Functional outcome of quadruple amputees with end-stage renal disease

A rare but catastrophic complication in end-stage renal disease (ESRD) patients with peripheral vascular disease is amputation of all four limbs secondary to gangrene. We present three patients with ESRD who underwent quadruple amputation. The purpose of this case study is to investigate the functional benefit of inpatient rehabilitation for such amputees. Our large, tertiary acute care hospital admitted 1,469 patients with ESRD during a continuous 63-month period. There were 72 amputation procedures: 57 involving lower limbs, and 15 involving upper limbs. Three patients had all four limbs amputated; these three were subsequently admitted to our acute inpatient rehabilitation center. Their median Functional Independence Measurement (FIM) score on admission was 52 and on discharge was 75. Their median length of stay was 24.5 days, which may be attributed to early postoperative therapy and de-emphasis on prosthetic replacement. At discharge, all three patients were able to perform sliding board transfers and self-propel wheelchairs modified with quad knobs and brake extenders. Each continued hemodialysis three times per week. Two patients were independent with feeding using adaptive equipment, and one required verbal cues. Two patients were able to write using dorsal wrist splints and pencil holders. One patient was able to use a speaker phone and lift lightweight objects with a left below-the-elbow hook-type prosthesis. Our review of these three cases demonstrates that inpatient rehabilitation can improve functional scores in quadruple amputee patients with ESRD. A large multicenter study is warranted to obtain adequate sample size to demonstrate statistical significance.