From the Guidelines
Bilateral below-knee amputations (BKAs) in elderly patients should prioritize a multidisciplinary approach focusing on rehabilitation, prosthetic fitting, and addressing age-related challenges to optimize quality of life (QOL) and minimize morbidity and mortality. According to the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease 1, factors influencing QOL among amputees include patient factors such as age, sex, and presence of diabetes, as well as professional-controlled factors like timing of amputation, informed decision-making, and postamputation support.
Key considerations in managing bilateral BKAs in elderly patients include:
- Early initiation of physical therapy to promote mobility and strength
- Proper wound healing and pain management using multimodal analgesia
- Prosthetic fitting with lightweight prosthetics and stable knee joints
- Management of comorbidities like diabetes and vascular disease
- Prevention of falls through home modifications and assistive devices
- Addressing psychological impacts through counseling and support groups
- Nutritional support with adequate protein intake and vitamin supplementation, as these factors can significantly influence QOL and outcomes in this patient population, as noted in the guideline 1.
Given the lack of evidence from RCTs to guide the selection process for the optimal level of amputation, a conservative approach prioritizing preservation of maximal tissue of the limb is recommended, with the goal of preventing limb loss and reducing nontraumatic amputation, as proposed by the AHA 1.
From the Research
Bilateral Below-Knee Amputations in the Elderly
- The decision to undergo prosthetic rehabilitation for elderly bilateral amputees is complex and depends on various factors, including the level of amputation, associated diseases, and successful prosthetic use after the first leg amputation 2.
- A study of 80 patients with bilateral below-knee amputations found that 71% of patients with atherosclerotic conditions achieved some functional use of bilateral prostheses, and the average survival after the second amputation was 44 months for those deceased, and 64 months for those alive at the end of the study period 3.
- Another study of 18 vascular amputees over 55 years of age found that 12 underwent bilateral below-knee amputation, and 6 patients (50%) were fitted with prostheses, achieving a high functional level of rehabilitation despite a high mean age of 67.8 years 2.
Prosthetic Rehabilitation and Pain Management
- Prosthetic rehabilitation can be an effective way to improve functional outcomes for elderly bilateral amputees, but it requires careful evaluation and management by a multidisciplinary team 2.
- Post-amputation pain is a common complication, and its management can be challenging, with various treatment options available, including medical, rehabilitation, and surgical approaches 4.
- A study of opioid utilization after lower extremity amputation found that younger patients, males, patients with below-knee amputations, and those who receive amputations for vascular disease at non-training institutions have higher post-operative opioid utilization during the hospital stay 5.
Patient Selection and Outcomes
- The selection of patients for bilateral below-knee amputation and prosthetic rehabilitation depends on various factors, including the level of amputation, associated diseases, and mental status 3.
- A study of 2399 patients who underwent above-knee or below-knee amputation with peripheral vascular disease found that patients with below-knee amputations, males, Caucasians, younger patients, and those at non-training institutions had higher post-operative opioid utilization during the hospital stay 5.
- The outcomes of bilateral below-knee amputation and prosthetic rehabilitation can be favorable, with many patients achieving functional use of prostheses and improving their quality of life 2, 3.