Summary Of Replies RE: elective bilateral amputations
steve williams
Description
Collection
Title:
Summary Of Replies RE: elective bilateral amputations
Creator:
steve williams
Date:
5/15/2012
Text:
Thanks to all that took the time to read the summary of my post Polio
patient considering bilateral amputations that he feels may improve his
quality of life. Many responders emphasized the importance psychological
counseling for persons dealing with an elective amputation decision, I
completely agree and will encourage this. Some responders seemed to have
missed some important points in the case presentation and my role in his
care. First, I am not giving him advice on which direction to go, I am
simply giving him information so that he can make his own decision, I feel
this is part of our role if we are caring clinicians. We all have the
right and responsibility to make our own informed health care decisions. In
defense of the surgeon that gave him a 50% success rate for a total knee
replacement on his right side, I have to agree this is probably accurate.
The muscle weakness and abnormal biomechanical forces across this knee
replacement will likely cause the joint to fail unless it protected with a
stance control KAFO like he currently wears on his left side. I have seen
this occur in many patients that have a hyperextension instability prior to
total knee replacement. Responder #6 suggested a stance control KAFO with
the addition of hip flexion assist, but I can not support encumbering him
with any device crossing his hip joint. At the suggestion of Responder # 8
I will also reinforce to DP the impact of proprioceptive loss from his
feet and the possibility of phantom pain, and the possibility continued
pain as a result of altered neural pain pathways that can occur in chronic
pain patients. DP also needs to understand that he will likely need to
continue to rely on external support and should consider wheelchair use
for some activities to preserve his shoulders. If DP does choose
amputation, it seems that the consensus is a well performed knee
disarticulation amputation is the best option, with use of microprocessor
knees. Responder #10 suggested that if his recources or insurance will
allow, bent knee prostheses could be constructed to give DP a sense of
what prosthetic usage would be like before he actually had amputations. I
will share that thought with him.
Thanks again for all the constructive input, and to Responder #1; I
think you need some anger management classes
Sincerely,
Steve Williams C.O.
Flint, MI
Responder 1.
I am very surprised after reading your question about patient D.P. that
you would even consider encouraging him toward any thoughts supporting limb
amputation as a solution for the problems he relates to you. There are so
many problems Mr. 'D.P. describes; the biggest being psychological. As a
professional yourself with a C.O. title I imagine obtained through a ABC
suggested academic curriculum certainly proves that O and P higher learning
has a long way to go. It definitely has left out many areas of medical
knowledge and considerations when teaching future clinicians about chronic
pain. The patient D.P. appears to have serious psychological depression
due to his chronic and acute a pain problems. He needs outpatient or
inpatient mental health treatment and should start by seeing his personal
physician for a referral. Orthotists or Prosthetists, Physical Therapists,
Occupational Therapists, and other Allied Health titled care providers are
not licensed to administering medical advice for your patient D.P.. Any
type of advice given to D.P. would be interpreted as practicing medicine
without a license. I am sure you mean well; but good intentions never
trumped over professional training. I suggest you stop providing any
prosthetic solutions that would require surgery as being an option. Since
you sincerely seem to want help from your peer group my personal suggestion
is for you to take some post graduate coursework in chronic pain
management. In addition spend more time in any college or university
medical library to learn more about severe clinical depression. Today's
prosthetics advancements none are not even close to justifying any
amputation for D.P..
Responder 2.
I read with interest your notes about your patient. I have a bilateral AK
amputee that walks with to canes for support for the past 45 years. He has
had both shoulders done in the past because of the extra forces transmitted
into the shoulders using the canes for weight bearing. I don't know if you
could get a bilateral AK to walk without some external support. If you can
find a doctor to do the surgery for him I would consider doing the Knee
Disarticulations and retain the patella placed at the end of the femur..
That way when he is not in prosthesis he can still use the ends of the
stumps for end bearing support on chairs or other furniture to move around
on.
That will be a lot for him to consider but good luck with this patient.
Responder 3.
Personally, I would never recommend that somebody have another amputation
because if he is not successful with prosthetics and you recommended it..
Respoder 4.
He should not consider having bilat ak amps. He will be far less functional
and will go off his feet sooner and into a wheelchair.
He needs to be managed orthotically as best as possible, consider
stance-phase KAFOs.
Responder 5.
With the amputations being bilateral there would be no down tick on going
the disarticulation route.
If he gains the ability to end weight bear on both limbs that would be
huge. I would suggest one limb at a time, normally.
Though current his condition may not give an advantage of PT and mastering
the first prosthesis before a second surgery.
I personally chose amputation over a limb that didn't work and caused pain.
Though I ran over my leg with a mover and dealt with
surgeries for 13 years and finally chose a transtibial level amputation.I
have a post polio pt that chose amputation at 60. BK also, and doing
great.Unless he has outstanding insurance or finances, the Power knee and
Proprio foot for two legs will easily reach $150,000.
Two MPK knees and a good Dynamic foot with torsion should suit him well if
he is active.
Responder 6.
I'd recommend he trust that the Orthopedic surgeon can get better results
than the 50% estimated outcome he's covering his professional ass with.
Add another stance control KAFO to the right, with some type of hip flexion
assist and recurvatum control, if the surgery goes well. Amputation, as a
last resort, can result in phantom pain and other issues. Without hip
flexor strength, I don't see how AK or TK would offer a smoother gait with
less dependence on crutches.
Responder 7.
Great write up! I'll address questions 3 and 4.
Bilateral knee disarticulation, if performed well are superior to b TF due
to end bearing capability, longer leverage, intact musculature, ability to
suspend anatomically, and perhaps most importantly, the ability to provide
sockets with lower trimlines.
Ideally, the condyles should be shaved, the femur should be well padded,
and the patella should be removed or sutured in place.
If soft tissue coverage is limited due to atrophy, at least one knee
disarticulation will provide more comfort around the proximal brims as the
sockets won't be the same height, thus reducing the pinching effect of two
TF sockets. The kd in this case would be harder to get comfortable but with
a custom liner would be worth it.
Kd's would also be ideal if the patient ends up not using prostheses, which
is likely considering the poor prognoses of b TF/kd amputation levels and
px ambulation. These would improve sitting balance and allow limited end
bearing unlike b tf's.
Good physical therapy and progressive height increase of shorties should
proceed the introduction of knees. I prefer microprocessor knees because of
stumble recovery features such as geniums, c-legs, or plié 2.0's. Manual
locking knees are useful if the height of the prostheses is enough to make
wheelchair ambulation cumbersome.
House legs are an option as well and may be an option as the patients only
prostheses or additional prostheses. For kd's, these are made with sock
interface, pelite liners, and use anatomical suspension. They are short,
lightweight, and are easy to don and doff. I have an article I am writing
regarding house legs that I can send if interested.
Hope this information helps!
Please let me know if you have any other questions!
Responder 8.
In 40 plus years as a CP, I have been involved with several elective
amputations, working in a team situation affiliated at consecutive times
with
the Medical schools at Northwestern; Stanford and UC San Francisco. I have
observed many of these cases go very wrong. Patients have
come completely apart psychologically and socially. Not all did but a
significant number did.
My first suggestion is for someone to get the patient to enlist the
help of a good Psychotherapist. Not for just one touch and go assessment
but for a meaningful series of individual therapy sessions.
Not that the idea of bilateral amputation is an illogical option but that
there are obviously many strong emotional currents in the patients life.
He has delt with a terrible affliction and pain of a certain kind over 48
or so years. That is a lot of emotionally charged living and adapting
experience.
This will be quite a different life journey as an amputee.
There may be deep thoughts/feelings that you do not know about. The
patient may not even be totally aware of them.
It has been my experience that the candidate for amputation should have
professional assistance going through this baggage before an irreversible
procedure is done. Who knows what his true expectations are?
Considerations: What is his support system?
What are the thoughts of
his family/Loved ones?
What is the
pain/biomechanical status of that Left Femur with the old compound fx?
One of his hopes is to
become pain free. We all know about the mystery of Phantom Pain. That
should be firmly
addressed. Specially since
those pain pathways have been so frequently activated through the years.
The pain may not go away.
Why has he not employed a
wheelchair? Does this indicate a personal drive or a denial?
Amputation is ablative and
the Somatic Image is forever changed. He has evidenced a strong drive to be
ambulating and walking
like others, will he be
able to accept this sudden new major deformity.
There is little doubt that
crutch use has compromised the shoulder joints. Being on bi-lateral above
the Knee prostheses does not free one
from the need for crutches.
It will also demand at times the use of a wheelchair.
He appears to believe that
artificial limbs are 'powered' and can ambulate for him.
Proprioceptive sense - I
believe, he currently has sensation in his feet. This too will be forever
gone.
With compliment to you for seeking peer consultation on behalf of
your patient I wish you both good result.
P.S. Your case presentation is excellent.
Responder 9.
All double amputees in my experience, through knee or trans-femoral, or
a mix of both, still rely on crutches or sticks most of the time. I'm
not sure if elective amputation will relieve his knees or shoulders.
Also, no matter how 'smart' the prosthetic knee units, they will not
'walk' for him - I'm mentioning this in regard to the apparent reduced
neurological function. If he has joint contractures, this will affect
the prosthetist's ability to bench-align, and ultimitely dynamically
align the prostheses.
A complicated one. Good luck.
Responder 10.
Wow, scares the crap out of me. I have a hard time believing that he would
not still be dependent upon canes/crutches. If he were to proceed I would
absolutely vote for knee disarticulations over transfemoral amputations. I
would suggest that prior to amputations the gentleman be fitted with
bilateral bent knee prostheses and allowed to attempt ambulation in the
parallel bars so that he can have a taste of what prosthetic usage would be
like.
patient considering bilateral amputations that he feels may improve his
quality of life. Many responders emphasized the importance psychological
counseling for persons dealing with an elective amputation decision, I
completely agree and will encourage this. Some responders seemed to have
missed some important points in the case presentation and my role in his
care. First, I am not giving him advice on which direction to go, I am
simply giving him information so that he can make his own decision, I feel
this is part of our role if we are caring clinicians. We all have the
right and responsibility to make our own informed health care decisions. In
defense of the surgeon that gave him a 50% success rate for a total knee
replacement on his right side, I have to agree this is probably accurate.
The muscle weakness and abnormal biomechanical forces across this knee
replacement will likely cause the joint to fail unless it protected with a
stance control KAFO like he currently wears on his left side. I have seen
this occur in many patients that have a hyperextension instability prior to
total knee replacement. Responder #6 suggested a stance control KAFO with
the addition of hip flexion assist, but I can not support encumbering him
with any device crossing his hip joint. At the suggestion of Responder # 8
I will also reinforce to DP the impact of proprioceptive loss from his
feet and the possibility of phantom pain, and the possibility continued
pain as a result of altered neural pain pathways that can occur in chronic
pain patients. DP also needs to understand that he will likely need to
continue to rely on external support and should consider wheelchair use
for some activities to preserve his shoulders. If DP does choose
amputation, it seems that the consensus is a well performed knee
disarticulation amputation is the best option, with use of microprocessor
knees. Responder #10 suggested that if his recources or insurance will
allow, bent knee prostheses could be constructed to give DP a sense of
what prosthetic usage would be like before he actually had amputations. I
will share that thought with him.
Thanks again for all the constructive input, and to Responder #1; I
think you need some anger management classes
Sincerely,
Steve Williams C.O.
Flint, MI
Responder 1.
I am very surprised after reading your question about patient D.P. that
you would even consider encouraging him toward any thoughts supporting limb
amputation as a solution for the problems he relates to you. There are so
many problems Mr. 'D.P. describes; the biggest being psychological. As a
professional yourself with a C.O. title I imagine obtained through a ABC
suggested academic curriculum certainly proves that O and P higher learning
has a long way to go. It definitely has left out many areas of medical
knowledge and considerations when teaching future clinicians about chronic
pain. The patient D.P. appears to have serious psychological depression
due to his chronic and acute a pain problems. He needs outpatient or
inpatient mental health treatment and should start by seeing his personal
physician for a referral. Orthotists or Prosthetists, Physical Therapists,
Occupational Therapists, and other Allied Health titled care providers are
not licensed to administering medical advice for your patient D.P.. Any
type of advice given to D.P. would be interpreted as practicing medicine
without a license. I am sure you mean well; but good intentions never
trumped over professional training. I suggest you stop providing any
prosthetic solutions that would require surgery as being an option. Since
you sincerely seem to want help from your peer group my personal suggestion
is for you to take some post graduate coursework in chronic pain
management. In addition spend more time in any college or university
medical library to learn more about severe clinical depression. Today's
prosthetics advancements none are not even close to justifying any
amputation for D.P..
Responder 2.
I read with interest your notes about your patient. I have a bilateral AK
amputee that walks with to canes for support for the past 45 years. He has
had both shoulders done in the past because of the extra forces transmitted
into the shoulders using the canes for weight bearing. I don't know if you
could get a bilateral AK to walk without some external support. If you can
find a doctor to do the surgery for him I would consider doing the Knee
Disarticulations and retain the patella placed at the end of the femur..
That way when he is not in prosthesis he can still use the ends of the
stumps for end bearing support on chairs or other furniture to move around
on.
That will be a lot for him to consider but good luck with this patient.
Responder 3.
Personally, I would never recommend that somebody have another amputation
because if he is not successful with prosthetics and you recommended it..
Respoder 4.
He should not consider having bilat ak amps. He will be far less functional
and will go off his feet sooner and into a wheelchair.
He needs to be managed orthotically as best as possible, consider
stance-phase KAFOs.
Responder 5.
With the amputations being bilateral there would be no down tick on going
the disarticulation route.
If he gains the ability to end weight bear on both limbs that would be
huge. I would suggest one limb at a time, normally.
Though current his condition may not give an advantage of PT and mastering
the first prosthesis before a second surgery.
I personally chose amputation over a limb that didn't work and caused pain.
Though I ran over my leg with a mover and dealt with
surgeries for 13 years and finally chose a transtibial level amputation.I
have a post polio pt that chose amputation at 60. BK also, and doing
great.Unless he has outstanding insurance or finances, the Power knee and
Proprio foot for two legs will easily reach $150,000.
Two MPK knees and a good Dynamic foot with torsion should suit him well if
he is active.
Responder 6.
I'd recommend he trust that the Orthopedic surgeon can get better results
than the 50% estimated outcome he's covering his professional ass with.
Add another stance control KAFO to the right, with some type of hip flexion
assist and recurvatum control, if the surgery goes well. Amputation, as a
last resort, can result in phantom pain and other issues. Without hip
flexor strength, I don't see how AK or TK would offer a smoother gait with
less dependence on crutches.
Responder 7.
Great write up! I'll address questions 3 and 4.
Bilateral knee disarticulation, if performed well are superior to b TF due
to end bearing capability, longer leverage, intact musculature, ability to
suspend anatomically, and perhaps most importantly, the ability to provide
sockets with lower trimlines.
Ideally, the condyles should be shaved, the femur should be well padded,
and the patella should be removed or sutured in place.
If soft tissue coverage is limited due to atrophy, at least one knee
disarticulation will provide more comfort around the proximal brims as the
sockets won't be the same height, thus reducing the pinching effect of two
TF sockets. The kd in this case would be harder to get comfortable but with
a custom liner would be worth it.
Kd's would also be ideal if the patient ends up not using prostheses, which
is likely considering the poor prognoses of b TF/kd amputation levels and
px ambulation. These would improve sitting balance and allow limited end
bearing unlike b tf's.
Good physical therapy and progressive height increase of shorties should
proceed the introduction of knees. I prefer microprocessor knees because of
stumble recovery features such as geniums, c-legs, or plié 2.0's. Manual
locking knees are useful if the height of the prostheses is enough to make
wheelchair ambulation cumbersome.
House legs are an option as well and may be an option as the patients only
prostheses or additional prostheses. For kd's, these are made with sock
interface, pelite liners, and use anatomical suspension. They are short,
lightweight, and are easy to don and doff. I have an article I am writing
regarding house legs that I can send if interested.
Hope this information helps!
Please let me know if you have any other questions!
Responder 8.
In 40 plus years as a CP, I have been involved with several elective
amputations, working in a team situation affiliated at consecutive times
with
the Medical schools at Northwestern; Stanford and UC San Francisco. I have
observed many of these cases go very wrong. Patients have
come completely apart psychologically and socially. Not all did but a
significant number did.
My first suggestion is for someone to get the patient to enlist the
help of a good Psychotherapist. Not for just one touch and go assessment
but for a meaningful series of individual therapy sessions.
Not that the idea of bilateral amputation is an illogical option but that
there are obviously many strong emotional currents in the patients life.
He has delt with a terrible affliction and pain of a certain kind over 48
or so years. That is a lot of emotionally charged living and adapting
experience.
This will be quite a different life journey as an amputee.
There may be deep thoughts/feelings that you do not know about. The
patient may not even be totally aware of them.
It has been my experience that the candidate for amputation should have
professional assistance going through this baggage before an irreversible
procedure is done. Who knows what his true expectations are?
Considerations: What is his support system?
What are the thoughts of
his family/Loved ones?
What is the
pain/biomechanical status of that Left Femur with the old compound fx?
One of his hopes is to
become pain free. We all know about the mystery of Phantom Pain. That
should be firmly
addressed. Specially since
those pain pathways have been so frequently activated through the years.
The pain may not go away.
Why has he not employed a
wheelchair? Does this indicate a personal drive or a denial?
Amputation is ablative and
the Somatic Image is forever changed. He has evidenced a strong drive to be
ambulating and walking
like others, will he be
able to accept this sudden new major deformity.
There is little doubt that
crutch use has compromised the shoulder joints. Being on bi-lateral above
the Knee prostheses does not free one
from the need for crutches.
It will also demand at times the use of a wheelchair.
He appears to believe that
artificial limbs are 'powered' and can ambulate for him.
Proprioceptive sense - I
believe, he currently has sensation in his feet. This too will be forever
gone.
With compliment to you for seeking peer consultation on behalf of
your patient I wish you both good result.
P.S. Your case presentation is excellent.
Responder 9.
All double amputees in my experience, through knee or trans-femoral, or
a mix of both, still rely on crutches or sticks most of the time. I'm
not sure if elective amputation will relieve his knees or shoulders.
Also, no matter how 'smart' the prosthetic knee units, they will not
'walk' for him - I'm mentioning this in regard to the apparent reduced
neurological function. If he has joint contractures, this will affect
the prosthetist's ability to bench-align, and ultimitely dynamically
align the prostheses.
A complicated one. Good luck.
Responder 10.
Wow, scares the crap out of me. I have a hard time believing that he would
not still be dependent upon canes/crutches. If he were to proceed I would
absolutely vote for knee disarticulations over transfemoral amputations. I
would suggest that prior to amputations the gentleman be fitted with
bilateral bent knee prostheses and allowed to attempt ambulation in the
parallel bars so that he can have a taste of what prosthetic usage would be
like.
Citation
steve williams, “Summary Of Replies RE: elective bilateral amputations,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 25, 2024, https://library.drfop.org/items/show/233681.
