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Stubby prostheses: An alternative to conventional prosthetic devices
DEVICES
Stubby Prostheses: An Alternative To Conventional Prosthetic Devices Stanley F. Wainapel,
MD, Harold March, MD, Laurence Steve, MPA, PT
Albert Einstein College of Medicine, Bronx, NY 10461 ABSTRACT. Wainapel SF, March H, Lawrence S: Stubby protheses: an alternative to conventional prosthetic devices. Arch Phys Med Rehahil 66:264-266, 1985. l Stubby prostheses offer potential advantages over conventional prosthetic devices in terms of safety, stability, and energy efficiency. Although cosmesis is compromised in the process, these short nonarticulated pylon prostheses may be a viable option to consider in bilateral A-K or knee disarticulation amputee patients under the following circumstances: (1) as a training tool to determine whether progression to full-length articulated devices is feasible; (2) as permanent prostheses for the patient whose primary need for ambulation is within his own home; (3) for the elderly bilateral amputee in whom ambulation is feasible hut safety and energy effkiency are of particular importance; and (4) as a definitive device in the patient who expresses a preference for them. Two patients who have become successful users of stubby prostheses are presented to illustrate these points. KEY WORDS: Equipment design: Prosthesis; Prosthesis design
Stubby prostheses (also referred to as “stubbies”) are short, nonarticulated pylon prosthetic devices which have been suggested as an alternative to full-length articulated prostheses in bilateral A-K amputee patients, particularly in the more elderly patient population. Previous advocates of stubbies3-” have stressed the following advantages related to their use: (1) lowered height and center of gravity, improving safety and reducing the danger of serious falls; and (2) eliminated prosthetic knee joint, improving patient stability. For the new amputee patient, stubbies condition the amputated limbs, particularly aiding in avoiding flexion contracture. The more contemporary designs (fig 1) include posteriorly protruding rocker bottoms for improved balance. Cosmesis is the primary disadvantage of stubbies, which makes them unacceptable to many individuals. Other problems include difficulty in transferring and in climbing stairs, curbs, and ramps. However, use of stubbies may be indicated and, in fact, may have a salutory effect on the quality of life. Two patients are described. CASE
within his apartment. Although he does not use them when outside his home. he takes great pride in remaining ambulatory. Casr of both At age formed walked weight
2. This U-year-old man was born with congenital anomalies legs; as a baby he could crawl but was never able to walk, 5 years. bilateral knee disarticulation amputations were perand he was fitted with conventional-length prostheses. He satisfactorily with them until age 15 years when excessive gain made it impossible for him to fit into the sockets of his
REPORTS
Case I. A 73-year-old man with diabetes and a long-standing history of chronic congestive heart failure (treated with digoxin and hydrochlorthiazide) underwent bilateral A-K amputations for nonhealing leg ulcerations. He was not given any prostheses and led a bed to chair existence at the time of our evaluation one year after amputations. At this time he demonstrated hip flexion contractures of 40” on the right and 25” on the left. Because of his strong motivation to walk, the patient was admitted and underwent an aggressive program of upper extremity conditioning and passive stretching of his hip flexion contractures, which were almost completely eliminated. He was measured for and provided with bilateral stubby prostheses with quadrilateral sockets, hip joints, double pelvic bands. and rocker bottoms (fig 1). After a period of five weeks of inpatient prosthetic training he was able to ambulate 40ft to 6Oft independently using an adolescent walkerette. He left the hospital after a total stay of 74 days and has been using his stubbies primarily for amubulation
Arch Phys Med Rehabil Vol66, April 1665
Fig l-Patient 1 ambulating with stubbies and adolescent walkerette. *Note posteriorly protruding rocker bottoms.
Submitted for publicaton January 20. 1984. Accepted in revised form August I, 1984. Dr. Wainapel is now associated with University Hospml, Boston. MA 021 IX.
265
STUBBYPROSTHESES, Wainapsl
his stubby prostheses and an 2adolescent-sized walkerette (the latter was needed because of his shortness of stature when using his stubbies). It was believed that his ambulatory potential with full-length conventional prostheses was questionable and therefore the stubbies would be the prostheses of choice. A special table, the construction of which is described elsewhere,’ was designed to facilitate the donning of his prostheses. This table gave the patient the ability to don his stubbies while sitting upright in his wheelchair, avoiding the cumbersome and fatiguing process of doing so in bed, and the subsequent task of transferring from bed to wheelchair while wearing the stubbies. The second patient was younger and more athletic than the first. He also had a lower level of amputations (knee disarticulations) and had been a prosthetic user since childhood. This man expressed a clear preference for stubbies, feeling that he could walk more quickly, easily, and safely with them. Since he was capable of ambulation with either type of prostheses, it was possible to compare them in terms of energy expenditure. The results of these studies are summarized in the table, with the patient freely choosing his comfortable walking speed. It was found that when using stubbies he showed a 25% faster walking speed, 7.5% lower oxygen consumption per meter, and 15.2% higher oxygen consumption per minute. Considering the short stride length with stubbies and the resulting increased number of steps required to cover any distances, it is not surprising that the energy expenditure per minute was increased, but it should be noted that the energy expenditure per unit of distance (a measure of energy efficiency) was reduced in the face of this shorter stride length. Using the value of 0.16mL O*/kg/m for normal ambulation reported by Waters and associates7 this would translate into a 34% increase with Fig 2-Patient
2 ambulating
with stubbies.
most recent prostheses. For unknown reasons, he was then given stubby prostheses without hip joints, pelvic bands, or rocker bottoms (fig 2) and used them until age 21 years, when he asked for fulllength prostheses for improved cosmesis. He found that he frequently fell while walking with his new limbs, and resumed using his old stubbies. During the last six years he has had no falls and has been extraordinarily active, even engaging in vigorous sports such as handball. He has worn his full-length prostheses only twice during this period; once on the day of his wedding and once on the day we performed energy cost studies while he used them. When using the full-length prostheses he required the assistance of bilateral axillary crutches for balance (fig 3).
DISCUSSION The first and could
patient
described
only ambulate
was elderly,
for relatively
had heart
disease,
short distances
using
Energy Cost Studies for Patient 2: (a) When Walking With Stubby Prostheses; (b) When Walking With Conventional Prostheses lall values reDresent the averaae of two walks).
of
Type prostheses
Time
Stubbies
Distance Nm
2 mia/ 460/140 59 set Conventional 3 min/ 460/140 45 set
Speedkec !Wm
ml O2 /kg/min
m/O2 BP /kg/m Pulse (mm&)
2.5/0.77
9.85
0.215
80
179183
2.010.63
8.55
0.230
91
160/80
Fig 3-Patient
2 ambulating with full-length Nary crutches.
prostheses and ax-
Arch Phys Med Rehabil Vol96, April 1999
STUBBY PROSTHESES,
stubbies vs. a 44% increase with full-length prostheses. However, because this patient is not a bilateral A-K amputee patient, these energy cost studies are not comparable to the much higher values previously reported in bilateral A-K amputee patients by Huang and associates.* Our energy costs were performed only on a single individual and one cannot generalize the results with confidence, but in this patient they certainly suggest that his preference for stubbies was based on considerations of energy efficiency in addition to the previously reported advantages of safety and stability. This agrees with McKenzie’s5 comment that effort is minimized by the use of stubbies. Both Lowenthal and associates3 and McKenzie5 have used stubby prostheses as training devices to determine whether prosthetic ambulation is a feasible goal. In one of Lowenthal’s five cases it was elected to progress to full-length prostheses; the patient’s gait was more labored and his endurance reduced, but it was believed that the patient’s improved morale was sufficient compensation for these losses. Of McKenzie’s 38 bilateral A-K amputee patients, 14 became successful stubby users, but of these, only 5 were able to progress to full-length articulated prostheses. It would appear that stubby prostheses will serve as the prostheses of choice in most patients. Reporting on their series of 26 bilateral A-K amputee patients, Sakuma and associate& reviewed published reports on stubby prostheses but did not use these devices for tlieir patients, citing the disadvantages of unacceptable cosmesis, high cost, limited usefulness, and limited value as an evaluation tool.
they nevertheless have a place in the management and rehabilitation of selected patients. Indications for their use would include the following: (1) patients where considerations of safety, stability, and energy efficiency are paramount, such as the elderly amputee with cardio-vascular disease; (2) patients who are marginal in terms of ambulation potential, using stubbies to establish whether full-length prostheses should even be considered, and (3) patients who need or desire a form of nonwheelchair ambulation within their homes, for example, to get down a corridor or through doors too narrow to permit passage of a wheelchair. ADDRESS REPRINT REQUESTS Stanley F. Wainapel. MD University Hospital Boston, MA 021 IX
2.
3.
4. 5. 6.
7.
While we would agree that stubbies are not appropriate for all patients with bilateral amputations at or above the knee,
JL, Malone DG, Haraoui B, Wahl SM, Schrieber L, Klippel JH, Steinberg AD, Wilder RL: Rheumatoid arthritis: evolving concepts of pathogenesis and treatment. Annals Internal Medicine 101:8103U4, 1984. Rheumatoid arthritis is a chronic inflammatory synovitis that primarily involves peripheral diarthroidial joints. Immunohistologic analysis of diseased synovium has shown a spectrum of abnormalities that resemble various stages of a cell-mediated, or delayed-type, immune reaction. The infiltrating mononuclear cells produce various factors that modulate adjacent tissues and appear to produce the characteristic destructive features of the disorder. Our understanding of the mechanisms of action of various therapeutic modes also indicates that the disease is primarily mediated by activated mononuclear cells. All effective therapies have been shown to affect either mononuclear cell function or the rates of production or elimination of these cells. The disorder likely represents the pathologic expression of a genetically controlled host immune response to an undefined causative stimulus. The stimulus could be an infectious agent(s), a product(s) derived from an infectious agent(s), a constituent(s) of synovial or connective tissue, or a combination of these.
Arch Phys Med Rehabll Vol66, April 1666
Figueroa C, Rivera D, Wainapel SF: Table to facilitate donning stubby prostheses by bilateral above-knee amputees. Phys Ther 60:90%11, 1980. Huang CT, Moore NB, Jackson JR, Fine PR, Kuhlemier KV. Traugh GH, Sanders PT: Energy cost of ambulation for amputees: Study using mobile automatic metabolic analyzer. Arch Phys Med Rehabil58521, 1977. Lowenthal M, Posniak AO, Tobis SJ: Rehabilitation of elderly double above-knee amputee. Arch Phys Med Rehabil 39:290-
295, 1958. Mazet R Jr: Geriatric amputee. Artif Limbs 11:33111. 1967. McKenzie DS: Elderly amputee. Br Med J 1:153-156. 1953. Sakuma J. Hinterbuchner C, Green RF, Silber M: Rehabilitation of geriatric patients having bilateral lower extremity amputations. Arch Phys Med Rehabil 55:101-l 1 I, 1974. Waters RL. Perry J, Antonelli D, Hislop H: Energy cost of walking of amputees: influence of level of amputaton. J Bone Joint Surg [Am] S&42-46. 1976.
of selected literature
Decker
l
TO:
References
1.
CONCLUSION
ABSTRACTS
Wainapel
Chantraine A, Crielaard JM, Onkelinx A, Pirnay F: Energy expenditure of ambulation in paraplegics: effects of long term use of bracing. Paraplegia 22:173-181, 1984. l
Energy metabolism data were collected in a series of seven male paraplegic patients with complete cord lesions (T9 to Ll ). Among these four had just been rehabilitated and three had been using their bilateral long leg braces for more than 4 years. A group of five healthy volunteers was used as a control. All the subjects ambulated on a treadmill between parallel bars and in a second trial they ambulated on the floor using forearm crutches. Mean O2 consumption was 1.46 ml Oz/kg/m for the unaccustomed paraplegics who had never used long-leg braces before, 0.61 for paraplegics used to walking with braces, and 0.83 for the healthy subjects walking between parallel bars with a swing-through gait. The second trial (on the floor), showed a mean O2 consumption of 0.73 ml Ozikglm for the paraplegic brace-user with a high heart rate (156/min.). This mean O2 consumption was much lower than the values of the paraplegic non-user and slightly higher than the normal subjects.
Stubby Prostheses: An Alternative To Conventional Prosthetic Devices Stanley F. Wainapel,
MD, Harold March, MD, Laurence Steve, MPA, PT
Albert Einstein College of Medicine, Bronx, NY 10461 ABSTRACT. Wainapel SF, March H, Lawrence S: Stubby protheses: an alternative to conventional prosthetic devices. Arch Phys Med Rehahil 66:264-266, 1985. l Stubby prostheses offer potential advantages over conventional prosthetic devices in terms of safety, stability, and energy efficiency. Although cosmesis is compromised in the process, these short nonarticulated pylon prostheses may be a viable option to consider in bilateral A-K or knee disarticulation amputee patients under the following circumstances: (1) as a training tool to determine whether progression to full-length articulated devices is feasible; (2) as permanent prostheses for the patient whose primary need for ambulation is within his own home; (3) for the elderly bilateral amputee in whom ambulation is feasible hut safety and energy effkiency are of particular importance; and (4) as a definitive device in the patient who expresses a preference for them. Two patients who have become successful users of stubby prostheses are presented to illustrate these points. KEY WORDS: Equipment design: Prosthesis; Prosthesis design
Stubby prostheses (also referred to as “stubbies”) are short, nonarticulated pylon prosthetic devices which have been suggested as an alternative to full-length articulated prostheses in bilateral A-K amputee patients, particularly in the more elderly patient population. Previous advocates of stubbies3-” have stressed the following advantages related to their use: (1) lowered height and center of gravity, improving safety and reducing the danger of serious falls; and (2) eliminated prosthetic knee joint, improving patient stability. For the new amputee patient, stubbies condition the amputated limbs, particularly aiding in avoiding flexion contracture. The more contemporary designs (fig 1) include posteriorly protruding rocker bottoms for improved balance. Cosmesis is the primary disadvantage of stubbies, which makes them unacceptable to many individuals. Other problems include difficulty in transferring and in climbing stairs, curbs, and ramps. However, use of stubbies may be indicated and, in fact, may have a salutory effect on the quality of life. Two patients are described. CASE
within his apartment. Although he does not use them when outside his home. he takes great pride in remaining ambulatory. Casr of both At age formed walked weight
2. This U-year-old man was born with congenital anomalies legs; as a baby he could crawl but was never able to walk, 5 years. bilateral knee disarticulation amputations were perand he was fitted with conventional-length prostheses. He satisfactorily with them until age 15 years when excessive gain made it impossible for him to fit into the sockets of his
REPORTS
Case I. A 73-year-old man with diabetes and a long-standing history of chronic congestive heart failure (treated with digoxin and hydrochlorthiazide) underwent bilateral A-K amputations for nonhealing leg ulcerations. He was not given any prostheses and led a bed to chair existence at the time of our evaluation one year after amputations. At this time he demonstrated hip flexion contractures of 40” on the right and 25” on the left. Because of his strong motivation to walk, the patient was admitted and underwent an aggressive program of upper extremity conditioning and passive stretching of his hip flexion contractures, which were almost completely eliminated. He was measured for and provided with bilateral stubby prostheses with quadrilateral sockets, hip joints, double pelvic bands. and rocker bottoms (fig 1). After a period of five weeks of inpatient prosthetic training he was able to ambulate 40ft to 6Oft independently using an adolescent walkerette. He left the hospital after a total stay of 74 days and has been using his stubbies primarily for amubulation
Arch Phys Med Rehabil Vol66, April 1665
Fig l-Patient 1 ambulating with stubbies and adolescent walkerette. *Note posteriorly protruding rocker bottoms.
Submitted for publicaton January 20. 1984. Accepted in revised form August I, 1984. Dr. Wainapel is now associated with University Hospml, Boston. MA 021 IX.
265
STUBBYPROSTHESES, Wainapsl
his stubby prostheses and an 2adolescent-sized walkerette (the latter was needed because of his shortness of stature when using his stubbies). It was believed that his ambulatory potential with full-length conventional prostheses was questionable and therefore the stubbies would be the prostheses of choice. A special table, the construction of which is described elsewhere,’ was designed to facilitate the donning of his prostheses. This table gave the patient the ability to don his stubbies while sitting upright in his wheelchair, avoiding the cumbersome and fatiguing process of doing so in bed, and the subsequent task of transferring from bed to wheelchair while wearing the stubbies. The second patient was younger and more athletic than the first. He also had a lower level of amputations (knee disarticulations) and had been a prosthetic user since childhood. This man expressed a clear preference for stubbies, feeling that he could walk more quickly, easily, and safely with them. Since he was capable of ambulation with either type of prostheses, it was possible to compare them in terms of energy expenditure. The results of these studies are summarized in the table, with the patient freely choosing his comfortable walking speed. It was found that when using stubbies he showed a 25% faster walking speed, 7.5% lower oxygen consumption per meter, and 15.2% higher oxygen consumption per minute. Considering the short stride length with stubbies and the resulting increased number of steps required to cover any distances, it is not surprising that the energy expenditure per minute was increased, but it should be noted that the energy expenditure per unit of distance (a measure of energy efficiency) was reduced in the face of this shorter stride length. Using the value of 0.16mL O*/kg/m for normal ambulation reported by Waters and associates7 this would translate into a 34% increase with Fig 2-Patient
2 ambulating
with stubbies.
most recent prostheses. For unknown reasons, he was then given stubby prostheses without hip joints, pelvic bands, or rocker bottoms (fig 2) and used them until age 21 years, when he asked for fulllength prostheses for improved cosmesis. He found that he frequently fell while walking with his new limbs, and resumed using his old stubbies. During the last six years he has had no falls and has been extraordinarily active, even engaging in vigorous sports such as handball. He has worn his full-length prostheses only twice during this period; once on the day of his wedding and once on the day we performed energy cost studies while he used them. When using the full-length prostheses he required the assistance of bilateral axillary crutches for balance (fig 3).
DISCUSSION The first and could
patient
described
only ambulate
was elderly,
for relatively
had heart
disease,
short distances
using
Energy Cost Studies for Patient 2: (a) When Walking With Stubby Prostheses; (b) When Walking With Conventional Prostheses lall values reDresent the averaae of two walks).
of
Type prostheses
Time
Stubbies
Distance Nm
2 mia/ 460/140 59 set Conventional 3 min/ 460/140 45 set
Speedkec !Wm
ml O2 /kg/min
m/O2 BP /kg/m Pulse (mm&)
2.5/0.77
9.85
0.215
80
179183
2.010.63
8.55
0.230
91
160/80
Fig 3-Patient
2 ambulating with full-length Nary crutches.
prostheses and ax-
Arch Phys Med Rehabil Vol96, April 1999
STUBBY PROSTHESES,
stubbies vs. a 44% increase with full-length prostheses. However, because this patient is not a bilateral A-K amputee patient, these energy cost studies are not comparable to the much higher values previously reported in bilateral A-K amputee patients by Huang and associates.* Our energy costs were performed only on a single individual and one cannot generalize the results with confidence, but in this patient they certainly suggest that his preference for stubbies was based on considerations of energy efficiency in addition to the previously reported advantages of safety and stability. This agrees with McKenzie’s5 comment that effort is minimized by the use of stubbies. Both Lowenthal and associates3 and McKenzie5 have used stubby prostheses as training devices to determine whether prosthetic ambulation is a feasible goal. In one of Lowenthal’s five cases it was elected to progress to full-length prostheses; the patient’s gait was more labored and his endurance reduced, but it was believed that the patient’s improved morale was sufficient compensation for these losses. Of McKenzie’s 38 bilateral A-K amputee patients, 14 became successful stubby users, but of these, only 5 were able to progress to full-length articulated prostheses. It would appear that stubby prostheses will serve as the prostheses of choice in most patients. Reporting on their series of 26 bilateral A-K amputee patients, Sakuma and associate& reviewed published reports on stubby prostheses but did not use these devices for tlieir patients, citing the disadvantages of unacceptable cosmesis, high cost, limited usefulness, and limited value as an evaluation tool.
they nevertheless have a place in the management and rehabilitation of selected patients. Indications for their use would include the following: (1) patients where considerations of safety, stability, and energy efficiency are paramount, such as the elderly amputee with cardio-vascular disease; (2) patients who are marginal in terms of ambulation potential, using stubbies to establish whether full-length prostheses should even be considered, and (3) patients who need or desire a form of nonwheelchair ambulation within their homes, for example, to get down a corridor or through doors too narrow to permit passage of a wheelchair. ADDRESS REPRINT REQUESTS Stanley F. Wainapel. MD University Hospital Boston, MA 021 IX
2.
3.
4. 5. 6.
7.
While we would agree that stubbies are not appropriate for all patients with bilateral amputations at or above the knee,
JL, Malone DG, Haraoui B, Wahl SM, Schrieber L, Klippel JH, Steinberg AD, Wilder RL: Rheumatoid arthritis: evolving concepts of pathogenesis and treatment. Annals Internal Medicine 101:8103U4, 1984. Rheumatoid arthritis is a chronic inflammatory synovitis that primarily involves peripheral diarthroidial joints. Immunohistologic analysis of diseased synovium has shown a spectrum of abnormalities that resemble various stages of a cell-mediated, or delayed-type, immune reaction. The infiltrating mononuclear cells produce various factors that modulate adjacent tissues and appear to produce the characteristic destructive features of the disorder. Our understanding of the mechanisms of action of various therapeutic modes also indicates that the disease is primarily mediated by activated mononuclear cells. All effective therapies have been shown to affect either mononuclear cell function or the rates of production or elimination of these cells. The disorder likely represents the pathologic expression of a genetically controlled host immune response to an undefined causative stimulus. The stimulus could be an infectious agent(s), a product(s) derived from an infectious agent(s), a constituent(s) of synovial or connective tissue, or a combination of these.
Arch Phys Med Rehabll Vol66, April 1666
Figueroa C, Rivera D, Wainapel SF: Table to facilitate donning stubby prostheses by bilateral above-knee amputees. Phys Ther 60:90%11, 1980. Huang CT, Moore NB, Jackson JR, Fine PR, Kuhlemier KV. Traugh GH, Sanders PT: Energy cost of ambulation for amputees: Study using mobile automatic metabolic analyzer. Arch Phys Med Rehabil58521, 1977. Lowenthal M, Posniak AO, Tobis SJ: Rehabilitation of elderly double above-knee amputee. Arch Phys Med Rehabil 39:290-
295, 1958. Mazet R Jr: Geriatric amputee. Artif Limbs 11:33111. 1967. McKenzie DS: Elderly amputee. Br Med J 1:153-156. 1953. Sakuma J. Hinterbuchner C, Green RF, Silber M: Rehabilitation of geriatric patients having bilateral lower extremity amputations. Arch Phys Med Rehabil 55:101-l 1 I, 1974. Waters RL. Perry J, Antonelli D, Hislop H: Energy cost of walking of amputees: influence of level of amputaton. J Bone Joint Surg [Am] S&42-46. 1976.
of selected literature
Decker
l
TO:
References
1.
CONCLUSION
ABSTRACTS
Wainapel
Chantraine A, Crielaard JM, Onkelinx A, Pirnay F: Energy expenditure of ambulation in paraplegics: effects of long term use of bracing. Paraplegia 22:173-181, 1984. l
Energy metabolism data were collected in a series of seven male paraplegic patients with complete cord lesions (T9 to Ll ). Among these four had just been rehabilitated and three had been using their bilateral long leg braces for more than 4 years. A group of five healthy volunteers was used as a control. All the subjects ambulated on a treadmill between parallel bars and in a second trial they ambulated on the floor using forearm crutches. Mean O2 consumption was 1.46 ml Oz/kg/m for the unaccustomed paraplegics who had never used long-leg braces before, 0.61 for paraplegics used to walking with braces, and 0.83 for the healthy subjects walking between parallel bars with a swing-through gait. The second trial (on the floor), showed a mean O2 consumption of 0.73 ml Ozikglm for the paraplegic brace-user with a high heart rate (156/min.). This mean O2 consumption was much lower than the values of the paraplegic non-user and slightly higher than the normal subjects.