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In recent years, numerous studies have examined the relative bone density values of residual limbs following amputation, comparing these against the values of the sound-side limbs or those observed in matched controls. With only rare, individual exceptions, the density values of the amputated limbs are consistently below those of controls.

Does Amputation Level Matter?

The answer to this question depends on who you ask. The observations of Smith et al. suggest that amputation level has no effect on BMD values at either the femoral neck or the total proximal femur.The observations from other samples suggest that amputation level does matter and that the residual limb of individuals with transfemoral amputations have markedly lower BMD (bone mineral density) than the residual limbs of individuals with transtibial amputations. Leclerq et al., in their analysis of 99 lower-limb amputees, found that hip BMD was lower in the affected side than it was in the intact limbs and the percentage difference in BMD between limbs was significantly greater for subjects with transfemoral amputations than it was for transtibial subjects.In the most carefully controlled trial, Sherk et al. compared the BMD values of 14 amputee subjects. DXA bonedensity values at the femoral neck and found fairly substantial BMD compromise within the transfemoral group.

Male vs. Female?

It is commonly recognized that women are at greater risk for osteoporosis than men. There has been only one published report with data by gender and the findings are quite pronounced.  Smith et al. found that male DXA examination of the lumbar spine were within normal limits for bone mineral density, but the females were soundly in the osteopenic category irrespective of the BMD of their affected femurs. Similarly, the observed BMD values of the sound-side femur in the two groups were markedly different.  The male subgroup reported normal BMD values and that of the female subgroup was identified as having osteopenia in the soundside femur. Thus, the elevated risk of osteoporosis among able-bodied women appears to carry over into those with amputations, with women demonstrating significantly lower BMD values than their male counterparts at all tested bony locations, with particularly concerning values at the affected femur.

Does Activity Level Impact BMD?

The research by Leclercq et al. suggests that those subjects who wear a prosthesis at least six hours a day have significantly greater BMD than those who wore their prosthesis less than that.  The data of Yazicioglu et al. seem to support this premise.

In Summary

The greatest concern with decreased BMD values is elevated fracture risk. The likelihood of a fracture at a location of declining SD roughly doubles. So for the amputee in the research of Smith et al., 48 percent carry a two-fold risk of hip fracture, and 33 percent face at least a four-fold risk of hip fracture. For the older amputee like that examined in Kulkarni et al.,  the patients carried a fourfold risk of femoral neck fracture.

Younger, more active amputees seemed to have the largest fracture risk, suggesting one of the possible reasons for the high number of fractures among transtibial amputees. Second, the possible influence of the prosthetic socket as either a causative or protective agent can be reasonably questioned.  The current role of the prosthesis in promoting or guarding against femur fracture is uncertain.

Compromise to bone density appears to be considerably greater among females and those with transfemoral amputation levels and is aggravated with increasing time since amputation, reduced activity levels, and general aging. While the published observations regarding BMD levels would suggest sizeable elevations in ultimate fracture risks, the older literature fails to support large fracture rates in this population, and there is no recent literature to confirm or refute actual fracture rates in the past few decades. In the absence of such literature, it becomes the responsibility of treating clinicians to be mindful of the relative BMD compromises their patients face and plan their treatment strategies accordingly.

Adapted from an article by Phil Stevens, MEd, CPO with Hanger Prosthetics & Orthotics, Salt Lake City, Utah.

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I recently attended a monthly meeting of my local CMSA Chapter.  The sponsor for the meeting was Snell Orthotics and Prosthetics of Little Rock who had invited BiOM to come and speak to us about advanced prosthetics.  John Braddock of BiOM and a patient model showed us an example with the iWalk PowerFoot.  During the presentation, John shared with us that select service members are participating in a program that will allow them to return to active duty.

The Tactical Defense Institute (TDI) in West Union, Ohio, is where the participants went to attend this pilot program designed to help learn how to better handle firearms while using these advanced “bionic” limbs.  The U.S. Departments of Defense (DoD) and Veterans Affairs (VA) have funded the development of advanced prosthetic devices that can help amputee veterans who want to return to active duty achieve this goal. However, to make optimal use of these devices users must be well trained in a high-stakes environment. TDI is just the place for that training due to its rural, 186-acre setting complete with seven shooting ranges, three live-fire houses, and more.  The tactical skills training helps participants overcome feelings of vulnerability.  The first event at TDI event was so successful that an official firearms course for individuals with amputations will take place next May.

Related articles

• “Bionic” limbs in development at Vanderbilt University (vp-medical.com)
• PowerFoot: The Next Step (oandp.com)

Professor Michael Goldfarb, right, with amputee Craig Hutto who is wearing the new bionic leg developed at Vanderbilt (Photo: John Russell, Vanderbilt University)

A project at Vanderbilt University is building  a “smart” prosthesis that gives amputees a more natural gait.  Michael Goldfarb, a professor of mechanical engineering, at Vanderbilt’s Center for Intelligent Mechatronics, has been working for several years with Craig Hutto, who lost his leg in 2005 when he was attacked by a shark. Hutto, who is a lab assistant, has offered valuable input on what works and what doesn’t work for amputees. That has gone a long way towards making the bionic leg comfortable and workable in real-world conditions.

As a life care planner specializing in amputation injury, I always follow new technologies and refinements in prosthetics.  Lately, there have been an extraordinary number of improvements, both from the perspective of making prostheses safer as well as making them perform more “naturally”.

Stumble recovery is a feature of many of the “bionic” type lower extremity limbs on the market today, as well as on the one featured in this article by GizMag.  This is an extremely important feature, as without it, above knee amputees have a tremendous tendency to fall when walking over different terrains.

I attended a seminar a couple of years ago, and one of the speakers was an above knee amputee whose story brought to my attention the amount of mental energy that not having stumble recovery takes.  This gentleman told the group about how, prior to having his “bionic” limb, he would have to visually survey every single potential fall hazard and memorize those hazards everywhere he went.  He compared having a traditional, mechanical knee to driving in a snow- storm versus driving on a beautiful fall day.  That was how much mental energy it took him all day, every day.  This  expenditure was in addition to the amount of physical energy it took to ambulate.

V-Leg has taken decreasing energy expenditure a step farther.  According to Vanderbilt’s Center for Intelligent Mechatronics website:  “Despite significant technological advances over the past decade commercial above knee prostheses remain limited to energetically passive devices.

That is, the joints of the prostheses can either store or dissipate energy, but cannot provide any net power over a gait cycle. During level walking, transfemoral amputees expend up to 60% more  metabolic energy relative to healthy subjects, and exert as much as three times the affected-side hip power and torque relative to healthy subjects (which also results in significantly increased socket interface forces), presumably due to the lack of power generation at the knee and ankle joints. The inability to deliver joint power also impairs or precludes other locomotive functions, such as walking upstairs and up slopes or ramps.

It is our hypothesis that a prosthesis with actively powered knee and ankle joints will significantly enhance the mobility of these transfemoral amputees, both by diminishing the biomechanical disparity between transfemoral amputees and healthy persons during level walking, and by enabling forms of locomotion, such as ramp and stair climbing, not presently afforded by passive prostheses.” (http://research.vuse.vanderbilt.edu/cim/research_leg.html)

Of note is that there are other component manufacturers, such as Otto Bock and Ossur that offer power knees with power ankles in development.  As things continue to develop, I will continue to provide updates on the progress of these bionic and biometric devices.

Related articles

• Amputees Walk Farther, More Naturally With New Prosthesis from Vanderbilt (medgadget.com)
• Cadence prosthetic and pedal for amputee cyclists | Bicycle Design (vp-medical.com)
• Shevonne: Shark Attack Victim Gets ‘Bionic’ Leg (news.discovery.com)

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Great news! The deadline to apply for the Amputee Coalition scholarship has been extended to April 30^th. The scholarship is provided through the Amputee Coalition’s Bridge to Ability Fund and enables new amputees to attend the Amputee Coalition’s national conference. To be held June 1-4 in Kansas City, the conference provides amputees an opportunity to share, connect and learn from others. Make sure you get your application in by April 30th. You can find more information here: http://www.amputee-coalition.org/scholarship/bridge_to_ability/.

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• Amputee Summer Camp For Kids Gets Help From CBS Star (huffingtonpost.com)
• FOR KIDS: Feeling better about an artificial limb (sciencenews.org)

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This month represents the first National Limb Loss Awareness month.  As an Nurse Life Care Planner that specializes in developing life care plans for amputees, I am delighted that this issue is getting the attention it deserves.  Did you know 60% of limb loss is preventable?  That is due to the fact that the number ONE reason for lower limb amputation is diabetes.

Here are some statistics on amputations in the United States:

• U.S. Amputee Population Approximately 1.7 million
• 82% of Amputations Are Dysvascular Related
• 97% are  of Dyvsacular amputations lower limb
• In General Amputee Population 90% are Lower Extremity
• Upper extremity amputations account for the remaining 10% of General Amputee Population
• As differentiated from disease related and congenital amputations, 70% of Traumatic Amputations are Upper Extremity

The Amputee Coalition of America has an excellent website that provides tips for avoiding amputation, information about limb loss, how to choose a prosthetist, resource links and much more that is of interest to anyone at risk, who has a friend or relative at risk or who suffers from limb loss and for just general information.

http://www.amputee-coalition.org/Limb-Loss-Awareness

I encourage you to visit this site, particularly if you are one of the more than 24 million Americans with diabetes.

Related articles from VP Medical Consulting

• Workplace Amputation Injury at 10,000 per Year
• Electrical Amputation after 7,200 Volts
• ACA Scholarships Available for Those with Limb Loss
• No Hands No Feet
• Resources for Amputees: Amputation levels
• Limb Loss and the Grieving Process: Part 1 and Part 2

Prosthetic technology continues to improve dramatically (as evidenced by this old prosthetic fitting image!), and the Department of Defense is one of the key drivers in these developments.  While reading this article about Mr. Loosen, the vet who is the first in the older group to receive this new X2 knee, I recalled a presentation that I attended on prosthetics about a year ago.  The amputee that presented was describing how much concentration was required to simply walk across the room on the “standard” type of above knee prosthesis.

He showed a slide of a lovely curving road on a beautiful fall day and asked the group how we would feel driving down it.  Then he showed a traffic-congested road in blizzard conditions, and asked how much more attention the audience would have to pay to simply driving  in those conditions, versus the first one.

His point?  Prior to having a microprocessor knee, similar to the knee mentioned in the article, just walking across a room was like the snowy road.  The energy expenditure for having to be that on alert was tremendous.  And, he still fell on a regular basis.

With the microprocessor knee, all of that changed.  He can walk with confidence, and he rarely falls—(falling is a tremendous hazard for an above knee amputee).

So, I was delighted to read that our returning soldiers as well as our older vets, will have the well-deserved opportunity to obtain microprocessor type knees that are even an improvement over what the presenter at that meeting wears.

Here is a quick look at the statistics:

• Since 2001, 900 soldiers have lost a limb in battle

• Total veteran amputee population right now is 45,000

• Each year 5000 veterans become amputees—primarily through disease processes and traumatic injuries.

Related articles

• Quadruple Amputee Swims the English Channel (vp-medical.com)
• New prosthesis sends feedback to the brain, might alleviate phantom pain (engadget.com)
• Artificial Limbs for Sports (foxnews.com)
• High-Tech Knee Holds Promise of Improving the Lives of Veterans Young and Old (nytimes.com)
• Breakthrough Prosthetic Socket System Greatly Improves Comfort and Performance for Individuals with Limb Loss (prweb.com)

The Whitesell Corporation is feeling the sting of a whole bunch of OSHA citations with fines of more than $3 million dollars.  The company makes fasteners and cold-formed metal products, and now faces 72 violations for amputation hazards and other risks at their locations in Alabama.

They have allegedly willfully tampered with safety mechanisms in order to speed up production.  Am employee’s hand was amputated as a result.  Thirteen of their citations were for failures to use Lockout/Tag out procedures intended to safeguard workers.

As a nurse life care planner specializing in creating life plans for amputees, I have seen all manner of freak accidents in the workplace.  For the most part, these events are the result of an unavoidable incident.

In this case, however, the company elected to disregard even the most basic safety standards,  and in total received citations and fines for 41 willful violations.

As a result of management’s desire to speed up the production line, they dispensed with Lock Out/Tag Out procedures which are standard operating procedure in a plant, and which are legislated to be in place in a manufacturing environment.

To give readers an idea of the importance of LO/TO, I am providing an explanation:

“Lockout/Tagout (LOTO)” refers to specific practices and procedures to safeguard employees from the unexpected energization or startup of machinery and equipment, or the release of hazardous energy during service or maintenance activities.

Approximately 3 million workers service equipment and face the greatest risk of injury if lockout/tagout is not properly implemented. Compliance with the lockout/tagout standard (29 CFR 1910.147) prevents an estimated 120 fatalities and 50,000 injuries each year.  In a study conducted by the United Auto Workers (UAW), 20% of the fatalities (83 of 414) that occurred among their members between 1973 and 1995 were attributed to inadequate hazardous energy control procedures specifically, lockout/tagout procedures.

Related articles

• Dealing with Hazardous Substances on the Construction Site (constructionlawva.com)

USA Today reported that quadruple amputee, Frenchman Philippe Croizon, swam across the English Channel using customize flipper prosthesis in 13.5 hours.  This article is one that is both heartwarming and also provides a real life look at how an amputee can excel at anything he or she puts their mind to.  In my role of life care planner for an amputee, one of my primary goals is to gain a clear understanding of the types of activities and interests the individual has so that we can make sure that these interests and goals are factored into the plan.

Providing an amputee with the proper prosthetic devices is an essential part of the life care plan and is required (in addition to other equipment and services) to help the individual maintain their quality of life after an amputation.  Terminal devices, such as a swimming leg or golfing “hand” allows the amputee to be able to participate in activities that will also ensure that they are active and getting exercise, which in turn, prevents obesity, muscular atrophy, urinary tract disease and other conditions associated with a sedentary lifestyle.

Philippe Croizon, the amputee who made this swim, is an inspiration to us all!

Related articles

• Quadruple Amputee Swims Across the English Channel (neatorama.com)
• Quadruple amputee swims English Channel (boingboing.net)
• Quadruple amputee attempts English Channel swim (seattletimes.nwsource.com)
• Quadruple Amputee Swims English Channel (cbsnews.com)

This is one of those stories that completely inspires me! Specializing in amputee cases, I see the entire range of responses among individuals who lose limbs—from those who let the depression and loss permanently affect their attitudes towards their self image and let the mental side block their ability to make the most of today’s modern prosthetics to people like this young man, who grab the tiger by the tail and don’t let anything stop them.

A couple of points that make this story stand out even more is the rarity of an individual with triple amputations—as an indication, single upper limb amputations are only abut 25% of all amputations. Clearly, these types of injuries are much more complicated to treat and recover from, but Mike Atherton had some key components in place:

• His attitude
• Family and community support
• He is accustomed to being a team player, as evidenced by his skills on the water
• Medical care that was able to meet the needs of this very motivated person

Another interesting point is that his injuries were due to a boat explosion, but he was able to put that trauma behind him and get back to the sport he loves.

I have a hard enough time getting my old bones up and behind a boat. Next time I water ski, I will certainly be thinking of this exceptional young man and mentally cheering him on!

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• Artificial Limbs for Sports (foxnews.com)
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