Published online: 2019-04-29 THIEME

134 Review Article

Prosthetic Rehabilitation in the Lower Limb

Bernard O’Keeffe1 Shraddha Rout1

1 Otto Bock Health Care India, Mumbai, Maharashtra, India Address for correspondence Bernard O’Keeffe, BSc Prosthetics,
Otto Bock Health Care India, 1st Floor, Vikas Centre, Dr. C. G. Road,
Chembur East, Mumbai 400074, Maharashtra, India
(e-mail: [Link]@[Link]).

Indian J Plast Surg 2019;52:134–144

Abstract Lower limb amputations form a considerable number with 5,436,000 Indians having
locomotor disability. Most members of this group are young, active earning males.
The major cause of amputation is trauma. Hence, this population must be rehabili-
tated with priority, and best concerted efforts must be made by the medical community.
In this article, the authors present available modern technologies in India and share best
practices from their experience of treating Indian amputees for the past 20 years. The
Keywords objective is to demonstrate to the medical community the optimal outcomes that can be
►►lower limb achieved and help them make correct decisions on behalf of patients and their families.
amputations The article discusses history of prostheses, how to select optimal amputation
►►prosthetics level, preamputation preparation, determinants of good outcomes, preprosthetic
►►leg prosthetics preparation, components of prosthesis, their function and significance, rehabilitation
►►considerations before process and guidelines, prescription criteria, and also special considerations such as
amputations multiple amputees or children.

Introduction Although the wooden toe offered no function, it possibly

made the noblewoman “complete,” by allowing her to wear
Data from Census 20111 state that there are 5,436,000 an Egyptian sandal. Metal hooks and wooden pegs crafted by
people with locomotor disabilities in India. Unfortunately, artisans—which seem as mere exaggerations today—were a
there is little data available on the number of amputees in reality for many centuries later.
India. Nevertheless, as a medical community, it is extremely The major advances in amputation surgery as well as
important to put in our best efforts to rehabilitate this subset prosthetic technology came during or after the American
of patients for social reasons. The major cause for amputations Civil War (1861–1865).3 Use of ether or chloroform for
in India is trauma.2 It is known that trauma disproportionately anesthesia, use of bromine to prevent gangrene, allowing only
affects young, economically active, male individuals who have experienced surgeons to perform amputations, mass casualty
a significant lifespan ahead of them. Successfully rehabilitated, management systems—these and many more techniques
these young amputees have a potential to become contributing, reduced mortality. However, soldiers who survived—many of
happy members of our society. them amputated—had to be rehabilitated. In Europe and in
This article is our effort to present best possible solutions USA, many entrepreneurs designed newer types of prosthetic
currently available for lower limb amputees and highlight components as well as suspension techniques benefitting
how incorporating these solutions in the rehabilitation amputees (►Fig. 1).
plan can help enhance quality of life for these amputees and, The World War I saw the need for providing prostheses
effectively, those of the families dependent on them. to war amputees quickly, especially in Germany. German
technician Otto Bock started serial production of prosthetic
Brief History
components, eliminating the need to handcraft individual
History of artificial limbs for the lower extremity is extremely components, reducing rehabilitation time (►Fig. 1). As wood
interesting and often intertwined with the history of war was beginning to become scarce, newer materials such as
and of surgery. plastics were now used as substitutes.
The first established example of a prosthesis is the In 1915, the first pneumatically powered hand was
Egyptian noblewoman’s toe dating back to 950–710 BC. introduced in Germany.4 Pneumatics and, eventually,

published online
April 29, 2019 DOI [Link] ©2019 Association of Plastic
10.1055/s-0039-1687919 Surgeons of India
ISSN 0970-0358.
 Prosthetic Rehabilitation in Lower Limb Amputations O’Keeffe, Rout 135

Fig. 1 Components of artificial limbs are being mass-produced in a factory.

hydraulics found their way into lower limb prosthetics The first Paralympic games were held at Rome in 1960.
as well. However, the key milestone in the history of leg Since then, Paralympic movement has inspired thousands of
prosthetics was introduction of the C-leg in 1999—the first disabled athletes and other amputees to participate in sports
fully microprocessor-controlled prosthetic knee. Clinically and has introduced improved prosthetic designs exclusively
proven to reduce falls, C-leg today has become a standard of for sport use.
care for above-knee amputees5 and can be seen being used by Currently for prosthetic rehabilitation, advanced compo-
several Indian amputees as well. nents and techniques are available and accessible. Correct,
Iraq and Afghanistan conflicts also saw a large number usable information about the available choices and processes
of young soldiers being severely injured due to the new can help the teams guide the patient and family appropriately.
devastating weaponry, yet surviving due to advanced Great outcomes could be achieved if the surgical team
evacuation techniques. These amputees did not want to be intervenes and helps the patient and family make a reliable
pushed back to “desk jobs” but wanted to get back to service, choice of a skilled and experienced service provider as well
even to active combat. The Genium X3 was a result of R&D as an appropriate prosthetic solution.
from the U.S. Army, which allowed these veterans to run, This is just to reiterate the African proverb that says,
climb stairs one over one, perform activities in or even under “If you want to go faster, go alone. If you want to go longer,
water, and go back to active service6 (►Fig. 2). go together!”

Fig. 2 An American war amputee from 2002 was medically cleared return to flying status in June 2007 with his microprocessor-controlled
transfemoral prosthesis.

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136 Prosthetic Rehabilitation in Lower Limb Amputations O’Keeffe, Rout

Selection of Amputation Level In his case, the prosthetist will not be able to use a “rotation
joint”—an accessory that allows the lower segment to rotate
Several assessment scores are available to help surgeons and clear way for kneeling—as it makes the prosthetic thigh
make “salvage or amputation” decision.7 Hence, we will not longer than the normal thigh. This may keep the person
elaborate on tools to make this decision. away from achieving “complete” rehabilitation. Therefore
However, with our 20 years of experience in treating in this case, a transfemoral amputation could have been
Indian amputees, we wish to outline certain insights that can considered.
assist during amputation decision. Pain on weight-bearing, limited, or no ROM at the proximal
The obvious principles here include (1) preserve joint and very short bony and muscular lever arms are the
as many joints as possible and (2) preserve maximum indicators to consider a proximal level of amputation (►Fig. 4).
possible bone length. Transfemoral versus knee disarticulation has been a
A study evaluating 28 transtibial (TT) amputees for their long-standing debate. Once again, the decision must be
functional mobility concluded that the amputation technique made based on individual patient situation and, preferably,
and resulting residual-limb factors may be important for in consultation with an experienced prosthetist. We have
patients to achieve functional prosthetic use.8 put together a comparison of advantages and disadvantages
Ideally, a residual limb length of less than 5 cm in of knee disarticulation amputation over a transfemoral
transfemoral or TT is not viable for a prosthesis (►Fig. 3). one in ►Table 1.
However, we recommend that the decision to choose the
next higher amputation level be made in consultation with
Preamputation Preparation
an experienced prosthetist. For example, in a TT residual
limb, length less than 5 cm is short per say, but if reasonable The key determinant of success in prosthetic rehabilitation is
range of motion (ROM) is available at the knee, it is preferred the surgeon’s approach toward amputation. Instead of consid-
over a transfemoral amputation. With advanced prosthetic ering amputation as a failure to save the limb, if it is viewed
suspension techniques, the patient can still achieve an as a preparation for patient’s mobility and independence,
outcome that may be considered suboptimal for a TT amputee the same attitude can translate to all other medical and para-
but still will be better than that for a transfemoral amputee! medical team members, including the patient and the family.
Another perspective to take note of is that longest possible Preempting the patient about “what lies ahead” is also
may not always be ideal. If the available clearance (distance equally important. The patient/his family may not be aware
between the end of residual limb from ground or from the about modern prosthetic options and outcomes that can be
next higher joint) is very limited, special components built achieved. We recommend that an experienced prosthetist
to be of low height need to be used. This may compromise should conduct preamputation counseling, using realistic
function and add unnecessary costs. We will like to share outcome videos or peer interactions. This can bring the patient
an example of a knee disarticulation amputee for whom and the caregivers into the right frame of mind and help them
kneeling in prayer is crucial to follow his religious beliefs. optimally utilize the time until prosthetic fitment begins.

Fig. 3 Ideal residual limb lengths.

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 Prosthetic Rehabilitation in Lower Limb Amputations O’Keeffe, Rout 137

Fig. 4 Examples of when a proximal amputation could have been a better choice rather than “preserving” what was available.

Table 1 Knee disarticulation amputation—advantages and the following criteria, arriving at one overall score for each
disadvantages patient. The maximum score that could be achieved was 100.
For Against
1. Wound
Lower infection rates 9
Cosmetically less appealing due
2. Edema
to bulbous residual limb end
3. Scar
Preserves the epiphy- Cosmesis compromised if the 4. Skin
seal growth plates in prosthetic thigh is longer than
children the normal thigh, especially 5. Length
while sitting 6. Shape
Better sitting balance in Limits the choice of prosthetic 7. Tenderness
case of nonambulatory, joints that can be used 8. Proximal joint contracture
bilateral cases 9. Bone end sculpted (and covered)
Lower metabolic costs, 10. Dog ears
better walking speeds10 11. Redundant tissue
Better suspension, 12. Additional scars/other factors
hence better control Scores > 60 directly linked to improved outcomes.
over the prosthesis
The authors opine that it will be a good practice to
Easier to don and doff, document quality of stump and correlate with prosthetic
ability to use for a lon-
outcomes later.
ger time11
Superior performance
in sports Preprosthetic Preparation
Following discharge from the hospital, prosthetic fitment
commences not before 6 to 8 weeks after amputation,
Amputation Techniques and Predictors of
even later for dysvascular amputees. It is common for
Rehabilitation Outcomes
patients to not undergo physiotherapy, not follow
Various amputation techniques are sufficiently described correct positioning techniques and nutrition, eventually
in the clinical literature elsewhere and hence elaborate ending up with reduced ROM or even contractures and
description to be out of the scope of this article. poor strength and balance. This delays the prosthetic
However, we want to draw attention to residual limb-re- rehabilitation and contributes to suboptimal outcomes.
lated criteria that directly link to successful rehabilitation To avoid this, the authors recommend the following
as described by Chakrabarty.12 Chakrabarty rated residual postoperative, preprosthetic protocol that they have been
limbs of 132 unilateral TT and transfemoral amputees on using successfully.

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138 Prosthetic Rehabilitation in Lower Limb Amputations O’Keeffe, Rout

1. Edema therapy: Gentle bandaging can normally start on starting from scar upward. Apply prescribed antiseptics
day 1. The residual limb should be positioned above heart and moisturizers.
level to encourage a good venous return. 7. Stump hygiene: The patient and caregivers must be
2. Correct patient and stump positioning (►Fig. 5): Passing instructed on appropriate skin care—washing with clean
on instructions to the patient and caregivers to be water and unscented soap after the wound is appropriately
followed after discharge is crucial. The patient must healed and drying thoroughly with a clean dry towel.
maintain the residual limb straight, without using any
pillows under the joint. Lying flat on belly with head Components of Prostheses
away from amputation side for at least 30 min/day
Discussion of detailed componentry used in a prosthetic
will help reduce flexion tendency. While sitting on
limb is out of scope for this article. However, we describe key
a wheelchair, a flat plank must be used underneath
parts of the prosthesis (►Fig. 6) and their functions so that
the residual limb, instead of leaving it hanging with
the readers can help their patients make useful prescription
knee flexed. If not followed correctly, the patient may
choices:
end up with a contracture by the time he presents for
prosthetic fitting. 1. Interface materials/socket liners: New materials and
3. Mobilization: The residual limb and other joints should be developments in interface technologies offer a world of
moved several times a day. The patient can be encouraged benefits to prosthetic patients. Old generation of prostheses
to sit on a chair without a back support. were directly applied on skin, creating abrasions, excessive
4. Stump shaping/bandaging: The patient and family must sweating, and eventually affecting user compliance.
be trained on use of crepe bandaging or stump shrinkers. Residual limb liners made of new materials—foams,
They must also be instructed to visually examine for any gels, especially silicone gels—make wearing a prosthesis
redness or discoloration after the bandage is removed. comfortable. Even for traumatic cases with poor skin
5. Muscular training: Often with prolonged illness or conditions or dysvascular patients, silicone, polyurethane,
hospitalization, the patient has overall weakness and and copolymer gel liners offer great protection, leading to
balance issues. The time between discharge and start of increased time of prosthetic usage.
prosthetic fitment can be effectively utilized to overcome 2. Prosthetic socket: This is the customized part of the
this. The therapist can work on trunk strengthening, prosthesis that is crucial to prosthetic performance. The
intact limb strengthening, and muscle strengthening for socket should offer comfort and grip the residual limb in all
the residual limb among other things. stages of walking and other activities. Socket designs and
6. Scar treatment and skin preparation: In the authors’ suspension techniques are determined based on patient’s
experience, adherent, immobile scars and pain/sensitivity residual limb conditions and other patient factors. For
at the site of scar interferes with prosthetic fittings. example, for a dysvascular TT amputee, a socket with a gel
Textured objects such as Turkish towel, soft brush, beans, liner offering total surface weight-bearing (TSWB) design
rice, and straw are used for desensitization. Massage and vacuum-based suspension is advantageous13 versus

Fig. 5 Positioning after amputation.

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 Prosthetic Rehabilitation in Lower Limb Amputations O’Keeffe, Rout 139

Fig. 6 Key parts of below- and above-knee prostheses.

one with foam liner and specific/patellar tendon weight (ability to swing the knee-foot segment of the prosthesis to
bearing (PTB). The latter may cause uneven distribution clear ground during swing phase of gait). In older amputees,
of weight leading to skin breakdowns. The fitting pros- safety offered by the knee joint is a key criterion. At the same
thetist’s skill and experience is as much a decisive factor time, the knee joint must minimize energy cost of walking,
in designing a good fitting socket as an operating sur- must be lightweight, offer physiologic gait, etc. In younger,
geon’s skill and experience in performing a successful more active amputees, higher knee joint function in terms of
amputation. different walking speeds, ability to manage slopes and steps,
3. Prosthetic knee joints: For transfemoral, knee disarticulation, reliability of construction, etc. is expected.
and hip disarticulation amputations, various types of Microprocessor-controlled knees (►Fig. 7) have been a
prosthetic knees are available. While prescribing, two main game changer in prosthetics since their launch in 1999.14 A set
functions need to be considered—stance control (safety while of sensors give feedback about knee joint position in space,
standing and mid-stance stage of gait) and swing control speed, direction of movement, etc. to a microprocessor that

Fig. 7 The Genium microprocessor-controlled knee offers excellent safety even on difficult terrains.

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140 Prosthetic Rehabilitation in Lower Limb Amputations O’Keeffe, Rout

stores thousands of gait algorithms. The microprocessor then to be a part of the prescription after assessing individual
defines the situation—user is changing speed/falling/getting activities of daily living (ADL) needs.
down the slopes/sitting in a chair—and controls the hydraulic
resistance of the knee joint accordingly. The hydraulic resis- Rehabilitation Process and Timelines
tance adjustment leads to either increased speed of swing or
makes knee flexion very difficult. This allows the user the Although rehabilitation starts immediately after the
time to shift balance to intact foot avoiding a fall. Making the amputation, it is a continuous process for prosthetic service
knee flexion slightly difficult can allow safe getting down the providers. Prosthetic fitting can start as soon as surgical
slopes. Whereas, no resistance at the knee can allow com- wounds are sufficiently healed, normally within 6 to 8 weeks
fortable sitting on the chair. of amputation, with exceptions for dysvascular or multitrauma
The MPK technology is not new to India anymore, and patients. Then on, initial prosthetic fitting and training may
several amputees today are enjoying higher safety and take 2 weeks. However, the real challenge starts only when the
higher function offered by it. patient is fitted with the prosthesis and starts reintegration into
his daily life. It is most important for the prosthetic service pro-
4. Prosthetic feet: Feet absorb shocks at heel strike, stabilize
vider to work closely with the patient and therapist to resolve
the prosthesis during stance phase of gait, and then
challenges of daily living. There may be a particularly steep
smoothly roll over and propel the body forward by pushing
slope to be encountered on the patient’s way to workplace or
the ground behind. Amputees of different mobility grades
a particular height of the sitting chair. Together, the prosthetist
require these functions in different amounts. Choosing
and the patient should be able to adjust the functions offered by
a foot wisely can make a great impact on the prosthetic
the prosthesis to fulfill user requirements. Regular follow-ups
outcome. The newer designs of feet are mostly made
and ongoing resetting of rehabilitation goals are very important.
of carbon fiber and offer dynamic function. In older
With time and usage, the residual limb shrinks. The
amputees, however, stability offered by the foot is also
socket and the prosthesis may need readjustments until the
equally important.
residual limb volume stabilizes sufficiently. With modular
Microprocessor technology has also made its headway in components being in use today, only the socket part can
feet. The benefits of microprocessor feet and ankles are the be changed, without having to change the rest of the
ability to lift the forefoot during ground clearance, avoiding components.
falls, safety especially on uneven terrain, and reduced peak A prosthesis may last for 5 to 7 years typically under
pressures on the residual limb.15 Indian conditions, with intermittent requirement of change
of consumables—socks, straps, liners, etc. However, at the
5. Functional adaptors: Specific functions required during
time of upgradation or change, users’ changed activity level
an amputee’s everyday activity are performed by
and requirements from the prosthesis must be reviewed.
functional adaptors. A rotation joint (►Fig. 8) may offer
knee rotation, making it easy to wear and remove shoes,
whereas a torsion adaptor may ease the residual limb Prescription Criteria
of stress in turning round as in swinging in cricket/golf. It is important that a prosthesis be functional as well as
These accessories are always optional and can be chosen economical, matching the amputee’s requirements.
The authors use a functional classification based on
activity levels to determine needs of the amputee and then
select components to provide function accordingly. These
activity levels are described in ►Table 2.

Special Considerations—Children, Multiple

Amputations, Sports
Children are special. Their rehabilitation requirements
are different from those of an adult. Children’s prostheses
must allow some kind of growth adjustments. Children are
extremely active, so the componentry used must be robust;
at the same time, follow-up and repair services must be
reliably available. Among the “soft factors” of treatment,
the prosthesis as well as the fitting process must be
enjoyable for the child to get her to use the prosthesis. The
objective of treatment here should be to allow the child
to fully reintegrate into her routine activity—schooling,
cycling, and playing football. Only then we will be able
Fig 8 A transfemoral amputee uses a rotation joint for comfortable to help the child to grow up without complexes and
sitting. inhibitions into a happy individual.

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 Prosthetic Rehabilitation in Lower Limb Amputations O’Keeffe, Rout 141

Sport is essential for life—especially for amputees. It

can help fight stresses that disability brings along. Sport
can also help amputees delay lifestyle-related issues such
as early osteoarthritis and back pain. Prostheses for sports
have different functional requirements from those used
in daily life. They have to be robust to absorb shocks and
extremely dynamic. Carbon fiber is the material of choice
when it comes to sport feet design.

Outcome Measurements
Measuring and documenting prosthetic outcomes
have recently picked up speed in the developed world
where most treatments are paid for by the government
or insurance. In India, however, this practice is almost
nonexistent.
The authors routinely use outcome measures in their
clinical practice (►Fig. 10). The patients are evaluated
pre-fitting, post-fitting, at 2 to 3 weeks follow-up,
and then ongoing follow ups. The questionnaire is a
mix of self-reported qualitative questionnaire and
performance-based tests such as time-up and go (TUG),
four square step, and 6-minute walk. The data are stored at
a central server. Analysis can be made by comparing socket
comfort, pain, time taken to complete four square step test
(dynamic balance), and distance covered in the 6-minute
walk test over follow-up intervals.
According to us, this holds great potential for objectively
analyzing benefits of treatments, for which most of the times
amputees pay from their own pockets.
Fig. 9 A four-limb amputee determinedly uses her running blades
to compete in marathons.
Summary
Multiple amputations are not uncommon in India, where Prosthetic service provision is at a very interesting turn
trauma is a major cause of amputation. Therapy and ADL in history. New, modern components and techniques are
training play a very important role in rehabilitating multiple available, but experienced, mature clinicians to apply them
amputees. Most advanced prosthetic componentry may are scarce. Right from decision to amputate to the choice
not be utilized to the fullest if the patient has poor trunk of an appropriate prosthetic prescription, the decision is a
musculature. The energy cost of walking is high in such major one with a lot at stake. Often, patients and families
cases, and there are chances that the patient may settle are in a vulnerable emotional and financial state at this
down to wheelchair mobility if he/she gets tired quickly. stage. Correct direction from the surgical team may help
The choice of an appropriate prosthetic service provider the patient and families choose the right service provider
experienced in treating multiple amputees becomes a key and, ultimately, be optimally rehabilitated and fully inte-
determinant of successful rehabilitation (►Fig. 9). grated in the society.

Table 2 Activity level assessment to determine prosthetic needs of the amputee

Mobility grade Limited mobility Everyday life Active life
Prosthetic Mostly indoor usage, with/ Indoor as well as outdoor usage, without Active usage on uneven terrain, use
usage without a walking aid. One walking aid. Occasional leisure sport activity, of different walking speeds during the
consistent walking speed two or three different walking speeds day, frequent leisure sport activity
Requirements •• Safety •• Cosmesis •• Function
from the •• Low weight •• Function •• Robustness
prosthesis •• Reliability •• Energy return

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142 Prosthetic Rehabilitation in Lower Limb Amputations O’Keeffe, Rout

Fig. 10 An indicative example of a treatment progress report of a lower limb amputee.

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 Prosthetic Rehabilitation in Lower Limb Amputations O’Keeffe, Rout 143

Conflict of Interest 8 Arwert HJ, van Doorn-Loogman MH, Koning J, Terburg M,

The author(s) are employed by Otto Bock Health Care Rol M, Roebroeck ME. Residual-limb quality and functional
mobility 1 year after transtibial amputation caused by vascular
India Pvt. Ltd.
insufficiency. J Rehabil Res Dev 2007;44(5):717–722
Fund source 9 Smith DG. the knee disarticulation: it’s better when it’s better
and it’s not when it’s not. In Motion 2004;14(1)
The author(s) received no specific funding for this work.
10 Pinzur MS, Gold J, Schwartz D, Gross N. Energy demands for
walking in dysvascular amputees as related to the level of
amputation. Orthopedics 1992;15(9):1033–1036, discussion
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