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PREDICTING WALKING ABILITY AFTER AMPUTATION 133

is related to residual-limb quality in general as well intact knee joint for providing the TTA patient with
as for specific bony aspects of the residual limb. A the ability to return to high-level mobility activities
tibial length of 12 to 15 cm from the knee joint line following rehabilitation (31). Stineman et al. reported
correlated with a better functional outcome than ADLs and mobility (physical functioning) using gains
shorter tibial lengths. Surgical technique and attention in motor FIM™ scores achieved by rehabilitation dis-
to the residual limb length ensures a more likely good charge. TFA was associated with lower motor FIM™
functional outcome after TTA (29). In a high quality gains, but no direct correlation between amputation
article, Suckow et al. reported TTA and transfemoral level and prosthetic candidacy was reported. There
amputee (TFA) patients were equally likely to ambu- was no statistically significant difference in prosthetic
late independently or with assistance (within groups) limb procurement for the group who received impa-
at hospital discharge. Between groups, however, there tient rehabilitation compared to the group who did
were significant differences based on level of ampu- not (21). van Eijk et al., in a medium quality article,
tation. Patients who underwent a minor amputation reported amputation level (low versus high) was sig-
were more likely to ambulate with or without assis- nificantly positively associated with prosthetic use
tance but less so than patients who did not have an (20). Further, van Eijk et al. found level as a predictor
amputation after lower extremity bypass (23). Linberg for ability to complete the TUG test. Webster et al.,
et al., in a high quality article, reported a significant in a high quality article, reported TFA patients were
difference in 6MWT performance between bilateral significantly less likely to achieve prosthetic fitting
TTA patients and TFA patients, with bilateral TTA success at one year (18). Wezenberg et al. reported
patients walking further (12). Chin et al. reported, in that the level of amputation was not associated with
a medium quality study, solely on the hip disarticu- VO2 peak (28). Sansam et al. previously found that
lation amputee (HDA), where older HDA patients in the majority of studies reported better walking ability
good physical condition and with a low prevalence and greater ability to achieve ADLs after distal and
of comorbidities were able to successfully walk with unilateral amputations compared with more proxi-
a prosthesis in a community setting (10). Czerniecki mal or bilateral amputations. At this time, it seems
et al. reported the rates of success were similar: 35%, the preponderance of evidence suggests that level
31%, and 33% of amputees with transmetatarsal (TM), of amputation is a factor in determining prosthetic
TTA, and TFA, respectively, achieved mobility success ability but not a preclusion from candidacy. Finally,
when seen in a comprehensive inpatient rehabilitation having more intact joints (i.e., having an intact knee
unit (27). Fortington et al. reported poorer perfor- compared with not having it) is consistent with a
mance by people with a TFA versus TTA. Slower higher potential level of function in TTA patients.
five-meter walk tests and fewer steps taken per day Moreover, the longer the transtibial residual limb,
were reported one year after amputation. One year the greater potential there is for increased functional
after discharge, people with TFA or TTA increased level. It is noteworthy, however, that having a long
the number of steps taken per day from 570 steps at TTA is not requisite for achieving community ambu-
discharge to 1314 steps and were able to maintain lation, as those with HDA can achieve community
this level in the second year (30). Grameaux et al. ambulation as well.
did not find a statistically significant worse result
in bioenergetic efficiency after TFA but did find a Physical Fitness
reduction in walking speed. Only when age was taken Raya et al., in a high quality article, reported
into account in a multiple regression model did the hip strength and balance were significant fac-
impact of the level of amputation become statistically tors impacting 6MWT scores in individuals with
significant (24). Hamamura et al. reported, in a high LLA. The 6MWT can identify impairments of the
quality study, no significant difference between the musculoskeletal system that can affect ambulation
successful and unsuccessful ambulator groups when ability such as weakness in the muscles that support
considering amputation level (17). Guanard et al., in a ambulation (32). Chin et al. reported that when older
high quality article, reported on the importance of an HDA patients are in good physical condition, they