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Functional and Clinical Outcomes of Upper Extremity Amputation

Fitzgibbons, Peter MD; Medvedev, Gleb MD

JAAOS - Journal of the American Academy of Orthopaedic Surgeons: December 2015 - Volume 23 - Issue 12 - p 751–760
doi: 10.5435/JAAOS-D-14-00302
Review Article
Free

Upper extremity amputation is an uncommon but often necessary procedure. It can be required as a result of trauma, infection, or malignancy. Amputation is a life-changing procedure. Careful planning for it must not only include the level of amputation and assurance of durable soft-tissue coverage of the amputation site, but it must also consider patients’ goals and occupations, as well as social factors affecting amputees. The choice of prosthesis is an individual matter, but new technology permits lighter and more multifunctional prostheses. Targeted muscle reinnervation can be used to achieve improved myoelectric signaling and possibly decrease limb pain following amputation. Rehabilitation is crucial to achieving favorable results.

From the Medstar Orthopaedic Institute at Washington Hospital Center, Washington, DC (Dr. Fitzgibbons), and George Washington University, Washington, DC (Dr. Medvedev).

Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Fitzgibbons and Dr. Medvedev.

Received August 28, 2014

Accepted February 14, 2015

Amputation is a life-changing event that incurs the loss of a great degree of function. Although surgeons have developed successful techniques for performing amputations, their understanding of its functional and clinical outcomes is not as advanced. Upper extremity (UE) amputation in the adult can be the result of trauma, vascular disease, infection, or malignancy. It is estimated that in 2005, 41,000 people were living with major UE amputations.1 Projections suggest that the overall number of both lower extremity (LE) and UE amputations will triple by 2050.1 Most UE amputation is the result of trauma.1 Civilian injuries leading to amputation are generally industrial crush injuries. Military personnel can suffer amputation-necessitating injury from both direct combat and improvised explosive devices.2 Multidisciplinary teams can speed the recovery of patients with all of these types of injury. Proper prosthetic fitting and training can improve the outcomes of amputation and allow patients who undergo it to more rapidly return to their work and activities of daily living (ADLs) than they otherwise could.3

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Anatomic Considerations: Level of Amputation

The upper extremity requires a great range of motion (ROM) to properly position the hand in space for the performance of daily functions. In cases of amputation, preservation of this ability is crucial to improved outcomes. This preservation of motion can in part be achieved by maximizing the length of the amputation stump. In forearm amputation, the level chosen for amputation becomes crucial because forearm length is proportionate to the range of forearm pronosupination.2 In transradial amputations, close proximity of the amputation site to the elbow can decrease pronosupination to an almost nonexistent state2,4 (Figure 1). The level of amputation will also determine motion at the elbow. In the case of proximal amputations, the socket of a prosthesis may impede flexion at the elbow.2 In humeral amputation, the preservation of length is similarly important to that in transradial amputation for both prosthetic use and fit.

Figure 1

Figure 1

Soft-tissue coverage of the amputation site can be challenging when attempting to preserve upper limb length and may require free-tissue transfers or flaps. The use of these can increase both healing time and the time to return to activities but must be considered so as to minimize loss of motion. Baccarani et al5 performed free-tissue transfers in 13 patients to preserve UE length. Complications occurred in 38% of the patients but length was preserved in all 13. Indications for the use of free-tissue transfer were to preserve function of the shoulder and elbow, retain pinch function in the hand, and maintain a skeletal length of the residual limb of at least 7 cm. The preserved limb length in the study allowed improved function in many of the patients through either choice of prosthesis or the preservation of major joints.5

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Forearm Amputations

Notes on Technique

Below-elbow, or transradial, amputations are the most commonly performed UE amputations proximal to the wrist6 (Figure 2). Preservation of forearm stump length in these procedures is important for proper positioning of the stump in space by allowing maximum pronation and supination.

Figure 2

Figure 2

For more proximal levels of UE amputation, preservation of the ulna to a minimum of 5 cm is important for fitting of a prosthesis.4 The biceps tendon is transferred to the ulna. Tensioning of muscles and tendons must be done carefully to avoid flexion contracture at the elbow. For patients with LE injury or disability, retention of the ulna allows platform weight bearing.

Muscle stabilization is recommended to allow continued contraction of the forearm and prevent painful stumps.7 This can be achieved with myodesis, the attachment of muscle to bone or periosteum; myoplasty, the attachment of a muscle to its antagonist muscle; or myofascial closure, the attachment of muscle to fascia. Myodesis provides the strongest attachment and allows more individualized muscle function,8 which, in activating one muscle without forcing another to contract, enhances the ability of myoelectric prostheses to operate.

An elastic bandage used for dressing to prevent stump edema also facilitates early fitting of a prosthesis. Active ROM exercise at the elbow and shoulder should begin immediately after amputation.4

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Prosthetic Options

The fitting of a prosthesis can begin immediately or within 30 days after UE amputation, with less concern for wound breakdown than in LE amputation.9 Early fitting also provides protection for the amputation stump and control of edema and pain, and permits an early start to prosthesis training.2 A variety of prostheses exist for transradial amputees, consisting of cosmetic (Figure 3), body-powered, myoelectric (Figure 4), and hybrid (myoelectric/body-powered) prostheses.10 Cosmetic prostheses tend to be the most lightweight and require the least amount of harnessing. However, they provide the least amount of functional use. Body-powered prostheses use a system of cables that attach the harness of the prosthesis to a terminal device. They are the most durable prostheses for transradial amputation and provide the greatest sensory feedback. The shoulder harnesses of body-powered prostheses exist in two common forms: a figure-of-8 brace and a shoulder saddle with a chest strap. The figure-of-8 brace can accept heavier loads than the shoulder saddle brace but irritates the axilla. The lack of cosmesis with the figure-of-8 prosthesis, as well as its harnessing and the gross body movement required to operate it, can prompt its refusal by patients.

Figure 3

Figure 3

Figure 4

Figure 4

Myoelectric prosthetic devices use muscle contraction to initiate function of the terminal device. This occurs through electrodes that sense muscular activity. These devices can be used in dual setups to perform multiple functions based on muscles that are contracting. They tend to be the most expensive and heaviest prostheses for transradial amputees, have limited sensory feedback, and require the most training. Suspension for these devices can be achieved with a socket, and in the absence of a need for heavy lifting, they need not require a shoulder harness.10 Myoelectric prostheses are chiefly used for ADLs, but their use is limited even for these activities.11 Hybrid devices use a combination of cables and myoelectrically powered devices to perform multiple functions. This option is generally used by transhumeral amputees to perform grasping and elbow functions.

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Outcomes

Postoperative complications of UE amputation are common, especially with high-energy mechanisms of injury. Phantom pain tends to be the norm rather than the exception. The functional outcome in transradial amputation is improved with increased use of prostheses. A review by Tintle et al7 of a group of studies with a mean sample size of 85 patients found a rate of prosthesis use of 80% to 94%.

In a retrospective analysis, Tintle et al12 reviewed 100 combat-related major UE amputations. Complications and revision surgeries were recorded for all types of UE amputation; 42% of cases required revision surgery, with most revision surgeries involving irrigation and débridement for deep infection. There was no significant difference in the rates of complications between below-elbow and above-elbow amputation. The study population had chiefly experienced blast injures, in which the rate of infection is higher than for the types of injuries experienced by the general population. In terms of functional outcomes, a survey showed that 84% of the patients were using one or more types of prostheses. Additionally, the rate of use of prostheses increased from 19% to 87% after revision surgery in the revision cohort.12 Revisions were done for heterotopic ossification, infection, neuromas, contractures, and symptomatic scars, suggesting that the lack of use of an upper limb that has undergone amputation may be related to reversible factors. Myoelectric prostheses were the most preferred type of prosthesis at 66%. Patients who had undergone transradial amputation were found to have a greater risk of phantom pain (4.7-fold) and of requiring neuropathic pain medication (2.8-fold) than those undergoing other types of amputation.12

A retrospective review by Tennent et al13 of limb amputees in the US military found that UE amputees had a significantly greater combined disability rating than did LE amputees, at 82.9% versus 62.3%, respectively. Of the UE amputees, 47% had transradial amputations. Posttraumatic stress disorder was diagnosed in 17% of the isolated UE amputees and was responsible for the second highest degree of disability. Additionally, UE amputees were at significantly greater risk than LE amputees of having posttraumatic stress disorder and major nerve injury. No UE amputees were found fit for duty, 8% continued on active duty, and most were permanently retired or disabled. Tennent et al13 emphasized the high degree of disability that accompanies UE loss in an active population. They also highlighted the significant effects of psychological comorbidities on these patients’ disability status.

Østlie et al,14 in a survey of 224 UE amputees living in Norway, found a 4.5% rate of rejection and 13.4% rate of discontinued use of a primary prosthesis. Within the cohort that had undergone transradial amputation, however, the rate of rejection of a primary prosthesis was only 0.8% and, that for discontinuation of use of a secondary prosthesis was 6.2%. Prosthesis training seemed to be a major issue in the rejection of prostheses. In the survey by Østlie et al,14 62.7% of their respondents said that they had received adequate training and education regarding the use of their prostheses. Additionally, early fitting of prostheses is not a widely accepted concept. Only 50 of the 224 patients were fitted with their prostheses within 3 months after amputation. From 2000 to 2007, the average number of months to the first fitting of a prosthesis was 7.0.14 Recent advances in design of the liners and sockets of prostheses and in prosthetic materials may improve the ease of fitting.

Early fitting is not the only predictor of prosthesis use. Wright et al6 noted a correlation between shoulder stiffness and discontinuation of prosthesis use in 135 patients with major UE amputations. Shoulder stiffness also correlated with the presence of phantom limb pain (PLP). Other reasons for discontinuing the use of a prosthesis were limited usefulness, heavy weight, and stump-socket discomfort.6 With advances in lightweight materials and terminal devices, some of these issues can be resolved.

From a functional point of view, transradial amputations are responsible for a higher level of prosthetic usage than are elbow disarticulations and transhumeral amputations. Even without a prosthesis, patients with transradial amputations can use the stump of their forearm for daily activities. The major setback in daily function in this amputation group is PLP and the need for neuropathic medications. Although pain can be a disabling factor for transradial amputees, they have been shown to have higher employment rates than persons with UE amputations at higher levels.6

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Elbow Disarticulation

Notes on Technique

Elbow disarticulation is the least common of the three UE amputation procedures discussed here. It can provide an advantage over transhumeral amputation in preserving the ability to transmit internal and external rotation to a prosthesis by means of the bulbous end of the distal humerus, and can permit this end of the humerus to function as an improved weight-bearing surface when no prosthesis is used. This is useful for patients requiring crutches or walkers. However, with the change in position of the elbow joint brought about by amputation, cosmetic issues arise. Osteotomy that shortens the distal humerus to improve the fitting of a prosthesis has been described and can be done either immediately or as a delayed procedure.15

If soft tissue is lacking at the distal end of the humerus, as may happen with very thin patients, its coverage can be achieved with a reflected flap of biceps, triceps, or brachialis muscle. Distal muscle stabilization in the humerus, through myodesis, is recommended.

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Prosthetic Options

Prostheses for use after elbow disarticulation are similar to those used after transradial amputation. However, special considerations exist for patients receiving forearm prostheses. Because the elbow joint is no longer present, but the humerus remains at full length, the center of rotation of a prosthetic elbow must move distally. This can create a cosmetic issue as the result of a patient’s differing arm lengths. Prosthesis suspension can also vary, with the Munster and Northwestern Supracondylar suspension devices more easily used than a shoulder harness, although the limit of its carrying weight is less. Beyond cosmetic issues, prostheses for use after elbow disarticulation must be chosen with consideration of elbow motion and hand grasping. This can be achieved with a fairlead cable system, in which two separate cable housings direct different motions. Another method is to have a locking joint at the elbow that is manually controlled with the patient’s contralateral hand. However, this is attended by issues of durability.

Myoelectric and hybrid prostheses can prove more useful than harness and cable systems because of their ability to handle dual functions.

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Outcomes

Most of the literature on elbow disarticulation includes it with other types of amputations. The isolation of data for elbow disarticulation is necessary to better understand its outcomes. To gather information about their prosthetic usage and pain, Dudkiewicz et al16 retrospectively reviewed 45 patients who had undergone UE amputation. They excluded amputations incurred by accidents during roadwork and those that occurred as combat injuries. Four of their patients had elbow disarticulation, and most of their patients used cosmetic prostheses. The prevalence of PLP in their study population was 35.71% and that of pain in the amputation stump was 7.14%, which was not subclassified into the prevalence of PLP as opposed to stump pain according to the level of amputation. Of the patients in the elbow disarticulation group, 50% used a prosthesis on a permanent basis, none used a prosthesis temporarily, and 50% had ceased using a prosthesis.16 Phantom pain contributed to the disuse of prostheses, whereas pain in the amputation stump did not affect prosthetic usage. The elbow disarticulation group results are limited by the small sample size and may not correlate well to the overall population.

McFarland et al17 surveyed veterans of the Vietnam and Iraqi conflicts (Operation Iraqi Freedom/Operation Enduring Freedom) about their use of prosthetic devices following UE amputation. Of 97 participants in their survey, 2 veterans of the Vietnam conflict and 3 veterans of the Iraqi conflict had elbow disarticulations. Two of these 5 participants rated their health status as good to excellent. All 97 participants in the survey by McFarland et al17 who had undergone elbow disarticulation had suffered other combat-related injuries. One of the two veterans of the Vietnam conflict had stopped using a prosthesis, but none of the three veterans of the Iraqi conflict had done so. However, all four of these survey participants showed a trend toward lower activity in performing daily tasks. The average number of prostheses ever received by participants in the survey was highest in the elbow disarticulation group, at 3.3 prostheses per person per year. Myoelectric prostheses were favored by veterans of the Iraqi conflict and body-powered prostheses by those of the Vietnam conflict.

Prosthesis rejection rates in the studies by Dudkiewicz et al16 and McFarland et al17 were 50% and 20%, respectively. However, this information is based on a combined total of nine patients in the two studies. Larger studies are required to understand prosthetic use and PLP in patients with elbow disarticulations.

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Transhumeral Amputations

Technique Notes

Preservation of humeral length is as important in transhumeral amputation as preservation of bone length after transradial amputation. A length of 5 to 7 cm of the humerus should be retained to allow proper prosthesis fitting.4,7,8,18 If this is not done, the patient may lose abduction and adduction as controls for certain prosthetic options.4 Retention of the insertions of the deltoid, pectoralis major, and latissimus dorsi muscles aid in maximizing ROM at the shoulder7 (Figure 5). At the axillary level of amputation, fitting of a prosthesis can present problems to patients with shoulder disarticulations because of a short stump length.

Figure 5

Figure 5

Free muscle transfers of the latissimus dorsi, parascapular, and other muscles have been described as options for wound coverage after transhumeral amputation.5 Following transhumeral amputation with split-thickness skin grafting is an additional option.

Very proximal amputations of the humerus may benefit from glenohumeral arthrodesis. Without arthrodesis, an abduction contracture may occur as the result of overpowering by the rotator cuff. In such amputations, the humeral head is left for cosmetic reasons but does not aid in function, making glenohumeral arthrodesis a viable option.

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Prosthetic Options

Harnessing is usually required to suspend any UE prosthesis (Figure 6). Elbow and hand functions should be maintained for optimal functional outcomes. Dual cables and locking elbows can be applied as described earlier. Proximal amputations may decrease the functional ROM needed at the shoulder for using such prostheses. Gross body motion may be required for their operation and may increase the patient’s reliance on use of the intact side of the body.

Figure 6

Figure 6

Myoelectric prostheses also have disadvantages in terms of elbow and hand function. Signaling may not be as apparent to such a device when the activating muscles are in close proximity to one another. For this reason, hybrid prostheses are beneficial for patients with UE amputations. Typically, such hybrid devices combine a body-powered elbow with a myoelectric terminal device. This allows the improved control of myoelectric signaling with fewer electrodes.

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Outcomes

Historically, acceptance rates of prostheses by patients with transhumeral amputations ranged from 43% to 83% in series reported from 1986 to 1995.6,7,19-21 Larger, heavier, and less cosmetic prostheses can have decreased use. Functional outcomes of patients with transhumeral amputations have also been difficult to measure, as in other types of UE amputation, because no standardized measures of their function have been developed.

In the study by Dudkiewicz et al,16 30 of 42 patients had transhumeral amputations. A survey of prosthesis use revealed that 14 patients (46%) used their prostheses permanently, whereas 9 patients (30%) did not use a prosthesis at all. The rate of PLP in all of the groups of amputees in the study was 35%, and this pain affected the daily use of prostheses. This is contrary to an earlier suggestion by Pinzur et al20 that PLP does not affect prosthesis use.

McFarland et al17 examined upper limb loss in veterans of the Vietnam and Iraqi conflicts. Thirty-four of their patients had transhumeral amputations, with the percentage of veterans of the Iraqi conflict who continued on active duty significantly exceeding that of veterans of the Vietnam conflict who did so (29% versus 0%, respectively; P < 0.05). Prosthesis usage rates were 60% to 64% among those with transhumeral amputation. Veterans of the Vietnam conflict with transradial amputations preferred body-powered prostheses, whereas those with transhumeral amputations preferred hybrid myoelectric prostheses. Most of the patients in both groups performed ADLs with the remaining hand, with very few in the Vietnam group using their prostheses.

Transhumeral limb loss was a significant predictor of decreased activity levels among both Vietnam and Iraqi conflict veterans. Currently, many patients report the weight, discomfort, and effect on the contralateral limb of upper limb prostheses as drawbacks to their use. With advances in lighter-weight materials and myoelectric signaling, it may be possible to improve the utility of upper limb prostheses. Hanley et al,22 in a survey of 104 patients, found that the use of upper limb prostheses was associated with back, neck, and nonamputated-limb pain in 52%, 43%, and 33%, respectively. When PLP and stump pain were included, 90% of the patients reported having pain, and 76% reported having more than one type of pain.

In the study by Østlie et al14 of Norwegian UE amputees, the transhumeral amputees had a primary prosthesis-rejection rate of 10.4% compared with 0.8% in the transradial amputee group. The chief reasons for prosthesis rejection included inability of the prosthesis to meet the patient’s needs and lack of a perceived need for the prosthesis. Age >60 years was found to increase the risk of primary prosthesis rejection 5.8-fold. Amputees with more proximal amputations, such as those with transhumeral amputations, were 12.8 times more likely to reject a prosthesis than were those with amputations at distal levels. Secondary prosthesis rejection among amputees with transhumeral amputations was 27.5%, as compared with 6.2% on the group with transradial amputations. Dissatisfaction with comfort, function, and control were the main reasons for rejection of a prosthesis. Women and proximal amputees were more likely than other groups to reject prostheses secondarily.14

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Targeted Muscle Reinnervation for Transhumeral Amputation

Targeted muscle reinnervation is a new and evolving technique for providing improved control of UE prostheses. It involves the transfer of nerves that have lost their motor connections with distal muscles to redundant proximal muscles, to which these nerves can provide an input for prosthetic control.23 This allows more intuitive control of a prosthesis such that a radial nerve signal, amplified by the lateral triceps to which it has been transferred, for example, might control prosthetic hand opening (Figure 7). Similarly, the median nerve can control hand closing through the medial biceps. A variety of neurotization patterns have been used successfully for different levels of amputation.24 Both surgical techniques to improve signal acquisition and electromyographic pattern-recognition algorithms continue to be developed, allowing smoother, more intuitive, and ultimately more functional prosthetic use.25

Figure 7

Figure 7

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Phantom Limb Pain

PLP is perceived pain in the amputated portion of a limb. The most common risk factors for PLP are female sex, upper limb amputation, and short elapsed time from amputation.26 PLP should be distinguished from residual limb pain (RLP) following an amputation. This may be difficult because the prevalence of RLP in patients with PLP is significant.27 However, a long-term follow up study by Hunter et al28 did not show significant influence of RLP on PLP incidence. With prevalence ranging from 51% to 80%, it is important to understand both the cause and treatment of this common phenomenon.29

Several theories exist about the mechanism responsible for PLP. They can be grouped into mechanisms involving the central and those involving the peripheral nervous system. A review of these theories is presented by Weeks et al.30 Theories of PLP involving the central nervous system are subdivided into the categories of cortical remapping, body schema, and neuromatrix. Cortical remapping is the most widely accepted theory of a central nervous system–based mechanism of PLP and is founded on reorganization of the primary somatosensory and motor cortices in the brain following amputation.30,31

MacIver et al31 used functional MRI to investigate 13 UE amputees having PLP. The imaging in their study was done during hand and lip motions. Compared with controls, the amputees had significant reorganization of both their motor and sensory cortices. Perceived hand motion in the amputated limb demonstrated activation within the lip area. Patients then underwent mental imagery training, which involved encouraging them to imagine comfortable and thorough movement and sensation in the phantom limb. After training, the patients’ cortical reorganization diminished and they reported a reduction in the intensity of PLP.

Peripheral theories suggest the involvement of peripheral neuromas and their abnormal activity as the basis for PLP. RLP has previously been correlated to PLP, a theory supported by studies involving stump injections to relieve PLP.32

Chabal et al32 investigated PLP through the perineural injection of normal saline, lidocaine, or gallamine, which increases neuronal activity. Nine patients participated in the study and reported that PLP decreased with lidocaine and increased with gallamine. Peripheral nerves play a role in PLP but are not the sole modulators of pain because the lidocaine injections did not entirely relieve pain. PLP is likely to have a multitude of contributions from the central and peripheral nervous systems.

Treatment of PLP remains a challenge because of its multimodal causes. Currently, no consensus exists on an optimal treatment for it. Morphine and other opiates have long been an option for treating many types of pain.33 McCormick et al33 in a systematic review found level 2 evidence to support morphine and ketamine use for the short-term perioperative treatment of PLP and oral treatment with morphine to be more useful for chronic PLP. Some studies have shown tramadol to be no more effective than placebo for PLP and methadone to have no effect on PLP.30 Together with questionable efficacy, opioids carry risks of overdose, dependence, and abuse.

Gabapentin and pregabalin are used to treat neuropathic pain. However, their application in PLP remains controversial. In studies focusing on PLP, gabapentin did not produce significant improvement compared with a placebo.34,35 Pregabalin lacks research support for its use, although physicians have used it on an off-label basis. Evidence for an analgesic effect of pregabalin in PLP exists mainly in case reports or small series.33

Besides oral pharmaceuticals, bupivacaine, ketamine, or botulinum toxin given by injection or infusion have been evaluated as therapy for PLP. Bupivacaine infused perineurally or through an epidural catheter has produced improvement in acute PLP.32,33 It may be mixed with clonidine, morphine, or both. Long-term results have not been as promising with similar outcomes in placebo patients at 1-year follow-up for perineural administration. However, epidural administration has shown a decrease in PLP incidence at 1 year.33 Ketamine has also produced improvement of PLP in the acute setting, although its long-term effects are questionable.33

Wu et al36 compared the injection of botulinum toxin with that of lidocaine/depomedrol for the relief of residual pain and PLP in amputees. The rationale for giving botulinum was to stop painful muscle spasm and myofascial pain. Neither treatment group had a reduction in PLP, but both groups had a reduction in RLP.

Injection of lidocaine is not limited to the residual limb in amputees. Because PLP has been thought to mirror muscle pain in the contralateral limb, lidocaine has been given in that limb. Casale et al37 used lidocaine injection into the contralateral limbs of amputees to decrease PLP. Although their study was limited to eight participants, it showed a significant improvement in PLP in the lidocaine as opposed to the placebo group.

Beyond pharmacologic treatment, substantial research has been dedicated to mind-body therapy for PLP. Such therapy includes mirror therapy, hypnosis, and biofeedback. Alternative treatments for PLP are also available, such as electromagnetic therapy, transcranial stimulation, and the use of electromagnetically shielded limb covers. Mirror therapy is the most promising nonpharmacologic therapy currently available for PLP. To maximize the relief of PLP, it should be combined on an individual-patient basis with medications or injections.

Mirror therapy uses a “virtual limb” created through a mirror to show movement of the contralateral limb. This technique was first suggested by Ramachandran and Rogers-Ramachandran38 in 1996. They showed that amputees felt movement in their phantom limbs when their corresponding intact limbs were superimposed on images of their missing limbs in a mirror. PLP can be thought of as pain from a paralyzed muscle. To relieve pain that the brain perceives as originating from an uncomfortable limb position, the motor cortex sends signals to induce motion in the missing limb, but does not receive feedback to indicate that movement has occurred.

Chan et al39 conducted a randomized controlled study of mirror therapy, mental visualization, and sham therapy with a covered mirror in patients with PLP. They found significant relief of PLP in the mirror therapy group but not in the mental visualization or sham therapy groups.

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Summary

Although rare, UE amputation is still required in cases of severe vascular disease, tumor, infection, and trauma. Maximizing functional outcomes in patients with UE amputations begins with the level of amputation. Maximum effort to preserve residual limb length allows increased motion of a prosthesis. This can and should be achieved with soft-tissue transfers when distal coverage of an amputation wound is otherwise inadequate. The choice of prosthesis following UE amputation remains an individual matter for the patient, but newer technology is allowing lighter and more multifunctional prostheses. Targeted muscle reinnervation can be used to achieve improved myoelectric signaling and possibly decrease limb pain following UE amputation.

PLP is not a well-understood phenomenon. Its presence following UE amputation is significant, with phantom sensations reaching a prevalence of 76%.40 Treatment modalities for it are numerous, and further investigation is needed to understand the best approach to its treatment.

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References

Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, references 32, 34-37, and 39 are level II studies. References 1, 11, 14, 17, 19, and 28 are level III studies. References 5, 6, 9, 12, 16, 20-23, 25, 27, 28, 31, 38, and 40 are level IV studies. Reference 15 is level V expert opinion.

References printed in bold type are those published within the past 5 years.

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          Keywords:

          Transradial; elbow disarticulation; transhumeral; phantom limb pain; amputation; upper extremity

          © 2015 by American Academy of Orthopaedic Surgeons