SLR - March 2011 - Thomas Chambers
Reference: Jeans KA, Browne RH and Karol LA. Effects of Amputation Level on Energy Expenditure During Overground Walking by Children with an Amputation. J Bone Joint Surg Am. 2011;93:49-56.
Scientific Literature Review
Reviewed By: Thomas Chambers, DPM, PGY-1
Residency Program: Southern Arizona VA Healthcare System
Podiatric Relevance:
Would a pediatric patient be better off with a higher level of amputation versus a distal one that could be performed by a podiatrist such as a Symes amputation? Although studies have been done in adults to evaluate the energy requirements following lower limb amputation, few studies have been conducted to evaluate energy consumption for children following a lower extremity amputation. Because studies have shown differences in oxygen consumption between adults and children, it is unclear if the studies on adults can be properly correlated with those on children.
Methods:
Inclusion criteria included a unilateral or bilateral amputation in a patient greater than four months old. They had to be free of neurological involvement or any prosthetic complications. Any malfunctioning prosthesis was repaired prior to study. Levels of amputation included: Symes, transtibial, knee disarticulation, transfemoral and hip disarticulation.
Metabolic testing and heart monitoring was used first during a five minute seated test, then a 10 minute walk at self selected speed around a 40 meter loop, and then during three minutes of recovery. Metabolic testing on normal children was used as a control group. Measurements included: resting VO2 rate and heart rate; walking VO2 rate, VO2 cost, heart rate and self selected velocity.
Results:
73 children between 4 and 19 years of age were selected for the study and divided into groups based on level of amputation. Seven had bilateral amputations and were placed in a separate group. All were tested at least 1 year after gait training to acclimatize to their prosthesis. Transfemoral and hip disarticulation showed an increase in VO2 cost and decreased self selected velocity than the control subjects and lower level amputation. The heart rate in the hip disarticulation group was greater than the Symes group. The patients with bilateral amputations had a significantly slower self selected walking speed than the control, but were similar in speed when compared to the unilateral. Resting heart rate was increased in the unilateral group over the bilateral group.
Conclusions:
The energy expenditure requirements have been previously well-documented in adult amputees and have shown an increased in energy demands required to ambulate. This study showed no significant difference in oxygen cost, heart rate and walking velocity in the majority of patients that had a Symes, transtibial or knee disarticulation. There also was no significant difference between these lower level amputees and the control group. This study demonstrates that, for the purposes of podiatric surgery, a Symes amputation for a pediatric patient is an acceptable alternative to a transtibial amputation.