevaluated and updated by the clinician. The data from this study are encouraging that prosthetic rehabilitation is a viable option in many patients who undergo pelvic-level amputation. At the authors" institution, the authors have changed their practice based on these observations with more aggressive attempts at rehabilitation and
P = 0.8 P = 0.10
V V
P = 0.001 P = 0.11 P = 0.18 P = 0.62 P = 1.0 P = 1.0 P = 1.0 P = 1.0 P = 0.11
25.5 (2.64Y245.8) 6.61 (0.73Y59.52) 4.25 (0.45Y40.01) 2.31 (0.22Y24.30) 1.52 (0.24Y9.38) 1.47 (0.12Y17.67) 1.13 (0.32Y3.95) 0.82 (0.20Y3.26) 0.22 (0.03Y1.33)
prosthetic fitting, with every patient undergoing a pelvic-level amputation evaluated by a Physical Medicine and Rehabilitation consultant for potential prosthetic fitting. Although most of the patients that were fit for a prosthetic limb used their prosthesis, four patients (19%) did not. In two patients, the prosthesis caused skin irritation, one patient felt that ambulating with the limb was too strenuous, and one patient did not want to don and doff the prosthesis. With advances in technology that allow better, easier fitting, perhaps these patients can be successfully fit in the future. Likewise, advances in prosthetic design and components have occurred over the course of this study, such as microprocessor knees and polycentric hips, which allowed for the prosthesis to adapt to the walking surface of the patient, allowing the patient to navigate environmental obstacles such as stairs and inclines.15,16 The results of this study partially support the authors" hypothesis that there are certain factors preoperatively that are associated with patients who
FIGURE 1 Kaplan-Meier survival estimates of patients who are successful prosthetic users (group 1, red) compared with those who were not (group 2, blue). The overall 5- and 10-yr survival for group 1 was 89% and 69%, whereas that for group 2 was 36% and 29%.
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Am. J. Phys. Med. Rehabil. & Vol. 94, No. 12, December 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
are unlikely to successfully use a prosthetic limb after hip disarticulationY or hemipelvectomy-level amputation. A history of CAD was the only variable examined that could be a potential preoperative associated risk factor of unsuccessful prosthetic use. Although CAD was the only significant factor found to be correlated to prosthetic fitting, the data present a potentially more useful conclusion. None of the remaining factors investigated excluded a patient from successful prosthetic fitting. The successful prosthetic use population of the study was extremely diverse. Patients ranged in age from 16 to 74 yrs, with a preoperative BMI ranging from 18.4 to 36.1 kg/m2. Having realistic expectations of what is possible in prosthetic rehabilitation after hip disarticulation or hemipelvectomy is important both for the patient to make an informed decision and for the clinician to counsel them to facilitate realistic goal setting during the perioperative period. The patients who were prosthetic users experienced extended survival times compared with those who were unable to use a prosthetic limb. This is likely multifactorial as a large number of patients who were not fit with a prosthesis died before 6 mos postoperatively and had significant medical comorbidities that precluded fitting. Although the authors acknowledge that there is significant selection bias, the data show that most of the patients who are successfully fit with a prosthetic limb are likely to survive at least 5 yrs postoperatively. In addition to longer survival times, patients in this series used their prostheses, with most of the patients (61%) reporting that they used their prosthesis every day between 3 and 8 hrs. Although most patients required some form of gait aid, the authors feel that it is a realistic expectation to use a gait aid to optimize gait, balance, and stability. In this group, however, 50% (n = 9) of the patients were able to ambulate with no or a single gait aid. This allowed them one free hand, which has a positive impact on functional independence and mobility. There are several limitations to this study. First, the patients" baseline functional status, which may be associated with the likelihood of successful prosthetic use, was not taken into account because of the inconsistent documentation in the medical record. Likewise, the authors were unable to perform any functional scores based on the inconsistent documentation in the medical record and the time the prosthesis is worn is based on patient reporting. Because of the rarity of this surgery, the sample size of the study was small. With the www.ajpmr.com
surgical technique, outcomes, and postoperative management varying widely, it is difficult to study this patient population as one homogenous group. Likewise, the retrospective nature of this study puts obvious constraints on the data the authors are able to collect, making it difficult to compare outcomes among patients. Specifically, the authors" definition of successful use is based on patient reported times, which is flawed by recall bias and the authors" definition of successful use. The authors" definition of successful use is not a validated outcome measure. Selection bias exists in the survival of patients who are successful prosthetic users, and this is not meant to imply that patient survival is improved by successful prosthetic fitting. Longer life span gives greater longitudinal opportunity for prosthetic fitting and rehabilitation. It is also possible that with longer follow-up, patients who initially were not fit a prosthesis could become successful prosthetic users. Additionally, patients who have advancing malignancies often lack the performance status for prosthetic fitting, and the focus of their care is commonly directed elsewhere. In conclusion, prosthetic rehabilitation should be a viable option for patients who require hemipelvectomy- or hip disarticulationYlevel amputation. The range of characteristics and comorbidities of patients who were fit and who used a prosthesis is broad, and the presence of CAD is the only factor that potentially affects successful prosthetic fitting and use. Most patients that undergo successful prosthetic rehabilitation enjoy long periods of survival and wear their prosthesis.
REFERENCES 1. Taylor GW, Rogers WP: Hindquarter amputation: Experience with 18 cases. N Engl J Med 1953; 249:963Y9 2. Carter SR, Eastwood DM, Grimer RJ, et al: Hindquarter amputation for tumours of the musculoskeletal system. J Bone Joint Surg Br 1990;72:490Y3 3. Jaques DP, Coit DG, Brennan MF: Major amputation for advanced malignant melanoma. Surg Gynecol Obstet 1989;169:1Y6 4. Baliski CR, Schachar NS, McKinnon JG, et al: Hemipelvectomy: A changing perspective for a rare procedure. Can J Surg 2004;47:99Y103 5. Karakousis CP, Emrich LJ, Driscoll DL: Variants of hemipelvectomy and their complications. Am J Surg 1989;158:404Y8 6. Senchenkov A, Moran SL, Petty PM, et al: Predictors of complications and outcomes of external hemipelvectomy wounds: A count of 160 consecutive cases. Ann Surg Oncol 2008;15:355Y63
Prosthetic Rehabilitation After Pelvic-Level Amputation Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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7. Yari P, Digkstra P, Geertzen J: Functional outcome of hip disarticulation and hemipelvectomy: A cross-sectional national descriptive study in the Netherlands. Clin Rehabil 2008;22:1127Y33 8. Schnall B, Baum B, Andrews A: Gait characteristics of a soldier with a traumatic hip disarticulation. Phys Ther 2008;88:1568Y77 9. Unruh T, Fisher DF, Unruh TA, et al: Hip disarticulation: An 11-year experience. Arch Surg 1990;125:791Y3 10. Marshal C, Stansby G: Amputation and rehabilitation. Vasc Surg II 2010;28:284Y7 11. Fisher SV, Gullickson G: Energy cost of ambulation in health and disability: A literature review. Arch Phys Med Rehabil 1978;59:124Y33 12. Chin T, Oyabu H, Maeda Y, et al: Energy consumption during prosthetic walking and wheelchair locomo-
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tion by elderly hip disarticulation amputees. Am J Phys Med Rehabil 2009;88:399Y403 13. Nowroozi F, Salvanelli ML, Gerber LH: Energy expenditure in hip disarticulation and hemipelvectomy amputees. Am J Phys Med Rehabil 1983;64:300Y3 14. Senchenkov A, Moran SL, Petty PM, et al: Predictors of complications and outcomes of external hemipelvectomy wounds: Account of 160 consecutive cases. Ann Surg Oncol 2008;15:355Y63 15. Highsmith MJ, Kahle JT, Bongiorni DR, et al: Safety, energy efficiency, and cost efficacy of the C-Leg for transfemoral amputees: A review of the literature. Prosthet Orthot Int 2010;34:362Y77 16. Ludwigs E, Bellman M, Schmalz T, et al: Biomechanical differences between two exoprosthetic hip joint systems during level walking. Prosthet Orthot Int 2010;34:449Y60
Am. J. Phys. Med. Rehabil. & Vol. 94, No. 12, December 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Prosthetic Rehabilitation
ORIGINAL RESEARCH ARTICLE
Affiliations: From the Departments of Orthopedic Surgery (MEK, MTH, TCS, PSR, FHS) and Physical Medicine and Rehabilitation (KLA), Mayo Clinic, Rochester, Minnesota.
Prosthetic Rehabilitation After Hip Disarticulation or Hemipelvectomy
Correspondence: All correspondence and requests for reprints should be addressed to: Franklin H. Sim, MD, Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
Disclosures: Michael E. Kralovec and Matthew T. Houdek contributed equally in the preparation of this article. No disclosures of funding were received for this work from the National Institutes of Health, the Wellcome Trust, or the Howard Hughes Medical Institute. Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
0894-9115/15/9412-1035 American Journal of Physical Medicine & Rehabilitation Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/PHM.0000000000000292
ABSTRACT Kralovec ME, Houdek MT, Andrews KL, Shives TC, Rose PS, Sim FH: Prosthetic rehabilitation after hip disarticulation or hemipelvectomy. Am J Phys Med Rehabil 2015;94:1035Y1040.
Objective:
Prosthetic rehabilitation after pelvic-level amputation (hemipelvectomy/ hip disarticulation) is difficult, and because of this, many patients are never fit with a prosthetic limb. The objectives of the study were to evaluate the characteristics of successful prosthetic users and to determine what factors are associated with successful prosthetic fitting and use.
Design: The authors identified 43 patients who underwent hip disarticulation/ hemipelvectomy between 2000 and 2010 and were candidates for prosthetic fitting at the authors" institution. The medical records of these patients were then reviewed for pertinent demographic and medical characteristics to identify the profile of successful prosthetic users.
Results: Of 43 patients, 18 (43%) successfully used a prosthetic limb. The only preoperative factor associated with unsuccessful prosthetic fitting was coronary artery disease. Specifically, age, body mass index, other medical comorbidities, and demographic characteristics were not associated with successful or unsuccessful prosthetic fitting. Successful users wore their prosthesis an average of 5.8 hrs/day, and most ambulated with one or both hands free.
Conclusions: Successful prosthetic rehabilitation after hemipelvectomy and hip disarticulation is possible. Increased body mass index, advanced age, depression, and other comorbidities should not discourage prosthetic rehabilitation. Most patients that undergo prosthetic rehabilitation enjoy long periods of survival and wear their prosthesis for most of the day. Key Words:
www.ajpmr.com
Prosthetic Rehabilitation, Hip Disarticulation, Hemipelvectomy
Prosthetic Rehabilitation After Pelvic-Level Amputation Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
1035
OBJECTIVE Pelvic-level amputation (hip disarticulation or external hemipelvectomy) is a rare operative procedure performed for advanced malignancy, untreatable ischemia, or fulminant infection, with historic mortality rates exceeding 50%.1 Through advances in anesthesia and surgical care, the reported mortality rates after high-level amputations have dramatically been reduced to 0%Y10%.2Y5 Although the mortality rate has substantially decreased, these procedures continue to be associated with significant morbidity, with complications ranging from 50% to 80%.4,6 In a large study by Senchenkov et al.,6 more than half of the patients developed a postoperative complication, most notably wound infections and flap necrosis. After hip disarticulation or hemipelvectomy amputation, prosthetic training is a challenge. During the rehabilitation process, it is difficult for the patient to control the swing phase of gait, as well as stance, while attempting to stabilize a prosthesis.7,8 Because of these difficulties, some patients choose to function from a wheelchair base or ambulate with a one-legged gait using crutches or a walker. Although the use of a prosthetic limb is difficult, there is a select group of patients who choose to wear a prosthetic limb, some all day, whereas others prefer to combine use of the prosthesis with one-legged gait or wheelchair mobility. The aims of this study were twofold. First, the authors sought to identify the demographic features of patients who successfully use a prosthesis and compare them to patients who do not successfully use a prosthesis after hip disarticulation or hemipelvectomy. Second, the authors attempted to identify any preoperative risk factors that were associated with successful or unsuccessful prosthetic use in patients undergoing a hip disarticulation or hemipelvectomy.
DESIGN After the approval of the authors" institutional review board, the authors retrospectively reviewed their surgical database for patients who underwent a pelvic-level amputation over a 10-yr period (2000Y2010). Written consent was not obtained from each patient in this chart review. At the authors" tertiary, academic medical center, a total of 135 patients underwent hip disarticulation or hemipelvectomy over the study period. Ninety-two (68%) of these patients were excluded. Factors why patients were excluded were as follows: (1) patients elected to carry out their rehabilitation and follow-up care closer to home at another institution
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(n = 72, 53%), (2) patients did not live at least 6 mos postoperatively (n = 18, 13%), and (3) patients had a preexisting neurologic dysfunction on the contralateral side, that is, paraplegia (n = 2, 1%). After the exclusion of these patients, there were 43 patients included in this review. The sample was predominantly male (n = 33, 77%), with a mean age of 52.6 yrs (range, 14Y88 yrs). The most common indication for amputation was an oncologic process (n = 34, 79%). The medical record of each patient was reviewed for pertinent patient demographics, including age, sex, indication for amputation, level of amputation, medical comorbidities, marital status, and preoperative body mass index (BMI). The medical record and therapy notes were also analyzed for the maximum distance the patient was able to ambulate without stopping, the number of hours per day they feel they wear their prosthesis, and their main reasons why they like to use a prosthesis over other modes of ambulation such as crutches or a wheelchair. Prosthetic use was based off a review of the patients" medical records. Patients who were fit with a prosthesis after prosthetic rehabilitation and used a prosthesis at least three times a week for at least 1 hr/day at the time of their last clinical visit or physical therapy appointment were considered successful users. For the purposes of analyzing the data, the authors divided patients into two groups. Group 1 (n = 18 patients) was composed of those who successfully used a prosthesis (successful). Group 2 (n = 25 patients) was composed of patients who did not use a prosthesis regardless of reason. The clinical features of patients were analyzed for comparability by using Student"s t tests, Fisher"s exact test, and odds ratios. Survival estimates were made using the Kaplan-Meier survival method, with comparisons between the patients successfully fit with a prosthetic limb and those who did not use a prosthesis using the log-rank test. All statistical calculations were made using JMP version 9 (Statistical Analysis Software, Cary, NC), with statistical significance set at a P value of less than 0.05.
RESULTS Baseline demographic and clinical characteristics of the 43 patients are described in Table 1. Eighteen patients (42%) were successfully fit and used a prosthetic limb at the last follow-up. Twelve (67%) of the successful users underwent a hemipelvectomy, whereas six (33%) underwent a hip disarticulation. In the remaining 25 patients, reasons why a prosthetic limb was not used included the following: not offered prosthetic fitting
Am. J. Phys. Med. Rehabil. & Vol. 94, No. 12, December 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
TABLE 1 Demographics of patients undergoing pelvic amputations
Patients Men Women Mean age, yrs Mean BMI, kg/m2 Indications Oncology Infection Ischemia
Total Cohort
Hemipelvectomy
Hip Disarticulation
43 33 10 52.6 27.8
29 23 6 47.9 27.7
14 10 4 63.2 27.9
34 6 3
28 1 0
6 5 3
(n = 9), wound healing complications not allowing fitting (n = 6), deemed not medically stable for fitting (n = 6), and fitted with a prosthetic limb but chose not to wear it (n = 4). None of the patients who were not initially offered a prosthesis went onto a prosthetic fitting at a later date. One patient with wound healing complications was fit for a prosthesis at the 2-yr postoperative mark. The mean time from amputation to prosthetic fitting was 7 mos (range, 2Y24 mos). Group 1 patients wore their prosthesis for a mean of 6 hrs/day (range, 1Y12 hrs/day). All were able to ambulate with or without the use of gait aids for a mean distance of 158 ft (range, 100Y200 ft) between rest periods. Five (28%) wore their prosthesis longer than 8 hrs/day, 11 (62%) wore their prosthesis between 3 and 8 hrs/day, and 2 (11%) patients wore their prosthesis shorter than 3 hrs/day (Table 2). Nine patients (50%) were able to ambulate with either a cane, a single crutch, or no gait aid, leaving one hand free. In a review of the patients" preoperative medical comorbidities, the only statistically significant association of not being fit and using a prosthesis was the presence of coronary artery disease (CAD) (P =
0.001; odds ratio, 25.2) (Table 3). BMI, age, marital status, presence of contralateral lower extremity osteoarthritis, depression, cerebrovascular disease, diabetes mellitus, pulmonary disease (chronic obstructive pulmonary disease or asthma), history of previous orthopedic surgeries, and dementia were not significantly associated with successful prosthetic fitting. Over the course of the study period, the 5- and 10-yr survival estimates for patients fitted with a prosthetic limb had significantly improved overall survival (89% and 69%; P = 0.001), compared with patients who did not use a prosthetic limb, whose 5- and 10-yr survival estimates were 36% and 29% (Fig. 1).
CONCLUSION Previous studies on patients with pelvic amputations have shown high rates of morbidity and mortality, with a low incidence of successful ambulation or prosthetic fit.9,10 After hemipelvectomy or hip disarticulation amputation, prosthetic use has previously been shown to require more energy expenditure than walking with crutches or functioning from a wheelchair base.11Y13
TABLE 2 Ambulation characteristics of prosthetic users Prosthetic Users Average hours of prosthetic use 98 hrs/day 3Y8 hrs/day G3 hrs/day Average maximum distance ambulated, ft Gait aids None Cane Single forearm crutch Two forearm crutches Walker
www.ajpmr.com
6 5 11 2 158 2 3 3 4 5
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1037
TABLE 3 Factors associated with successful prosthetic use Fit with Prosthesis Not Fit with Prosthesis Significance Odds Ratio (95% CI) Mean BMI Mean age Presence of condition CAD Previous orthopedic procedures Arthritis Cardiovascular disease Diabetes mellitus Dementia Married Pulmonary conditions Depression
27.6 47.1 Yes 1 1 1 1 2 1 11 5 5
28.1 56.7 Yes 9 7 5 3 4 2 16 6 2
Overall, less than half (42%, n = 18) of patients were successfully fit and used a prosthetic limb. Given the morbidity associated with this surgery, as well as the disease processes that prompt it, it is expected that some patients are unable to undergo successful prosthetic rehabilitation due to medical and wound healing complications.14 That being said, one of the more compelling findings regarding the group of nonprosthetic users was that they were never offered one. One in five patients were not offered a prosthetic limb and told they were not a candidate for a prosthetic limb or they would Bfunction[ better without one. As advances occur in prosthetic devices and rehabilitation, the criteria of who makes a good prosthetic candidate should be constantly reevaluated and updated by the clinician. The data from this study are encouraging that prosthetic rehabilitation is a viable option in many patients who undergo pelvic-level amputation. At the authors" institution, the authors have changed their practice based on these observations with more aggressive attempts at rehabilitation and
P = 0.8 P = 0.10
V V
P = 0.001 P = 0.11 P = 0.18 P = 0.62 P = 1.0 P = 1.0 P = 1.0 P = 1.0 P = 0.11
25.5 (2.64Y245.8) 6.61 (0.73Y59.52) 4.25 (0.45Y40.01) 2.31 (0.22Y24.30) 1.52 (0.24Y9.38) 1.47 (0.12Y17.67) 1.13 (0.32Y3.95) 0.82 (0.20Y3.26) 0.22 (0.03Y1.33)
prosthetic fitting, with every patient undergoing a pelvic-level amputation evaluated by a Physical Medicine and Rehabilitation consultant for potential prosthetic fitting. Although most of the patients that were fit for a prosthetic limb used their prosthesis, four patients (19%) did not. In two patients, the prosthesis caused skin irritation, one patient felt that ambulating with the limb was too strenuous, and one patient did not want to don and doff the prosthesis. With advances in technology that allow better, easier fitting, perhaps these patients can be successfully fit in the future. Likewise, advances in prosthetic design and components have occurred over the course of this study, such as microprocessor knees and polycentric hips, which allowed for the prosthesis to adapt to the walking surface of the patient, allowing the patient to navigate environmental obstacles such as stairs and inclines.15,16 The results of this study partially support the authors" hypothesis that there are certain factors preoperatively that are associated with patients who
FIGURE 1 Kaplan-Meier survival estimates of patients who are successful prosthetic users (group 1, red) compared with those who were not (group 2, blue). The overall 5- and 10-yr survival for group 1 was 89% and 69%, whereas that for group 2 was 36% and 29%.
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Am. J. Phys. Med. Rehabil. & Vol. 94, No. 12, December 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
are unlikely to successfully use a prosthetic limb after hip disarticulationY or hemipelvectomy-level amputation. A history of CAD was the only variable examined that could be a potential preoperative associated risk factor of unsuccessful prosthetic use. Although CAD was the only significant factor found to be correlated to prosthetic fitting, the data present a potentially more useful conclusion. None of the remaining factors investigated excluded a patient from successful prosthetic fitting. The successful prosthetic use population of the study was extremely diverse. Patients ranged in age from 16 to 74 yrs, with a preoperative BMI ranging from 18.4 to 36.1 kg/m2. Having realistic expectations of what is possible in prosthetic rehabilitation after hip disarticulation or hemipelvectomy is important both for the patient to make an informed decision and for the clinician to counsel them to facilitate realistic goal setting during the perioperative period. The patients who were prosthetic users experienced extended survival times compared with those who were unable to use a prosthetic limb. This is likely multifactorial as a large number of patients who were not fit with a prosthesis died before 6 mos postoperatively and had significant medical comorbidities that precluded fitting. Although the authors acknowledge that there is significant selection bias, the data show that most of the patients who are successfully fit with a prosthetic limb are likely to survive at least 5 yrs postoperatively. In addition to longer survival times, patients in this series used their prostheses, with most of the patients (61%) reporting that they used their prosthesis every day between 3 and 8 hrs. Although most patients required some form of gait aid, the authors feel that it is a realistic expectation to use a gait aid to optimize gait, balance, and stability. In this group, however, 50% (n = 9) of the patients were able to ambulate with no or a single gait aid. This allowed them one free hand, which has a positive impact on functional independence and mobility. There are several limitations to this study. First, the patients" baseline functional status, which may be associated with the likelihood of successful prosthetic use, was not taken into account because of the inconsistent documentation in the medical record. Likewise, the authors were unable to perform any functional scores based on the inconsistent documentation in the medical record and the time the prosthesis is worn is based on patient reporting. Because of the rarity of this surgery, the sample size of the study was small. With the www.ajpmr.com
surgical technique, outcomes, and postoperative management varying widely, it is difficult to study this patient population as one homogenous group. Likewise, the retrospective nature of this study puts obvious constraints on the data the authors are able to collect, making it difficult to compare outcomes among patients. Specifically, the authors" definition of successful use is based on patient reported times, which is flawed by recall bias and the authors" definition of successful use. The authors" definition of successful use is not a validated outcome measure. Selection bias exists in the survival of patients who are successful prosthetic users, and this is not meant to imply that patient survival is improved by successful prosthetic fitting. Longer life span gives greater longitudinal opportunity for prosthetic fitting and rehabilitation. It is also possible that with longer follow-up, patients who initially were not fit a prosthesis could become successful prosthetic users. Additionally, patients who have advancing malignancies often lack the performance status for prosthetic fitting, and the focus of their care is commonly directed elsewhere. In conclusion, prosthetic rehabilitation should be a viable option for patients who require hemipelvectomy- or hip disarticulationYlevel amputation. The range of characteristics and comorbidities of patients who were fit and who used a prosthesis is broad, and the presence of CAD is the only factor that potentially affects successful prosthetic fitting and use. Most patients that undergo successful prosthetic rehabilitation enjoy long periods of survival and wear their prosthesis.
REFERENCES 1. Taylor GW, Rogers WP: Hindquarter amputation: Experience with 18 cases. N Engl J Med 1953; 249:963Y9 2. Carter SR, Eastwood DM, Grimer RJ, et al: Hindquarter amputation for tumours of the musculoskeletal system. J Bone Joint Surg Br 1990;72:490Y3 3. Jaques DP, Coit DG, Brennan MF: Major amputation for advanced malignant melanoma. Surg Gynecol Obstet 1989;169:1Y6 4. Baliski CR, Schachar NS, McKinnon JG, et al: Hemipelvectomy: A changing perspective for a rare procedure. Can J Surg 2004;47:99Y103 5. Karakousis CP, Emrich LJ, Driscoll DL: Variants of hemipelvectomy and their complications. Am J Surg 1989;158:404Y8 6. Senchenkov A, Moran SL, Petty PM, et al: Predictors of complications and outcomes of external hemipelvectomy wounds: A count of 160 consecutive cases. Ann Surg Oncol 2008;15:355Y63
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7. Yari P, Digkstra P, Geertzen J: Functional outcome of hip disarticulation and hemipelvectomy: A cross-sectional national descriptive study in the Netherlands. Clin Rehabil 2008;22:1127Y33 8. Schnall B, Baum B, Andrews A: Gait characteristics of a soldier with a traumatic hip disarticulation. Phys Ther 2008;88:1568Y77 9. Unruh T, Fisher DF, Unruh TA, et al: Hip disarticulation: An 11-year experience. Arch Surg 1990;125:791Y3 10. Marshal C, Stansby G: Amputation and rehabilitation. Vasc Surg II 2010;28:284Y7 11. Fisher SV, Gullickson G: Energy cost of ambulation in health and disability: A literature review. Arch Phys Med Rehabil 1978;59:124Y33 12. Chin T, Oyabu H, Maeda Y, et al: Energy consumption during prosthetic walking and wheelchair locomo-
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tion by elderly hip disarticulation amputees. Am J Phys Med Rehabil 2009;88:399Y403 13. Nowroozi F, Salvanelli ML, Gerber LH: Energy expenditure in hip disarticulation and hemipelvectomy amputees. Am J Phys Med Rehabil 1983;64:300Y3 14. Senchenkov A, Moran SL, Petty PM, et al: Predictors of complications and outcomes of external hemipelvectomy wounds: Account of 160 consecutive cases. Ann Surg Oncol 2008;15:355Y63 15. Highsmith MJ, Kahle JT, Bongiorni DR, et al: Safety, energy efficiency, and cost efficacy of the C-Leg for transfemoral amputees: A review of the literature. Prosthet Orthot Int 2010;34:362Y77 16. Ludwigs E, Bellman M, Schmalz T, et al: Biomechanical differences between two exoprosthetic hip joint systems during level walking. Prosthet Orthot Int 2010;34:449Y60
Am. J. Phys. Med. Rehabil. & Vol. 94, No. 12, December 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
