Limb Loss Statistics
- There are nearly 2 million people living with limb loss in the United States.
- Approximately 185,000 amputations occur in the United States each year.
- Among those living with limb loss, the main causes are vascular disease (54%) – including diabetes and peripheral arterial disease – trauma (45%) and cancer (less than 2%).
An amputation is a life-altering experience. The psychological and emotional effects of losing a limb can be extremely significant, not only for the injured person but also for those close to them such as their family, friends and colleagues. The most important factor in moving forward is to accept the limb loss with a positive attitude. Regardless of your age or cause of amputation, new concerns and questions may be flooding your mind. Keeping your communication channels open, setting up your rehabilitation goals early and understanding the process of getting fitted with a prosthetic limb goes a long way towards successful prosthetic rehabilitation.
Various levels of amputation
Lower Limb Prosthetics
The Rehabilitation Process
Your treatment team will decide when you can start with intensive rehabilitation based on how your recovery is going. During your rehabilitation process, you’ll be fit with a prosthesis tailored to your specific needs, and supported by a rehabilitation team that could include doctors, physical and occupational therapists, a prosthetist and nursing staff. These professionals are there to support you and to ensure that you are well prepared. During rehabilitation you will learn how to properly care for your residual limb, as well as the rest of your body.
Before you can wear prosthesis, your residual limb must be healed and have attained the proper shape. This means that all fluids that accumulated due to the operation have been removed through compression therapy and that the residual limb edema has subsided.
Once your residual limb has been properly formed and can bear weight, you may be fitted with an early or interim prosthesis. Then you’ll begin to practice using your prosthetic leg. At first you’ll learn how to put the prosthesis on and take it off as well as take care of it. Later, you’ll learn how to walk with the prosthesis, which is known as gait training.
With the aid of pressure applied to the residual limb over a large surface area, swelling (edema) of the residual limb can be reduced and the residual limb can be formed for the future prosthetic fitting. This compression of the residual limb contributes to being able to do your prosthetic fitting as soon as possible and to making it easier to adjust your prosthesis. In addition, compression aids circulation in the residual limb. This reduces the amount of pain and results in improved healing of the scar.
Various techniques are used for compression therapy: The residual limb may be wrapped with an elastic bandage, or compression socks or a prefabricated silicone liner may be worn.
Compression socks can also be used instead of bandages. The socks are also elastic and available in various sizes. Custom sizes can also be made if the standard sizes do not fit you. Like elastic bandages, the socks must be washed daily and laid out to dry so that they do not lose their elasticity.
The advantage of residual limb socks is that they are easy to put on and take off. You can use suspenders attached to a hip belt to hold the socks up. Or you can use a pelvic band which is fastened permanently to the sock.
Immediate and Early Fitting
In some cases, an initial prosthesis may be fit about 10 days to two weeks after a lower limb amputation. With such an immediate fitting, some weight can be applied to the residual limb early on and the first walking exercises can be started. However, this type of prosthesis is not suited to all amputations. Your doctor, physiotherapist, and prosthetist will decide together if this is an option for you. If such an early fitting is possible for you, you will receive an interim prosthesis, which is designed for initial walking and standing exercises.
Adjustable Postoperative Preparatory Prosthetic System for Transtibial Amputees
- Prepares Patient during early and preparatory stages of rehabilitation
- Provides easy access to bandages and dressings for attentive wound care
- Adjustable designs accommodate compression and swelling of wound area
- Accepts elastic wrap (ACE) or shrinkers, to reduce swelling
- Permits measured and controlled weight bearing
- Allows patient to begin immediate post-operative rehabilitation and early ambulation
- Helps build patient tolerance for permanent socket
- Ventilated system helps enhance postoperative healing
- Helps maintain correct extension alignment
- Shapes and prepares the residual limb for a definitive prosthesis
The Prosthetic Fitting
After your amputation you should be fitted with the appropriate prosthesis for your needs. Things that influence selection of a suitable prosthesis for you include your level of physical fitness and health, the amputation level, the demands you place on the prosthesis and your professional and private environment.
Your prosthesis will help restore a large part of your mobility and contribute to your ability to manage your life without help from others. By wearing your prosthesis, you’ll help avoid postural and balance problems that can arise due to the missing weight of your amputated leg. In addition, you also avoid excessive strain and long-term damage to your sound leg by wearing your prosthesis.
Once your residual limb has healed and you are in good health again, the process of fitting your final prosthesis will begin. Even before this stage, however, your prosthetist will likely meet with you in order to better understand your needs and wishes. In addition, he or she will assess your residual limb shortly after the amputation and find out if an interim prosthesis is appropriate for you.
An interim prosthesis helps you to perform standing and walking exercises early on. In addition, your prosthetist gets to know your individual ideas and needs, which provides them with important information about which prosthetic components are suited to you. They will then fit the prosthetic socket, and adjust the prosthesis to your unique needs.
After the prosthetic components for you have been determined, the prosthetic socket will be made and then finally aligned to best fit your walking style and ability. The proper fit of the socket is extremely important-just like a shoe, if it doesn’t fit well you won’t be able to walk correctly.
Just as important is the alignment of the prosthesis, which can determine whether you walk with a correct, efficient, and comfortable gait.
You may undergo several trial fittings to make sure the socket and alignment are correct. Be patient with the process-your prosthetist will be working hard to make sure everything works as well as possible.
The functionality provided by prosthetic components such as prosthetic feet and prosthetic knee joints can vary a lot. This means that it’s important to select the right prosthetic components. These components and targeted training in how to use them are decisive factors in allowing you to achieve your individual therapy goals.
Training to use your prosthesis
The goal of rehabilitation training with a physical therapist is to help you gain as much mobility and independence as possible.
Your therapist will help you learn how to use your prosthesis properly. This includes putting the prosthesis on and taking it off, getting up and sitting down, and balance and gait training.
Putting on and taking off your prosthesis
Correctly putting your prosthesis on (donning) and taking it off (doffing) by yourself is an important everyday task. Your family or friends may need to help you initially, but the goal is for you to ultimately be able to do this on your own.
There are many different ways to put your prosthesis depending on the type of prosthesis you have and the condition of your residual limb. Your therapist will show you which ones are suitable for you.
You have already learnt to care for your residual limb, but your prosthesis must also be cared for and cleaned every day, too.
Wipe the inside of the socket with a moist cloth to remove sweat residue and skin particles.
Keeping the contact surface with the skin clean helps to avoid skin irritation. If you wear a liner, please care for it daily according to the user manual.
It is humanly impossible to completely reproduce the complex workings of the human foot and ankle. Ideally a prosthetic foot should be light because its weight is added to the rest of the leg prosthesis. If the foot is too heavy, the suspension system may be affected and with it the connection to the socket and your limb.
A good prosthetic foot should also be strong, as it will be taking on huge force and torque as you walk and run. Feet must also be small enough to fit within a foot shell, a cosmetic covering for the prosthetic foot, and thus fit within a shoe. Being light, strong, and small, and yet functional and durable is the challenge.
Early designs for prosthetic feet were often a solid piece of wood. A similar design, the SACH (solid-ankle-cushioned-heel) is still in use because of its sturdy function, especially useful for individuals with lower activity levels. A SACH foot typically has a rigid inner structure (wood or plastic) surrounded by a compressible foam cosmetic shell.
Today’s more sophisticated feet, which add more functions, are secured inside a cosmetic shell. Most people never see their prosthetic foot without this exterior shell. The cosmetic shell, which stretches around the foot prosthesis and is held in place, serves two purposes:It makes your foot prosthesis look like an anatomical foot and it fills the space in your shoe.
What’s inside the shell can vary dramatically. Prosthetic feet are designed to meet the needs that fit your lifestyle and activity level. Here are some factors to consider.
The materials in a prosthetic foot differ by activity level. Wood, plastic and foam are usually found in feet designed for individuals who have low activity levels and require stability. Carbon fiber feet meet the functional needs for shock absorption and energy efficiency, and are lightweight as well.
A prosthetic foot has to feel good for you to meet your activity goals. Comfort allows you to be more active, and the function of your prosthetic foot directly affects comfort.
Prosthetic feet are designed to mimic a human foot at a specific activity level. For people who cannot walk, the function is largely cosmetic. For those who are most active, a prosthetic foot must mimic a normal foot during the act of walking. It must act as a shock absorber as you strike your heel to the ground, adapt to uneven terrain, provide a smooth rollover from heel to toe, and provide a rigid lever for propelling forward when you finish your step (“toe-off”).
Some prosthetic feet are designed to mimic the ankle, which allows the foot to move in multiple planes. Multi-axial capability in a foot allows you to raise and lower the forefoot; move the forefoot to the left and right; and roll the foot slightly to the inside and to the outside. Multi-axial motion is needed to walk comfortably and confidently on uneven ground, when your foot must adapt to whatever it encounters.
A foot made with carbon fiber for energy storage literally gives you a spring in your step. The carbon fiber acts as a spring, compressing as you apply weight and propelling you forward as your foot rolls, returning energy to your step as the spring releases. Some prostheses have one spring in the heel and a second spring in the forefoot: just what you need for walking at various speeds, running, climbing hills or descending stairs with a secure, confident stride. With carbon fiber, the longer the spring, the more energy it can store and the more responsive the foot will be.
Prosthetic knees are designed for people who have amputations above their knee, and thus lack the knee joint and lower leg. In reality, you need more than just the knee.
In general, there are two kinds of prosthetic knees: mechanical and microprocessor. Mechanical knees all use a mechanical hinge to replace your knee joint. How quickly or easily the hinge swings is often controlled by friction, some type of hydraulic system or a locking mechanism.
Microprocessors, on the other hand, provide a more sophisticated method of control to a prosthetic knee. These more complex knee joints are designed to help you walk with a much more stable and efficient gait that more closely resembles a natural walking pattern.
After amputation, you want a prosthetic leg system that allows you to resume the activities that are important to you as an individual. The more active you want to be, the more attention you should give to suspension, the method of connecting a prosthesis to your residual limb.
You want your suspension system to:
- Match your activity level and keep your limb in good health
- Ensure your comfort
- Provide security with every step
- Be aware of the trade-off between convenience and performance. If you insist on speed when putting on and taking off your prosthesis (“donning and doffing”), you will have to sacrifice some prosthetic control.
A sleeve creates a seal around the top edge of the socket, then a pump and exhaust valve remove virtually all air between the socket and the liner as you wear them. The system regulates the vacuum level within a defined range. Vacuum enhances how well your socket adheres to your limb, which reduces shear, regulates residual-limb volume changes and improves circulation in your limb.
In this case, you use a padded liner with a pin at the end. The pin is inserted into a shuttle lock built into the bottom of your socket, the only connection point. One variation for above-knee prostheses, called a lanyard system, uses a strap to pull the liner into the socket. The lanyard also connects the socket to the liner near the top, which slightly reduces rotation and shear.
A suction system consists of a soft liner, a one-way valve and a sealing sleeve. Inserting your liner-covered limb into the socket and applying body weight as you stand expels excess air through the valve. Suction provides even adhesion to the entire interior surface of the socket for security, stability and reduced friction and shear.
Each suspension system has strengths and weaknesses. Here are some of the factors to think about, and how the systems compare:
Shuttle-lock systems, best suited for older amputees and patients with reduced mobility are mainly for amputees with a mobility or activity level of 1 or 2. Suction can be used for all activity levels. Vacuum is appropriate for activity levels 2 to 4, including the most active amputees.
Vacuum and suction both require a total-surface-bearing socket, which distributes even pressure on your residual limb throughout every square inch of the socket’s surface area. That pressure relief alone makes these suspension systems more comfortable. The superior connection with vacuum, allowing minimal movement of the limb in the socket, makes it the most comfortable. Suction ranks second in linkage. Shuttle-lock systems offer the least control of forces and allow the most movement and rubbing in the socket, the cause of calluses, blisters and sores.
Vacuum offers the highest performance for maximum confidence and prosthetic control, which promotes a smoother, more symmetrical gait that uses less energy. Shuttle-lock systems fulfill the needs of users with a low activity level, but users with a high activity level probably would notice a lack of control and security.
Because a pump can generate five times the air-pressure differential of suction, vacuum scores highest here. Some patients say the sense of control is almost like having their leg back. Shuttle-lock systems have the lowest level of proprioception.
Vacuum excels at limb health. Vacuum actually increases hydration and blood flow, so open wounds can heal even while you continue wearing the prosthesis. In addition, vacuum helps regulate volume changes in your leg as tissues shrink or expand during the day. As a result, your limb retains its size and shape all day, which helps to maintain a consistent fit.
In contrast, other suspension systems constrict blood vessels, causing leg volume to drop an average of 10 to 14 percent as fluids are squeezed out of your leg throughout the day. A prosthesis that fits tightly in the morning will loosen as the day progresses. Too much movement within a socket can cause pain, blistering and sores. Movement in and out of the socket can lead to repetitive impact forces as the socket slides during while you’re lifting your leg to take a step and pounds it back onto your limb when you put weight on your foot again.
Shuttle-lock systems are the easiest to put on and take off. However, users of these systems may need to add or remove prosthetic socks up to three or four times a day to compensate for changes in leg volume.
With vacuum and suction, your daily routine includes rolling on a liner and shorter prosthetic sock; sliding into the socket; rubbing lotion on your leg at the top of the liner to prevent dragging on the skin; and rolling up the sleeve attached to the socket’s perimeter to create a seal with the liner.
Because there’s no need to modify the fit throughout the day, active vacuum may save on total time. Either way, most users say the morning regimen is worth it to enjoy the all-day benefits
The liner is a protective cover made of a flexible, cushioning material. Worn over your residual limb, it reduces movement and chafing between the skin and the socket. Liners are designed with specific characteristics to work with different suspension systems.
Selecting the right liner helps ensure that your prosthesis fits well and is comfortable to wear. Liners are available with a few special features. There are antibacterial additives, textile outer layers for easier application, anatomical shaping, non-stick treatments, variable thicknesses to accommodate sensitive skin, pre-flexed knees, as well as tough tear- and puncture-resistant formulas.
Custom liners can be manufactured if you need a personalized fit to accommodate a unique shape or unusual length or thickness.
Sealing sleeves are needed for vacuum and suction suspension. They create a seal around the socket’s top edge. After donning a liner (which acts as a second skin) and a prosthetic sock, you insert your residual limb into the socket. The liner extends beyond the sock, so rolling up the sleeve attached to the outside of the socket creates an airtight seal where the sleeve and liner overlap. The prosthesis stays attached with pump-activated vacuum or valve-assisted suction.
Sleeves are made from a variety of elastic materials to maintain a seal. The ideal sleeve offers a good balance of durability and flexibility. A thick sleeve is durable but may tend to bunch up and interfere with the knee’s range of motion. A thin sleeve has plenty of flex but may not last long. Your activity largely determines how long a sleeve will last before it stretches out or develops holes, reducing its ability to maintain suspension. Sleeves often include a protective gaiter to extend longevity and sealing ability.
Sleeve features include, a non-stick coating, a textile outer layer for abrasion resistance, and pre-flexed knees for easier bending and wrinkle reduction.