As science and technology have advanced, multiple reconstruction procedures have emerged for congenital problems in the lower limb. The surgical approach to a malformation of the lower limb involves treating longitudinal deficiencies, foot and ankle problems, restoring articular stability, and limb length discrepancy. Over the years, reconstructive procedures of greater complexity and sophistication have been developed for limb salvage, mainly for congenital limb deficiencies but also for severe traumatic injuries. Results have been variable in terms of achieving correction of the deformities and limb length discrepancies to provide a near-normal limb as a successful functional outcome. Although this kind of treatment involves a prolonged treatment time that usually requires more than one surgical procedure, the final outcome at times is an amputation due to an unaesthetic and failed functional limb. Multiple surgeries and lengthy treatment time additionally impede children from achieving normal psychosocial development due to repeated and prolonged hospitalization time and absence from school.1
The treatment with an amputation and early prosthesis fitting has the advantage of correcting the limb length discrepancy, articular instability, angular deformity, and providing pain relief in one surgical event, letting the child experience a greater independence with a near to normal psychosocial function.2
The aims of this study were to determine the difference in terms of functional outcome, satisfaction, and psychosocial adaptation in patients with primary transtibial amputations comparing those with multiple failed reconstruction procedures whose final treatment required a transtibial amputation.
This is a retrospective review of patients who had a transtibial amputation between the years 1991 and 2008 at the Shriners Hospital for Children in Mexico City, Mexico. The study protocol was reviewed and approved by the institutional review board of the Shriners Hospital for Children, Mexico City, Mexico. To be included in this study, the patient had to have a unilateral transtibial amputation with a normal range of motion of the hip and knee without any neurological deficit. All of the patients had a complete clinical and radiographic chart with follow-up at least every 6 months.
We included 77 patients in this study. Ten patients were excluded for having bilateral amputations, 5 for having a decreased range of motion of the knee, and 3 for having a pathological function in the contralateral lower limb. Our final number of patients was 59, 34 in the primary amputation group and 25 in the multiple surgeries group. In Table 1, we show the etiology for the amputation.
The Pediatric Outcome Data Collection Instrument (PODCI) was applied according to the age of the patients to determine the functional outcome and satisfaction. The PODCI is a functional scale that evaluates four functional assessment scores: 1) upper limb; 2) transfers and basic mobility; 3) sports and physical function; and 4) comfort and pain. With the average of these 4 subcategories, you get the global functional value. This scale is measured from 0 (lowest) to 100 (highest).
The Trinity Amputation and Prosthesis Experience Scale (TAPES)9 part I was used for the psychosocial component in terms of adaptation to the use of the prosthesis. The TAPES examines the psychosocial process involved in adjusting to an artificial limb. The psychosocial scale (part I) consists of 3 subscales (general adjustment, social adjustment, and adjustment to limitation) consisting of 5 items each. It is graded according to the level of agreement to the questions from 0 to 4, and then an average from each subscale is obtained.
Both of these measuring instruments were applied postoperatively to all the patients at their latest follow-up visit.
To determine if there was a statistical difference between both groups, a Student t-test for nonpaired groups was used. A value of p < 0.05 with a 95% confidence interval (CI) was considered to be significant.
We analyzed the number of times a remodeling residual limb procedure was done, number of surgical procedures, and time of use of the prosthesis for each group (Table 2). We found a significant difference in the number of surgical procedures on the multiple surgeries group, with an average of 4.65 compared with 2.37 in the primary group. The other variables analyzed had no statistically significant difference. Tables 3 and 4 show the results of the PODCI and TAPES.
We found a difference in the values between the 2 groups in the subscales of transfers, pain, and global function. The median values for transfers, even with a statistical difference, are within the normal accepted values compared with the normal population.3
For the pain subscale, we observed a significant difference on the multiple surgeries, indicating that those patients with previous surgical treatments before the amputation have a greater frequency of pain than those with a primary amputation.
The global functional outcome in patients with primary amputations is within the normal value for the normal population, compared with those with multiple surgeries whose PODCI values are below the accepted normal values, indicating a better functional outcome in the primary group.
We did not find any significant difference in the subscale of sports activity; in both groups, the values were below the expected for the normal population. Regarding the satisfaction subscales, there was no difference between both groups, finding that both are equally satisfied with the outcome of having a lower-limb prosthesis.
With the TAPES scale, we found that there is a significant difference in the adjustment of limitation, which indicates that those patients in the multiple surgeries group have a perception of being more dependent on family and friends than those in the primary group. The other subscales did not indicate a significant difference.
In children, congenital problems are the most frequent cause of lower-limb amputations. The reconstruction procedures as an initial treatment are seen as an excellent alternative, although it is highly important to do a detailed evaluation of each case to be able to offer real expectations regarding the advantages and projected results that these procedures will have on functional abilities. It is also very important to consider the age of the child and the impact on the psychosocial development of the child that will probably be affected by the time required for the reconstruction procedures as well as the time spent in the hospital and doctor’s office for monitoring the surgical results and modification of the dynamic variables in treatment.
The study performed by Quon et al.3 found that factors with a major influence in choosing between an amputation over a reconstruction procedure are related to pain and improving functional outcome.4
When evaluating whether to perform a reconstruction procedure in a child with a congenital problem, it is of paramount importance to take into consideration the great differences between child patients and adults including the prediction of the expected growth, the remodeling potential, the risk of having a physeal injury that changes the expected result, and possible pathological soft tissue problems adjacent to the affected limb.5 All of these factors are involved in the complexity of the reconstruction procedures and the risk of having a poor outcome.
The decision for the selection between an amputation versus a reconstruction procedure is complex. It involves the recommendations of the doctor as well as the expectations and preference of the patient and his/her parents. Parents frequently refuse the amputation treatment because they see it as a radical treatment, and sometimes they are unable to identify the magnitude of the deformity and limb length discrepancy, which at a young age is not appreciated as considerable. It is important to discuss the biological and psychological variables previously mentioned as well as potential complications and the possibility that if reconstructive treatment fails, the final outcome may be an amputation.6
The study of Naudie et al.7 on the management of patients with fibular hemimelia found that there is a significant difference in the number of complications and additional surgeries in patients with reconstructive procedures compared with those treated with amputation.
McCarthy et al.8 found that children having early amputations are more active, have less pain, and are more satisfied with the results of those patients with reconstructive procedures.
This study reaffirmed the aforementioned results of previous research. We found a greater frequency of pain and lower values in the global functional outcome in the multiple surgeries group. Despite these findings, we could not confirm a difference between both groups in our population in terms of satisfaction.
We found lower values in adjustment to limitation to be a significant variable. We believe this is due to the fact that children with multiple surgical procedures have a reduced time to have a social adaptation due to the increased amount of time reconstruction procedures require. This is associated with the psychological aspect of a failed treatment and the effect on the child’s hope to have a near-normal and aesthetic limb.
In this study, we were able to analyze the differences between the 2 groups that underwent transtibial amputations as well as the repercussions of multiple failed surgical procedures on the outcome. We could confirm that those patients with multiple procedures had a different outcome regardless of having received the same final treatment, including an increase in the likelihood of having pain, a decreased functional outcome, and decreased perception of independence.
When we evaluate a patient with a lower-limb problem, whether congenital or traumatic, it is of paramount importance to determine very clearly the severity of the problem and to generate a realistic prognosis and chance of success with available treatments taking into consideration age as well as the natural history of the disease.
It is not the goal of this article to recommend the abandonment of reconstruction procedures for lower-limb deformities, but to encourage surgeons to adhere to minimal established criteria for reconstruction procedures and to communicate closely with the patient and family about the limitations of these types of treatments, the time they will need to invest, and the possibility of an amputation as the final outcome if the reconstructive treatment fails. We also consider that it is important to explain to both the patient and his or her family, based on the results presented on this study, that those patients with a failed treatment with multiple previous surgical procedures are at an increased risk of having more pain, a decreased functional outcome, and a perception of being more dependant, compared with those who have a primary amputation.
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