Prosthetics and Orthotics International

Chronic ankle instability as a prevalent consequence of ankle sprain causes various impairments such as balance and postural control deficits. Foot orthoses are one of the common interventions for rehabilitation of patients with chronic ankle instability.

To investigate the effect of custom-molded foot orthoses with textured surfaces on dynamic balance of chronic ankle instability patients and to compare their effects with other types of foot orthoses.

This is a repeated measure design.

A total of 30 participants were recruited based on the guideline introduced by the International Ankle Consortium. The effect of prefabricated, custom-molded, and custom-molded with textured surface foot orthoses was evaluated on dynamic balance by the Star Excursion Balance Test. Normalized reach distances in anteromedial, medial, and posteromedial directions of the test were computed to be used for statistical analysis.

The foot orthoses increased reach distances compared to the no-orthosis conditions in all three directions. The custom-molded with textured surface foot orthosis has significant differences compared with prefabricated foot orthosis (p = 0.001) in all measured directions and with custom-molded foot orthosis (p < 0.01) in medial and posteromedial directions.

Foot orthoses improve reach distances in patients with chronic ankle instability. Custom-molded with textured surface foot orthosis has a more pronounced effect compared with other foot orthoses.

The custom-molded foot orthosis with textured surface could be an effective device to improve dynamic balance in chronic ankle instability (CAI) patients. It may be considered as an efficient intervention to reduce ankle sprain recurrence in these individuals, although further research should be conducted.

Different types of ankle-foot orthoses are commonly used following lower limb surgery in children with bilateral spastic cerebral palsy. After three-dimensional gait analysis 1 year postoperatively, many children are recommended continued use of ankle-foot orthoses.

Our aims were to quantify the impact of ankle-foot orthoses on gait 1 year postoperatively and evaluate predictors for clinically important improvement.

Prospective cohort study.

A total of 34 ambulating children with bilateral cerebral palsy, with mean age 11 years (range 6–17), comprising 12 girls and 22 boys, were measured with three-dimensional gait analysis preoperatively (barefoot) and 1 year postoperatively (barefoot and with ankle-foot orthoses). Outcome was evaluated using gait profile score, key kinematic, kinetic and temporal–spatial variables in paired sample comparisons. Logistic regression was used to evaluate predictors for clinically important improvement with orthoses (⩾1.6° change in gait profile score).

Walking barefoot 1 year postoperatively, major improvements were seen in gait profile score and key variables. With ankle-foot orthoses, there were significantly improved step length and velocity, additional moderate reduction/improvement in gait profile score and knee moments and decreased stance ankle dorsiflexion compared to barefoot. Children using ground reaction ankle-foot orthoses (n = 14) decreased stance knee flexion from 13.9° walking barefoot to 8.2° with orthoses. High gait profile score and more gait dysfunction preoperatively were significant predictors of clinically important improvement walking with orthoses.

The results indicate improved gait function walking with ankle-foot orthoses versus barefoot 1 year after lower limb surgery. Stronger impact of ankle-foot orthoses was found in children with more pronounced gait dysfunction preoperatively.

The 1-year postoperative three-dimensional gait analysis is a useful method to assess treatment outcome after lower limb surgery in children with bilateral cerebral palsy and could also guide clinicians whether further treatment with ankle-foot orthoses is indicated, using clinically important differences as thresholds to evaluate their impact on gait.

Infrapatellar strapping is a treatment technique used in various knee pathologies; however, its effect on pain and functional performance among young athletes has not been studied.

To evaluate the effect of infrapatellar strap on pain and jumping performance among young athletes diagnosed with patellar tendinopathy.

Pre-/post-test (within-subject research design).

A total of 16 young male basketball and volleyball athletes (age range, 12–18 years) diagnosed with patellar tendinopathy were included in the study. Infrapatellar strap was applied beneath the patella, over the patellar tendon. The athletes performed four jumping tests: squat jump, drop jump, single-leg jump, and jumps 30 s test, with and without the strap. Pain severity in the symptomatic knee during jumping was assessed using a visual analog scale and jumping performance parameters were assessed using an Optojump Next optical measurement system.

Pain severity reported by the participants decreased in drop test, single-leg jump test, and jumps 30 s test while using the infrapatellar strap compared with no strap condition (p < 0.05). No significant difference in jumping performance was found between jumping with and without the strap.

The infrapatellar strap was effective in reducing local pain among young male athletes without altered jumping performance.

The infrapatellar strap can be recommended to use during physical activity as part of the physical therapy treatments for patellar tendinopathy. Given the low cost, ease to use, and being a non-invasive method without adverse effects, it is an appropriate intervention for young athletes.

The volume of a prosthesis user’s residual limb changes during the day and may affect the fit of the prosthesis. These changes must be managed by the user to prevent discomfort, skin breakdown, and falls.

The objectives were to test how activity, time of day, and intermittent doffing affected residual limb fluid volume in people with transtibial amputation.

Standardized, repeated measure (A-B-A) out-of-laboratory protocol.

Participants with transtibial amputation completed three 6-h test sessions. Two sessions served as controls (A protocol) during which participants left their prosthesis donned, and one session was an intervention (B protocol) where participants doffed their prosthesis twice for 20 min during the 6 h of testing. Within-socket fluid volume was measured using a custom portable bioimpedance analysis system.

A total of 13 participants completed the study. The rate of limb fluid volume loss was higher early in the session compared with late in the session. Participants experienced less fluid volume loss during high activity than low activity. Socket users with pin suspension experienced less posterior fluid volume loss when they intermittently doffed their prosthesis. Intermittent doffing did not benefit limb fluid volume of mechanical vacuum and suction suspension users.

High activity may reduce fluid volume loss compared with low activity. Intermittent doffing may provide volume accommodation for transtibial prosthesis users with pin suspension.

Prosthetists should query their patients about the intensity of activity they conduct when advising them on limb volume management. Patients using sockets with pin suspension may be able to offset limb fluid volume loss by periodically doffing the prosthesis.

A well-fitting and comfortable ischial containment socket relies on accurately replicating the transverse plane angle of the ischium and ischial ramus angle, inside the medial socket brim. Prediction of the ischial ramus angle, may provide a way to determine the ischial ramus angle without in vivo measurement.

To determine the accuracy with which the ischial ramus angle could be predicted and identify which variables contributed significantly to the prediction.

Cross-sectional study.

Computed tomography scans were randomly sampled from a cadaveric database (n = 200). Standard multiple regression models were developed to predict the ischial ramus angle based on pelvic measures.

The regression model explained 10.5% of the variance in ischial ramus angle (p = 0.018). The standard error of the estimate was 11.32°. While regression models by sex explained a larger proportion of the variance, the resulting accuracy was not improved.

The regression models explained a small proportion of variance in ischial ramus angle. The average error associated with the prediction was too large to accurately predict the ischial ramus angle for use in clinical practice. Contrary to commonly held beliefs, there was no statistically significant difference in ischial ramus angle between sexes.

Prediction of ischial ramus angle does not have sufficient accuracy to be clinically useful, but descriptive data may help clinicians identify casting errors and correct these in a plaster positive, knowing that the average ischial ramus angle was 32.65°±5.59° (relative to mid-sagittal plane) and does not vary between sexes.

Thermal discomfort among lower-limb prosthesis wearers is prevalent with social and medical consequences.

This study aimed to verify the feasibility of out-of-laboratory thermal comfort studies.

Repeated measures pilot study.

Thermistors were placed on participants’ residual limbs during two experimental phases. In phase 1, mean limb temperature was calculated over a controlled 55-min rest-exercise-rest protocol. In phase 2, participants conducted activities of their choosing wherever they wanted away from the lab, while limb temperature data were collected. Descriptive statistics and statistical differences between phases are presented.

Five male amputees participated with an average age ±standard deviation of 30 ± 9 years. In phase 1, mean limb temperature change ranged between 1.6°C and 3.7°C. In phase 2, mean limb temperature change ranged between 1.8°C and 5.1°C. Limb temperature was significantly higher in out-of-lab studies (+1.9°C, p = 0.043) compared to in-lab studies.

Independent multiple-hour temperature studies are shown to be feasible. Results also indicate that out-of-lab residual limb temperature can be significantly higher than in-lab temperatures.

Thermal discomfort and sweating may lead to skin conditions and reduce quality of life among prosthesis wearers. Out-of-lab, long-term temperature studies are needed to comprehensively characterize thermal discomfort to create preventive solutions.

A stance-yielding mechanism for prosthetic knees may reduce lower limb loading during specific activities, but quantitative data are insufficient.

To clarify the biomechanical effect of a non-microprocessor-controlled stance-yielding mechanism on ramp descent for individuals with unilateral transfemoral amputation.

Intra-subject intervention study.

Seven individuals with unilateral transfemoral amputation underwent three-dimensional motion analysis of ramp descent with and without activating a stance-yielding mechanism. Regarding early-stance internal joint moment and ground reaction force, whole-group and subgroup analyses stratified by stance prosthetic knee flexion were performed to verify differences in prosthetic side and contralateral limb loading between conditions.

Whole-group analysis revealed significant reduction in early-stance prosthetic knee extension moment with stance-yielding mechanism activation. Changes in prosthetic side hip extension moment and contralateral limb loading were inconsistent between conditions. Subjects with prosthetic stance knee flexion walked slower with a smaller stride and greater increase in aft ground reaction force and ankle dorsiflexion moment when stance-yielding was activated.

Stance-yielding mechanism has a biomechanical potential to decrease excessive knee hyperextension. However, prosthetic side stance knee flexion induced by the stance-yielding mechanism might not necessarily reduce the mechanical load on residual hip or contralateral lower limb joints.

This study showed individual variability in the possibility of reducing the load on the remaining lower limb when using a non-microprocessor-controlled stance-yielding knee. This suggests that individualized prosthetic management and monitoring the activities of individuals wearing a stance-yielding prosthetic knee are crucial to maximize the benefits of stance-yielding prosthetic knees.

The current method of prescribing composite running-specific energy-storing-and-returning feet is subjective and is based only on the amputee’s static body weight/mass.

The aim was to investigate their dynamic characteristics and create a relationship between these dynamic data and the prescription of foot.

Experimental Assessment.

This article presents the modal analysis results of the full range of Össur Flex-Run^™ running feet that are commercially available (1LO–9LO) using experimental modal analysis technique under a constant mass at 53 kg and boundary condition.

It was shown that both the undamped natural frequency and stiffness increase linearly from the lowest to the highest stiffness category of foot which allows for a more informed prescription of foot when tuning to a matched natural frequency. The low damping characteristics determined experimentally that ranged between 1.5% and 2.0% indicates that the feet require less input energy to maintain the steady-state cyclic motion before take-off from the ground. An analysis of the mode shapes also showed a unique design feature of these feet that is hypothesised to enhance their performance.

A better understanding of dynamic characteristics of the feet can help tune the feet to the user’s requirements in promoting a better gait performance.

The dynamic data determined from this study are needed to better inform the amputees in predicting the natural frequency of the foot prescribed. The amputees can intuitively tune the cyclic body rhythm during walking or running to match with the natural frequency. This could eventually promote a better gait performance.

Gaitography is gait parametrization from center-of-pressure trajectories of walking on an instrumented treadmill. Gaitograms may be useful for prosthetic gait analyses, as they can be rapidly and unobtrusively collected over multiple gait cycles without constraining foot placement. However, its reliability must still be established for prosthetic gait.

To evaluate (a) within-method test–retest repeatability and (b) between-methods agreement for temporal gait events (foot contact, foot off) and gait characteristics (e.g. step times, single-support duration).

Cohort study with repeated measurements.

Ten male proficient prosthetic walkers with a unilateral trans-femoral or trans-tibial amputation were equipped with a pressure-insole system and were invited to walk on separate days on an instrumented treadmill.

We found better between-methods reproducibility than within-method repeatability in temporal gait characteristics. Step times, stride times, and foot-contact events matched well between the two methods. In contrast, insole-based foot-off events were detected one-to-two samples earlier. Likewise, a similar bias was observed for temporal gait characteristics that incorporated foot-off events.

Notwithstanding small systematic biases, the good between-methods agreement indicates that temporal gait characteristics may be determined interchangeably with gaitograms and insoles in persons with a prosthesis. However, the relatively poorer test–retest repeatability hinders longitudinal assessments with either method.

Clinical practice could potentially benefit from gaitography as an efficient, unobtrusive, easy to use, automatized, and patient-friendly means to objectively parametrize prosthetic gait, with immediate availability of test results allowing for prompt clinical decision-making. Temporal gait parameters demonstrate good between-methods agreement, but poorer within-method repeatability hinders detecting prosthetic gait changes.

Prosthetic socket fit is an important element associated with successful ambulation and use of a prosthesis. Prosthetists and rehabilitation clinicians would benefit from an assessment tool that discriminates between and quantifies the multiple determinants that influence the lower limb amputee’s performance and satisfaction of a prosthetic socket.

To determine the internal consistency of the comprehensive lower limb amputee socket survey, a new self-report measure of prosthetic socket satisfaction that quantifies suspension, stability, comfort, and appearance.

Cross-sectional sample of active amputees.

Interviews were conducted with prosthetists, physical therapists, and lower limb amputees to identify clinical concerns and common activities influencing socket fit. An expert panel of five clinicians reviewed the items and constructed the original version of the comprehensive lower limb amputee socket survey which was then administered to a convenience sample of 47 active lower limb amputees. Item analysis and Cronbach’s alpha were used to determine the final version of the comprehensive lower limb amputee socket survey.

Following item raw score-to-total score correlation with Cronbach’s alpha for comprehensive lower limb amputee socket survey determinants, internal consistency improved when nine questions were eliminated.

The comprehensive lower limb amputee socket survey is a self-report measure of prosthetic socket satisfaction with very good internal consistency.

When socket problems occur, the ability to determine the specific cause can reduce modification time, enhance socket fit, and promote patient satisfaction. A standardized multi-dimensional assessment measure of socket satisfaction enables prosthetists to quantify the multiple determinants of socket satisfaction, improve patient communication, and demonstrate the value of socket interventions.

International Classification of Function, Health and Disability provides a common framework and universal language for rehabilitation professionals across the globe.

To identify problems in functioning and mobility relevant to persons with lower-limb amputation from an expert’s point of view and quantify these problems using the International Classification of Function, Health and Disability.

Qualitative study using electronic and paper surveys.

Electronic or paper survey was done across six countries targeting clinicians involved in pre- and post-amputation care. Meaningful concepts were extracted from the responses and linked to suitable second-level and where applicable third-level International Classification of Function, Health and Disability categories. Categorical frequency analysis was completed for the combined data and for each location.

A total of 183 experts from 6 different countries responded to the survey. A total of 2171 concepts were identified, 82% of which could be linked to a second-level International Classification of Function, Health and Disability category. The categorical frequency analysis revealed that the categories of walking, design and construction of buildings for public and private use and sensation of pain were the most frequently occurring concepts and was similar across the six countries.

The International Classification of Function, Health and Disability can be utilised as a common framework for communication among clinicians involved in rehabilitation of persons with lower-limb amputation across the globe. The most important factors that were identified by experts in amputee rehabilitation working in different international locations were similar.

The challenges faced by the clinicians involved in care of persons with lower extremity amputation vary across different parts of the world. The overarching goal for the clinician irrespective of the location is to improve mobility and quality of life of their clients. The International Classification of Function, Health and Disability provides a common language between the various stakeholders in amputee rehabilitation across the globe.

Persons with disabilities who reside in rural areas experience challenges accessing and utilising health services and rehabilitation. Due to the high prevalence of diabetes mellitus in rural regions, the risk of having a lower-limb amputation is increasing. Comprehensive rehabilitation is vital to mitigate the negative impact that a lower-limb amputation has on a person.

To explore the barriers and facilitators to accessing rehabilitation experienced by persons with lower-limb amputations in a rural setting.

A qualitative descriptive approach was used to collect and analyse data.

Data were collected from 11 conveniently sampled participants from three sub-district hospitals in the rural iLembe district, Kwa-Zulu Natal, South Africa. Data were collected using semi-structured interviews to explore the barriers and facilitators perceived by persons with lower-limb amputations in a rural region.

The three main barriers identified in this study were environmental factors, financial constraints and impairments. These barriers negatively impacted the participant’s utilisation of rehabilitation. The two main facilitators identified were environmental facilitators and personal factors which aided participant’s utilisation of rehabilitation.

Access to rehabilitation was mainly hindered by the challenges utilising transport to the hospital, while self-motivation to improve was the strongest facilitator to utilising rehabilitation.

Rehabilitation is essential in preparation for prosthetic fitting. If a person cannot access rehabilitation services, they will remain dependent on caregivers. Highlighting the challenges to utilisation of rehabilitation in rural areas can assist to reduce these barriers and improve the functional status of persons with lower-limb amputations.

The 2008 Sichuan Earthquake resulted in many amputees, yet due to the rare incidence, few studies have explored the rehabilitation outcomes and quality of life of bilateral lower limb amputees after major natural disasters.

To evaluate rehabilitation outcomes of 17 young and adult bilateral lower limb amputees under the StandTall rehabilitation programme and to identify factors associated with successful functional recovery of bilateral amputees after large-scale disasters.

Cross-sectional study.

Mobility (amputee mobility predictor), prosthesis use (Houghton Scale) and health-related quality of life (Trinity Amputation and Prosthesis Experience Scale, Short Form 12) were evaluated through questionnaires and performance-based assessments. Means of scores were compared using T-tests.

Subjects with bilateral through-knee or transtibial amputations had less activity restriction (p < 0.01) and higher mobility (p = 0.03). Subjects using prostheses more than 50% waking time had better general adjustment (p = 0.02) and less functional restriction (p = 0.01). Exercise and education were associated with higher mobility (p = 0.06) and mental quality of life, respectively (p = 0.09).

Amputation level and knee joint salvage, prosthesis use, exercise and education were associated with better rehabilitation outcomes including ambulation, adjustment and quality of life in bilateral lower limb amputees from the 2008 Sichuan Earthquake.

The study examined a unique group of traumatic bilateral lower limb amputees who were young and healthy before having traumatic amputations from a single episode of natural disaster. The factors associated with better functional recovery after the earthquake were investigated and may support future development of post-disaster rehabilitation strategies for bilateral lower limb amputees.

Amputation of a limb impacts on patients’ self-perception and quality of life. Prostheses directly anchored to the skeleton are being investigated, aiming to avoid soft tissue complications.

We report outcome data for the UK trial of the Osseointegrated Prosthesis for the Rehabilitation of Amputees Implant System with a minimum of 9-year follow-up.

Eighteen transfemoral amputees received unilateral implants between 1997 and 2008. Five were implanted before a formalised protocol, called Osseointegrated Prosthesis for the Rehabilitation of Amputees, was developed. Mean follow-up of the Pre-Osseointegrated Prosthesis for the Rehabilitation of Amputees group is 11.4 years (1.8–18.6 years), while for the Post-Osseointegrated Prosthesis for the Rehabilitation of Amputees group it is 12.3 years (2.9–15.9).

The Kaplan–Meier cumulative survivorship is 40% for the Pre-Osseointegrated Prosthesis for the Rehabilitation of Amputees group and 80.21% for the Post-Osseointegrated Prosthesis for the Rehabilitation of Amputees group. Five implants (28%) have been removed, three (17%) for deep infection, one (5.6%) for chronic pain, later proven to be infected and one (5.6%) due to implant fracture secondary to loosening due to infection. Two patients (11%) have peri-implant infections suppressed with oral antibiotics. Eleven cases (61%) of superficial infection were successfully treated with antibiotics. 36-Item short-form health survey and Questionnaire for persons with a Transfemoral Amputation showed significant improvements in quality of life up to 5 years after implantation.

This small cohort of patients demonstrates osseointegrated prosthesis allows prolonged usage and improves patients’ quality of life compared to conventional prostheses.

These prostheses may provide a future gold standard for amputees and this study provides the first outcome data over such a time period to be reported from outside of the developers group.

For transfemoral amputations, the residual femoral length is critically important to prosthetic function. The aim of this report is to describe a novel method of extending femoral length and to assess its stability over time.

A 57-year-old woman with recurrent parosteal osteosarcoma was treated with above-knee amputation. A portion of the distal femoral endoprosthesis, which included uncemented fixation with a Compress^® stem, was retained in an effort to extend the short femoral remnant and maximize stump length.

At 3 years follow-up, the Compress stem remained well-fixed, and there was no soft tissue breakdown over the implant. The patient ambulated with a prosthetic limb and no external support.

To the best of our knowledge, this is the first report of using the Compress device as a means to maintain stable fixation and extend residual femoral length following above-knee amputation.

Extension of residual bone length in amputated limbs can help improve prosthetic fitting and function. The Compress device may be useful in this application as a means of secure fixation for a modular metallic prosthesis.