Biomechanical analysis of stair ascent in persons with Chopart amputation.

BACKGROUND: Compared to walking on level ground, ascending stairs requires a large range of motion not only of the hip and knee joint, but also of the ankle joint. The prosthesis often worn by persons with partial foot amputation largely prevents the ankle motion needed during stair ascent. OBJECTIVES: Aim of this study was to assess subjects with a Chopart amputation utilizing a clamshell device during stair ascent to identify potential biomechanical deficits. STUDY DESIGN: Cross-sectional study with reference group. METHODS: Six subjects with unilateral Chopart amputation and 17 unimpaired subjects underwent three-dimensional motion analysis while ascending stairs in a step-over-step manner. RESULTS: During weight acceptance, the involved side showed increased external hip-flexing and reduced knee-flexing moments and the sound side a higher ankle power than in the control group. The sound side showed higher external knee-flexing, dorsi-flexing, and hip-adducting moments than the controls during weight acceptance. CONCLUSION: The mechanism observed on the involved side differs from that in controls, but is comparable to the mechanisms used by subjects with transtibial amputation reported in the literature. However, compensatory movements on the sound side take place at the ankle and knee joint, differing from subjects with more proximal amputations. CLINICAL RELEVANCE: This study underpins the importance of adequate foot leverage and ankle function in cases of partial foot amputation, particularly in transfer situations such as stair ascent. If ankle range of motion is adequate, prosthetic/orthotic devices combining shank leverage with a hinged spring mechanism at the ankle may be promising.

[Expert assessment of lower extremity prosthetics]. / Begutachtung von Prothesenversorgungen der unteren Extremität.

Although the number of major amputations is declining throughout Germany, more than 57,000 surgical procedures for amputation still take place. As a consequence of high prosthetic care costs, these often lead to disputes before the social court in which expert medical opinions are required. With knowledge of the legal norms, the remit of the expert opinion can be fulfilled. The expert begins with evaluation of the patient's file and a search of the contested parts. The investigation includes a medical history, in addition to a physical examination, in order to be able to comment on the disputed beneficial use of the therapeutic appliance and respond to questions of proof. Questionnaires may be helpful.

[Insoles, knee braces and ankle-foot orthoses in the treatment of medial gonarthrosis : A literature review]. / Einlagen, Knie- und Unterschenkelorthesen in der Behandlung der medialen Gonarthrose : Eine aktuelle Literaturübersicht.

BACKGROUND: Osteoarthritis is the most common joint disease worldwide and mostly affects the knee joint (gonarthrosis). In treatment algorithms, technical aids in the form of laterally wedged insoles, valgizing knee braces and ankle-foot orthoses have an importance in the treatment of medial unicompartmental knee joint disease. However, national and international guidelines differ in their recommendations. INSOLES: Taking into account a great amount of scientific work, the measurable effect of laterally wedged insoles appears to be low, so that a justifying indication only exists at low gonarthrosis levels. KNEE BRACES: Valgizing knee braces have shown stronger biomechanical and clinical effects, but with a slightly increased complication potential and low compliance. Low to medium-grade arthrosis can be treated. ANKLE-FOOT ORTHOSES: Ankle-foot arthroses have not yet been conclusively examined. Initial work indicates biomechanical and clinical efficacy. The overall effects and indications appear comparable to knee braces, probably with less complication potential.

Wearing Time of Ankle-Foot Orthoses with Modular Shank Supply in Cerebral Palsy: A Descriptive Analysis in a Clinically Prospective Approach.

OBJECTIVE: To date there is only limited knowledge about the wearing time of orthoses. Ankle-foot orthoses (AFOs) have not been studied with this research question. Additional influences of the orthotic design as well as weekdays and the weekend are also unknown. DESIGN: Monocentric, clinically prospective intervention study. PATIENTS: Inclusion of 10 patients with bilateral spastic cerebral palsy. METHODS: Equipment of all subjects with a dynamic ankle-foot orthosis (DAFO) and modular shank supply (MSS, dynamic elastic shank adaptation or ground reaction AFO). Integration of temperature sensors for recording the wearing time for a period of 3 months. RESULTS: The actual wearing time was below the recommendations on actually worn days as well as the average of the entire study period. In addition, the actual usage in terms of days and hours was well below the recommendations. The wearing time showed differences between weekdays and weekend. Differences between DAFO and MSS were not detectable. CONCLUSION: The actual usage behavior of ankle-foot orthoses differs from the recommendations of the prescriber. This applies to both DAFOs and modular use with shank supplies. Environmental factors may have a significant impact on wearing times on weekdays and the weekend.

Prosthetic restoration of the forefoot lever after Chopart amputation and its consequences onto the limb during gait.

BACKGROUND: In subjects with Chopart amputation the foot lever is clearly diminished. Usually high or low profile prostheses are routinely utilized to re-establish the lost forefoot lever. RESEARCH QUESTION: The aim of this study was to investigate to what extent the proposed prostheses were able to replace the forefoot lever in chopart-amputees. METHODS: An instrumented 3D gait analysis, including plantar and socket pressure measurements, was performed in thirteen subjects with Chopart amputation using a clamshell and/or a Bellmann prosthesis including an ankle foot orthosis during level ground walking. RESULTS: The largest range of motion (p < 0.05) in the ankle joint was seen for the Bellmann prosthesis (32 ±â€¯3°) followed by the Bellmann prosthesis with ankle-foot orthosis (22 ±â€¯6°) whereas in the clamshell prosthesis (10 ±â€¯4°) almost no ankle motion was seen. Conversely, the highest ankle joint moment (p < 0.05) was seen for the clamshell prosthesis (1.04 ±â€¯0.24Nm/kg) followed by the Bellmann prosthesis with ankle-foot orthosis (0.66 ±â€¯0.14Nm/kg) and, finally, the Bellmann (0.37 ±â€¯0.11Nm/kg) alone offering the lowest joint moment. CONCLUSION: High-profile prostheses with ventral shell are more suitable to reacquire the lost forefoot lever after Chopart amputation. However, the issue of restricted range of motion in the ankle joint with the clamshell prosthesis needs to be addressed.

The added value of orthotic management in the context of multi-level surgery in children with cerebral palsy.

BACKGROUND: Treatment of cerebral palsy includes an interdisciplinary concept and in more severe cases the well-established multi-level surgery (MLS). Different kinds of orthoses are typically part of postoperative treatment but there is a lack of knowledge about their additional benefit. RESEARCH QUESTION: Do ankle foot orthoses lead to an additional, measurable improvement of gait after MLS? METHODS: 20 children with bilateral spastic cerebral palsy (9 retrospective, 11 in a postoperative clinical routine) were included. All had a preoperative gait analysis before MLS. Postoperatively, they were fitted with different ankle foot orthoses (AFO), depending on their individual needs. Dynamic ankle foot orthoses (DAFO), combined DAFO with additional dynamic, elastic shank adaptation (DESA) and ground reaction force AFOs (GRAFO) were used. Patients underwent a second gait analysis 1.5 (± 0.6) years postoperatively barefoot and with orthoses. Data analysis included testing for normal distribution (Shapiro-Wilk-Test) and further nonparametric statistical testing on basis of a Wilcoxon Single-Rank Test. RESULTS: The operation produced changes in the hip, knee and ankle joint, and the pelvis. Spatiotemporal parameters showed significant changes due to additional use of the orthoses. Further, additional kinematic changes occurred at the hip, knee and ankle joint as well as the foot. The Gillette Gait Index (GGI) improved significantly by supplementary orthoses, but not by surgery alone. The Gait Profile Score (GPS) and Gait Deviation Index (GDI) rather showed changes due to the surgery. SIGNIFICANCE: MLS significantly improves GPS and GDI more than a year after surgery, which can be interpreted as an improvement in gait pattern. In contrast, the GGI is improved by additional postoperative orthotic treatment, which implies that walking ability itself has improved, rather than the gait pattern. Orthoses show a positive additional effect on surgical results at different anatomical levels. Spatiotemporal parameters are positively influenced solely by additional orthotic support.

Structural changes in the thigh muscles following trans-femoral amputation.

INTRODUCTION: Early ambulation is the principal objective in trans-femoral amputees. Postamputation modifications complicate the rehabilitation process due to a reduced control at the interface between stump and prosthesis. The aim of this study is to determine whether magnetic resonance imaging depicts the amount of fatty degeneration of the thigh muscles after trans-femoral amputation (TFA). METHODS: A total of 12 patients following a TFA on the basis of a bone neoplasm or metastasis with an evaluable postoperative MRI were identified. Using the Goutallier classification, the fatty degeneration of the thigh muscles was analyzed in the middle (M) and at the distal end (E) of the residual limb at T1 (10.6 months) and T2 (25.6 months). RESULTS: Analysis at two different levels showed different grades of fatty degeneration of thigh muscles after TFA at T1 and T2. Comparing fatty degeneration at both levels of the stump, the quadriceps femoris revealed a significant change (p = 0.01) at T1 and M. sartorius and adductor (p = 0.02) at T2. CONCLUSIONS: MRI is an excellent diagnostic tool to evaluate fatty degeneration after TFA. The highest amount of fatty degeneration of the quadriceps muscle was monitored within the first 10 months. Early physiotherapy is important to strengthen the remaining stump muscles during rehabilitation.

[Functional Electrical Stimulation in a Case of Drop Foot and Atactic Gait: Expert Assessment of Contested Medical Aids]. / Funktionelle Elektrostimulation bei Fußheberschwäche und ataktischem Gangbild: Gutachterliches Vorgehen bei streitiger Hilfsmittelversorgung.

Expert medical opinions are necessary in pretrial cases and other legal matters. They act as means of evidence for administrative bodies and courts. It may be necessary to adapt the method of evaluation depending upon the issue or subject matter to be evaluated. We report on a social court case, which needed to answer the question of the medical necessity of a functional electrical stimulation orthosis prescribed to improve the function of a drop foot accompanied by an atactic gait disorder. The claimant suffered from a stroke, which had occurred several years before. Her aids were an ankle-foot-orthosis for foot lift and a wheeled walker. The current treatment was to be augmented by the disputed device. The statutory health insurance declined to meet the costs. They failed to find relevant benefits after analysis of video tapes of the patient's gait while using an electrical stimulation orthosis. The social court requested an expert opinion to answer the question as to whether or not there was a relevant functional benefit to using functional electrical stimulation over the existing orthosis or to an alternative treatment. Video documentation was desired by the court. We used the clinic's gait analysis laboratory, which is equipped with a gait course and the claimed video documentation. Standardised video documentation offers substantial advantages for answering forensic questions such as these. It assures reproducibility and comparability of all tested scenarios, with objectification of the individual advantages or limitations. This gain in both validity and reliability fulfills the scientific requirements placed upon an expert assessment.

[Functional impact of carbon fiber springs in ankle-foot orthoses]. / Funktionelle Auswirkungen des Einsatzes von Karbonfedern bei Unterschenkelorthesen.

BACKGROUND: Patients with calf muscle insufficiency are often dependent on ankle-foot orthoses (AFO). The orthosis should improve walking and posture and should prevent structural deformities. AFOs are usually manufactured with a dorsiflexion stop. In the current study, orthoses with a dorsal carbon fiber spring were compared with the classic design. PATIENTS AND METHODS: Five patients with spina bifida, one with poliomyelitis, and one with a tibial nerve block took part in the study. All participants underwent a 3-D gait analysis including data collection of kinematics (VICON) and kinetics (Kistler). RESULTS: It was found that the use of a carbon fiber spring significantly increases the energy return during the third rocker for a push-off effect (p<0.05). The measurements showed further that the carbon spring was able to support the patient during the complete stance phase. The analysis of the ankle and knee kinematics reveals that the spring contributes to a more physiological gait (p<0.05). CONCLUSION: This investigation showed that the use of a carbon spring and the alignment positively influenced the gait pattern during the stance phase.