Prosthetics and Orthotics International

Hundreds of investigations examining biomechanical outcomes of various prostheses have been completed, but one question remains unanswered: how much time should an amputee be given to accommodate to a new prosthesis prior to biomechanical testing?

To examine the literature for accommodation time given during biomechanical investigations to determine whether consensus exists.

Systematic review.

A systematic search was completed on 7 January 2016 using PubMed and Scopus.

The search resulted in 156 investigations. Twenty-eight studies did not provide an accommodation or were unclear (e.g. provided a “break in period”), 5 studies tested their participants more than once, 25 tested only once and on the same day participants received a new prosthesis (median (range): above-knee: 60 (10–300) min; below-knee: 18 (5–300) min), and 98 tested once and gave a minimum of 1 day for accommodation (hip: 77 (60–180) days; above-knee: 42 (1–540) days; below-knee: 21 (1–475) days).

The lack of research specifically examining accommodation and the high variability in this review’s results indicates that it remains undecided how much accommodation is necessary. There is a need for longitudinal biomechanical investigations to determine how outcomes change as amputees accommodate to a new prosthesis.

The results of this review indicate that little research has been done regarding lower-limb amputees accommodating to a new prosthesis. Improper accommodation could lead to increased variability in results, results that are not reflective of long-term use, and could cause clinicians to make inappropriate decisions regarding a prosthesis.

Many individuals with lower limb loss report concern with walking ability after completing structured traditional rehabilitation.

The purpose of this study was to explore the impact of a supervised community–based exercise program on balance, balance confidence, and gait in individuals with lower limb amputation.

Repeated measures.

The supervised exercise program was offered biweekly for 6 weeks. The GAITRite System by CIR Systems, Inc., the Figure-of-8 Walk Test, and Activity-specific Balance Confidence Scale were used to measure clinical outcomes pre- and post-intervention.

In total, 16 participants with lower limb amputation (mean age: 50.8 years) completed the study. A multivariate, repeated measures analysis of variance indicated a statistically significant effect of training across six clinical outcome measures (F(6, 10) = 4.514, p = .018). Moderate effect sizes were found for the Figure-of-8 Walk Test (η² = .586), Activity-specific Balance Confidence Scale (η² = .504), and gait velocity at comfortable walking speed (η² = .574). The average increase in gait speed was clinically meaningful at .14 m/s.

The supervised community–based exercise program implemented in this study was designed to address specific functional needs for individuals with lower limb loss. Each participant experienced clinically meaningful improvements in balance, balance confidence, and walking ability.

The provision of a supervised community–based exercise program, after traditional rehabilitation, provides opportunity to offer a continuum of care that may enhance prosthetic functional ability and active participation in the community for individuals with lower limb amputation.

Challenges exist with the provision of appropriate mobility assistive devices in rural areas. The use of the direct manufacturing prosthetic socket system is a possible solution to these challenges.

The objective of this study was to test and explore the clients’ perspectives with the application of this device.

Within a mixed-methods approach, a longitudinal sequential explanatory design was applied.

The Orthotic and Prosthetic User’s Survey was administered to explore the use of the direct manufacturing prosthetic socket system in terms of function, health-related quality of life and client satisfaction. A conveniently selected sample of 21 individuals who suffered a unilateral trans-tibial amputation was included. Data were collected at 1, 3 and 6 months post fitting, and two focus group discussions were also administered.

Of the 21 participants recruited, 11 returned for follow up. Although participants reported favourably about the prosthesis, their scores were generally worse than the norms with regard to function and quality of life. Participants highlighted the need for improvement in the cosmetic appearance of the prosthesis.

The direct manufacturing prosthetic socket system could be considered as an alternative technique of socket manufacturing for individuals living in rural areas due to the shorter manufacture time and promising initial results, but further research on this topic with a bigger sample is recommended.

The direct manufacturing prosthetic socket system may be considered as an alternative to the traditional prosthetic socket manufacturing technique used in South Africa. As this device requires only one visit and therefore decreased travel by the patients to the hospitals, it could be applicable to more amputees who cannot return to hospital post discharge.

Dynamic elastic response prosthetic feet are designed to mimic the functional characteristics of the native foot/ankle joint. Numerous designs of dynamic elastic response feet exist which make the prescription process difficult, especially because of the lack of empirical evidence describing the objective performance characteristics of the feet.

To quantify the mechanical properties of available dynamic elastic response prosthetic feet, specifically the stiffness and hysteresis.

Mechanical testing of dynamic elastic response prosthetic feet.

Static Proof Testing in accordance with ISO 10328 was conducted on seven dynamic elastic response prosthetic feet. Load–displacement data were used to calculate the instantaneous stiffness in both the heel and forefoot regions, as well as hysteresis associated with each foot.

Heel stiffness was greater than forefoot stiffness for all feet. The heel of the glass composite prosthetic foot was stiffer than the carbon fiber feet and it exhibited less hysteresis. Two different carbon fiber feet had the stiffest forefoot regions.

Mechanical testing is a reproducible method that can be used to provide objective evidence about dynamic elastic response prosthetic foot performance and aid in the prescription process.

The quantitative stiffness and hysteresis data from this study can be used by prosthetists to aid the prescription process and make it more objective.

Most amputees live with their prostheses for a long time. Therefore, quality of life is an important outcome for lower limb amputees.

To translate the Prosthesis Evaluation Questionnaire (PEQ) and evaluate psychometric properties.

Methodological research.

Lower limb amputees responded to electronic versions of the PEQ and SF-36v2 at baseline (n=64), after two weeks (n=51), and after 12 weeks (n=50). Reliability was assessed using Cronbach’s alpha and intraclass correlation coefficient (ICC) analyses of the baseline and two weeks test-retest data. Estimates for standard error of measurement (SEM) were calculated based on reliability estimates. Construct validity was evaluated by testing using hypotheses testing.

Reliability estimates (ICC/Cronbach’s alpha) for the nine subscales were: Social Burden (0.85/0.76), Appearance (0.85/0.72), Residual Limb Health (0.80/0.69), Well-Being (0.78/0.90), Utility (0.76/0.89), Frustration (0.74/0.90), Perceived Response (0.62/0.80), Ambulation (0.61/0.94), Sounds (0.51/0.65). Construct validity was supported in three out of four subscales evaluated.

The subscales Social Burden, Appearance, Well-Being, Utility and Frustration had consistent high reliability, supporting their use in assessing the prosthesis related quality of life in lower limb amputees. Results were mixed on three other scales (Residual Limb Health, Perceived Response, and Ambulation), while one scale, Sounds, had consistent low reliability.

For the first time a patient reported disease specific quality of life measure for lower limb amputees is available in Danish. Health care providers can now identify patients with reduced quality of life and measure treatment and rehabilitation effects over time.

This study aimed to evaluate and compare a newly designed suspension system with a common suspension in the market.

Prospective study.

Looped liners with hook fastener and Iceross Dermo Liner with pin/lock system were mechanically tested using a tensile testing machine in terms of system safety. A total of 10 transtibial amputees participated in this study and were asked to use these two different suspension systems. The pistoning was measured between the liner and socket through a photographic method. Three static axial loading conditions were implemented, namely, 30, 60, and 90 N. Furthermore, subjective feedback was obtained.

Tensile test results showed that both systems could safely tolerate the load applied to the prosthesis during ambulation. Clinical evaluation confirmed extremely low pistoning in both systems (i.e. less than 0.4 cm after adding 90 N traction load to the prosthesis). Subjective feedback also showed satisfaction with both systems. However, less traction at the end of the residual limb was reported while looped liner was used.

The looped liner with hook fastener is safe and a good alternative for individuals with transtibial amputation as this system could solve some problems with the current systems.

The looped liner and hook fastener were shown to be good alternative suspension for people with lower limb amputation especially those who have difficulty to use and align the pin/lock systems. This system could safely tolerate centrifugal forces applied to the prosthesis during normal and fast walking.

Limited information is available concerning the effects of prosthetic foot components on energy costs and ambulatory performance for transfemoral amputees.

Compare energy costs (VO₂; gait economy) and ambulatory performance (self-selected walking speeds, self-selected running speeds, peak running speeds) differences during walking and running for transfemoral amputees and matched, non-amputee runners.

Repeated measures.

Transfemoral amputees were accommodated and tested with three prosthetic feet: conventional foot, solid-ankle cushioned heel (SACH); energy storing and return foot, Renegade; and running-specific energy storing and return foot, Nitro.

During walking, VO₂ was similar between transfemoral amputees but was increased compared to controls. Self-selected walking speeds were slower for SACH compared to Renegade and Nitro. For transfemoral amputees, gait economy was decreased and self-selected walking speeds were slower compared to controls. During fixed running speeds, transfemoral amputees ran using Nitro, and VO₂ was greater compared to controls. Transfemoral amputees ran at self-selected running speeds using Renegade and Nitro. Self-selected running speeds were slower for Renegade compared to Nitro. For transfemoral amputees, gait economy was decreased and self-selected running speeds were slower compared to controls. VO₂ peak was similar between transfemoral amputees and controls, but controls achieved greater peak running speeds and % grade.

Energy costs were greater and ambulatory performance was lower for transfemoral amputees compared to matched, non-amputee controls for all prosthetic foot conditions.

Both types of energy storing and return feet may improve walking performance for transfemoral amputees by providing faster self-selected walking speeds. For transfemoral amputees interested in performing vigorous running (exercise and running competition), clinicians should recommend a running-specific energy storing and return foot.

Although anthropometric factors could influence sprint performance in able-bodied sprinters, little is known about the relationships between these anthropometric factors and sprint performance in amputee sprinters.

To investigate the relationships between body height and spatiotemporal parameters of 100-m sprints in unilateral transtibial amputee and able-bodied sprinters.

This is a cross-sectional study.

We analyzed elite-level 100-m races of 14 male unilateral transtibial amputee sprinters and 22 male able-bodied sprinters from publicly available Internet broadcasts. For each sprinter’s run, the mean step length and frequency were determined using the number of steps in conjunction with the official race time. Furthermore, body height data for sprinters in both groups were obtained from publicly available resources.

Linear relationships were found between body height and mean step length and frequency in able-bodied sprinters, respectively. However, there were no significant relationships between body height and spatiotemporal parameters in transtibial amputee sprinters.

The results of this study suggest that the relationship between body height and spatiotemporal parameters during a 100-m sprint is not the same between unilateral transtibial amputees and able-bodied sprinters.

Understanding of the relationship between body height and spatiotemporal parameters during a 100-m sprint would provide important information that could be utilized for evaluating prosthetic sprint performance and coaching.

It has been reported that cycling-specific research relating to participants with an amputation is extremely limited in both volume and frequency. However, practitioners might participate in the development of cycling-specific prosthetic limbs. This technical note presents the development of a successful design of a prosthetic limb developed specifically for competitive cycling.

This project resulted in a hollow composite construction which was low in weight and shaped to reduce a rider’s aerodynamic drag.

The new prosthesis reduces the overall mass of more traditional designs by a significant amount yet provides a more aerodynamic shape over traditional approaches. These decisions have yielded a measurable increase in cycling performance. While further refinement is needed to reduce the aerodynamic drag as much as possible, this project highlights the benefits that can exist by optimising the design of sports-specific prosthetic limbs.

This project resulted in the creation of a cycling-specific prosthesis which was tailored to the needs of a high-performance environment. Whilst further optimisation is possible, this project provides insight into the development of sports-specific prostheses.

Spina bifida is an uncommon cause for lower limb amputation. The causes and level of amputation and mobility outcome for these patients have not been reported previously.

To identify the causes and level of amputation and the mobility outcome for amputee patients with spina bifida.

Retrospective case series.

Chart review of patients identified by computer as having an amputation secondary to neurological or congenital cause. Additional patients identified from the Regional Spina Bifida Medical Clinic. Demographics, cause and level of mobility pre- and post-amputation recorded from the prosthetic notes.

In total, 16 patients were identified who had a diagnosis of spina bifida and a lower limb amputation. Mean age at the time of amputation was 28.5 years. In total, 15 patients had a transtibial amputation. In total, 14 patients post-amputation were able to maintain their mobility, wheelchair or walking, without any change in type of aid needed.

Patients with spina bifida appear to require lower limb amputation at a younger age than patients with peripheral vascular disease. Almost all patients had prior chronic skin infection/osteomyelitis as precursors for amputation. The most common level for amputation was transtibial. Mobility was maintained for all patients, albeit for two in a more supported way.

Spina bifida is an uncommon reason for amputation. Patients, are often younger and medically complicated. Chronic skin ulceration, was the most common indication for amputation. Wheelchair or walking ambulance was maintained at the same level for most patients.

After amputation, the brain is known to be reorganized especially in the primary motor cortex. We report a case to show changes in the corticospinal tract in a patient with serial bilateral transtibial amputations using diffusion tensor imaging.

A 78-year-old man had a transtibial amputation on his left side in 2008 and he underwent a right transtibial amputation in 2011. An initial brain magnetic resonance imaging with a diffusion tensor imaging was performed before starting rehabilitation on his right transtibial prosthesis, and a follow-up magnetic resonance imaging with diffusion tensor imaging was performed 2 years after this.

In the initial diffusion tensor imaging, the number of fiber lines in his right corticospinal tract was larger than that in his left corticospinal tract. At follow-up diffusion tensor imaging, there was no definite difference in the number of fiber lines between both corticospinal tracts.

We found that side-to-side corticospinal tract differences were equalized after using bilateral prostheses.

This case report suggests that diffusion tensor imaging tractography could be a useful method to understand corticomotor reorganization after using prosthesis in transtibial amputation.

After amputation patients are more likely to injure their residual limb. An injury of a previously amputated limb, especially if the residuum is not anatomically normal, poses a dilemma for management.

This case report discusses a femoral fracture sustained proximal to a through-knee amputation.

The fracture was at the site of a malunited fracture. A shortening osteotomy with bone graft was undertaken to improve alignment and prosthetic fit and remove poor-quality bone. This was stabilised using an intramedullary nail, supplemented with an anti-rotation plate. This fracture went on to uneventful union, and the patient was able to comfortably use a prosthesis with increased functionality compared with prior to the recent injury.

This management enabled quick healing of the fracture without the need to resort to a more proximal amputation.

In these unusual cases, careful planning is necessary to ensure all aspects of the problem is dealt with. Each case should be treated on its own merits.

This case demonstrates the difficulty in care of complex limb trauma and offers a solution for management of similar cases. Excellent results are possible when all surgical options are considered.

Rotationplasty is an important and demanding challenge for physiotherapists. The aim of this paper is to describe the functional outcome achieved by a patient undergoing rotationplasty in adult age following osteosarcoma.

The patient was followed throughout the rehabilitation course and the results achieved were recorded at 6, 9 and 12 months after surgery.

The results progressively improved in terms of function, functional performance and quality of life. The MSTS and TESS scales showed an improvement respectively of 20 and 23 percentage points, reaching levels of 80% and 87%. The quality of life perceived by the patient increased in the three assessments, the mental health score at one-year follow-up is higher than that expected for the population.

Rotationplasty, even in adult age, produces good results and in the treatment of tumours in adults this operation should be taken into consideration.

Rotationplasty in adult age following osteosarcoma combined with a rehabilitation program enabled a patient to reach a successful outcome in terms of functional performance and quality of life.

To overcome the challenges of rehabilitation of bilateral transfemoral amputees, we developed a novel “hip prosthesis in the sitting posture.”

A 64-year-old male bilateral transfemoral amputee was transferred for rehabilitation 4 months following a burn injury. His wounds remained unhealed for 20 months; thus, he was unable to participate in standing training with the standard prosthetic sockets. Hip prosthesis in the sitting posture has very little friction between the sockets and residual limbs, which facilitated our patient to begin standing and walking exercises.

The patient’s refractory wounds healed 1 month after initiating exercises using hip prosthesis in the sitting posture, and he could begin rehabilitation with the standard prostheses.

Hip prosthesis in the sitting posture enabled a bilateral transfemoral amputee with unhealed residual limbs to stand, walk, and begin balance training. Hip prosthesis in the sitting posture is an effective temporary prosthesis to prevent disuse until wounds are healed and to continue rehabilitation with standard prostheses.

Hip prosthesis in the sitting posture is useful for bilateral transfemoral amputees with unhealed residual limbs after burn injuries to prevent disuse and maintain motivation for walking.

This novel case report describes the problems of prescribing a prosthetic socket in a left transfemoral amputee secondary to chronic patellofemoral instability compounded by complex regional pain syndrome.

Following the amputation, complex regional pain syndrome symptoms recurred in the residual limb, presenting mainly with oedema. Due to extreme daily volume fluctuations of the residual limb, a conventional, laminated thermoplastic socket fitting was not feasible.

An adjustable, modular socket design was trialled. The residual limb volume fluctuations were accommodated within the socket. Amputee rehabilitation could be continued, and the rehabilitation goals were achieved. The patient was able to wear the prosthesis for 8 h daily and to walk unaided indoors and outdoors.

An adjustable, modular socket design accommodated the daily residual limb volume fluctuations and provided a successful outcome in this case. It demonstrates the complexities of socket fitting and design with volume fluctuations.

Ongoing complex regional pain syndrome symptoms within the residual limb can lead to fitting difficulties in a conventional, laminated thermoplastic socket due to volume fluctuations. An adjustable, modular socket design can accommodate this and provide a successful outcome.