Prosthetic Foot Selection for Individuals with Lower-Limb Amputation: A Clinical Practice Guideline

Design and preliminary verification of a novel powered ankle-foot prosthesis: From the perspective of lower-limb biomechanics compared with ESAR foot

A novel powered ankle-foot prosthesis is designed. The effect of wearing the novel prosthesis and an energy-storage-and-return (ESAR) foot on lower-limb biomechanics is investigated to preliminarily evaluate the design. With necessary auxiliary materials, a non-amputated subject (a rookie at using prostheses) is recruited to walk on level ground with an ESAR and the novel powered prostheses separately. The results of the stride characteristics, the ground reaction force (GRF) components, kinematics, and kinetics in the sagittal plane are compared. Wearing the powered prosthesis has less prolongation of the gait cycle on the unaffected side than wearing the ESAR foot. Wearing ESAR or proposed powered prostheses influences the GRF, kinematics, and kinetics on the affected and unaffected sides to some extent. Thereinto, the knee moment on the affected side is influenced most. Regarding normal walking as the reference, among the total of 15 indexes, the influences of wearing the proposed powered prosthesis on six indexes on the affected side (ankle's/knee's/hip's angles, hip's moment, and Z- and X-axis GRF components) and five indexes on the unaffected side (ankle's/knee's/hip's angles and ankle's/hip's moments) are slighter than those of wearing the ESAR foot. The influences of wearing the powered prosthesis on two indexes on the unaffected side (knee's moment and X-axis GRF component) are similar to those of wearing the ESAR foot. The greatest improvement of wearing the powered prosthesis is to provide further plantarflexion after reaching the origin of the ankle joint before toe-off, which means that the designed powered device can provide further propulsive power for the lifting of the human body's centre of gravity during walking on level ground. The results demonstrate that wearing the novel powered ankle-foot prosthesis benefits the rookie in recovering the normal gait more than wearing the ESAR foot.

A disparity in prosthetic access for Ecuadorians with lower-limb amputation

BACKGROUND

Individuals with disabilities in low- and middle-income countries face barriers to rehabilitation services, including prosthetic care. Many countries, such as Ecuador, have adapted policies toward achieving universal health care coverage. For optimal functional outcomes, understanding the physical potential of prosthetic users is critical for appropriate prosthetic services.

OBJECTIVE

To determine the association between the functional level of Ecuadorians with lower-limb amputations and the functional level of their prosthetic componentry.

STUDY DESIGN

Retrospective study.

METHODS

A data set containing functional level (K-Level) of Ecuadorians with lower-limb amputations and the K-Level of their prosthesis was analyzed.

RESULTS

A diverse cohort of 164 participants with unilateral lower-limb amputation was recruited. Most participants were male (76.8%) with transfemoral amputations (56.1%) due to traumatic causes (51.2%). There was a small, positive, and statistically significant correlation between participants' functional levels and prosthetic componentry. Participants's functional levels were typically superior (median = 3) to their prostheses' functional abilities (median = 1), and 37.2% of participants did not have a prosthesis at the time of assessment.

CONCLUSIONS

These data indicated that participants whose physical ability exceeded basic ambulation lacked access to prostheses to match their functional abilities. The detailed disparity between physical potential and prosthetic access derived from the study's analysis supports investment into high functioning prosthetic componentry and further investigation into where gaps in care exist.

The development of rating scales to evaluate experiential prosthetic foot preference for people with lower limb amputation

BACKGROUND

Selection of a foot is an important aspect of prosthetic prescription and vital to maximizing mobility and functional goals after lower limb amputation. Development of a standardized approach to soliciting user experiential preferences is needed to improve evaluation and comparison of prosthetic feet.

OBJECTIVE

To develop rating scales to assess prosthetic foot preference and to evaluate use of these scales in people with transtibial amputation after trialing different prosthetic feet.

DESIGN

Participant-blinded, repeated measures crossover trial.

SETTING

Veterans Affairs and Department of Defense Medical Centers, laboratory setting.

PARTICIPANTS

Seventy-two male prosthesis users with unilateral transtibial amputation started, and 68 participants completed this study.

INTERVENTIONS

Participants trialed three mobility-level appropriate commercial prosthetic feet briefly in the laboratory.

MAIN OUTCOME MEASURES

"Activity-specific" rating scales were developed to assess participants' ability with a given prosthetic foot to perform typical mobility activities (eg, walking at different speeds, on inclines, and stairs) and "global" scales to rate overall perceived energy required to walk, satisfaction, and willingness to regularly use the prosthetic foot. Foot preference was determined by comparing the rating scale scores, after laboratory testing.

RESULTS

The greatest within-participant differences in scores among feet were observed in the "incline" activity, where 57% ± 6% of participants reported 2+ point differences. There was a significant association (p < .05) between all "activity-specific" rating scores (except standing) and each "global" rating score.

CONCLUSIONS

The standardized rating scales developed in this study could be used to assess prosthetic foot preference in both the research and clinical settings to guide prosthetic foot prescription for people with lower limb amputation capable of a range of mobility levels.

The Moment Criterion of Anthropomorphicity of Prosthetic Feet as a Potential Predictor of Their Functionality for Transtibial Amputees

The purpose of this paper is to discuss a new quantitative mechanical parameter of prosthetic feet called the Index of Anthropomorphicity (IA), which has the potential to be adopted as an objective predictor of their functionality. The objectives are to present the research findings supporting the introduction of IA and unify previous results into a coherent theory. The IA is founded on the moment criterion of the anthropomorphicity of prosthetic feet. The term "anthropomorphicity" is defined for this application. Studies with a small number of human subjects and prostheses have shown that the value of the parameter is positively correlated with patient comfort and with the restoration of certain normal gait characteristics. Confirmatory studies with controlled human trials and mechanical tests with a wider selection of prosthesis types can give prosthesis manufacturers a new criterion to follow in the design process, and prosthetists may use the IA for selecting more suitable prostheses for a patient's comfort and health.

Localization of composite prosthetic feet: manufacturing processes and production guidelines

Amputation levels in Egypt and the surrounding neighborhood require a state intervention to localize the manufacturing of prosthetic feet. Amputations are mainly due to chronic diseases, accidents, and hostilities' casualties. The prosthetic foot type is traditionally classified according to the number of axial rotational movements, and is recently classified according to the energy activeness of the foot. The localization of this industry needs a preliminary survey of the domestic technological levels with respect to the foot type. Upon the results of this survey, the energy storage response foot has appealing metrics to proceed with its manufacturing. A prototype manufacturing chain is designed and a set of these feet with a certain commercial size of 27 is manufactured. Resin impregnation technology for carbon fiber composites is followed in this work. The feet are tested according to ISO 22,675. Based on the dimensional and mechanical results, a manufacturing value chain is proposed with the prospective resin transfer molding technology. This value chain will guarantee the required localization as well as the natural growth of this value chain with all related activities like accreditation of practices as well as manpower certification.

Successful transfemoral prosthesis in a patient with haemophilia A and factor VIII inhibitors: A case report

Haemophilia A patients who develop factor VIII inhibitors pose a challenge with respect to bleeding and orthopaedic management. This is particularly relevant in cases requiring amputation. We present here a case of a patient with severe haemophilia A and inhibitors who had a history of multiple surgeries due to periprosthetic joint infection and a non-healing wound which led to above-knee amputation. Following the implementation of appropriate and suitable transfemoral prosthesis and emicizumab therapy, the patient experienced a significant improvement in mobility and quality of life without any adverse events or bleeding episodes. Additional studies are required to more fully understand treatment options for lower limb amputations in the haemophilia population.

Continuous relative phases of walking with an articulated passive ankle-foot prosthesis in individuals with a unilateral transfemoral and transtibial amputation: an explorative case-control study

BACKGROUND

A mechanical ankle-foot prosthesis (Talaris Demonstrator) was developed to improve prosthetic gait in people with a lower-limb amputation. This study aims to evaluate the Talaris Demonstrator (TD) during level walking by mapping coordination patterns based on the sagittal continuous relative phase (CRP).

METHODS

Individuals with a unilateral transtibial amputation, transfemoral amputation and able-bodied individuals completed 6 minutes of treadmill walking in consecutive blocks of 2 minutes at self-selected (SS) speed, 75% SS speed and 125% SS speed. Lower extremity kinematics were captured and hip-knee and knee-ankle CRPs were calculated. Statistical non-parametric mapping was applied and statistical significance was set at 0.05.

RESULTS

The hip-knee CRP at 75% SS walking speed with the TD was larger in the amputated limb of participants with a transfemoral amputation compared to able-bodied individuals at the beginning and end of the gait cycle (p = 0.009). In people with a transtibial amputation, the knee-ankle CRP at SS and 125% SS walking speeds with the TD were smaller in the amputated limb at the beginning of the gait cycle compared to able-bodied individuals (p = 0.014 and p = 0.014, respectively). Additionally, no significant differences were found between both prostheses. However, visual interpretation indicates a potential advantage of the TD over the individual's current prosthesis.

CONCLUSION

This study provides lower-limb coordination patterns in people with a lower-limb amputation and reveals a possible beneficial effect of the TD over the individuals' current prosthesis. Future research should include a well-sampled investigation of the adaptation process combined with the prolonged effects of the TD.

Transfemoral interface considerations: A clinical consensus practice guideline

BACKGROUND

Although there have been a number of studies exploring the impact and efficacy of transfemoral prosthetic components such as knee and foot mechanisms, the empirical evidence surrounding transfemoral prosthetic interface considerations is limited. This constitutes a substantial void for practicing clinicians seeking to apply best practices for patients who use transfemoral prostheses. Recent years have seen increased production and availability of clinical practice guidelines germane to prosthetic rehabilitation. In those areas where empirical evidence is lacking, consensus clinical opinions may constitute the highest level of evidence.

OBJECTIVE

A consensus exercise was performed to generate clinical practice recommendations in the areas of transfemoral interface considerations including socket variations and critical design features, suspension and interface considerations, alignment, heat retention and dermatologic considerations, female considerations, surgical considerations, and both regulatory and ethical considerations related to osseointegration.

METHODS

This began with the generation of postulate items through systematic and narrative literature reviews. A Delphi consensus exercise was performed among clinical experts in government hospital and private clinical practice settings, culminating in a series of clinical practice recommendations associated with the prosthesis-limb interface for individuals with transfemoral amputation.

RESULTS

The completed recommendations include guidance statements relative to socket variations and critical design features, female considerations, suspension and interface considerations, surgical variations and prescription considerations, rehabilitation team considerations and both regulatory and ethical considerations related to osseointegration.

CONCLUSIONS

The Delphi process facilitated the development of practice guidelines for transfemoral prosthetic interface considerations based on aggregated subject matter expertise.

Evaluation of an articulated passive ankle-foot prosthesis

Background

Current ankle prostheses for people with unilateral transtibial amputation (TTA) or transfemoral amputation (TFA) are unable to mimic able-bodied performance during daily activities. A new mechanical ankle–foot prosthesis was developed to further optimise the gait of people with a lower-limb amputation. This study aimed to evaluate the Talaris Demonstrator (TD) during daily activities by means of performance-related, physiological and subjective outcome measures.

Materials and methods

Forty-two participants completed a protocol assessing performance and functional mobility with their current prosthesis and the TD. The protocol comprised the L-test, 2 min of stair climbing, 2 min of inclined treadmill walking, 6 min of treadmill walking at 3 different speeds in consecutive blocks of 2 min, and a 3-m Backward Walk test (3mBWT). Heart rate was measured during each task, and oxygen uptake was collected during all tasks except for the L-test and 3mBWT. Time of execution was recorded on the L-test and 3mBWT, and the rate of perceived exertion (score = 6–20), fatigue and comfort (score = 0–100) were assessed after each task. Paired sample t-tests and Wilcoxon Signed-rank tests were performed to compare outcomes between prosthetic devices. Benjamini–Hochberg corrections were applied to control for multiple comparisons with a level of significance set at α = 0.05.

Results

Subjects with a TTA (N = 28) were faster with their current prosthesis compared to the TD on the L-test and 3mBWT (p = 0.005). In participants with a TFA (N = 14), we observed a tendency towards a higher heart rate during the L-test and towards increased comfort during inclined walking, with the TD compared to the participants’ current prosthetic device (0.05 < p < 0.10). Further, no significant results were observed.

Conclusion

The Talaris Demonstrator is a novel state-of-the-art passive ankle–foot prosthesis for both people with a TTA and TFA. Subjective measures indicate the added value of this device, while overall task performance and intensity of effort do not differ between the Talaris Demonstrator and the current prosthesis. Further investigations unravelling both acute and more prolonged adaptations will be conducted to evaluate the TD more thoroughly.

Biomechanical factors affecting individuals with lower limb amputations running using running-specific prostheses: A systematic review

BACKGROUND

Running-specific prostheses (RSPs) are biomechanically designed to enable individuals with lower limb amputations to engage in high level sports.

RESEARCH QUESTION

What is the influence of RSP use on the running biomechanics of individuals with lower limb amputations?

METHODS

An article search was conducted in six databases since their inception to July 2021. Two independent reviewers assessed the title, abstract and full texts in the review process. The quality of the papers was appraised. The review included a total of 35 articles.

RESULTS

Main findings indicate force production is a limitation of RSPs. Individuals with lower limb absence employ a variety of compensatory strategies such as adjusting their step frequency, contact length and joint kinetics to improve their running performance. Leg stiffness modulation and external factors relating to the RSP design and fitting play important roles in RSP biomechanics. For individuals with unilateral amputations, the increased loading of the intact limb could increase the risk of acute injury or chronic joint degradation.

SIGNIFICANCE

To improve their running performance, runners with lower limb amputations employ various compensatory strategies, such as altering the spatiotemporal and kinetic parameters. Factors relating to RSP height, stiffness, shape, and alignment also play an important role in terms of running biomechanics and should be considered in RSP design and fitting. Future studies should focus on the use of RSPs for recreation, in pediatric populations, with certain amputation levels, as well as the impact of training and running techniques.

The Value of Health Economics and Outcomes Research in Prosthetics and Orthotics

The demand has increased for evidence regarding the effectiveness and value of prosthetic and orthotic rehabilitation interventions. Clinicians and managers are under pressure to provide treatment recommendations and demonstrate effectiveness through outcomes. It is often assumed that rehabilitation interventions, including the provision of custom-made and custom-fit orthotic and prosthetic devices, are beneficial to patients. Assessing the value of orthotic and prosthetic services has become more critical to continue to ensure equitable access to needed services. Health economics and outcomes research methods serve as tools to gauge the value of prosthetic and orthotic rehabilitation interventions. The purpose of this article is to provide an overview of the current need of health economics and outcomes research in orthotics and prosthetics, to introduce common economic methods that assist to generate real-world evidence, and to discusses the potential value of economic methods for clinicians and clinical practice.

Cycling in people with a lower limb amputation

Background

To evaluate cycling participation and identify barriers and facilitators related to cycling participation in people with a lower limb amputation (LLA) in the Netherlands.

Methods

A questionnaire was sent to adults with a LLA between March and August 2019 to obtain information regarding prosthesis, individual’s characteristics, amputation, cycling barriers and facilitators, and prosthetic satisfaction. The questionnaires were distributed via 8 orthopedic workshops, post and were given directly. To find cycling predictors, variables associated with cycling (p < 0.1) were entered into a logistic regression analysis. Non-significant variables were removed manually.

Results

Participants (n = 207, 71% males) had a mean age of 62.0 ± 13.0 years. The most frequent level of amputation was transtibial (42%), and trauma was the most frequent cause of amputation (43%). After the LLA, 141 participants (68%) cycled for recreation (80%), physical fitness (74%), and transport (50%). In the past six months, cyclists cycled for recreation (79%) and transport (66%). Most cycled less than once a day. Recreational cyclists cycled alone (75%) for a median duration of 45 min or 14 km per ride. Cyclists with a transportation purpose usually cycled to go shopping (80%) or to visit friends (68%), with a median duration of 20 min or five kilometers per ride. Cyclists reported more facilitators (median (IQR) = 5 (3, 7) than non-cyclists 0 (0, 3). The majority of cyclists reported a positive attitude toward cycling (89%) and cycled because of health benefits (81%). A dynamic foot (odds ratio: 5.2, 95% CI 2.0, 13.3) and a higher number of facilitators (odds ratio: 1.3, 95% CI 1.2, 1.5) positively predicted cycling, whereas the presence of other underlying diseases (odds ratio: 0.4, 95% CI 0.2, 0.9) negatively predicted cycling (R²: 40.2%).

Conclusion

In the Netherlands, the majority of adults cycled after a LLA, mainly for recreational purposes. A dynamic foot, a higher number of facilitators, and no other underlying diseases increases the likelihood of cycling after a LLA. The results suggest that personal motivation and a higher mobility level could be the key to increasing cycling participation. Future research should determine the association between motivation, mobility levels, and cycling with a LLA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-021-00302-3.

Using a microprocessor knee (C-Leg) with appropriate foot transitioned individuals with dysvascular transfemoral amputations to higher performance levels: a longitudinal randomized clinical trial

Background

Individuals with transfemoral amputations who are considered to be limited community ambulators are classified as Medicare functional classification (MFCL) level K2. These individuals are usually prescribed a non-microprocessor controlled knee (NMPK) with an appropriate foot for simple walking functions. However, existing research suggests that these individuals can benefit from using a microprocessor controlled knee (MPK) and appropriate foot for their ambulation, but cannot obtain one due to insurance policy restrictions. With a steady increase in older adults with amputations due to vascular conditions, it is critical to evaluate whether advanced prostheses can provide better safety and performance capabilities to maintain and improve quality of life in individuals who are predominantly designated MFCL level K2. To decipher this we conducted a 13 month longitudinal clinical trial to determine the benefits of using a C-Leg and 1M10 foot in individuals at K2 level with transfemoral amputation due to vascular disease. This longitudinal clinical trial incorporated recommendations prescribed by the lower limb prosthesis workgroup to design a study that can add evidence to improve reimbursement policy through clinical outcomes using an MPK in K2 level individuals with transfemoral amputation who were using an NMPK for everyday use.

Methods

Ten individuals (mean age: 63 ± 9 years) with unilateral transfemoral amputation due to vascular conditions designated as MFCL K2 participated in this longitudinal crossover randomized clinical trial. Baseline outcomes were collected with their current prosthesis. Participants were then randomized to one of two groups, either an intervention with the MPK with a standardized 1M10 foot or their predicate NMPK with a standardized 1M10 foot. On completion of the first intervention, participants crossed over to the next group to complete the study. Each intervention lasted for 6 months (3 months of acclimation and 3 months of take-home trial to monitor home use). At the end of each intervention, clinical outcomes and self-reported outcomes were collected to compare with their baseline performance. A generalized linear model ANOVA was used to compare the performance of each intervention with respect to their own baseline.

Results

Statistically significant and clinically meaningful improvements were observed in gait performance, safety, and participant-reported measures when using the MPK C-Leg + 1M10 foot. Most participants were able to achieve higher clinical scores in gait speed, balance, self-reported mobility, and fall safety, while using the MPK + 1M10 combination. The improvement in scores were within range of scores achieved by individuals with K3 functional level as reported in previous studies.

Conclusions

Individuals with transfemoral amputation from dysvascular conditions designated MFCL level K2 benefited from using an MPK + appropriate foot. The inference and evidence from this longitudinal clinical trial will add to the knowledgebase related to reimbursement policy-making.

Trial registration This study is registered on clinical trials.gov with the study title “Functional outcomes in dysvascular transfemoral amputees” and the associated ClinicalTrials.gov Identifier: NCT01537211. The trial was retroactively registered on February 7, 2012 after the first participant was enrolled.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-021-00879-3.

Is lower limb salvage worthwhile after severe open tibial fractures in a developing country? An analysis of surgical outcomes, quality of life and cost implications

INTRODUCTION

Open tibial fractures are rare and difficult-to-treat injuries because of the involvement of bony, skin and neuromuscular injury along with co-morbidities. Often, during the management of very severe cases these injuries, the question arises, should we amputate or salvage the limb? This question has been explored previously in civilian and military contexts in the US and UK but remains unstudied in the alternative sociocultural and economic context of the developing world.

METHODS

We studied 78 adult patients with severe open tibial fracture that presented to our institution, a Level 1 trauma center in India, from February 2018 to June 2019. 20 patients underwent above-knee amputation (AKA), 16 underwent below-knee amputation (BKA), and 42 underwent limb salvage. We assessed injury severity using [our institution's] Open Injury Severity Score (GHOISS), which has separate sub-scores for bony injury, skin injury, neuromuscular injury and co-morbidities, and patients were only included with GHOISS > 13. We assessed functional outcome measures as well as economic costs as primary cost levied by our institution and other secondary costs.

RESULTS

Salvage (LEFS: mean=51, SF-12 PCS: mean=48, SF-12 MCS: mean=49) provided better outcomes to BKA (LEFS: mean=39, p=0.005, SF-12 PCS: mean=40, p=0.003, SF-12 MCS: mean=43, p=0.052) and AKA (LEFS: mean=31, p<0.001, SF-12 PCS: mean=34, p<0.001, SF-12 MCS: mean=43, p=0.043). Primary costs were higher for limb salvage (index: mean=$3100, total: mean=$4400) than both BKA (index: mean=$2500, p=0.012, total: mean=$2600, p<0.001) and AKA (index: mean=$2800, p=0.020, total: mean=$3200, p<0.001). Secondary costs were higher for limb salvage than both BKA and AKA (p<0.001). Patients who underwent salvage were more likely to return to work at 36 months post-injury compared to below-knee amputees (adjusted OR=0.11, p=0.010).

CONCLUSIONS

Limb salvage results in better functional outcomes compared with amputation at a higher upfront cost but a likely lower lifetime cost. Unlike other literature on the topic, amputation carries a heavy mental and physical toll in India, likely due to sociocultural differences and stigma. Amputation is a difficult decision for patients to accept and results in poorer outcomes; therefore, we believe that limbs should be aggressively salvaged in our developing country.

STUDY DESIGN

Therapeutic Level II Prospective Cohort Study.

Using a Simple Walking Model to Optimize Transfemoral Prostheses for Prosthetic Limb Stability-A Preliminary Study

The interaction between the prescribed prosthetic knee and foot is critical to the safety of transfemoral prosthesis users primarily during the stance phase of the gait, when knee buckling can result in a fall. Nonetheless, there is still a need for standardized approaches to quantify the effects of prosthetic component interactions and associated mechanical function on user gait biomechanics. A numerical model was defined to simulate sagittal plane prosthetic limb stance based on a single inverted pendulum and predict effects of prosthetic knee alignment and foot stiffness on knee moment to identify optimal solutions. Model validation against laboratory gait data suggests it is appropriate to preliminary simulate prosthetic gait during single-limb support, when prosthetic knee stability may be most at risk given reliance on the prosthetic limb and proximal anatomy, but only for knees with flexion smaller than 4°. Model predictions identify a solution space containing those combinations of knee alignment and foot stiffness (via roll-over shape radius) guaranteeing knee stability in early and mid- single-limb support, whilst facilitating knee break at the end of it. Specifically, a posterior to in-line knee alignment should be combined with low to medium ankle-foot stiffness, whereas anterior knee alignments and rigid feet should likely be avoided. Clinicians can use these solution spaces to optimize transfemoral prostheses including knees with little to no change in stance flexion, ensuring the safety of users. Model prediction can further inform in-vivo investigations on commercial device interactions, providing evidence for future Clinical Practice Guidelines on transfemoral prostheses design.

Obstacles to Prosthetic Care—Legal and Ethical Aspects of Access to Upper and Lower Limb Prosthetics in Germany and the Improvement of Prosthetic Care from a Social Perspective

Prosthetic technology for people with missing limbs has made great progress in recent decades. However, acceptance rates and user satisfaction are not only dependent on technical aspects, but also to a great extent on social and psychological factors. We propose that these factors should receive greater attention in order to improve prosthetic care and give recommendations how to incorporate the findings from social science in research and development (R&D) and in care practice. Limited access due to high costs of new prosthetic technology combined with rising costs in health care systems in general is a further issue we address. Our legal and ethical analysis of the reimbursement process in Germany shows that this issue requires further empirical investigation, a stakeholder dialogue and maybe even policy changes. Social science knowledge and participatory methods are of high relevance to answer questions about the benefit of prosthetics for users, based on individual needs and preferences, which should be at the core of debates on ethical resource allocation.

Mobility analysis of AmpuTees (MAAT 5): Impact of five common prosthetic ankle-foot categories for individuals with diabetic/dysvascular amputation

Introduction

Diabetes and vascular disease represent the most common etiologies for lower limb amputations. In lower limb loss rehabilitation, the prosthetic ankle-foot mechanism is the most common major component needed to restore function. The purpose of this study was to examine the impact of five common prosthetic ankle-foot mechanisms on functional mobility in a large sample of individuals with amputation due to diabetes/dysvascular disease.

Methods

A retrospective analysis of the Prosthetic Limb Users' Survey of Mobility (PLUS-M®) captured in the patient care setting. A total of 738 individuals were included and subsequently subdivided into five groups based on the ankle-foot mechanism of their current prosthesis. Groups were compared using a general linear univariate model with age, body mass index, comorbid health status, time since amputation, and amputation level entered as covariates.

Results

The microprocessor ankle-foot group had the highest mobility (F_4,728 = 3.845, p=0.004), which was followed by the vertical loading pylon type ankle-foot, the hydraulic ankle-foot, the flex-walk-type ankle-foot, and lastly the flex-foot-type ankle-foot.

Conclusion

These results demonstrate that the selection of different prosthetic ankle-foot technology directly impacts functional mobility for the patient with an amputation due to diabetes and/or vascular disease.

Prosthetic Knee Selection for Individuals with Unilateral Transfemoral Amputation: A Clinical Practice Guideline

Introduction

This guideline was developed to present the evidence and provide clinical recommendations on prosthetic knee selection for unilateral amputation at the knee disarticulation or transfemoral level.

Methods

The guideline is based upon the best available evidence as it relates to prosthetic knee selection after unilateral knee disarticulation or transfemoral amputation. Recommendations are drawn from systematic review, meta-analysis, and additional published practice guidelines.

Results

Recommendation 1. Fluid knee benefits and indications: Knees with hydraulic or pneumatic swing resistance are indicated for active walkers, permitting increased walking comfort, speed, and symmetry.Recommendation 2. Microprocessor knee benefits: Compared with nonmicroprocessor knees:a) With respect to self-report indices and measures, microprocessor knees are indicated to reduce stumbles, falls, and associated frustrations as well as the cognitive demands of ambulation.b) With respect to self-report indices and measures, microprocessor knees are indicated to increase confidence while walking, self-reported mobility, satisfaction, well-being, and quality of life.c) With respect to physical performance indices and measures, microprocessor knees are indicated to increase self-selected walking speed, walking speed on uneven terrain, and metabolic efficiency during gait.Recommendation 3. Microprocessor knee equivalence: Given the comparable values observed with the use of microprocessor and nonmicroprocessor knees with regard to daily step counts, temporal and spatial gait symmetry, self-reported general health, and total costs of prosthetic rehabilitation, these parameters may not be primary indications in prosthetic knee joint selection.Recommendation 4. Microprocessor knees for limited community ambulators: Among limited community ambulators, microprocessor knees are indicated to enable increases in level ground walking speed and walking speed on uneven terrain while substantially reducing uncontrolled falls and increasing both measured and perceived balance.

Conclusions

These clinical practice guidelines summarize the available evidence related to prosthetic knee selection for individuals with unilateral knee disarticulation or transfemoral amputation. The noted clinical practice guidelines are meant to serve on as "guides." They may not apply to all patients and clinical situations.