Prosthesis satisfaction and quality of life in US service members with combat-related major lower-limb amputation.

BACKGROUND: Military amputee patient care programs offer extensive services, including advanced prosthetic devices, to restore function and improve quality of life (QOL) among veterans and service members with combat-related limb loss, but research on satisfaction with these devices is limited. OBJECTIVE: To assess prosthesis satisfaction and QOL in US service members and veterans with combat-related major lower-limb amputation. STUDY DESIGN: Cross-sectional study. METHODS: Eighty-six participants with combat-related major lower-limb amputation completed the Orthotics and Prosthetics Users' Survey (OPUS) Satisfaction with Device scale and Quality of Well-Being Scale, Self-Administered, for the Wounded Warrior Recovery Project. RESULTS: Most participants (62%-88%) responded Agree or Strongly Agree to OPUS Satisfaction with Device items on the fit, weight, comfort, ease of donning, appearance, and durability of their prosthesis. By contrast, the majority of participants (55%-79%) responded Disagree or Strongly Disagree to items on clothes being free of wear and tear, skin free of abrasions and irritations, and the affordability of their prosthesis. In linear regression analysis, total OPUS Satisfaction with Device score was positively associated with Quality of Well-Being Scale, Self-Administered score (ß = 0.0058; P = 0.004). CONCLUSIONS: Findings indicate the majority of participants were satisfied with the overall functionality of their prosthesis, but dissatisfied with the effect of their prosthesis on clothing and skin, as well as expenses related to their prosthesis. Additionally, prosthesis satisfaction was positively associated with QOL.

Biomechanical improvements following foot strike biofeedback training for a patient using a passive dynamic ankle-foot orthosis during running.

BACKGROUND AND PURPOSE: Passive dynamic ankle-foot orthoses have potential to facilitate return to running after a lower limb trauma. However, transitioning patients to new movement patterns that enhance passive dynamic ankle-foot orthoses benefits can pose a challenge. The purpose of this case study was to report biomechanical and functional outcomes for a patient utilizing a passive dynamic ankle-foot orthoses following completion of a session-based, midfoot strike run training program. CASE DESCRIPTION AND METHODS: A patient using a passive dynamic ankle-foot orthoses to run due to surgically reconstructed tibia\fibula fracture underwent eight treadmill running sessions over 2 weeks while viewing continuous visual feedback on measured foot strike. FINDINGS AND OUTCOMES: After treatment, foot strike was changed from rearfoot to midfoot on the affected limb along with an 18% increase in mechanical work ratio of the ankle-foot-brace complex. Similar improvements were retained at one and five months following treatment. CONCLUSION: This report provides preliminary evidence that biofeedback-based foot strike training can enhance ankle-foot mechanical performance of patients using a passive dynamic ankle-foot orthoses to run. CLINICAL RELEVANCE: For patients using a passive dynamic ankle-foot orthoses to run following lower limb trauma, supplementing standard rehabilitation programs with biofeedback-based footstrike training may improve biomechanical performance and running capability.

Do Gait and Functional Parameters Change After Transtibial Amputation Following Attempted Limb Preservation in a Military Population?

BACKGROUND: Surgical attempts at lower limb preservation after trauma may be complicated by pain and gait disturbances, which can impact the activity level of a military service member. It is unclear how later transtibial amputation (TTA) might affect patients who elect this option after attempts at limb preservation. QUESTIONS/PURPOSES: The purposes of the study were to compare preamputation and postamputation (1) the numeric rating scale for pain and pain medication use; (2) self-reported activity level, Four Square Step Test (FSST) results, and assistive device use; and (3) spatiotemporal variables measured with instrumented gait analysis in individuals who elected TTA after multiple attempts at limb preservation. METHODS: Retrospective review revealed 10 patients with unilateral lower extremity injuries who underwent late TTA between 2008 and 2016. All patients had undergone multiple limb preservation attempts and had completed instrumented gait evaluations as part of their routine care before and after TTA. One patient was excluded as a result of short followup. The remaining nine patients (eight men, 29 ± 6 years) averaged five surgeries before amputation. Injuries were from improvised explosive devices (six), motorcycle accidents (two), and one training accident. Strict indications for amputation were pain, difficulties performing activities of daily living, limited physical function, and medication dependence. Data for the aforementioned purposes were collected by gait laboratory staff before and 8 to 17 months after amputation. Time to TTA after initial injury was 5 ± 3 years. At the start of the gait analysis study, pain was assessed at rest, activity level was recorded by patient report, and the FSST was administered. RESULTS: After TTA, there was a decrease in pain scores from 4 ± 2 to 1 ± 1 and patients using narcotics decreased from four to only one patient. Self-reported walking endurance increased from 1 ± 1 mile to 7 ± 8 miles and patients able to run increased from one patient to eight with the ninth having no desire to run but bicycled. Patient FSST times improved from 12 ± 10 seconds to 5 ± 1 seconds. No patients required assistive devices after TTA. There were improvements in velocity (108 ± 16 cm/s to 142 ± 7 cm/s), stride length (129 ± 14 cm to 154 ± 8 cm), cadence (101 ± 9 steps/min to 111 ± 7 steps/min), and step width (16 ± 3 cm to 12 ± 2 cm) between pre- and postassessments. Asymmetric single-limb stance time was measured both pre- and postamputation; this did not worsen with the increase in walking velocity. CONCLUSIONS: The findings of this study show that TTA after attempted limb preservation in a young, motivated group of service members after traumatic injuries can be successful in decreasing pain and narcotic use and can allow for high-level functional activities. Future studies will be needed to compare this cohort with patients who underwent early TTA after traumatic injury. However, we acknowledge that the resources and support structure available for this population are unique and may not be readily available to the general population. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Limb Salvage With Intrepid Dynamic Exoskeletal Orthosis Versus Transtibial Amputation: A Comparison of Functional Gait Outcomes.

OBJECTIVES: To determine if there is a difference in functional gait outcomes between patients with limb injuries treated with either transtibial amputation or limb preservation with the Intrepid Dynamic Exoskeletal Orthosis. DESIGN: Retrospective prognostic study. SETTING: Tertiary referral military hospital. PATIENTS: This study included 10 transtibial amputees and 10 limb preservation patients using the Intrepid Dynamic Exoskeletal Orthosis who were matched by body mass index after excluding for nontraumatic, proximal ipsilateral, contralateral, spine, or traumatic brain injuries. Transtibial amputation patients were also excluded if they did not have a gait study between 6 and 12 months after independent ambulation. Limb preservation were excluded if they did not complete the "Return to Run" program. INTERVENTIONS: An observational study of functional outcomes using instrumented gait analysis. OUTCOME MEASURES: Spatiotemporal, kinetic (vertical ground reaction force), unified deformable power, work, and efficiency. RESULTS: Limb preservation patients walked with a significantly slower cadence (P = 0.036) and spent less time on their affected limb in stance (P = 0.045), and longer in swing (P = 0.019). Amputees had significantly increased maximum positive power in both limbs (P = 0.004 and P = 0.029) and increased maximum negative power on the unaffected limb (P = 0.035). Amputees had significantly increased positive and negative work in the affected limb (P = 0.0009 and P = 0.014) and positive work in the unaffected limb (P = 0.042). There was no significant difference in the kinetic data or efficiency. CONCLUSIONS: Limb preservation patients spend less time on their affected limb as a percentage of the gait cycle. The unified deformable power demonstrated more dynamic gait in amputees, with peak values closer to normative data. LEVEL OF EVIDENCE: Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.