Original Research
Predicting successful prosthetic rehabilitation in major lower-limb amputation patients: a 15-year retrospective cohort study

https://doi.org/10.1016/j.bjpt.2017.08.002Get rights and content

Highlights

  • Walking ability with a prosthetic limb is basic for major lower-limb amputees.

  • Walking capacity is indicative of successful prosthetic rehabilitation.

  • Male gender is an independent predictor of failure regardless of walking aid.

  • Transtibial amputation is independently related to success irrespective of aid.

  • Older age and multimorbidity can predict failure if walking aid is considered.

Abstract

Objective

To determine and compare specific factors that could be associated and predictive with successful prosthetic rehabilitation in major lower-limb amputations.

Methods

A 15-year long (2000–2014) retrospective observational cohort study was conducted. Two different criteria were used to define successful prosthetic rehabilitation: (1) the ability to walk at least 45 m, regardless of assistive devices; and (2) walking >45 m without other ambulatory aids than one cane (if required). Age, gender, comorbidities, cause and level of amputation, stump characteristics, ulcers in the preserved limb, and time between surgery and physical therapy were examined as predictors of successful prosthetic rehabilitation.

Results

A total of 169 patients (61.60 ± 15.9 years) were included. Regarding walking ability with or without walking aids, the presence of ulcers in the preserved limb was individually associated with failed prosthetic rehabilitation (p < 0.001), while being male (OR = 0.21; 95%CI = 0.06–0.80) and transtibial level of amputation (OR = 6.73; 95%CI = 1.92–23.64) were identified as independent predictors of failure and success, respectively. Regarding the criterion of successful rehabilitation, a shorter time until rehabilitation was individually associated with improved walking ability (p < 0.013), while failure could be predicted by comorbidities (OR = 0.48; 95%CI = 0.29–0.78) and age groups of 65–75 years old (OR = 0.19; 95%CI = 0.05–0.78) and over 75 years old (OR = 0.19; 95%CI = 0.04–0.91).

Conclusions

Regarding walking ability with or without walking aids, male gender and transtibial level of amputation are independently associated with failure and success respectively, whereas older age and comorbidities can predict failed prosthetic rehabilitation when assistive walking devices are considered. Future prospective cohort studies are needed to confirm these findings.

Introduction

Major lower-extremity amputations have a great impact on the psychological and physical well-being, the mobility and the social life of individuals. Close monitoring of lower-limb amputee patients in multidisciplinary rehabilitation units plays an important role in the recovery or maintenance of function, as well as in the return to daily work, social, and sports activities.1

The ability to walk with a prosthetic limb is of paramount importance for major lower-limb amputees. From a physical health perspective, being unable to walk after a lower limb amputation can lead to physical deterioration and comorbidities, and be detrimental to overall health.2, 3 As far as psychological and social aspects are concerned, the inability to walk may have a negative impact on the individual's participation in daily life activities, on their body image perception, and on their degree of social reintegration, seriously affecting their quality of life.4, 5 Furthermore, prosthetic rehabilitation and the identification of prognostic factors are of great interest not only from a social and sanitary point of view, but also from the financial perspective of the cost of prostheses and rehabilitation processes.6

It is therefore essential, for patients and health-care teams alike, to be able to predict a patient's ability to walk with a prosthesis, since any incorrect estimation may lead to supplying patients with prostheses they will not be able to use, an undesirable situation for both patients and health services.7 So far, studies on rehabilitation outcomes after lower-limb amputation have been performed on either relatively young patients or on the elderly. In other cases, research has been centered on specific causes or levels of amputation.6, 8, 9 An important limitation affecting previous studies is the lack of a standard definition for successful prosthetic rehabilitation, which has led many authors to set their own criteria.10, 11, 12, 13

The objective of this study was to analyze prosthetic rehabilitation and its effect on walking ability (according to two different definitions) in major lower-limb amputee patients treated in the outpatient service of a Prosthetics and Orthotics Rehabilitation Unit, and to determine and compare which specific factors are associated with walking ability and which are able to predict successful or failed prosthetic rehabilitation.

Section snippets

Design and participants

In this retrospective study we reviewed medical records from 335 major lower-limb amputees who took part in an outpatient rehabilitation program at the Prosthetics and Orthotics Rehabilitation Unit of the Virgen de las Nieves University Hospital of Granada (Spain), from January 1st 2000 to December 31st 2014. Prostheses for transfemoral amputations, in the case of patients between 60 and 65 years of age, were endoskeletal, with a resin- and carbon-fiber-laminated square socket, and fitted with

Results

A total of 169 patients met the inclusion criteria and were included in the study. The average age was 61.60 ± 15.9 years, ranging from 15 to 91 years, and 82.84% were male. The most frequent causes of amputation were vascular (70.41%), followed by traumatological, infective, and tumoral etiologies (18.93%, 4.73%, and 5.33%, respectively). Comorbidities and lower-limb characteristics by cause of amputation are displayed in Table 1. Patients with amputations of vascular etiology were significantly

Discussion

The present study examined and compared the independent association between a number of critical factors and successful prosthetic rehabilitation by examining walking ability at the time of discharge (for two definitions of walking ability). Our results indicate that gender and level of amputation were independently associated with walking ability with or without walking aids, whereas older age and comorbidities were able to predict failed prosthetic rehabilitation when the use of assistive

Conclusions

In summary, the results of this study showed that if walking ability is used as the only definition for successful prosthetic rehabilitation, the presence of ulcers in the preserved limb was individually related to failure, while male gender and transtibial level were independent predictors of failure and success respectively. However, when the use of assistive devices was taken into consideration, a shorter time to rehabilitation was individually associated with improved walking potential,

Conflicts of interest

The authors declare no conflicts of interest.

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