Prosthetics and Orthotics International

There is no central database that records the changing provision of prostheses in the United Kingdom. Experience suggests there have been some shifts in the population, particularly in the past decade. Because the detailed records of these changes are contained in the patients' medical records it is difficult to assess the substance of these data except on an individual basis; the larger picture requires the sifting of a centre's or many centres' data. This paper describes the analysis of one such set of records at the Oxford Limb Fitting Centre. It relates the profile of the population that attends the centre to the general population, and compares the information with that obtainable from other sources. The possible causes for the findings are discussed.

The aim of this study was to give a retrospective review of all lower limb amputations performed in the 3 northern provinces of the Netherlands in 1991–1992. Assembled data were compared with the existing information in the National Medical Register (NMR) over the same period.

With the participation of all regional hospitals, 473 lower limb amputations from transpelvic to transmetatarsal level were identified. Of the amputations 94% were performed for vascular pathology, 3% for trauma, and 3% for oncologic reasons. After surgery a prosthesis was provided to 48% of the amputees.

The actual number of performed amputations exceeds the number of amputations registered by the NMR by 9%. Incidence rates of lower limb amputations in the Netherlands are 18–20/100,000 over the last 12 years. These numbers are lower than in other areas and show no sharp decrease in frequency compared with other countries in Western Europe.

The purpose of this study was to compare prosthetic weight-bearing tolerance in the standing position to the dynamic vertical ground reaction forces (VGRF) experienced during walking in elderly dysvascular trans-tibial amputees. Ten unilateral trans-tibial amputees attending an amputee clinic (mean age =67±6.5 years) were selected as subjects. Selection criteria were the level of amputation, age, medical fitness to participate and informed consent. Each participant completed five trials of standing (static) weight bearing measurement followed by 10 walking (dynamic) trials on a 10m level walkway, five trials for each limb. Static weight bearing (SWB) was measured using standard bathroom scales. Dynamic weight bearing (DWB) was measured during gait using a Kistler multichannel force platform. T-tests for dependent means indicated that the forces borne in prosthetic single limb stance (mean=0.97±0.03 times body weight (BW)) were significantly lower than the forces borne by the prosthetic limb during the first peak (weight acceptance) VGRF (mean = 1.08±0.08 BW; t = −4.999; p = 0.001) and significantly higher than the midstance VGRF (mean = 0.82±0.07 BW; t = 5.401; p<0.001). However, there was no significant difference between SWB and the second peak (push-off) VGRF generated by the prosthetic limb during walking (mean = 0.96±0.03 BW). It was concluded that clinical gait training may utilise SWB as a guide to an amputees' prosthetic weight bearing tolerance and requirements during walking.

A new static alignment method for trans-tibial prostheses is suggested using the individual load line as a reference.

Standing posture and static alignment of 18 experienced trans-tibial prosthetic users with good walking ability were determined and compared with 20 healthy persons. The individual load line was defined by means of the new Otto Bock alignment system “L.A.S.A.R. Posture”.

The sagittal standing posture of trans-tibial amputees and non-amputees differs. Normally only a prosthesis worn by the trans-tibial amputee and dynamically aligned over an extended period of time satisfies biomechanical rules of alignment. In contrast, prostheses aligned during one session in the traditional subjective manner seem to lack any recognizable biomechanical systematics. Initial results suggest the knee centre should be 10 to 30mm behind the load line, depending on patient's weight. This knee position is independent on the type of the prosthetic foot.

The aim of this study was to assess, by means of gait analysis, the effect on the gait of a transtibial amputee of altering the mass and the moment of inertia of a dynamic elastic response prosthesis. One male amputee was analysed for four to five walking trials at normal and fast cadences, using the VICON system of motion analysis and an AMTI force plate. The kinematic variables of cadence, swing time, single support time and joint angles for the knee and hip on the affected and intact sides were analysed. The ground reaction force was also analysed. The sample size was limited to one as an example to indicate the changes which are possible through simply changing the inertial characteristics. Descriptive statistics are used to demonstrate these changes. Three mass conditions for the prosthesis were analysed m₁: 1080g; m₂: 1080 + 530g; m₃: 1080 + 1460g. The m₁ condition is the mass of the prosthesis with no added weight while m₂ and m₃ were attachments of the same geometrical shape but were made from different materials. It was felt that the large mass range would highlight biomechanical adjustments as a result of its alteration. The effect on selected temporal characteristics were that as the speed increased the cadence changed and the affected side single support times as a percentage of the gait cycle were altered. The effect on the joint angles was also apparent at the hip and knee of both sides. The ground reaction force patterns were similar for all three mass conditions, though the impact peak which was evident in the intact limb was missing, indicating a shock absorbing property in the prosthesis. Clearly, changing the mass and moment of inertia has an effect on the kinematic variables of gait and should be considered when designing a prosthesis.

The management of the individual with a trans-tibial amputation has been strongly influenced by the increasing use of the ICEROSS socket system over recent years. Despite this growth in clinical experience, there has been very little research into its place in current prosthetic practice, and prescribing activity is largely determined by personal experience. In order to formulate the current consensus view on the use of ICEROSS, questionnaires were sent to 42 doctors and 43 senior prosthetists around the UK. The influence of 38 different factors on prescribing activity was assessed using a grading system (ranging from “primary indication” to “absolute contraindication”). An 85% response rate was achieved and no significant differences in response between the two professional groups were identified. Those factors considered by most to be positive indications for using ICEROSS were “pistoning”, “shear-sensitive skin / split-skin grafts”, “patient unsuccessful with supracondylar (s/c) or cuff suspension” and “insufficient suspension due to change in type or level of activity”. Those considered by most to be absolute contra-indications were “ulceration / unhealed scars”, “poor patient hygiene” and “poor patient commitment to prosthetic rehabilitation”. This consensus of opinion is in keeping with the results of the few published audits of ICEROSS usage. There was a lack of consensus, however, about the use of ICEROSS in some situations, including skin complications.

Whilst some consensus does exist about the use of ICEROSS, the results of this survey indicate significant variations in clinical practice which serve to illustrate the urgent need for data from prospective clinical trials.

The purpose of this study is to analyze the movement of unilateral trans-femoral amputees' gait and find patterns of compensated movement to accommodate the loss of locomotor power on one side. A 3-D analyzer system and force plate were used to measure 12 amputees.

The main focus was to find characterized movement particularly of the upper body such as pelvis, shoulder and arms. It was Saunders et al. (1953), who said that the human body can be purposely divided into two subsystems in analyzing man's locomotion.

This study, however is not to measure the level of function, but to evaluate the appearance of gait.

Twelve markers were placed on the subjects, and two locations for measuring points were used to measure movement of the torso in three axis (X, Y, Z) without measuring the position of the centre of gravity. The two points were at shoulder level, and at pelvic level.

Lissajou's figure was used to evaluate the movements at these two marks. The quality of the gait was determined through subjective evaluation by the author. Determination was made on two factors, one from observing the gait of the amputees and the other, patterns from their Lissajou's figure of two measuring points.

Then they were categorized as good walker or “other”. Good walkers had results at shoulder level which were closer to the symmetrical Lissajou's figure of normal walkers. Yet the symmetrical pattern was not present at the pelvis level for the good walker.

The aim of this study was to investigate whether or not the one-leg cycling test driven by the subject's sound leg as the exercise load method is an applicable method for determining the anaerobic threshold (AT) of lower limb amputees. To evaluate physical fitness, a graded exercise test that monitored gas exchange, ventilation and heart rate (HR) was performed in 51 unilateral lower limb amputees. AT was successfully measured for 42 out of 51 subjects, an 82.3% success rate. The average AT was 12.7 ± 2.2 ml/kg/min, and the average HR at AT point was 117.7 ± 16.2 beats/min. The average peak oxygen uptake was 20.1 ± 5.6 ml/kg/min, and the average peak HR was 145.1 ± 22.4 beats/min. The peak HR exceeded the HR at AT by an average 27.4 beats/min, which indicates that a comparatively intense exercise load above the AT level is possible. The average AT was 40.9% of the predicted maximum oxygen uptake, which seems reasonable when compared to the reports of other researchers. These results suggested that the one-leg cycling test driven by the sound limb is of use as a method for determining the AT of lower limb amputees.

A 7 year retrospective review of 42 patients of 16 years or over using the ORLAU Parawalker has been conducted to establish the degree of long-term compliance in using the orthosis on a regular basis. Regular use was defined as putting the orthosis on at least once a week.

All subjects had been supplied with an ORLAU Parawalker via the routine supply procedures adopted in Oswestry, and were followed up at regular 6 month intervals as part of the standard treatment regime.

The records from routine follow-up were surveyed for those patients who were continuing to use their orthosis to establish age, length of time since supply of orthosis and cause of lesion. Average period of usage is calculated for those still using their orthosis, and for all patients in the study.

Of the 42 subjects, 32 were myelomeningocele patients with confirmed absence of innervation of hip extensors and abductors, the remainder being paraplegic patients with traumatic or acquired complete thoracic lesions. Compliance figures were extracted from the results, as were the minimum possible average periods of usage. The respective results were:

of the 32 myelomeningocele patients 59.4% continued usage after an average period of 85.5 months, and

The performance of myelomeningocele patients suggests that their additional deformities do not lead to inferior compliance as adults and that a high proportion to continue to walk after adolescence.

Patients with osteoarthritis of the hip were treated with a conservative therapy of heel lifting. Orthoses were applied on 35 hips in 33 subjects and the cases were followed for 23 months on average. Dramatic pain relief was reported, but the time required to reduce or completely relieve pain increased according to the stage of osteoarthritis. The radiological results were not satisfactory.

During the follow-up, only two hips showed improvement, 22 showed no change, and 11 deteriorated. The mechanism of heel lifting in relation to the hip joint was analysed, showing that pelvic obliquity was achieved and the trunk stabilized. In conclusion this simple orthosis was effective as a palliative therapy for osteoarthritis of the hip.

Reflex sympathetic dystrophy (RSD) is characterized mostly by: (burning) pain, restricted range of motion, oedema and autonomic disturbances. Amputations in case of RSD patients should only be performed in cases of a dysfunctional limb, life threatening conditions such as untreatable infections or in cases of unbearable pain. The authors describe a patient in whom amputation became inevitable because of threatening infections.

Orthopadie-technische Indikationen (Orthopaedic Technical Indications) Andre Bähler. Verlag Hans Huber, Bern; Gottingen; Toronto; Seattle, 1996. pp. 592, illustrated.