Is skin pressure a relevant factor for socket assessment in patients with lower limb amputation?

BACKGROUND: Prosthetic rehabilitation improves the overall quality of life of patients, despite discomfort and medical complications. No quantitative assessment of prosthesis-patient interaction is used in routine protocols and prosthesis quality still results from the manufacturer's know-how. OBJECTIVE: Our objective is to investigate whether pressure can be a relevant factor for assessing socket adequacy. METHODS: A total of 8 transtibial amputee volunteers took part in this experimental study. The protocol included static standing and 2 minutes walking tests while the stump-to-socket interface pressures were measured. Questionnaires on comfort and pain were also conducted. RESULTS: During static standing test, maximum pressures were recorded in the proximal region of the leg, with a peak value reaching 121.1 ± 31.6 kPa. During dynamic tests, maximum pressures of 254.1 ± 61.2 kPa were recorded during the loading phase of the step. A significant correlation was found between the pain score and static maximum recorded pressure (r= 0.81). CONCLUSIONS: The protocol proposed and evaluated in this study is a repeatable, easy-to-set quantified analysis of the patient to socket interaction while standing and walking. This approach is likely to improve feedback for prosthesis manufacturers and consequently the overall design of prostheses.

Six-Month Assessment of a Hand Prosthesis with Intraneural Tactile Feedback.

OBJECTIVE: Hand amputation is a highly disabling event, which significantly affects quality of life. An effective hand replacement can be achieved if the user, in addition to motor functions, is provided with the sensations that are naturally perceived while grasping and moving. Intraneural peripheral electrodes have shown promising results toward the restoration of the sense of touch. However, the long-term usability and clinical relevance of intraneural sensory feedback have not yet been clearly demonstrated. METHODS: To this aim, we performed a 6-month clinical study with 3 transradial amputees who received implants of transverse intrafascicular multichannel electrodes (TIMEs) in their median and ulnar nerves. After calibration, electrical stimulation was delivered through the TIMEs connected to artificial sensors in the digits of a prosthesis to generate sensory feedback, which was then used by the subjects while performing different grasping tasks. RESULTS: All subjects, notwithstanding their important clinical differences, reported stimulation-induced sensations from the phantom hand for the whole duration of the trial. They also successfully integrated the sensory feedback into their motor control strategies while performing experimental tests simulating tasks of real life (with and without the support of vision). Finally, they reported a decrement of their phantom limb pain and a general improvement in mood state. INTERPRETATION: The promising results achieved with all subjects show the feasibility of the use of intraneural stimulation in clinical settings. ANN NEUROL 2019;85:137-154.

The influence of traumatic transfemoral amputation on metabolic cost across walking speeds.

BACKGROUND: Recent literature indicates equivalent costs of walking can be achieved after a transtibial amputation when the individual is young, active, and/or has extensive access to rehabilitative care. It is unknown if a similar cohort with transfemoral amputation can also achieve lower metabolic costs of walking than previously reported. OBJECTIVE: Compare metabolic cost in individuals with a transfemoral amputation to controls and to the literature across a range of walking speeds. STUDY DESIGN: Cross-sectional. METHODS: A total of 14 individuals with a unilateral transfemoral amputation (27 ± 5 years, N = 4 mechanical knee, N = 10 microprocessor knee) and 14 able-bodied controls (26 ± 6 years) walked at self-selected and four standardized speeds. Heart rate, metabolic rate (mL O2/kg/min), metabolic cost (mL O2/kg/m), and rating of perceived exertion were calculated. RESULTS: Self-selected speed was 8.6% slower in the transfemoral amputation group ( p = 0.031). Across standardized speeds, both metabolic rate and metabolic cost ranged from 44%-47% greater in the transfemoral amputation group ( p < 0.001), heart rate was 24%-33% greater ( p < 0.001), and perceived exertion was 24%-35% greater ( p < 0.009). CONCLUSION: Although the transfemoral amputation group was relatively young, physically fit, and had extensive access to rehabilitative care, the metabolic cost of walking fell within the ranges of the literature on older or presumably less fit individuals with transfemoral amputation. Clinical relevance Developments in prosthetic technology and/or rehabilitative care may be warranted and may reduce the metabolic cost of walking in individuals with a transfemoral amputation.

A comprehensive musculoskeletal and peripheral nervous system assessment of war-related bilateral upper extremity amputees.

BACKGROUND: Upper limb amputations are one of the unpleasant war injuries that armed forces are exposed to frequently. The present study aimed to assess the musculoskeletal and peripheral nervous systems in Iraq-Iran war veterans with bilateral upper extremity amputation. METHODS: The study consisted of taking a history and clinical examinations including demographic data, presence and location of pain, level of amputation, passive and active ranges of movement of the joints across the upper and lower extremities and spine, manual palpation, neurological examination, blood circulation pulses and issues related to a prosthetic limb. In this study, 103 Iranian bilateral upper extremity amputees (206 amputations) from the Iran-Iraq war were evaluated, and a detailed questionnaire was also administered. RESULTS: The most common level of amputation was the finger or wrist level (108, 52.4 %). Based on clinical examination, we found high frequencies of limited active and passive joint range of movement across the scapula, shoulder, elbow, wrist and metacarpophalangeal, interphalangeal and thumb joints. Based on muscle strength testing, we found varying degrees of weakness across the upper limbs. Musculoskeletal disorders included epicondylitis (65, 31.6 %), rotator cuff injury (24, 11.7 %), bicipital tendonitis (69, 33.5 %), shoulder drop (42, 20.4 %) and muscle atrophy (19, 9.2 %). Peripheral nerve disorders included carpal tunnel syndrome in 13 (6.3 %) and unilateral brachial plexus injury in 1 (1 %). Fifty-three (51.5 %) were diagnosed with facet joint syndrome at the level of the cervical spine (the most frequent site). Using a prosthesis was reported by 65 (63.1 %), both left and right sides. The back was the most common site of pain (71.8 %). CONCLUSION: The high prevalence of neuro-musculoskeletal disorders among bilateral upper extremity amputees indicates that they need regular rehabilitation care.

Pediatric limb differences and amputations.

Congenital limb differences are uncommon birth defects that may go undetected even with prenatal screening ultrasound scans and often go undetected until birth. For children with congenital limb differences, a diagnostic evaluation should be done to rule out syndromes involving other organ systems or known associations. The most common etiology of acquired amputation is trauma. Postamputation complications include pain and terminal bony overgrowth. A multidisciplinary approach to management with the child and family can lead to a successful, functional, and fulfilling life.

Impact of limb loss in the United States.

The amputee gets lost in the American health care system because of fragmentation across the continuum. The journey of the diabetic patient with limb loss through the health care system is even more precarious than that of the traumatic amputee. Interventions to address these secondary conditions and improve the health and outcomes of persons with disability have focused on standard medical treatments, such as medication or physical rehabilitation therapies, often to the exclusion of psychosocial interventions. Each member of the amputee rehabilitation team plays a specific and important role in the care and recovery of the person with limb loss.

Prosthetic cost projections for servicemembers with major limb loss from Vietnam and OIF/OEF.

This study projects prosthetic- and assistive-device costs for veterans with limb loss from Vietnam and injured servicemembers returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) to inform the Department of Veterans Affairs (VA) for these veterans' future care. The 2005 Medicare prosthetic device component prices were applied to current prosthetic and assistive-device use obtained from a national survey of 581 veterans and servicemembers with major traumatic amputations. Projections were made for 5-year, 10-year, 20-year, and lifetime costs based on eight Markov models. Average 5-year projected costs for prosthetic and assistive-device replacement for the Vietnam group are lower than for the OIF/OEF cohort due in part to use of fewer and less technologically advanced prosthetic devices and higher frequency of prosthetic abandonment. By limb-loss level, for the Vietnam group and OIF/OEF cohort, 5-year projected unilateral upper limb average costs are $31,129 and $117,440, unilateral lower limb costs are $82,251 and $228,665, and multiple limb costs are $130,890 and $453,696, respectively. These figures provide the VA with a funding estimate for technologically advanced prosthetic and assistive devices within the framework of ongoing rehabilitation for veterans with traumatic limb loss from the Vietnam and OIF/OEF conflicts.

Department of Veterans Affairs compensation and medical care benefits accorded to veterans with major limb loss.

Veterans injured in theaters of combat operations are eligible for benefits, including medical care and compensation. This article describes veterans with service-connected disability for major lower- and/or upper-limb loss resulting from combat-field-associated injuries sustained in the Vietnam war, Operation Desert Shield/Operation Desert Storm, and Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF). Using the Department of Veterans Affairs (VA) Compensation and Pension Mini-Master file, we identified 2,690 veterans who in August 2007 received compensation for loss of one or more limbs. More than 97% sustained their injuries in Vietnam; most were young men who served in the U.S. Army or Marine Corps. All but 5% had at least 50% combined service-connected disability and nearly half had a 100% rating. In addition to limb loss, one of the most prevalent compensable conditions was posttraumatic stress disorder, present in 46% of OIF/OEF and 20% of Vietnam veterans. Of these veterans, 82% visited VA outpatient clinics in 2007, although only 4% were hospitalized. A special obligation exists to those who have sustained serious injuries related to combat; this responsibility extends for the life of the servicemember and beyond to his or her spouse and dependents.

Effects of paediatric limb loss on healthcare utilisation, schooling and parental labour supply.

PURPOSE: To explore the impact of childhood limb loss on families in terms of healthcare utilisation, schooling and parental labour supply. METHODS: Data were obtained from a cross-sectional, retrospective pilot survey of 123 parents or caregivers of children with limb loss selected randomly after stratification by aetiology (i.e. trauma, malignancy and congenital limb deficiency) from among eligible families identified by the Amputee Coalition of America. Healthcare utilisation, school (child) and labour market (parents) participation were examined. RESULTS: Children with limb loss use health services frequently and miss school for limb loss-related concerns. Over half of all parents adjusted their work participation in response to their child's limb loss. The use of prostheses may increase direct and indirect costs of limb loss. Children with acquired limb loss (amputation following trauma or cancer) were more likely than those with a congenital limb deficiency to use a prosthesis. CONCLUSIONS: Our data suggest that the impact of limb loss on families of affected children may include substantial costs, particularly when school and work effects are taken into account. Further research is needed to identify the full household- and societal-level costs of childhood limb loss and suggest interventions to reduce the burden experienced by families.

[Replantation or prosthesis: individual planning]. / Replantation oder Prothese: Ansätze zu einer individuellen Sichtweise.

Rehabilitation of a replanted upper limb is difficult and has to start close to the operation. Physical and occupational therapy are working close together. The unimpaired opposite upper extremity must be trained as well. Replantation of upper limb causes not only a lot of reoperations with extended morbidity, but also problems in social, family and psychic. After eventual amputation of the upper limb prosthetic compensation is necessary as soon as possible. There is a gap open between the technical and financial possibilities. To avoid spine disorders a shoulder cap is necessary if prosthetic compensation is not possible in higher amputations.

Comparison of á priori alignment techniques for transtibial prostheses in the developing world - pilot study.

PURPOSE: The purpose of this study was to evaluate three alignment systems based on two alignment theories that can be utilized in the fabrication of monolimb prostheses that have acceptable alignment. A second goal was to assess the feasibility of technology transfer for providing prosthetic services to remote areas of landmine-affected countries. METHOD: Five prosthetists and five healthy transtibial amputees participated in the study. Each prosthetist was trained and then used each of the three systems to capture alignment measurements for one subject. Three monolimbs identified as X, Y and Z were fabricated for each subject and assessed during clinical static and dynamic gait conditions. Training materials and methods were also evaluated. RESULTS: All three systems captured acceptable alignments fairly well, although the two systems that incorporated weight-bearing into the alignment process had slightly better outcomes. Each system has its own advantages in terms of ease of use, required equipment, and ease of technology transfer. CONCLUSION: All three systems have the potential for application in outreach prosthetic services and warrant continued evaluation. Minor changes need to be incorporated into the alignment systems and procedures to make them easier to use and more effective.

Predictors of return to work following traumatic work-related lower extremity amputation.

PURPOSE: To determine factors predictive of return to work (RTW) and days of total disability (TD) in a population of persons working at the time of lower extremity amputation. METHOD: Retrospective chart and database review. RESULTS: Of 88 valid cases, 48% involved toe amputation, 23% transtibial, 14% partial foot, 14% transfemoral, and 2% high level. Fifty-eight percent of all subjects RTW, 19% were deemed 'fit for work', and 23% did not RTW. Days TD ranged from 0 to 1664, with a mean of 366 days. Toe amputation level showed a mean of 127 days of TD. Bivariate analysis showed amputation level, total costs to Workers Compensation Board (WCB), and days TD significantly related to RTW, and rehabilitation costs, vocational rehabilitation, work assessment, age, number of surgical procedures, number of days in acute care, and amputation level significantly related to days TD. In the multivariate model, only amputation level and higher gross annual income showed predictive value for RTW. However older age, more surgical procedures, less days in hospital, and higher amputation levels were all predictive of increased days TD. CONCLUSION: Toe amputation level had a surprisingly high number of days TD, which may have significant potential economic and disability impact on the workplace. Other factors beyond simply amputation level (such as previous income level) are important considerations for RTW.

Energy expenditure and biomechanical characteristics of lower limb amputee gait: the influence of prosthetic alignment and different prosthetic components.

In this study, the influence of different prosthetic alignments and components on oxygen consumption and the important biomechanical characteristics of the normal gait pattern of leg amputees was investigated. With 15 transtibial and 12 transfemoral amputees, the oxygen consumption during walking on a treadmill was analyzed and biomechanical parameters during walking on even ground at a self-selected speed were defined. The amputation of all patients was caused by trauma. Variations of the prosthetic alignment affect the energy consumption of transfemoral amputees more significantly than that of transtibial amputees. Comparison of different prosthetic feet worn by transtibial amputees did not show significant differences regarding metabolic parameters. Compared with conventional hydraulic knee controls, the oxygen consumption of transfemoral amputees provided with an electronically controlled hydraulic knee joint is reduced. All investigated variations can be clearly characterized by the sagittal moments acting on the joints of the prosthetic limb during gait.

Factors influencing use of digital prostheses in workers' compensation recipients.

The purposes of this study were to retrospectively identify factors associated with decreased use of digital prostheses in workers' compensation recipients 6 months after fitting and to identify characteristics of those individuals who requested and received a second set of prostheses after demonstrating consistent use of the first set. One hundred seventy-eight patients fitted with 281 digital prostheses completed a questionnaire 6 months after fitting. Forty-nine patients (28%) stated they never or occasionally used their prosthesis (low utilization) and 42 (24%) stated they used them more than 4 hours per day (high utilization). One hundred ten patients (62%) reported stump problems; 37 (21%) stated that the problem interfered with the use of the prosthesis. High utilization was associated with nonmanual employment after the injury. Low utilization was associated with male gender, stump problems, and a distal amputation level. Ring finger prostheses were least likely to be used; small finger prostheses, most likely. The country of origin of the patient was not associated with frequency of use. One hundred sixty-one patients had received the prostheses at least 3 years before the end of the study; 45% of these patients had requested and received a second set of prostheses. Women were more likely to request and receive a second set than men. We could not accurately predict future use of digital prostheses. Each case must be evaluated on an individual basis. (J Hand Surg 2000; 25A:80-85.

Case consultation: ablatio penis.

In male infants, traumatic ablation of the penis, with or without loss of the testicles may occur as a sequel to mutilatory violence, accidental injury, or circumcision error. Post-traumatically, one program of case management is surgical sex reassignment to live as a girl, with female hormonal therapy at the age of puberty. The other program is genital reconstructive surgery to live as a boy, with male hormonal therapy at puberty if the testicles are missing. In both programs, the long term outcome is less than perfect and is contingent on intervening variables that include societal ideology; surgical technology; juvenile and adolescent timing and frequency of hospital admissions construed by the child as nosocomial abuse; development of body image; health and sex education; fertility versus sterility; coitus and orgasm; possible lesbian orientation if living as a girl; and long-term cost accounting, including the psychic cost of being a pawn in possible malpractice litigation on whose disability a very large fortune in compensation may devolve. There is, as yet, no unanimously endorsed set of guidelines for the treatment of genital trauma and mutilation in infancy, and no provision for a statistical depository for outcome data.

Energy expenditure during ambulation in dysvascular and traumatic below-knee amputees: a comparison of five prosthetic feet.

Recent advancement in prosthetic technology has led to the development of dynamic elastic response feet (DER), which are reported to store and release energy to facilitate gait. To date, there has been no objective evidence to suggest energy conservation while using these foot designs. The purpose of this study was to compare the energy expenditure of five commercially available prosthetic feet (SACH and four DER feet) in both the traumatic and dysvascular populations during level walking. Seventeen male subjects with below-knee amputation (nine traumatic and seven dysvascular) were tested for energy expenditure (Douglas Bag technique) during a 20-min walk while wearing each of the prosthetic feet. The DER prosthetic foot designs were not shown to reduce the energy cost (ml O2/kg-m) or rate of energy expenditure (ml O2/kg-min) compared to the SACH foot. Overall, the traumatic amputees had a similar oxygen consumption per meter traveled compared to the dysvascular amputees; however, the rate of energy consumption was much higher in the traumatic group. This increased rate was a function of the greater walking velocity employed by the traumatic subjects, made possible by their better physical fitness.

The Jaipur limb and foot.

In the 12 years which have elapsed since the United Nations declared 1981 to be the Year of the Disabled, the number of amputees world-wide has risen alarmingly, continuing the pattern of the past 40 years, which have seen innumerable conflicts, large and small, with ever-increasing and indiscriminate use of 'improved' antipersonnel mines which have been sown in enormous numbers in rural areas. Even after fighting has ceased--as in Vietnam, which currently has some 200,000 amputees--fresh injuries are caused daily, often to children, by the long-delayed detonation of these weapons. Much of the research and development in prosthetics since World War II has concentrated on producing artificial limbs suitable for an affluent and industrialized society. These, being made from the most modern materials and incorporating the latest technology, are of necessity expensive even for affluent Americans or Europeans and quite out of reach for the 80 per cent of the world's amputees who live in the developing world and for the vast majority of whom these splendid prostheses may be entirely inappropriate. This article describes a foot and leg specifically designed to fit in with the customs and practices of just such people.