What's new in pediatric lower limb reconstruction?

The last years brought many advances relevant to lower limb reconstruction. It feels like guided growth has been looked at from every angle, and still there are new emerging concepts like rotational guided growth waiting to be validated. New hexapod external devices are more accurate and easier to use, and new unilateral fixators allow for more versatile and stable fixation and lengthening. Intramedullary nail lengthening has found its place as a standard procedure for various diagnoses in children and young adults. First results of new and exciting approaches like extramedullary implantable nail lengthening and lengthening plates have been reported. Pharmaceutical treatment has changed the course of certain diseases and must be integrated and considered when making a reconstructive treatment plan. As reconstructive surgery is rapidly advancing so are the technical options for prosthetic fitting, which makes it difficult for caregivers as well as for parents to make the decision between reconstruction and amputation surgery for the most severe cases of congenital deficiencies. This review is highlighting new developments of lower limb reconstruction and is reviewing the current literature.

Management of severe congenital femoral deficiency: Does surgical intervention enhance prosthetic function?

BACKGROUND OBJECTIVE: The purpose of this study was to evaluate prosthetic outcome in patients with severe congenital femoral deficiency and the potential benefits of surgical intervention on prosthetic fitting and gait. METHODS: A retrospective review identified 26 active case records with a proximal femoral focal deficiency using a prosthesis. Validated outcome measures evaluated comfort, function, and prosthetic use and quality-of-life assessment. Outcome compared age groups and surgical intervention. Gait analysis performed in 7 patients further evaluated hip and knee function. RESULTS: Eleven male patients and 15 female patients, including 13 children (mean age 10 years, range 5-16) and 13 adults (mean age 36 years, range 23-63) were evaluated. Better prosthetic function and PedsQL scores were recorded in the pediatric group. There was a trend for better scores after surgery. Gait analysis demonstrated reduced hip extension compensated by knee flexion in 3 patients, 2 patients had hip extension with near normal kinematics, 1 untreated patient walked with an unsteady gait, and the remaining walked well using an ischial-bearing prosthesis with pelvic compensatory movements. CONCLUSION: The management strategy in severe proximal femoral focal deficiency remains a major challenge. Hip reconstruction seems to improve functional scores. Overall, the scores seem to decline into adulthood but not significantly. Gait analysis before further surgical intervention is recommended because compensatory knee flexion may improve step length in terminal stance. Limited numbers, with short follow-up, prevents clear guidance on the benefit of surgery.

Factors affecting successful prosthetic use after hemipelvectomy and hip disarticulation amputations: Five-year experience from a tertiary prosthetic rehabilitation center.

BACKGROUND: Rehabilitation after hip disarticulation and hemipelvectomy amputations can be challenging, and many opt to forego prosthetic limb use. There is limited evidence on characteristics that result in successful prosthetic use; therefore, our study aimed to identify these to help guide patient expectations. METHODS: A retrospective review was performed on patients seen at a UK tertiary prosthetic center in the past 5 years with hip disarticulation or hemipelvectomy amputations. Details and etiology of amputation, length between assessment and delivery of prosthesis, goals, reasons for abandonment, and outcomes were recorded. Successful prosthetic use was defined as the use of a prosthesis at least 3 times a week. Characteristics were compared using odds ratios and Fisher exact test. RESULTS: Twenty-seven patient notes were analyzed: 42% female, 58% male, and age range 14-90. Thirty percent had a hemipelvectomy, and 70% had a hip disarticulation. Neoplasia accounted for 78% of etiologies followed by trauma 15% and infected endoprosthesis 7%. Sixty-seven percent trialed a walking prosthesis; 33% of these stopped eventually. There were no statistically significant findings of factors increasing odds of successful prosthetic use. However, age significantly increased the odds of being given a trial of a prosthesis. CONCLUSION: Although younger patients are more likely to be given the opportunity to trial a walking prosthesis, age does not seem to affect the overall outcome alone. In cases of neoplasia, there is often a delayed start to rehabilitation and prosthetic use, which may affect eventual success. Further studies are required to define the optimum characteristics for successful prosthetic use at higher amputation levels.

Fibular hemimelia and risk of patellar dislocations: A case series.

The likelihood of patellar instability and consequently, risk of patellar dislocations is higher in those with anatomical abnormalities. Fibular hemimelia is a congenital disorder resulting in partial or full absence of the fibula, often with absence of the lateral and cruciate ligaments, although this patient group rarely undergoes ligament reconstruction. There is potential for adverse outcomes, in the longer term, including, possible increased risk of patellar dislocation and pain in the knee and hip. We aim to investigate the potential risk of spontaneous, unprovoked patellar dislocation among patients with fibular hemimelia, through a review of medical records and radiological investigations. All patients with a diagnosis of fibular hemimelia were included (n = 25), regardless of ultimate approach to management. Tibiofemoral angle measurement and Caton-Deschamps indices were calculated where suitable radiology was available, to better establish extent of potential patellar instability. All the patients with normal Caton-Deschamps indices had only partial fibular absence, although this does not detract from absence or hypoplasia of the anterior cruciate ligament, as a risk factor for patellar dislocation by predisposing to anterior tibial translation. Notably, of the three patients with increased Caton-Deschamps indices, two had complete fibular absence and underwent definitive amputation surgery at age 18 months and 3 years, respectively. Ultimately, this was a young patient group and on-going follow-up might yield better understanding of knee stability. Maintaining a well-aligned lower limb throughout growth might be protective even in the presence of anatomical abnormalities. This article mainly aims to raise awareness among prosthetic and orthotic professionals regarding the increased risk of patella dislocations.

From outcome measurement to improving health outcomes after lower limb amputation-A narrative review exploring outcome measurement from a clinical practice perspective.

Outcome measurement is essential to understand the impact of clinical interventions and the performance of services. Despite national and professional body encouragement, and successful examples of system level outcome measurement within some health care settings, many barriers still exist preventing outcome measurement from becoming embedded in clinical practice. This paper presents a narrative review which aims to describe the state of the outcome measurement evidence base in prosthetic rehabilitation, as applied in clinical practice, with a view to identifying areas for future work aimed at making outcome measurement in prosthetic rehabilitation a meaningful reality. A literature search of four databases was undertaken, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis principals appropriate to narrative reviews, and using the search terms outcome, measur*, tool, scale, instrument, prosthe*, amput* and limb loss. A total of 1116 papers were identified. Following screening 35 papers, focusing on four main themes, were included in the review. Themes were: 1) What outcome domains should be measured? 2) How can these outcome domains be measured? 3) What are the barriers to outcome measurement? and 4) What can be learnt from examples of ROM in prosthetic rehabilitation? Findings suggest that successful outcome measurement is multifaceted. Understanding and embedding value at every step appears to be key to success. Addressing the questions of 'what' outcome domains to measure and 'how' to measure them, may help establish consensus. Routine outcome measurement practice at the clinical level should ensure data collection is valuable to clinical practice, makes use of information technology solutions and has organisational engagement.

Limb salvage versus below knee amputation for severe adult lower limb deformity - A retrospective, comparative series.

BACKGROUND: This study compares outcomes of patients with severe, multiplanar, fixed, pantalar deformities undergoing limb preservation with either pantalar fusion (PTF) or talectomy and tibiocalcaneal fusion (TCF), versus below knee amputation (BKA). METHODS: Fifty-one patients undergoing either PTF, TCF and BKA for failed management of severe pantalar deformity were evaluated retrospectively. Twenty-seven patients underwent PTF, 8 TCF and 16 BKA. Median age at surgery was 55.0 years (17-72 years) and median follow-up duration was 49.9 months (24.0-253.7 months). Clinical evaluation was undertaken using the MOxFQ, EQ-5D and Special Interest Group in Amputee Medicine score (SIGAM). Patients were also asked whether they were satisfied with their surgery and whether they would have the same surgery again. RESULTS: There was no statistically significant difference in functional outcomes, satisfaction, or complications between the groups. Twenty-two patients undergoing PTF (81.5%), 6 patients undergoing TCF (75%), and 15 patients undergoing BKA (93.8%) were satisfied overall (p = 0.414). There was no difference in the proportion of patients who would opt for the same procedure again (p = 0.142): 23 in the PTF group (85.2%), 8 in the TCF group (100%), and 11 in the BKA group (68.8%). Seven patients undergoing PTF (25.9%), 2 patients undergoing TCF (25%) and 6 patients undergoing BKA (37.5%) had major complications (p = 0.692). CONCLUSION: This study concludes that PTF, TCF and BKA can all provide an acceptable outcome in treatment of severe, degenerative pantalar deformities. This data may be useful in counselling patients when considering salvage versus amputation in such cases. LEVEL OF EVIDENCE: Level 3(Original) Clinical Research Article.

Brain and spinal stimulation therapies for phantom limb pain: a systematic review.

BACKGROUND: Although many treatments exist for phantom limb pain (PLP), the evidence supporting them is limited and there are no guidelines for PLP management. Brain and spinal cord neurostimulation therapies are targeted at patients with chronic PLP but have yet to be systematically reviewed. OBJECTIVE: To determine which types of brain and spinal stimulation therapy appear to be the best for treating chronic PLP. DESIGN: Systematic reviews of effectiveness and epidemiology studies, and a survey of NHS practice. POPULATION: All patients with PLP. INTERVENTIONS: Invasive interventions - deep brain stimulation (DBS), motor cortex stimulation (MCS), spinal cord stimulation (SCS) and dorsal root ganglion (DRG) stimulation. Non-invasive interventions - repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS). MAIN OUTCOME MEASURES: Phantom limb pain and quality of life. DATA SOURCES: Twelve databases (including MEDLINE and EMBASE) and clinical trial registries were searched in May 2017, with no date limits applied. REVIEW METHODS: Two reviewers screened titles and abstracts and full texts. Data extraction and quality assessments were undertaken by one reviewer and checked by another. A questionnaire was distributed to clinicians via established e-mail lists of two relevant clinical societies. All results were presented narratively with accompanying tables. RESULTS: Seven randomised controlled trials (RCTs), 30 non-comparative group studies, 18 case reports and 21 epidemiology studies were included. Results from a good-quality RCT suggested short-term benefits of rTMS in reducing PLP, but not in reducing anxiety or depression. Small randomised trials of tDCS suggested the possibility of modest, short-term reductions in PLP. No RCTs of invasive therapies were identified. Results from small, non-comparative group studies suggested that, although many patients benefited from short-term pain reduction, far fewer maintained their benefits. Most studies had important methodological or reporting limitations and few studies reported quality-of-life data. The evidence on prognostic factors for the development of chronic PLP from the longitudinal studies also had important limitations. The results from these studies suggested that pre-amputation pain and early PLP intensity are good predictors of chronic PLP. Results from the cross-sectional studies suggested that the proportion of patients with severe chronic PLP is between around 30% and 40% of the chronic PLP population, and that around one-quarter of chronic PLP patients find their PLP to be either moderately or severely limiting or bothersome. There were 37 responses to the questionnaire distributed to clinicians. SCS and DRG stimulation are frequently used in the NHS but the prevalence of use of DBS and MCS was low. Most responders considered SCS and DRG stimulation to be at least sometimes effective. Neurosurgeons had mixed views on DBS, but most considered MCS to rarely be effective. Most clinicians thought that a randomised trial design could be successfully used to study neurostimulation therapies. LIMITATION: There was a lack of robust research studies. CONCLUSIONS: Currently available studies of the efficacy, effectiveness and safety of neurostimulation treatments do not provide robust, reliable results. Therefore, it is uncertain which treatments are best for chronic PLP. FUTURE WORK: Randomised crossover trials, randomised N-of-1 trials and prospective registry trials are viable study designs for future research. STUDY REGISTRATION: The study is registered as PROSPERO CRD42017065387. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Management of lower limb amputations.

The most common reason for lower limb amputations in the UK is peripheral arterial disease. A thoughtful approach to surgery, with consideration of optimal amputation level and residual limb shape, can improve prosthetic use and functional outcomes. Prosthesis socket design and fit, as well as use of appropriate components, must be considered in accordance with the patient's activity level and potential. Major developments in prosthetics over the past 20 years, particularly in the area of joint design, including microprocessor knees, have increased options to improve ambulation. This is particularly significant among those with more proximal amputations, for whom energy expenditure on walking is even greater. Management of post-amputation pain syndromes including phantom limb pain can prove challenging, although there are novel options for pain control. Long-term care of both the residual and contralateral limbs is paramount to reduce risk of further amputation surgery, and optimize longer term function and quality of life.

Robotic therapy for phantom limb pain in upper limb amputees.

The system described in this paper combines virtual reality with haptic feedback to increase the level of immersion and invoke the sense of agency in patients with phantom limb pain with the aim of reducing perceived pain. This paper presents three case studies of an on-going clinical study. The initial results suggest an increased sense of embodiment of the virtual limb promotes a decrease in perceived levels of pain. The results strengthen the view that the cortical map does not fully "disappear" yet lays dormant.

The effect of electromagnetic shielding on phantom limb pain: A placebo-controlled double-blind crossover trial.

BACKGROUND: Environmental electromagnetic fields influence biological systems. Evidence suggests these have a role in the experience of phantom limb pain in patients with amputations. OBJECTIVES: This article followed a previous study to investigate the effect of electromagnetic field shielding with a specially designed prosthetic liner. STUDY DESIGN: Randomised placebo-controlled double-blind crossover trial. METHODS: Twenty suitable participants with transtibial amputations, phantom pain at least 1 year with no other treatable cause or pathology were requested to record daily pain, well-being, activity and hours of prosthetic use on pre-printed diary sheets. These were issued for three 2-week periods (baseline, electromagnetic shielding (verum) and visually identical placebo liners - randomly allocated). RESULTS: Thirty-three per cent of the recruited participants were unable to complete the trial. The resulting N was therefore smaller than was necessary for adequate power. The remaining data showed that maximum pain and well-being were improved from baseline under verum but not placebo. More participants improved on all variables with verum than placebo. CONCLUSION: Electromagnetic field shielding produced beneficial effects in those participants who could tolerate the liner. It is suggested that this might be due to protection of vulnerable nerve endings from nociceptive effects of environmental electromagnetic fields. CLINICAL RELEVANCE: Electromagnetic field shielding with a suitable limb/prosthesis interface can be considered a useful technique to improve pain and well-being in patients with phantom limb pain.

Developing prescribing guidelines for microprocessor-controlled prosthetic knees in the South East England.

BACKGROUND AND AIM: Microprocessor-controlled prosthetic knees have gained increasing popularity over the last decade. Research supports their provision to address specific problems or to achieve certain rehabilitation goals. However, there are yet no agreed protocols or prescribing criteria to assist clinicians in the identification and appropriate selection of suitable users. The aim is to reach professionals' agreement on specific prescribing guidelines for microprocessor-controlled prosthetic knees. TECHNIQUE: The study involved multidisciplinary teams from the Inter Regional Prosthetic Audit Group, representing nine Prosthetic Rehabilitation Centres in the South East England region. We used the Delphi technique with a total of three rounds to reach professionals' agreement. DISCUSSION: The prescribing guidelines were agreed and will be reviewed and updated depending on new research evidence and technical advances. CLINICAL RELEVANCE: This project is highly useful for professionals in a clinic setting to aid in appropriate patient selection and to justify the cost of prescribing microprocessor-controlled prosthetic knees.

Patient evaluation of the Echelon foot using the Seattle Prosthesis Evaluation Questionnaire.

BACKGROUND: The introduction of the Echelon prosthetic foot with a hydraulic self-aligning ankle adds improved adaptability to varied terrains and uneven walking surfaces. However, the specific indications for prescribing such components and the potential benefits are yet to be fully established. CASE DESCRIPTION AND METHODS: Nine amputees including three bilateral amputees evaluated their standard prostheses using the Seattle Prosthesis Evaluation Questionnaire. They were then provided with Echelon feet, and they evaluated them after 4 weeks of use. FINDINGS AND OUTCOMES: Improved satisfaction in all categories of use in relation to the Echelon foot with the greatest increase reported by bilateral amputees. CONCLUSION: The use of prosthetic feet with hydraulic self-aligning ankle improves prosthetic users' satisfaction in general with a particular benefit in bilateral amputees. CLINICAL RELEVANCE: Establish the clinical impact and user satisfaction after using Echelon feet in prosthetic users with different levels of amputations.