Prosthetics and Orthotics International

The Brian Blatchford Prize for the triennium 1992–1995 was awarded to Össur Kristinsson. This paper was based on his acceptance speech which was delivered at the World Assembly in Melbourne, Australia on 6th April 1995.

The aim of this experimental study was to investigate whether lightguide spectrophotometry in the visible wavelength range in skin could be used to predict stump healing viability in patients with critical lower limb ischaemia.

Remission spectra recorded at two sites (medial and lateral) on the line of a proposed trans-tibial amputation (TTA) and at 10mm intervals along the leg were analysed to give haemoglobin oxygenation (SO₂). Degree of tissue hypoxia (DTH) along the leg was defined as the percentage of values along the leg less than 10% SO₂. DTH and mean SO₂ values were compared with skin blood flow values ((I¹²⁵) 4-Iodoantipyrine clearance technique) and clinical outcome of trans-tibial amputation, (TTA) or trans-femoral amputation (TFA), in 41 patients. SO₂ histograms were also measured in 12 normal subjects for comparison.

The results of the study allowed the establishment of criteria for the accurate prediction of flap healing potential. Successful TTAs all displayed a minimum mean SO₂ at the medial and lateral measurement sites of 30%, together with a maximum degree of tissue hypoxia of 15% along the limb. The combination of these criteria gave a sensitivity and selectivity of 1.0 for prediction of a successful outcome of TTA.

The purpose of this study was to review the 68 patients who had been referred to Dundee Limb Fitting Centre during the period 1965–1994, with a congenital anomaly of a major limb requiring prosthetic replacement. A profile of the incidence of congenital anomalies, amputation levels and prosthetic fitting was obtained. During the period only 68 cases with 80 congenital anomalies were referred. During these 29 years, 20 cases required surgical amputation and overall 35 surgical procedures were performed in these cases, only 3 were in the upper limb. The incidence of upper and lower limb deficiency was similar. The patients represented a small proportion (1.6%) of the patients who were reported to have congenital anomalies. Figures indicated that about 8% of all live/still births have some form of anomaly. Prosthetic fitting and use was successful in all 68 cases but long term life follow-up is necessary to ensure continued prosthetic use.

The purpose of this study was to look at the current epidemiological trends of lower limb amputees in 1992 in the area of Southern Finland with 1.2 million inhabitants.

Similar data was collected earlier in 1984–85 and 1989. The amputation incidence was found to be 27.4 per 100,000 inhabitants. The trans-tibial/trans-femoral ratio was 0.78. The percentage of prosthetic fitting among patients undergoing unilateral trans-tibial amputation was 68% and the corresponding figure among the trans-femoral patients was 35%. The epidemiological data showed an improvement on that found 8 years earlier although the overall age structure is shifting upwards.

This retrospective study compares pre and post-amputation mobility and the influence of age and associated medical problems. Data from the charts of 120 male patients who underwent unilateral trans-tibial (below-knee) amputation at the Dallas Veteran's Administration Hospital between June, 1983 and October, 1991, were collected and analyzed. Mobility was assessed with a six level scale developed by Volpicelli et al. (1983). The presence of cardiac disease, pulmonary disease (COPD), peripheral vascular disease (PVD), diabetes mellitus, degenerative joint disease, blindness, cerebral vascular accident (CVA), and age are correlated with changes in mobility after amputation. Older patients had more medical problems and lower post-amputation scores. Individual medical problems did not influence mobility scores, but the presence of COPD and PVD lowered pre-amputation mobility scores. Cardiac disease and diabetes mellitus influenced post-amputation mobility scores by lowering them, either together or individually. Regardless of age, however, patients with more medical problems were poor ambulators. The cause of amputation per se did not influence mobility scores.

The investigators measured efficiencies of body powered prehensors and cable control components of prostheses available for young children. Results indicated that the cable control systems and hook type prehensors have moderate to high efficiencies, but children's body powered hands have very low efficiencies. Measures of arm and shoulder strength of 3–5 year-old limb deficient children, both on the limb deficient and sound sides, were less than that reported in the literature for normal children. The findings were examined in relation to children's strength available compared with prosthesis strength requirements. The comparison demonstrates a way to establish measurable efficiency targets for new prehensor designs.

The article includes detailed findings on children's strength, and findings on efficiencies of the prehensors and cable control systems of children's upper limb prostheses. Sample calculations may be useful to future designers of body powered prehensors for young children. A more efficient body powered hand is especially needed. Preliminary calculations indicate that the use of currently available children's voluntary opening (VO), body powered hands is not feasible, given the low strength of young limb deficient children and the low efficiencies of the VO hands. The use of voluntary closing (VC) hands may be feasible but remains to be tested.

The major objective of prosthetics the world over is the same, i.e. to restore the amputee to as functional a capacity as possible in his cultural environment, whilst attaining as good a cosmetic result as can be achieved. At first glance it would seem that this would mean there would be very little difference in approach to the subject in western and in third world countries. Availability of materials, resources and skilled personnel, together with a variety of cultural differences, however, make third world prosthetics a subject in itself.

This paper reviews the literature available on the subject, examines some different approaches to prosthetics in the third world, gives an overview of some materials and designs used and considers adaptations for cultural differences. It concludes that, whilst direct transfer of western prosthetics technology is useful in the short term, for long term benefit to the poorer amputees in the third world, culture-specific designs and materials are more appropriate.

In Europe, bespoke orthopaedic shoes are usually sent for a trial fitting in order to check the fit and indicate any modifications required before final finishing. The use of shell shoes at the fit assessment stage, rather than the traditional alternative of partially or fully finished shoes, can offer service advantages, and is widely used for example in the Netherlands. However the comparability of shell fit assessment with the traditional method of trial shoe fit assessment has not been evaluated, either to assess its sensitivity or to elucidate any difference in assessment technique required of the orthotist. In this work, the results of fit assessments by both methods are compared. The trial involved a group of normal subjects wearing high street shoes of styles similar to those used for orthopaedic footwear. The results indicate that the shell fit assessments were in the main comparable to those for trial shoe fit. The only consistent area of deviation noted, in the heel at the topline, is attributable to a construction factor in shoe making. Apart from this area, the orthotist need not adjust his technique to make use of the shell method.

The aim of this investigation was to analyze the external forces and biomechanical loading on the musculoskeletal system during wheelchair pushing, in relation to different push handle heights. In addition, recommendations for wheelchair pushing in accordance with push handle height are made.

Eight young, female subjects carried out three different wheelchair transport tasks at five different push handle heights in a standardized laboratory setting. Five pushing heights were selected as a percentage of the subjects shoulder-height (61, 69.5, 78, 86.5 and 95%). All three wheelchair transport tasks investigated required higher pushing handles in order to minimise net shoulder moments and external vertical forces on the hands. When pushing a wheelchair on to a pavement, net moments around wrists, elbows, shoulders compression and shear forces at L5-S1 and external vertical forces were lower using higher pushing heights. When low pushing handles are used, elderly female attendants are at risk of L5-S1 low back pain when lifting and pushing the wheelchair on to a pavement. A recommendation is made to reconsider height and position of the pushing handles of attendant propelled wheelchairs. For the investigated tasks, a pushing height of 86.5% (1.191 ± 0.034 m) was most favourable.

The grasping hand. L. MacKenzie and T. Iberall. North-Holland, 1994. ISBN 0–444–81746–8. 500pp. NLG 250, USD 142.75