Prosthetics and Orthotics International

Data on mortality for the ten years following lower limb amputation were obtained from all the 16 surgical units in Southern Finland and the National Social Insurance Institution. In Southern Finland during the period 1984-1985, amputations of the lower limb were performed on 705 patients, of whom 382 (54%) were women and 323 (46%) men. The majority of the amputations, 47%, were performed for vascular diseases and 41% were performed for diabetes mellitus. The overall survival was 62% at one year after amputation, 49% at two years, 27% at five years and 15% at ten years. The median survival after amputation was 1 yr 5 mth for the women and 2 yr 8 mth for the men. Of the arteriosclerotics, 43% died within one postoperative year while 43% lived longer than two years and 23% longer than five years. The median survival of arteriosclerotics was 1 yr 6 mth. The corresponding figure for patients with diabetes was 1 yr 11 mth. Of the diabetics, 38% died within one postoperative year while 47% lived longer than two years and 20% longer than five years. Of the trauma patients, 86% lived longer than five years and 71% longer than ten years. Of the trans-femoral amputees, 54% lived longer than one year, 36% over two years, 18% over five years and 8% over ten years. The corresponding figures for trans-tibial amputees were 70%. 53%, 21% and 4%. Many elderly vascular and diabetic patients undergoing amputation have a reduced physiological reserve and high mortality. The more proximal the amputation, the greater the risk that the patient will never be able to walk or that the duration of use of the prosthesis will be short. If a prosthesis seems to be a reasonable option for the elderly amputee, any delays in prosthetic fitting should be avoided in older age groups.

The aim of this study was to determine the degree of pelvic tilt in three dimensions, the trunk muscle strength and effects on gait in trans-tibial amputated patients. This study comprised of 22 unilateral trans-tibial amputated patients who were seen at the authors' Prosthetics and Orthotics Laboratory for the purpose of prosthetic provision. Measurements were made using plurimeter and caliper and gait observations were made by video camera.

In the sagittal and horizontal planes respectively the pelvic tilt was measured to be 12d` and 5.73d`, and such measurements in relation to the trunk extensor and flexor muscles were shown to be statistically significant (p<0.05). On the contrary, the same could not be said for frontal plane measurements. In addition, in 9 cases excessive knee flexion was noted during the stance phase having a direct influence on the pelvic tilt (p<0.05).

Flexible flat foot subjects attending the prosthetics and orthotics units come with prescriptions from orthopaedic surgeons for arch supports. Usually a pair of thermoformed plastic inserts are fabricated and fitted to treat the patients. However the effect of the orthotic treatment is not yet clear. A motion analysis system with two video cameras placed on the lateral and rear sides of the subject together with one force platform was used to investigate the immediate effects of the orthotic treatment. The force platform collected force data and the two cameras captured two-dimensional displacement data of the lower limb.

Eight subjects, all having an arch index (AI) larger than 3.O, participated in the study. For each subject, three successful steps on the force platform were videotaped for both the shod (with shoe only) and the orthotic (with shoe and orthosis) conditions. The kinetic variables were normalized to individual body weight and averaged for each subject. A Paired t-test was conducted to analyse sample means of matched pairs between the shod and the orthotic conditions.

The results showed changes in displacement data with relatively little change in the collected force data. The modified UCBL shoe insert evaluated significantly affected the orientation and movements of the subtalar joint, ankle joint and knee joint. These immediate effects reduced the degree and duration of abnormal pronation during the stance phase and thus had the potential for decreasing strain in the plantar ligaments and reducing abnormal tibial rotation which may be therapeutic for the foot.

The effects of a custom moulded insole and a rockerbar on peak pressure and force impulse as well as on pain scores in subjects with a history of metatarsalgia were studied. In addition the subjects' preference for the type of intervention was determined. Forty-two subjects with a history of primary metatarsalgia were selected. They were all provided with the same brand of extra depth shoes with a ready made insole. The effect of custom moulded insoles, a rockerbar and the interaction between the two interventions were studied by testing the four possible combinations: ready made insole without a rockerbar, ready made insole with a rockerbar, custom moulded insole without a rockerbar and custom moulded insole with rockerbar.

At the most important region, the central distal forefoot, a rockerbar caused a decrease in force impulse of 15.1% and a decrease in peak pressure of 15.7%.

The custom moulded insole produced a decrease of 10.1% in force impulse and of 18.2% in peak pressure.

Pain scores were significantly lower for interventions with a custom moulded insole, while the rockerbar showed no influence on pain scores. Subjects with pain preferred a custom moulded insole more often than subjects without pain.

Decrease of peak pressure or force impulse was not correlated to pain scores.

The use of either a custom moulded insole or a rockerbar proudced an important decrease of peak pressure and force impulse at the central distal forefoot and, therefore, either is suitable in any situation which a decrease of pressure is vital.

Previous publications have reported on the flexibility of ankle-foot orthoses (AFO) only in the same plane as the applied load. This paper reports on a test apparatus developed to detect the flexibility of an AFO in 5 degrees of freedom when subjected to a plantar/dorsiflexion moment, a medial/lateral moment or a torque. A moment applied to an AFO in one plane induces angulation and translation in all planes.

Although, the history of orthotic treatment for idiopathic scoliosis goes back more than fifty years, the mechanism of curve control by spinal orthosis is still controversial. Hypothetical explanations have been provided but few, if any, have been tested clinically. This study aims at the biomechanical evaluation of a spinal orthosis (Milwaukee brace) in order to improve understanding about the mechanism of curves control in orthotic movement.

From the results of the study, the change of the interface pressure between the patient's body and thoracic pad, and the tension of the thoracic strap were highly correlated (r=0.84) as patients performed different lying postures and daily activities. Lying on the thoracic pad is found to have the highest correctional force among different lying postures that may be favourable for preventing curve deterioration.

The findings indicate that an increase in tension of the thoracic strap will increase the interface pressure on the thoracic pad and thus increase the resultant force exerted on the patient's body by the thoracic pad. Care must be taken as an excessive strap tension will increase discomfort and restrict body shifting exercises. The results also suggest that in scoliosis with thoracic lordosis, a short outrigger (small pulling angle of the thoracic strap) should be used as it will decrease the anteriorly directed force component so as to prevent exaggerating the thoracic lordosis.

Bilateral lower limb amputees suffer from a lack of stability when seated without prostheses due to lack of ground reaction forces through the stumps. In patients for whom ambulation is not a realistic goal, the seated-popliteal weight bearing prosthesis provides a solution for stability when seated in a wheelchair, without the problem of tibial pressure experienced with patellar-tendon-bearing prostheses.

Congenital Limb Deficiency: Recommended Standards of Care Amputee Medical Rehabilitation Society; London, 1997