Elbow Disarticulation Amputation

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CHAPTER 73 Elbow Disarticulation Amputation

Thomas C. Shives, Karen L. Andrews

INTRODUCTION

Over the years, advances in upper extremity prosthetics have included improved surgical techniques, preoperative management, postoperative management, and advances in prosthetic technology. In the past decade, the greatest advances have occurred in prosthetic technologies, fabrication techniques, and components to more effectively replace the lost function of the extremity.7

DEMOGRAPHICS

Trauma is the leading cause of upper extremity limb loss, accounting for 80% of upper extremity amputations. Tumor is the most common cause of upper extremity amputation in children. From 1988 to 1996, the rate of trauma and cancer-related amputations declined. This decline was likely due to improved surgical reconstruction, advances in limb-sparing techniques, and prevention through improved occupational safety awareness.6

Following trauma, the decision to attempt limb salvage or proceed with amputation is complex. There is a bias toward limb salvage in upper extremity trauma surgery. The functional demands of the upper extremity are different from the lower extremity. Lack of weight bearing forces, the ability to function with partial sensation, and limited function of upper extremity prostheses are reasons sited for limb salvage and reimplantation.8

ELBOW DISARTICULATION AMPUTATION

Elbow disarticulation has advantages and disadvantages when compared with the transhumeral level of amputation. An elbow disarticulation amputation allows anatomic suspension, rotational control of the prosthesis, and reduces rotation of the socket on the residual limb. The major disadvantages are the suboptimal cosmetic appearance and limited availability of elbow components. The external hinge elbow mechanisms for elbow disarticulations are not very cosmetically pleasing.

In children with upper limb deficiency or amputation, growth and development, bony overgrowth and more rigorous use of a prosthetic device need to be considered. An elbow disarticulation amputation level for this population optimizes residual limb length and avoids bony overgrowth. The slowed humeral growth after elbow disarticulation results in a humeral length at maturity that allows the use of a prosthetic elbow while retaining the suspension and rotational control of an elbow disarticulation.1 In children, transhumeral amputation results in a high incidence of bony overgrowth. An elbow disarticulation preserves the epiphysis, prevents bony overgrowth, and maintains growth potential; therefore, elbow disarticulation is the level of choice.2

AMPUTATION SURGERY

Controversy exists whether to perform a long transhumeral amputation or an elbow disarticulation. Amputation surgery should be viewed as a reconstructive procedure. The basic principle of all upper limb amputations is preservation of maximal length consistent with optimal function, control of disease, and satisfactory surgical wound management. Adherent scarred distal tissues or redundant soft tissue should be avoided.

SKIN

There is no particular type of skin flap configuration that is better than another. When the soft tissues are normal, equal anterior and posterior flaps are generally preferred. However, skin flaps for traumatic amputations should be fashioned in any manner possible that preserves length. The nature of the trauma, including burns, may require extensive modification of the classic equal flap closure. Skin grafts are not a contraindication to prosthetic fit. Their use may be indicated, particularly in burn amputations. Skin on upper limb amputations is far less subject to pressure, shear, and stretching than it is in the weight-bearing lower limb. The skin that is used to close an amputation should be sensate and well vascularized.

NERVES AND BLOOD VESSELS

Major nerves about the elbow are transected sharply under tension. The transected nerve is allowed to retract into the adjacent soft tissues, away from the amputation site and away from the areas where it could become adherent and a source of pressure irritation from the socket.

Meticulous hemostasis is mandatory to avoid postoperative hematoma formation. All wounds are drained for 48 hours postoperatively.

BONE

Through-elbow amputation is carried out as a true disarticulation (Fig. 73-1). Minor contouring of the margins of the distal humerus is usually required to eliminate sharp condylar prominences. For above-elbow amputations, the bone edges should be slightly beveled so that there are no sharp prominences or rough bone edges.

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FIGURE 73-1 Cross-section of the elbow disarticulation before closure of the myoplasty. The myoplastic flaps must be sectioned with sufficient length to permit closure without tension

MUSCLE STABILIZATION

Whenever possible, the sectioned muscles and tendons are sewn to each other over the end of the humerus at the amputation site (Fig. 73-2). If possible, the triceps tendon and aponeurosis is retained and brought forward through and over the trochlea to be sewn under minimal tension to the brachialis muscles. The biceps tendon also can be interwoven into the brachialis muscle near the amputation site, giving excellent residual limb muscle control.

image

FIGURE 73-2 Muscle stabilization using anteroposterior myofascial flaps over the contoured distal humerus at the elbow level. The flaps must be stabilized directly to the periosteum or bone

Muscle stabilization requires firm fixation to the distal bone. When opposing muscles are sewn to each other over the bone or joint end without firm distal fixation, a “sling-like” effect can develop that causes bursa formation, reduces effectiveness of the muscles, and can be painful. A myodesis with two or four small 1/8-inch drill holes through the distal humerus may be necessary to accomplish good muscle stabilization.

NERVE TRANSFERS

In an attempt to improve functional control of myoelectric prostheses, the possibility of transferring residual nerves to spare muscles in or near the residual limb has been studied. Using nerves to reinnervate targeted muscle, the surface myoelectric signals from these muscles have been used to simultaneously control multiple degrees of freedom in a prosthesis.13

Research into this concept has been promising. Studies have shown that when large nerves (such as the brachial plexus nerves) are transferred onto relatively small muscle areas, the recovery of the muscle is very good.12 With targeted reinnervation, control of a prosthesis will be easier and more natural because the myoelectric signals are physiologically correlated to the movements of the lost arm. Although targeted reinnervation shows exciting potential, ongoing research is needed.13

ACUTE POST-AMPUTATION MANAGEMENT

Following surgery, the goals of the preprosthetic period are to

1. Promote residual limb shrinkage and shaping
2. Establish a home exercise program of range of motion (ROM), stretching, strengthening and conditioning
3. Increase upper extremity function
4. Review joint protection principles, energy conservation, and one-handed techniques
5. Optimize tasks required for daily living.
6. Evaluate adaptive and durable medical equipment needs
7. Determine the electrical potential provided by various muscles in the event myoelectric prosthetic components are prescribed.
8. Review the patient’s specific daily living, leisure, and work needs to determine possible prosthetic components and options.

Immediate and early postsurgical prosthetic fitting provides edema control, pain reduction, and protects the surgical incision.14 Successful prosthetic use is higher when fitting is completed within a “golden period” of 30 days after surgery.14 If prosthetic fitting and training are delayed, the patient can become adept at one-handed techniques, making it difficult to incorporate a prosthesis in their daily living activities. A second study has shown that even delayed fitting can be successful.22 Common reasons for rejecting a prosthetic limb include the perception of limited usefulness, excessive weight, and residual limb pain.

An early postoperative prosthesis using a plaster cast or a high temperature thermoplastic socket typically can be fit by the third day after surgery. Prepositioned or self-positioned locking elbows are used to avoid excess elbow motion and shearing along the surgical incision. If there is concern about healing of the surgical incision, a stump protector (rigid removable dressing), compressive dressing, or soft dressing can be used until the incision has healed and the patient is ready to be fit for their first definitive prosthesis.

PROSTHETIC MANAGEMENT

Successful rehabilitation and effective use of an elbow disarticulation prosthesis depends on many factors. Key elements that influence prosthetic outcomes include

1. Quality and nature of the skin and soft tissue coverage of the limb
2. Muscle function in the residual limb
3. Pain control
4. Joint ROM and strength of the residual limb and upper body
5. Rehabilitation support19

Careful surgery, evaluation, prosthetic fitting, and training are critical to successful outcome and optimal prosthetic function. The long-term rate of prosthetic wear for transhumeral and elbow disarticulation amputations is less than 50%.16 Although a prosthesis is not necessary for an amputee to function, recent studies suggest that overuse in the remaining hand and arm occurs in up to 50% of persons with upper limb amputations.10 Active use of a prosthesis is believed to reduce this risk.

The typical sequence of prosthetic rehabilitation involves initial fitting and training with a body-powered prosthesis, followed by a second prosthesis when the residual limb volume has stabilized 3 to 6 months following surgery. Prostheses can be divided into three groups:

1. Conventional or body powered
2. External powered or electric
3. Passive or cosmetic

Advantages of using a body-powered prosthesis for the first definitive prosthesis include the greater ease of fitting, greater ability to adapt to changes in residual limb volume, early training in daily living activities, and lower cost compared to external powered devices.

Because it is difficult to predict long-term acceptance of an upper limb prosthesis or an individual’s preferred type of prosthetic system (body or external powered), the initial definitive prosthesis should be used to explore prosthetic options. Individuals with a recent upper extremity amputation should be allowed time to explore advantages and disadvantages using a prosthesis and different terminal devices in a variety of home, work, and social settings.6

Prosthetic fitting should be initiated during the first month after upper limb amputation to maximize acceptance and use. Every person with an upper limb amputation should be given the opportunity to use a prosthesis, recognizing that it is ultimately the person’s choice whether a prosthesis becomes part of his or her daily life.

Body-powered cable systems offer the advantage of being low cost, light weight, and highly reliable because of their mechanical simplicity. Body-powered control systems also have significant disadvantages. The harness required to transmit muscle forces inevitably restricts the amputee’s work envelop and encumbers the unaffected side. The amputee often exerts significant effort with exaggerated body movements to generate sufficient force and excursion to operate a body-powered cable system. Higher level amputees may be physically unable to generate sufficient motion or force because of the limited leverage.

A patient must understand that successful prosthetic and physical rehabilitation is a prerequisite for optimal performance. A state-of-the-art prosthesis will not provide optimal performance to a user who is not physically capable of taking advantage of its features. Conversely, optimal performance will not be achieved with a prosthesis that does not provide a level of technical sophistication that matches or challenges the user’s physical capabilities.

The difference between body-powered and electric components should be reviewed. Advantages of a body-powered prosthesis with a hook terminal device include lighter weight, better durability, increased sensory feedback, less expense, and greater ease in seeing the manipulated object. Advantages of a myoelectric prosthesis include better appearance, moderate or no harnessing, less body movement to operate the prosthesis, the ability to reach overhead, better grip strength, and the ability to grasp larger objects.3 If the patient’s workplace has magnetic fields or large electrical currents, a myoelectric prostheses may not function unless special shielding materials are used during fabrication to prevent interference.

If force or excursion is inadequate for full body-powered control of a prosthesis, then external power will be needed to control the prosthesis. Myoelectric or Servo controls are available that provide proportional speed and force control. It is common to use a body-powered elbow and a switch or myoelectric control terminal device. This arrangement simplifies harnessing and reduces weight.

The amputee should be actively involved in the discussion of prosthetic options and given an objective, comprehensive overview of the advantages and disadvantages of available socket designs, suspensions, and components (elbow, forearm, wrist, and hand). Each of the components should be reviewed again whenever a patient returns to be cast for a new prosthesis. A careful inventory of the person’s lifestyle and future goals should be discussed. Early following amputation, people frequently have the unrealistic expectation that a prosthesis will simply replace their lost arm and hand. It is important to explain that a prosthesis will serve as a tool and discuss realistic functional expectations. With this knowledge, the patient is less likely to reject the device.

During fitting and training with a prosthesis, the initial wearing period should be no longer than 15 to 30 minutes three times daily, with frequent examination of the skin for evidence of redness, increased warmth, or breakdown. If redness persists for more than 20 minutes after the prosthesis is removed, the prosthetist should adjust the socket. If no skin problems are present, wearing periods can be increased in 30-minute increments. When a patient is able to tolerate wear for 3-hour intervals, he or she can advance to all-day wearing. The patient should continue to inspect the skin of the residual limb on a daily basis.

TERMINAL DEVICE

The human hand is a very complex anatomic and physiologic structure whose function cannot be replaced by the current level of prosthetic technology. A variety of prosthetic terminal devices are available including passive, body powered, and externally powered hooks and hands. The most commonly prescribed passive terminal device is the passive hand. Many passive hands have bendable or spring loaded fingers that can provide a static grasp for objects. Passive hands do not require cables or batteries for operation; they are light in weight and have a socially acceptable appearance. Prosthetic hands provide a three-jaw chuck pinch. Prosthetic hooks provide the equivalent of lateral or tip pinch.

Body-powered terminal devices can be opened or closed voluntarily. A voluntary opening device is maintained in the closed position by rubber bands. The patient opens the device by the pull of the cable on the harness system. The rubber bands provide the prehensile force. The maximal prehensile force is predetermined by the number of rubber bands (typically a maximum of six).

Voluntary closing terminal devices require a patient to close the device by pulling the cable on the harness system to grasp an object. Voluntary closing devices are held open and closed when the control cable is pulled. Pinch is regulated by the amount of force the user supplies to the control cable. Full range of pronation and supination are important to allow the terminal device to be positioned in the most functional position for a specific task.

Body-powered terminal devices transmit grasping forces and proprioception (hand positioning) from the harness and cables used to operate the hand.17 Externally powered devices can have a digital or proportional (stronger signal/faster action) control system.

Traditional myoelectric prosthetic hands do not provide feedback regarding the force exerted on a grasped object. The degree of control is imprecise; often more force is applied than necessary.17 Although the kinematics of currently available hand systems have not changed a great deal, significant progress has been made in control options to allow greater precision and ease of operation. A new feedback system with a miniature vibration motor, a piezoresistive force sensor, and control electronics has improved the ability to regulate grasping without the help of vision. The results suggest that more precise control and grasping force are possible with a feedback system.17

Multiple control options are now available, allowing better customization of prosthetic systems to the demands of individual users. Using a computer, a prosthetist can modify the parameters of every component integrated into the prosthesis. State-of-the-art hands have integrated sensors that reduce the user’s need to concentrate on controlling the grasping action.4 Onboard sensors for hand control can signal when to adjust grasping force (magnitude and direction), opening width, and speed of movement.

PROSTHETIC WRIST

A quick-disconnect wrist allows the patient to exchange terminal devices more easily. If the patient plans to only use one terminal device, a lighter weight constant friction wrist should be considered.

PROSTHETIC ELBOW

Prosthetic elbow joints can be passive, body powered, or externally powered. These devices are controlled by mechanical cables, external switches, or myoelectric signals. Mechanical elbows have a locking mechanism that is manually applied using the contralateral hand, the chin, or a cable system. The traditional body-powered locking elbow with harness control lock is generally preferred if the patient can operate it well. The flexion force across a mechanical elbow is dependent on the wearer’s strength, the comfort of the socket fit, and the ability to efficiently transfer the power from the residual limb to the prosthesis.

The elbow disarticulation level requires external locking elbow joints, adjacent to the humeral condyles, to achieve optimal length of the arm. These joints are larger and protrude on the medial aspect reducing the durability and cosmesis of the prosthesis. Limited flexion strength and increased maintenance are additional problems with this type of joint. Outside locking hinges are available in standard and heavy duty models. Standard units provide seven different locking positions throughout the range of flexion. The heavy duty models provide five locking positions.

Replacement of the anatomic elbow joint requires a substitute joint that permits flexion and extension to a range of approximately 135 degrees. The unit must permit locking of the elbow at various points throughout the 135-degree ROM. Amputations through the humerus (approximately 5 cm proximal to the elbow joint) provide adequate space to accommodate inside locking elbow mechanisms. Use of a standard prosthetic elbow unit for a person with an elbow disarticulation, however, results in excessively long humeral and shortened forearm segments and creates an unnatural appearance. Elbow center discrepancies also make tabletop activities difficult.

PROSTHETIC SOCKET

Traditionally, upper extremity prostheses have used a dual-wall socket design fabricated from lightweight plastic or graphite composite materials. With a dual-wall design, a rigid inner socket fabricated from a custom mold of the residual limb is the primary interface between the user and the prosthesis. Comfort and function are directly related to the quality of the fit of the inner socket. The outer socket wall has the shape and contour of the normal arm. This serves both a cosmetic function and supplies the foundation for the attachment of the suspension and control systems. This type of socket is durable. Variations in residual limb volume are easily accommodated using filler socks to adjust the fit.

Advances in prosthetic materials such as acrylic laminates, carbon graphite, and flexible thermoplastics allow prostheses to be more comfortable, lighter, and more durable. An elbow disarticulation socket is broad and flat distally to conform to the anatomic configuration of the distal humerus (Fig. 73-3). A total contact interface should be attempted at the elbow disarticulation level to allow efficient energy transfer from the residual limb to the prosthetic device. This design provides some self-suspension and allows active rotation of the prosthesis (internal and external rotation of the humerus).

image

FIGURE 73-3 An elbow disarticulation prosthesis with a broad and flat distal socket to conform to the anatomic configuration of the distal humerus.

(Courtesy of Mike Gozola, C.P., Prosthetic Laboratories, Rochester, MN.)

Recent use of silicone materials for the fabrication of prosthetic sockets has expanded the fitting options for upper limb amputees. Silicone suction technology allows suction suspension. Material thickness, stiffness, and color can be precisely controlled.20

SUSPENSION SYSTEM

The goal of suspension systems is to secure a prosthesis to the body. The elbow disarticulation prosthesis can be suspended by a harness, suction, anatomic, or a silicone sleeve suspension. The traditional figure-of-eight chest strap and shoulder saddle harnesses provide suspension and control of body-powered prostheses (Fig. 73-4). A figure-of-eight harness provides the greatest available excursion, but it can create pressure problems in the contralateral axilla. A shoulder saddle and chest strap suspension/control system reduces axillary forces and provides better lifting capability but does not harness contralateral shoulder excursion. Typically, a split Pelite insert, a windowed socket, or a flexible wall socket is used to provide entry and anatomic suspension at the elbow disarticulation level.

image

FIGURE 73-4 Body-powered elbow disarticulation prostheses with a figure-of-eight suspension and control system.

(Courtesy of Mike Gozola, C.P., Prosthetic Laboratories, Rochester, MN.)

Newer suspension systems include a silicone sleeve, suction, or seal-in liner suspension. These provide improved suspension and decrease pistoning and shear within the socket. These suspensions also simplify donning and allow independent donning of the prosthesis with one hand. Silicone liners accommodate mild to moderate volume changes in the residual limb and can be used successfully with both body-powered and externally powered components. The shape and pressure tolerance of the condyles determine the best suspension for the elbow disarticulation level.

Suction suspension is often used in conjunction with externally powered components to eliminate or reduce the amount of harnessing necessary. If the patient has a great deal of scarring or decreased skin integrity, a thicker liner can be used to enhance soft tissue supplementation. Liner thicknesses range from 3 to 9 mm. These suspensions also provide excellent skin protection and suspension for patients who are very active users.

PROSTHETIC TRAINING

Prosthetic training is integral to the rehabilitation process. An occupational therapist works closely with the patient’s prosthetist to review donning, carefully monitor the skin, gradually increase wear time, and optimize bimanual activities, prosthetic function, upper extremity function, and daily living activities.

FUNCTIONAL OUTCOMES

Independence in all functional activities is the goal for persons with an upper limb amputation. Following an elbow disarticulation, a person should be independent in all activities of daily living, driving, and work. Some work restrictions with regard to handling delicate, heavy, or voluminous objects may be necessary. Following an elbow disarticulation, a patient should typically be able to lift 10 to 15 pounds. The permanent partial impairment for this level of amputation according to the AMA Guides to Permanent Partial Disability is 57% of the whole person.

Prosthetic-specific, adult functional status measures need to be developed and validated. Building a core set of outcome measures will provide a comprehensive picture of different aspects of hand function and prosthetic use.21

SUMMARY

The rehabilitation process for a person with an elbow disarticulation is best accomplished with a comprehensive, multidisciplinary, specialized treatment team. A well-fitting prosthesis with appropriate components, supervised training, and ongoing follow-up optimizes prosthetic use and function. Targeted reinnervation and other research on the control of upper limb prostheses hold promise to allow more agile, intuitive control systems to increase prosthetic function, use, and quality of life for persons with limb loss.13

References

1 Abraham E., Pellicor J.R., Hamilton R.C., Hallman D.W., Ghosh L. Stump overgrowth in juvenile amputees. J. Pediatr. Orthop. 1986;6:66.

2 Atkin G.T. Surgical amputation in children. J. Bone Joint Surg. Am. 1963;45:1735.

3 Atkins D. Managing self-care in adults with upper extremity amputations. In: Christian C., editor. Ways of Living: Self-Care Strategies for Special Needs. 2nd ed. Bethesda, MD: American Occupational Therapy Association; 2000:221.

4 Chappell P.H., Kyberd P.J. Prehensile control of a hand prosthesis by microcontroller. J. Biomed. Eng. 1991;13:363.

5 Daly W. Clinical applications of roll-on sleeves for myoelectrically-controlled transradial and transhumeral prostheses. J. Prosthet. Orthot. 2000;12:88.

6 DeLisa J.A. Physical Medicine and Rehabilitation Principles and Practices, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2005.

7 Dillingham T.R., Pezzin L.E., MacKenzie E.J. Limb amputations and limb deficiency—epidemiology and most recent trends in the United States. South. Med. J. 2002;95:75.

8 Graham B., Adtkins P., Tsai T.M. Major reimplantation versus revision amputation and prosthetic fitting in the upper extremity—a late functional outcome study. J. Hand Surg. 1998;23:783.

9 Hoffer J.A., Loeb G.E. Implantable electrical and mechanical interfaces with nerve and muscle. Ann. Biomed. Eng. 1980;8:351.

10 Jones L.E., Davidson J.H. Save that arm: a study of problems in the remaining arm of unilateral upper limb amputees. Prosthet. Orthot. Int. 1999;23:55.

11 Kuiken T.A. Use of nerve-muscle grafts to improve the control of artificial limbs. J. Technol. Disabil. 2003;15:105.

12 Kuiken T.A., Rymer W.Z., Childress D.S. The hyper-reinnervation of rat skeletal muscles. Brain Res. 1995;1676:113.

13 Lipschutz R.D., Kuiken T.A., Miller L.A., Dumanian G.A., Stubblefield K.A. Shoulder disarticulation externally powered prosthetic fitting following targeted muscle reinnervation for improved myoelectric control. J. Prosthet. Orthot. 2006;18:28.

14 Malone J.M., Fleming L.L., Roberson J., Whitesides T.E.Jr, Leal J.M., Poole J.U., Grodin R.S. Immediate, early, and late post-surgical management of upper limb amputation. J. Rehabil. Res. Dev. 1984;21:33.

15 Michael J.W., Bowker J.H. Atlas of Amputations and Limb Deficiencies – Surgical, Prosthetic, and Rehabilitation Principles, 2nd ed. St. Louis: Mosby-Year Book, Inc, 1992.

16 Pinzur M.S., Angeltas J., Light T.R., Izuierdor R., Pluthat T. Functional outcome following traumatic upper limb amputation and prosthetic limb fitting. J. Hand Surg. 1994;19:836.

17 Pylatiuk C., Kargov A., Schulz S. Design and evaluation of a low-cost force feedback system for myoelectric prosthetic hands. J. Prosthet. Orthot. 2006;18:57.

18 Salam Y. The use of silicone suspension sleeves with myoelectric fitting. J. Prosthet. Orthop. 1994;6:119.

19 Smith D.G., Michael J.W., Bowker J.H., editors. Atlas of Amputations and Limb Deficiencies—Surgical, Prosthetic, and Rehabilitation Principles, 3rd ed., Rosemont, IL: American Academy of Orthopedic Surgeons, 2004.

20 Uellendahl J.E., Mandacina S., Ramdial S. Custom silicone sockets for myoelectric prostheses. J. Prosthet. Orthot. 2006;18:35.

21 Wright F.V. Measurement of functional outcome with individuals who use upper extremity prosthetic devices: current and future directions. J. Prosthet. Orthot. 2006;18:46.

22 Wright T.W., Hagen A.D., Wood M.B. Prosthetic usage in major upper extremity amputations. J. Hand Surg. 1995;28:619.

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