Brainstorming BilateralsBrainstorming Bilaterals

Case Studies

Bilateral amputees at RPCBilateral amputees at RPC

Rankin Park Statistics (Dec 02-Jan 06)Level No. Avg FIM Motor

Change2BKA 4 7.2

BK/AK 8 9.92

2AKA 3 16

Bilateral BKABilateral BKA

Bilateral BKABilateral BKA• Jake, 25 y/o male involved in a MVA resulting in

bilateral BKA, # L femur, dislocated L shoulder, and extensive burns to torso and legs. Patient had ORIF L leg and is NWB for 12/52 post-op, and required skin grafts to legs and torso. His upper limbs have FROM and strength.

• Patient is now 6/52 and just arrived to the rehabilitation ward. Previously Jake was fit and active, played sport socially, lived independently and worked full time in a relatively sedentary job. He would like to return to his job and living independently after rehab.

Bilateral BKABilateral BKA

1. What are the treatment priorities for this patient given their goals?

2. What factors may limit the progress of this patient?

3. What level of mobility would you expect this patient to achieve? What issues may effect this outcome?

4. How would this differ for other 2BKAs?

Bilateral BK/AKBilateral BK/AK

Bilateral AK/BK

• 75 yr old male admitted for rehab following a (R) AKA. Uncomplicated post op recovery.

• Pmhx: (L) BKA 8 yrs ago• HT• PVD• ETOH abuse• Ex heavy smoker

Bilateral AK/BK- Current status

• Independent with personal cares• Requires assistance to t/f to wheelchair

but is then independent on indoor surfaces• D/C destination to be determined• Demands a prosthesis to be able to walk

Bilateral AK/BK -Social history

• Previously lone liver, socially isolated.• Received assistance for

cooking,shopping,housework.• Fitted with interim prosthesis 8 yrs ago but

refused to use it.• Poor compliance with rehab in past.

Bilateral AK/BK-Discussion

• Would bilateral prostheses be appropriate for this pt ?

• What should treatment focus on ?• What else needs to be considered for this

pt to return home ?

Bilateral BK/TMTBilateral BK/TMT• 76 y.o. female. Background:

• NIDDM• Traumatic L BKA 10 years ago• Recent TMT amputation due to chronic toe

ulceration• Falls – 6 in the last 2 months• Still drives• Lives alone, no family near by (50klms away)• Hobbies – sewing, bingo 3x/week, choir (U3A),

baby sitting grandchildren some weekends.

Bilateral BK/TMT - Bilateral BK/TMT - DiscussionDiscussion

• What factors may have lead to the 2nd amputation? (preventable or not)

• What issues may effect her recovery and discharge?

• What considerations need to be made regarding prosthetic prescription?

Bilateral AKABilateral AKA

Bilateral AKABilateral AKA39 y.o. male

Workplace injury – run over by forklift

Degloving injuries

Complications – sepsis, PE

Bilateral AKABilateral AKA• Ongoing wound

issues included:• Hypergranulation• Foreign bodies, debris

surfacing after closure +/- breakdown

• “Tight” skin over residuum.

Bilateral AKABilateral AKA

Bilateral AKABilateral AKA• Marked mechanical

and phantom pain• Psyche involvement –

Post traumatic stress disorder?, depression, withdrawn.

Bilateral AKABilateral AKA• Seen at the Limb Centre 4+ months post

amputation. Initial program:• Strengthening – hip, UL, core stability• Hip F stretching• Compression pump therapy• Sitting balance• General fitness• Silicone liners - ? Precautions on grafted skin• Transfers, floor drill, problem solving functional

issues

Bilateral AKABilateral AKA• First appt!

Bilateral AKABilateral AKA

• High level sitting balance / core stability exercises

Bilateral AKABilateral AKA• Prosthetic fitting:

“Seal in” liners

• Gait training – Where do you start?– what level of mobility is

should you expect?

Bilateral AKABilateral AKA

First time on legs / sockets!

Bilateral AKABilateral AKA

Bilateral AKABilateral AKA

Bilateral AKABilateral AKA

Bilateral AKABilateral AKA

Complicating factors:• Multiple falls (++++) – from chair as well

as legs.• Stump wounds• Back pain• Home modifications

Bilateral AKABilateral AKA• Major house and car modifications• Ongoing Vocational and Leisure pursuits:

– Studying computers at TAFE (RTW strategy)– Exercise

• Swimming • Gym program• Ongoing physiotherapy.

• Prosthetic prescription – what is ideal?