Prosthetics and Orthotics International, 2004.

28, 9-21

From major amputation to prosthetic outcome: a prospective

study of 190 patients in a defined population

A. JOHANNESSON*, G.U. LARSSON** and T.OBERG***

*Department of Neuroscience and Locomotion, Psychiatry, Linkoping University, Sweden

**Department of Orthopaedics, HassleholmiKristanstad, Sweden
***Department of Rehabilitation, Jonkoping University, School of Health Sciences, Sweden

Abstract New procedures, treatments and techniques

In this prospective study, the overall
treatment and outcome of patients that
underwent major lower limb amputation in a
defined population is described. The study
was performed over a five year period in the
Health Care District of North-East SkAne,
Sweden.
Some 190 patients, permanent inhabitants of
the Health Care District, underwent major
lower limb amputation. Sixteen ( I 6) of these
patients had amputations before the study
started and went through late second leg
amputation during the period. One hundred
and seventy four (174)patients had primary
major amputation. Seventy nine (79) were
men and 95 were women, with a median age
of 81. The re-amputation rate was 17%
although the primary knee preservation ratio
was as high as 3.0:l.Rigid dressing was the
standard method following trans-tibia1
amputation and was used for 5-7 days.
I C E R O S P silicone liner was used for
compression therapy in 90% of all cases that
resulted in delivery of a prosthesis. Prostheses
were delivered to 43% of all patients with
primary amputations. These patients spent a
median of 13 days at the orthopaedic clinic, 55
days at the rehabilitation unit. Pressure casting
was used as a standard method in the
production of the prosthetic socket. ICEX'
carbon-fibre socket was used in 52%.
All correspondence to be addressed to: Anton
Johannesson. OTAB, Centralsjukhuset, SE-29 I 85
Kristianstad, Sweden. Email: aj.otab@telia.com.
9
were introduced, standardised and evaluated
whilst the routines in the hospital were
reorganised. In this way, a system has been
implemented that better guarantees the
outcome of the whole procedure and the
service received by this category of patients.
Introduction
Lower limb amputation is often the result of a
long and difficult period of illness for the elderly
patient. The underlying, systemic disease is
chronic and progressive. Lengthy attempts to
save the limb can severely compromise the
physical and emotional condition of the patient.
Rehabilitation of these patients is a challenge,
and a multi-disciplinary approach has proven to
be the most effective path (Murdoch 1994;
Seymour, 2002). A number of investigators have
studied major amputations but these studies have
varied due to the limitation or lack of definition,
and/or differences in methodology (Eneroth et
al., 1996).
Only a few prospective studies use clear
definitions when describing management and
outcomes following major lower limb
amputations, in a defined population (Eneroth et
al., 1996; Pohjolainen, 1991; Larsson, 1994;
Pernot et al., 2000). In these studies, the
outcomes following lower limb amputation have
been determined by the three traditional stages
of interest; level and technique, post-operative
treatment and rehabilitation. It is proposed that a
fourth, prosthetic outcome, is included in order
to obtain a better understanding of total outcome
following major amputation for these patients.
 10 A. Johannesson, G.(1. Larsson and T.Oberg
The field of interest for investigation can be
divided into:
Description of methodology
Incidence
Aetiology
Social status of the patient
Surgical technique
Post-operative treatment
Outcome regarding rehabilitation, prosthetic
fitting and function
Description of the prosthetic socket technique
used
Mortality and survival rate
In an extension of previous studies, the
authors have now examined the total outcome in
a defined population by identifying: 1) who the
patients are, 2) what kind of treatment they
receive, 3) what the rehabilitation outcome is,
and 4) what kind of prosthetic technique they are
provided with. In order to gain this information,
the population was monitored during five years,
with a minimum follow-up of 2 years.
Method
From 1995 until the end of 1999, all patients
undergoing major lower limb amputation in
the Health Care District of North-East
Skhe, Sweden were studied prospectively. The
district is part of S k h e County and during
the study period the mean population was
170,424 inhabitants (range=168,870-172.030).
The incidence was calculated by
(n/5)x 100,000/170,424.
In the district, there are 2 hospitals,
Kristianstad and Hiissleholm. They share the
same department of orthopaedics. One (1) is
specialised in acute care and the other one in
elective orthopaedic surgery. All surgical data
were consecutively recorded and processed in
uniform, computerised charts at the clinics.
Infection data were collected from a register for
postoperative infections run by the Clinic for
Infectious Diseases. Prosthetic records were
,used to collect data from the rehabilitation unit
at both hospitals. Data were also gathered from
the prosthetic workshop.
study sample
One hundred and ninety (190) patients,
permanent inhabitants of the Health Care
District, underwent major lower limb
amputation. Sixteen (16) of these patients had
amputations before the study started and went
through late second leg amputation during the
period. Five ( 5 ) patients were operated outside
the district. Four (4) of these patients were
operated at other hospitals in the county
because they were already undergoing
treatment in these hospitals before the
operation (3 due to cancer, 1 due to infection).
One (1) patient had an amputation following
trauma in a hospital outside the region but
received all aftercare in the authors' hospital.
No other major amputations were performed on
inhabitants with their home address in the
district, between 1995- 1999.
Management procedure and material
In Hassleholm-Kristianstad, a concept was
developed using standardised surgical
techniques, documentation, treatment of stumps,
early rehabilitation and follow-up. A
multidisciplinary team approach was used. The
team consists of an orthopaedic surgeon, a
prosthetist and a physiotherapist as permanent
members, with access to other specialists such as
a rehabilitation consultant, a nurse and an
occupational therapist. Orthopaedic surgeons
performed all amputations. A protocol was used
to assure a consistent surgical outcome and an
effective process. Only patients diagnosed as
diabetic before the amputation were recorded as
diabetic. Of the 174 patients that underwent
primary major amputation, 48 patients were
walking without aid 3 months before the
amputation, 78 used walking aids and 48 did not
walk at all.
Rigid plaster of Paris dressings were applied
on the operating table following trans-tibia1
amputations (TT). After 5-7 days, the plaster of
Paris dressing was removed and compression
treatment with a silicone liner was started
(serious senile dementia and purulent infection
were contraindications). Trans-femoral
amputees (TF) were managed with soft dressing
'and elastic bandage and afterwards in the same
manner as for trans-tibia1amputation. In both TF
and 'IT amputation, the silicone liner was
generally applied 5-7 days post-operatively.
Silicone liner
The construction and geometry of the silicone
liner (ICEROSS8Post Op, Ossur HF, Reykjavik,
Iceland) assures gradient and consistent
compression therapy. The main objectives of the
use of a silicone liner are to:
 From major amputation to prosthetic outcome 11

Definitions and abbreviations

Primary-: the first amputation procedure in a sequence until a final outcome (healing or
death) (Larsson, 1994).
New-: amputation of a limb upon which a previous amputation has been performed
and healed (Larsson, 1994).
Re-: amputation of a limb upon which a previous major amputation has been
performed but not yet healed (Larsson, 1994).
Bilateral-: simultaneous amputation on both lower limb, irrespective of amputation level
(Larsson, 1994).
Second leg-: amputation in a patient who has had previous amputation of the contralateral
leg (Larsson, 1994).
LateSecond leg-: major amputation in a patient who has had a previous amputation of the
contralateral leg before the study started (Authors own definition).
Final level-: the last amputation where healing has occurred, irrespective of level or side,
during a rehabilitation and/or time period (Authors own definition).
Major amputation-: amputation through ankle or higher (Eneroth e l af., 1996).
Minoramputation-: amputation below the ankle (Eneroth er al., 1996).
TT/TF ratio: Amputation performed at trans-tibial level (TT)divided by amputation at
knee disarticulation plus trans-femoral level (KD + TF)
PVD: -
Peripheral vascular disease - arterial occlusive disease due to
arteriosclerosis and/or diabetes

Functional assessment
Walker: Walking with or without aid.
Not walking: Sitting in a wheelchair or bedridden
Good function Patient fitted with prosthesis, wears it daily and is able to walk alone or
with prosthesis: with assistance outdoors or alone indoors.
Poor function Patient fitted with prosthesis but does not wear it daily but is unable to
with prosthesis: walk indoors without assistance or is dependent on a wheelchair most of the
time or all the time (Hermodsson and Persson, 1998)

Abbreviations according to I S 0 8548,8549:

TF = Trans-femoral amputation
KD = Knee disarticulation
TT= Trans-tibial amputation
AD = Ankle disarticulation

decrease oedema; temperature up to 131°C for 30 minutes and

shape the stump prior to prosthetic fitting;
contribute to pain relief;
accelerate the rehabilitation process.
The silicone liner is an alternative to
traditional stump managemeht including elastic
bandage and compression stockinette. Further
benefits have been found in the practical use of
the liner, such as the fact that the same level of
compression is achieved regardless of who
applies the liner. In traditional care, both the
compression and the quality of the dressing
vary, depending on the individual who performs
the treatment. The silicone material is possible
to clean and disinfect or sterilize to il
100Mpa, to avoid microbiological colonization.
As the oedema reduces, a smaller sized liner is
used to assure suitable compression.
Training
Training and exercises for standing and
weight bearing were started the day after
surgery, the patient’s general condition
permitting. Ambulation with a training
prosthesis was started when the plaster of Paris
dressing was removed. This training took place
in the geriatric rehabilitation department. All
patients that were defined by the team as
walkers. 3 months prior to the last amputation
12 A. Johannesson. G . U.Lursson and T.Oberg
Fig. 1. Schematic rehabilitation procedure.
were candidates for rehabilitation with a
prosthesis.
Prosthesis
Optimally, casting for the first definitive
prosthesis was carrisd out 3 weeks following the
operation. During the first 2 years of the study,
the sockets were made either in transparent
thermoplastic or laminated material. Since 1997,
a prosthesis that is cast and made directly on the
stump has been used instead (ICEXO, Ossur HF,
Reykjavik, Iceland). With this technique, the
definitive socket is moulded directly on the
stump with a carbon fibre braid and delivered
the same day to the patient.
The rehabilitation continued on an outpatient
basis when walking was re-established. This was
either done as all day visits to the rehabilitation
clinic or in the walking school. A group of
amputees attended the walking school once a
week, all amputees being welcome regardless of
when the amputation had taken place. The
patients were also asked to come to the walking
school for regular follow-ups by the
multidisciplinary team (Fig. 1).
Analysis
Values are given in median and range (except
in Table 8 where mean is given for comparison).
The Student t-test was used for comparing
continuous variables between two groups (e.g.
age, gender). For ordinal outcome the Mann-
Whitney test (comparison between groups) or
the Kruskal-Wallis (more than 2 groups) were
used. For unordered categorical outcome (e.g. .
Operation code) the Chi-square test was used.
To evaluate mortality the Kaplan-Meier product
limit estimator and log-rank test was used. All
data was analysed with SPSS' for Windows
version 11.0 (SPSS Inc. Chicago, USA).
Results
Patients
From 1995 through 1999, 174 patients
underwent primary major amputation (79 men
and 95 women). The overall median age was 8 1
(30-101) (Fig. 2). Men were younger than
women, the median age being 78 (30-92) and 83
(41-101) respectively (p<O.Ol). If cancer,
trauma and infection were excluded (n=7), the
median age for men was 79 (60-92). The other
Median 81.00
Mean 79.10
Std. Deviation 10.557
Range min 30
max 101
Percentiles 25 73.75
50 81.00
75 86.00
 From major amputation to prosthetic outcome
figures remained unchanged. The patients that
were amputated because of peripheral vascular
disease (PVD)without known diabetes (45 men
and 58 women) were older than patients
amputated with known diabetes (29 men and 35
women), the median age being 83 (61-101)
compared to 78 (41-96) (pc0.01). The
amputation was performed on the left side in 92
patients and 82 on the right. No significance was
found regarding amputation side. Women were
more frequently amputated on the left side
compared to the right (56/39), while the
differences for men were smaller (36/43)
Incidence
Major amputation incidence in the district
13
during the period is illustrated in Table l a and
with adjusted rate regarding age and gender in
Table lb.
In total, 250 major amputations were
performed on 221 limbs (Table 2). There were
24 re-amputations, 29 patients underwent
second leg amputation and 2 were bilateral
amputations. Five (5) patients underwent re-
amputation twice. Sixteen (16) patients
underwent primary amputation before 1995 and
had late second leg amputation on the
contralateral leg during the research period. One
(1) out of 10 patients went through second leg
amputation during the period and almost 1 out
o f 5, if late second leg amputations are taken
into account.

n 1 Per 100,000/year
Primarv amoutation [second leg" excluded)
I .
174 I 20.4
Primary amputation second leg including amp (+ 29) 203 23.8
Primary amputation late second including leg amp (+16) 219 25.7
All amputations 250 29.3
*Amputation through ankle or higher.
Table 1b. Gender-specific incidences for primary major amputation (per 100,000/year), standardised for age.
Gender Male Female
No. Rate No. Rate
N 1995- (per 100,OOO N 1995- (per 100,U
Population (in looOS)* % 1999 /year) (in 1OOOs)* % 1999 / year
4 0 56.20 66.90 2 0.7 53.92 63.03 2 0.7
51-60 10.97 13.06 1 I .8 10.63 12.43 5 9.4
61-70 7.77 9.25 16 41.2 8.38 9.79 12 28.6
71-80 6.45 7.68 26 80.6 7.93 9.28 19 47.9
81-90 2.59 3.08 32 247.0 4.61 5.38 51 221.5
91+ 0.02 0.03 2 1,626.0 0.07 0.08 6 1,651.1
Total 84.01 100.00 79 1,997.3 85.54 100.00 95 1,959.2
Age adjuste
rate 18.8 19.0

Table 2. Frequencies, regarding definition of amputation.

Frequency Percent
Primary Amputation 174 69.6
Re-amputation 24 9.6
Second leg amputation 29 11.6
Bilateral amputation 2 0.8
Second late amputation 16 6.4
Re-amputation final level amputation 5 2.0
Total 250 100.0
 Primary
Year amputations TF KD
1995 36 7 2
1996 44 16% 2 2s
1997 32 2 0
1998 35 4 3
1999 21 4 3
Total 174 33 10
The incidence of major lower l i b amputation
because of PVD without diabetes was
12.1/100,000 per year compared to 7.5/100,000 per
year for PVD and diabetics. Eight percent (8%)of
the patients had undergone minor amputation prior
to the major amputation and 23% had gone through
reconstructive vascular procedures.
Mean number -of primary amputations
performed per year was 35 compared to 50
amputation procedures carried out per year
(range-113-60). There were only small changes
in level distribution during the period (Table 3)
except in TFs where in 1996, 16 amputations
were performed compared to 2 the year after.
Transpelvic and transcoxal amputations were
not performed during the study period nor were
any major congenital deformities reported that
required a prosthetic application.
Clinical symptoms and findings were the
deciding factor for amputations. Some 47%
were due to progressive gangrene, 33% to
intolerable pain, 15% to septic and/or toxic
conditions and 5% to other reasons.
The re-amputation rate following primary
amputations was 17% (29/174), with yearly
range 13% to 21%. This corresponds to the
frequency of TF amputations. No re-amputation
was done after TF and 2 after knee
disarticulation (KD).
Surgical and postoperative outcome
Primary amputations were performed by 41
orthopaedic surgeons, 9 of whom performed a
total of 100 amputations (range = 6-22) with a
prosthetic outcome of 41%. This compares to
the 32 surgeons performing 1 to 5 operations
during the period with a prosthetic outcome of
37%. If the amputations conducted in other
hospitals (n = 5) are excluded, the prosthetic
outcome was 33% for the latter group. Some
23% of the patients had gone through
All major
?T AD amputations
27 53
1 60
30 48
28 46
20 43
130 1 250
revascularisation operation on the same side
before the amputation and 8% had gone
through minor amputations. In 97% of the
cases, primary sutures were used. Rigid, plaster
of Paris dressings were applied on the operating
table in 91% of all cases following trans-tibia1
amputations and in other cases soft dressing
was used. Sagittal flaps were used in 90% of all
trans-tibia1 amputations. Silicone liner for
compression therapy was used in 66% of the
primary cases and in 90% of all cases that
resulted in delivery of a prosthesis.
Infection
The use of active drainage showed no
significant difference compared to the use of no
drainage (Table 4 (a)), nor did the risk of
infection when different amputation levels (TT+
Ankle disarticulation (AD) vs. TF + KD) were
compared (Table 4 (b)).
Rehabilitation outcome in patients receiving a
prosthesis
The rehabilitation outcome is referred to as
cases (n = 90, 42 male and 48 female) or
patients (n = 83, 40 male and 43 female). The
reason is that during the study period, some
patients were rehabilitated more than once.
Two (2) patients were re-amputated at the
same level and received prostheses in both
'cases.
Seventy-six (76) cases spent a total of 1193
days at the orthopaedic ward (median 13 days)
after the amputation. Fourteen (14) cases, that
also received prostheses, were staying at other
clinics. The total number of cases that were
discharged to the rehabilitation clinic or
community based rehabilitation service centres
in the study was 85. They used a total of 4961
days for rehabilitation with a median of 55 days
per case (range: 1-210).
 From major amputation to prosthetic outcome 15
Table 4. (a) Infections relating to drainage.
Drainageunfection Deep Superficial Uncertain No infection Total
infection infection
Active % (n) 4.4 (7) 1.9 (3) 5.1 (8) 28.5 (45) 36.2% (63)
Not active % (n) 0 (0) 0.6 (1) 3.8 (6) 8.2 (13) 11.5% (20)
No drainage % (n) 5.7 (9) 7.0 (1 1) 5.1 (8) 29.7 (47) 43.1% (75)
Total 10.1 (16) 9.5 (15) 13.9 (22) 66.5 (105) 100% (158)

LeveNnfection Deep Superficial Uncertain No infection Total

infection infection
TT + AD (n) 13.1 (17) 10.0 (13) 14.6 (19) 62.3 (81) 74.7% (1 30)
TF + KD (n) 4.8 (2) 9.5 (4) 9.5 (4) 76.1 (32) 24.1% (42)
Not detectable 1.2% (2)
Total (n = 172) (19) (17) (23) (1 13) 100% (174)

Table 5. G = Good function with prosthesis: Patient fitted with prosthesis, wears it daily and is able to walk alone or with
assistance outdoors or alone indoors.
P = Poor function with proghesis: Patients fitted with a prosthesis but does not wear it daily or weus it daily but is unable
to walk indoors without assistance or is dependent on a wheelchair most of the time or all the time. (Hermodsson er al, 1998)
1 Ammtation level I AD
Total no. of amputation per
level (Total) (Total)
Number of prostheses and
functional level GP GP Total with prostheses
Prirnary- (1) (33) 681174 = 39 % **
n: 174 01I 4/4
Re-amputation (16) 701114 = 40 % **
n: 24 MI
Incl. final level, with (5) 751174 = 43 % **
prostheses n: 5 510
Incl. second leg- (10)
, n: 29 801174 = 46 % ***
Incl. late second leg-
n: 16 (3) I 88/190=46 %***
Incl. the bilateral-side
n: 2 901190 = 47 % ***
Total (1)
92*/250 = 37 % ****
1
GP: 011 I014
I Total prosthesis produced I =I
*Two patients were re-amputated (AD+TT and TT+lT) and'received prostheses in both cases during the same
rehabilitation period.
** Per amputee *** Per amputated leg **** Per total amputation

Some 73% of patients came from their own
home, 53% returned to their previous dwelling
and 47% to community service home (CSH).
Table 5 illustrates the outcome regarding
prosthetic fitting, function and level. Eighty-
eight (88) cases were rehabilitated with a
prosthesis. Functional assessment of the
outcome was carried out at discharge from the
hospital ward. Of the TT -tAD, 88% had good
results in walking ability (n = 73) compared to
73% of the T F + KD (n = 15). The
rehabilitation outcome including all patients
receiving a prosthesis for the first time was
43% (43% TT+AD and 33% TF+KD). The
 __

Age 78.0 (r = 30 - 96) 76.5 (r = 64 - 89) 78.0 (r = 30 - 96)

Days 47.5 (r = 13 - 188) 55.0 (r = 23 - 292) 48.0 (r = 13 - 292)

Number Days Median

Laminated 19
Thermoplastic 14
ICEX 43
* Prosthesis delivered the same day
primary TT/TF ratio was 3.0:l compared to
2.2:1, if all amputations were taken into
consideration.
Prosthetic fitting
Ninety-two (92) prostheses were made for 83
patients during the period (76 TT,14 TF, 1 KD
and 1 AD). Of these, 68 patients were fitted with
a prosthesis following primary amputation, 2
more after re-amputation, 5 after final
amputation, 5 after second leg amputation, 8
after late second leg amputation and 2 more if
the bilateral side is included. Table 6 shows the
median age and mean time from amputation to
delivery of prostheses. It took 15% longer to
deliver a TF/KD prosthesis compared to a
TT/AD prosthesis, when the median is
compared.
7 - 42 18 days
2-21 12 days
0-9 0 days*
50% in the laminate/therhoplastic group.
Different prosthetic feet and other components
were used with priority on low weight when the
first prosthesis was made.
Mortality
The overall mortality after one month was
16% (n = 27). after three months 31% (n = 41)
and after one year 47% (n = 82) and after two
years 60% (n = 104). Of the patients who
received prostheses, two died within 90 days, 11
(13%) died within a year and 23 (28%) within
two years (Fig. 3).
Discussion
Previous studies indicate the complexity in
reporting overall outcomes from a population
that goes through major lower limb amputation.

Pressure casting
The ICECAS'P pressure casting technique
was used in 87% of the cases in the production of
prosthetic sockets. In the remaining cases,
traditional hand casting was used because of the
technical restriction of the device due to
amputation level e.g. most of the TF or KD cases.
In all cases of TF and lT.an ICEROW silicone
liner served as the soft inner material. The hard
socket was created with ICEX* carbon fibre
socket made directly on the patient's stump in
,52% of all cases. Traditional production
methods, using thermoplastics made up 22% and
lamination 26%.
1 3E - 1
0.0
0 1 2 3 4 5 6 7
.
-PVD

The production time between different

Followup (years)
production methods of trans-tibia1 prostheses is
shown in Table 7.
One (1) patient, out of 43 in the I C E P group
n = 1 6 4 ) 31 123) 17 1 9 I 7 1 6 1 5 (PW+DW

did not receive a prosthesis on the same day.

n=I1031 % 1 4 2 1 XI 121 I 15 1 1 4 1 13 (PW)
Fig. 3. Survival after primary amputation, including
Some 46% of the patients changed socket within comparison between patients with and without diabetes.
a year due to volume changes, 43% ICEX and n indicates number of patients.
 From major amputation to prosthetic outcome 17

Table 8. Comparison between different studies from Scandinavia.

'Authors Observation Incidence TT Primary Re- Age** Mortality
time of major KDm TT:TF amputation (mean) in %
~
amputation =N ratio (%) after 2
per 100,OOO Years

Kald el al., 55
1989 0/61
Sweden 1980-82 46 =I19 0.8:l 10.1 79 56
Pohjolainen 233
et 01.. 1988-89 OD53
Finland 1984-85 33i28* =586 0.7:l 71* 43
Jensen et a[., I36

*incl. minor amputation. ** mean age when primary amputation was performed. tonly IT and KD presented
It also shows the need for clear guidelines for
comparison in descriptive studies. Many studies
report only the overall incidence of amputation
and mortality, whereas others include only
patients admitted for rehabilitation (Hermodsson
et af., 1998; Eneroth and Persson, 1992; Alaranta
el al., 1995). Knowledge about rehabilitation
methods and their results are needed (Pernot et
al., 2000). In this descriptive study the authors
have added more factors than in other similar
studies. The authors describe the methodology,
rehabilitation, prosthetic techniques, outcome
and mortality whereas in other studies some of
these parts are missing or the'definitions such as
MajorWinor amputation are put together and/or
the prosthetic technique is not described.
Comparison with other Scandinavian studies
If other Scandinavian studies conducted
within the last fifteen years (Table 8) are
considered, it clarifies the difficulties of
comparing results because of the different
definitions, methods and/or the focus of the
studies. The present study material does not
show a significant decrease in the incidence of
major amputation, although improvements have
been made in the conservative treatment of
diabetes and there is more widespread use of
vascular surgery. This could be because the
mean lifetime of the population has increased.
The average length of life in Sweden was 77.4
years for men and 82.0 years for women, in year
2000. Of particular interest is that, the remaining
life expectancy for 65 year old men was 16.5
years and for women 19.9 years (Sweden's
Health Care Report 2001, The National Board of
Health and Welfare).
The mean age (79.1) and the knee
preservation ratio (3.0 1) are close to the highest
ever reported (Eneroth and Persson, 1992). The
differences in amputation level per year reported
in Table 3, cannot be explained by differences in
the clinics involved. The re-amputation rate is
on a similar level as the other authors compared
(Eneroth and Persson, 1992; Kald et a1.,1989;
," and Ronningen, 2001). The T / T F ratio
W'rtso
18 A, Johannesson,G.U.Larsson and T. dberg
of 2.5 is know to be the golden standard
(Eneroth, 1997; Dormandy et al., 1994) this is
only achieved in 2 of the 8 studies. If the ratio is
high, the risk for infections could be predicted to
be higher. That statement could not be supported
in this study. It is an accepted fact that knee
disarticulation is preferred to trans-femoral
amputation for prosthetic candidates. The
question arises if that level is preferred over
trans-tibial amputation, because it is easier to
perform as the surgeon does not have to cut
through bone or use plaster of Paris. If that is the
case then the rehabilitation outcome will be at
risk due to inferior suspension and heavier
prostheses in comparison to TT prostheses.
The main differences compared to other
studies are the number of patients receiving
prostheses (Eneroth and Persson, 1992; Kald et
al., 1989; Pohjolainen and Alaranta, 1988) and
the time from amputation to delivery of the
definitive prosthesis (Laaperi et al., 1993;
Pohjolainen et al., 1989 ). Poor reporting or lack
of studies from other groups, could explain this.
Comparison with other studies
Other comparisons are difficult to carry out,
because of the differences in aetiology, age and
race. However in a recently presented study by
Fletcher et al. (2002) certain similarities could
be found; all patients in their study were
Caucasian, the median age was 79 years
compared to 81 in this study; diabetes occurred
in 49% of the cases compared to 38%; TTRF
ratio was 2.0:l compared to 3.0:l and 33% of
patients were fitted with a prosthesis, compared
to 43% in the authors’ study. The only difference
is the delivery time of definitive prostheses, 114
days in the Fletcher study, compared to 49 in the
present study. No description was made of the
treatment or the prosthetic technique used that
could explain these differences.
Definitions
,One source of error is when no difference is
made between minor and major amputations
(Pohjolainen et al., 1989; Ebskov, 1996).
This division is necessary due to differences
regarding the amount of tissue trauma, the
surgical technique, the postoperative treatment
and the rehabilitation. For instance following a
minor amputation a patient can spend most of
the healing time out of hospital, ambulation can
be maintained and the functional outcome is
totally different (Ebskov, 1996; Larsson et al.,
1998). Confusion in the definitionsof second leg
and bilateral amputations can be found in many
studies. In the current material only 2 patients
met the criterion of bilateral amputation.
Surgical experience
The surgical experience of the doctor that
performs the amputation has been discussed in
other studies (Campbell et al., 1994) and the
outcome regarding healing is difficult to predict
(Dormandy et al., 1994). In the present study,
there is an indication of better results regarding
prosthetic outcome for surgeons that perform
amputations more frequently.
Rigid dressing and compression treatment
The use of rigid dressing following TT
amputation has shown many advantages
compared to soft dressing. This method affects
in a positive way the outcome regarding pain,
length of hospital stay and time to prosthetic
fitting (Barber et al., 1983;.Gandhavadi, 1987;
Goldberg et al., 2000; Wong and Edelstein,
2000). In 1992, the first documented case of the
use of ICEROSS@ silicone liners for
compression treatment was tried out on a patient
5 days following TT amputation. The results
were encouraging and after a ma1 period, in
1995 the method became the standard
compression therapy at the authors, hospital
(Larsson and Johannesson, 2001).
Compression treatment using elastic bandages
has been shown to influence the shape of the
stump for prosthetic fitting (Manella et al.,
1981), although there are some disadvantages
(Isherwood et al., 1975) such as the possibility
of tourniquet effect and problems maintaining
adequate pressure. The roll-on design of the
silicone liner is often less traumatic to the suture
line when a sagittal incision is used (or the
transverse in TFs). Also, the same compression
is ‘achieved irrespective of who rolls on the liner
and the occlusive environment is favourable for
wound healing (Viger et al., 1999).
The outcome of rehabilitation in this study is
difficult to compare to others. This supports the
conclusion from Pernot et al. (2001) who found
that comparison of rehabilitation outcomes is not
possible, because of differences in selection
criteria and differences in defining walking
ability. In a newly reported meta-analysis
(Rommers et al., 2001), the conclusion was
 From major amputation to prosthetic outcome
drawn that there is no consensus regarding
measurement of mobility. The definition of
functional ability used in the present study is not
detailed enough to draw conclusions but gives
an indication of the outcomes. It shows and
supports other studies of poorer outcome
following TF compared to TT amputation.
Rehabilitation
Rehabilitation planning needs to start at the
same time as the decision to amputate is made
(Cutson and Bongiorni, 1996). The goal should
be to regain walking ability in those patients
who were walking 3 months prior to the
amputation. Following rehabilitation a helping
hand is often needed, from relatives or a partner,
for the amputee to be able to continue living in
his or her own home. The fact that almost half of
the patients (47%) are living alone prior to the
amputation needs to be-taken into consideration.
This allows a possibility to plan the resources
that are needed after the amputation.
This study shows the hospitalisation
requirements for these elderly patients. On
average the patients stay 2 weeks at the
orthopaedic ward and the rehabilitation takes 55
days. Five ( 5 ) out of 7 of the patients that receive
a prosthesis, return to their previous home. This
does not mean that the patients are discharged
from the multidisciplinary team. The difference
of being institutionalized or being able to
continue living in the community is often related
to the use of a prosthesis (Fletcher et al., 2001).
Therefore, continuous access to the team is
needed and regular checks should be made to
ensure that their level of function is maintained as
far as possible (Hemodsson and Persson, 1998).
Prosthetics
There are to the authors knowledge, no
descriptive studies refemng to the definitive
prosthetic technique used.
The prosthetic technique used in this study is
based on the technique that. Isherwood (1977)
started and that Kristinsson (1993) developed
further when in 1992 he presented the
ICECASP pressure casting technique. This
provides equal pressure around the stump when
casting, compared to traditional hand casting
that results in specific area pressure inside the
final socket. There is evidence supporting better
distribution of loads inside the prosthetic socket
when using the hydrocast socket (Convery and
19
Buis, 1999), but no long term outcome study has
been made on the subject. When the ICEX'
carbon braid was added into the system in 1997,
the production of a socket could be reduced to
one session. The advantage of combining
ICECAST and ICEX' was the reason that this
concept was chosen. It is the authors' opinion
that for elderly people, it is of vital importance
that rehabilitation takes place as soon as possible
due to their overall health status. Other aspects
are the cost of hospital stay (Apelqvist et al.,
1995; Eneroth et al., 1996) and the benefit of
delivering the prosthesis without delaying the
rehabilitation process. Although the provision of
the first definitive prosthesis takes place with a
mean delivery time of 48 days, and the study by
Lilja and Oberg (1997) recommends the proper
time for definitive socket to be around 120 days
after the amputation, the patients of this study on
average need no more than one prosthesis and
one new socket during the first year
(Hermodsson et al., 1998).
Mortality
The mortality rate in this study confirms the
findings in other Scandinavian studies (Jensen et
al., 1983). The life expectancy of the patients is
low (60% die within 2 years), with an expected
difference for patients rehabilitated with a
prosthesis, where 28% die within 2 years. No
differences were found regarding the mortality
rate between genders, age, amputation level or
diagnosis.
Conclusions
The main advances in the work presented in
this descriptive study, are that the authors have
documented and followed the patients in a
standardised manner. A system has been
introduced that better guarantees the outcome of
the work and the service for these patients.
Comparisons between different studies in this
field are shown to be difficult. Common
standards are needed.
A multidisciplinary team approach with a
specialist network, working with documented
methods and individual goals for the patients, is
recommended.
Acknowledgements
This study was supported by grants from
Clinical Research Council in Kristianstad and
Hassleholm, Sweden.
 20 A. Johonnesson. G. U.Lorsson and
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