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Do Gait and Functional Parameters Change After Transtibial Amputation Following Attempted Limb Preservation in a Military Population?

Spahn, Kimberly, MD; Wyatt, Marilynn P., PT, MA; Stewart, Julianne M., PT, DPT; Mazzone, Brittney N., PT, DPT; Yoder, Adam J., MS; Kuhn, Kevin M., MD

Clinical Orthopaedics and Related Research®: April 2019 - Volume 477 - Issue 4 - p 829–835
doi: 10.1097/CORR.0000000000000409

Background Surgical attempts at lower limb preservation after trauma may be complicated by pain and gait disturbances, which can impact the activity level of a military service member. It is unclear how later transtibial amputation (TTA) might affect patients who elect this option after attempts at limb preservation.

Questions/purposes The purposes of the study were to compare preamputation and postamputation (1) the numeric rating scale for pain and pain medication use; (2) self-reported activity level, Four Square Step Test (FSST) results, and assistive device use; and (3) spatiotemporal variables measured with instrumented gait analysis in individuals who elected TTA after multiple attempts at limb preservation.

Methods Retrospective review revealed 10 patients with unilateral lower extremity injuries who underwent late TTA between 2008 and 2016. All patients had undergone multiple limb preservation attempts and had completed instrumented gait evaluations as part of their routine care before and after TTA. One patient was excluded as a result of short followup. The remaining nine patients (eight men, 29 ± 6 years) averaged five surgeries before amputation. Injuries were from improvised explosive devices (six), motorcycle accidents (two), and one training accident. Strict indications for amputation were pain, difficulties performing activities of daily living, limited physical function, and medication dependence. Data for the aforementioned purposes were collected by gait laboratory staff before and 8 to 17 months after amputation. Time to TTA after initial injury was 5 ± 3 years. At the start of the gait analysis study, pain was assessed at rest, activity level was recorded by patient report, and the FSST was administered.

Results After TTA, there was a decrease in pain scores from 4 ± 2 to 1 ± 1 and patients using narcotics decreased from four to only one patient. Self-reported walking endurance increased from 1 ± 1 mile to 7 ± 8 miles and patients able to run increased from one patient to eight with the ninth having no desire to run but bicycled. Patient FSST times improved from 12 ± 10 seconds to 5 ± 1 seconds. No patients required assistive devices after TTA. There were improvements in velocity (108 ± 16 cm/s to 142 ± 7 cm/s), stride length (129 ± 14 cm to 154 ± 8 cm), cadence (101 ± 9 steps/min to 111 ± 7 steps/min), and step width (16 ± 3 cm to 12 ± 2 cm) between pre- and postassessments. Asymmetric single-limb stance time was measured both pre- and postamputation; this did not worsen with the increase in walking velocity.

Conclusions The findings of this study show that TTA after attempted limb preservation in a young, motivated group of service members after traumatic injuries can be successful in decreasing pain and narcotic use and can allow for high-level functional activities. Future studies will be needed to compare this cohort with patients who underwent early TTA after traumatic injury. However, we acknowledge that the resources and support structure available for this population are unique and may not be readily available to the general population.

Level of Evidence Level IV, therapeutic study.

K. Spahn, Department of Orthopedics, Naval Medical Center San Diego, San Diego, CA, USA

M. P. Wyatt, J. M. Stewart, C5 Gait Analysis Laboratory, Naval Medical Center San Diego, San Diego, CA, USA

B. N. Mazzone, A. J. Yoder, DoD-VA Extremity Trauma and Amputation Center of Excellence, San Diego, CA, USA; and Naval Medical Center San Diego, San Diego CA, USA

K. M. Kuhn, Department of Orthopaedic Surgery, Naval Medical Center San Diego, San Diego, CA, USA

M. P. Wyatt, C5 Gait Analysis Laboratory, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, USA, email:

Each author certifies that neither he or she, nor any member of his or her immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research®editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

The views expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the US Government.

Received March 30, 2018

Accepted June 25, 2018

© 2019 Lippincott Williams & Wilkins LWW
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