Management of lower limb amputations

Experiences of persons with lower limb amputation after prosthetic rehabilitation in Ghana: A qualitative inquiry

BACKGROUND

Lower limb amputations (LLAs) have long been associated with physical, social, and psychological consequences. Individuals with LLAs have challenges with mobility and often become isolated from their social networks. Disability rehabilitation technologies such as prosthetic devices are used to improve the mobility capabilities of lower limb amputees. To improve clinical outcomes, feedback from the prosthetic users is a key element to consider.

OBJECTIVES

The study sort to explore the experiences of lower-limb prosthetic users after prosthetic rehabilitation in a prosthetic and orthotic rehabilitation center in the Eastern Region of Ghana.

STUDY DESIGN

This study adopted an exploratory descriptive qualitative study design.

METHODS

A purposive sampling technique and semistructured interview guide was used to interview 17 participants by the first author. The social model of disability underpinned the study. Lower-limb prosthetic users (≥18 years) with unilateral LLA attending outpatient follow-up at a prosthetic and orthotic rehabilitation center were recruited. The interviews were audio recoded, transcribed verbatim, and analyzed using the procedure for thematic content analysis by Braun and Clarke (2013).

RESULTS

Participants reported injuries and tingling in their residual limb. Internal stigma resulting from negative comments and labeling from the public were reported. Prosthetic users experienced empathy and being treated as weaklings by their family/peers. Participants avoided relationships because of recurrent rejection, embarrassment, fear of sexual abuse, and exploitation. As a coping method, some participants chose to isolate themselves to avoid humiliation and public disgrace. Other coping mechanisms included watching television, listening to music, conversing with others, ignoring criticism, and having faith in God.

CONCLUSION

Participants' narrative in this study gave insight into the varied lived experiences on the individual level, family/peer level, and the coping mechanisms used. Challenges relating to discomfort from the prosthesis, internal stigma, relationship avoidance, and altered sexual life should be given much attention and used in implementing initiatives to improve clinical outcomes.

Advances in prosthetic technology: a perspective on ethical considerations for development and clinical translation

Technological advancements of prostheses in recent years, such as haptic feedback, active power, and machine learning for prosthetic control, have opened new doors for improved functioning, satisfaction, and overall quality of life. However, little attention has been paid to ethical considerations surrounding the development and translation of prosthetic technologies into clinical practice. This article, based on current literature, presents perspectives surrounding ethical considerations from the authors' multidisciplinary views as prosthetists (HG, AM, CLM, MGF), as well as combined research experience working directly with people using prostheses (AM, CLM, MGF), wearable technologies for rehabilitation (MGF, BN), machine learning and artificial intelligence (BN, KKQ), and ethics of advanced technologies (KKQ). The target audience for this article includes developers, manufacturers, and researchers of prosthetic devices and related technology. We present several ethical considerations for current advances in prosthetic technology, as well as topics for future research, that may inform product and policy decisions and positively influence the lives of those who can benefit from advances in prosthetic technology.

Lower limb prosthetic prescription

Lower limb amputations are the most common level of amputation. Mobilization of patients with lower limb amputations is an important rehabilitation goal. It is critical to prescribe the most appropriate prosthesis for the patient to achieve the rehabilitation goal in lower extremity amputations. Appropriate prosthesis prescription in lower extremity amputations is based on the selection of the correct prosthetic parts. The choice of prosthesis should be based on the patient's activity level and potential. The prosthesis decision should be made by a team, particularly with the participation of the patient.

The use of nonnormalized surface EMG and feature inputs for LSTM-based powered ankle prosthesis control algorithm development

Advancements in instrumentation support improved powered ankle prostheses hardware development. However, control algorithms have limitations regarding number and type of sensors utilized and achieving autonomous adaptation, which is key to a natural ambulation. Surface electromyogram (sEMG) sensors are promising. With a minimized number of sEMG inputs an economic control algorithm can be developed, whereas limiting the use of lower leg muscles will provide a practical algorithm for both ankle disarticulation and transtibial amputation. To determine appropriate sensor combinations, a systematic assessment of the predictive success of variations of multiple sEMG inputs in estimating ankle position and moment has to conducted. More importantly, tackling the use of nonnormalized sEMG data in such algorithm development to overcome processing complexities in real-time is essential, but lacking. We used healthy population level walking data to (1) develop sagittal ankle position and moment predicting algorithms using nonnormalized sEMG, and (2) rank all muscle combinations based on success to determine economic and practical algorithms. Eight lower extremity muscles were studied as sEMG inputs to a long-short-term memory (LSTM) neural network architecture: tibialis anterior (TA), soleus (SO), medial gastrocnemius (MG), peroneus longus (PL), rectus femoris (RF), vastus medialis (VM), biceps femoris (BF) and gluteus maximus (GMax). Five features extracted from nonnormalized sEMG amplitudes were used: integrated EMG (IEMG), mean absolute value (MAV), Willison amplitude (WAMP), root mean square (RMS) and waveform length (WL). Muscle and feature combination variations were ranked using Pearson's correlation coefficient (r > 0.90 indicates successful correlations), the root-mean-square error and one-dimensional statistical parametric mapping between the original data and LSTM response. The results showed that IEMG+WL yields the best feature combination performance. The best performing variation was MG + RF + VM (r_position = 0.9099 and r_moment = 0.9707) whereas, PL (r_position = 0.9001, r_moment = 0.9703) and GMax+VM (r_position = 0.9010, r_moment = 0.9718) were distinguished as the economic and practical variations, respectively. The study established for the first time the use of nonnormalized sEMG in control algorithm development for level walking.

Exercise Therapy in Nonspecific Low Back Pain among Individuals with Lower-Limb Amputation: A Systematic Review

Low back pain is very common condition that often becomes a long-lasting problem in prostheses users after lower limb amputation. The presented study aims to decide the potential benefits of exercise therapy on low back pain among lower limb amputees by using a systematic review. The PICO technique was used to answer the primary issue of this review: Does exercise treatment lessen the prevalence of low back pain in the population of lower limb amputees? Systematic review was conducted in the following databases: Medline-PubMed, EMBASE, Scopus, and Web of Science. Studies up to September 2010 published in English are included. Aim, target population, development and execution strategies, and treatment suggestions were among the data gathered. The primary outcomes of interest were exercise interventions as a therapy for low back pain but only two articles met including criteria. The search was broadened and 21 studies describing biomechanical changes in gait and pelvic-spine posture were analysed. This review indicates that movement therapy is a potential treatment strategy in low back pain among amputees. The major limitation of the study is the very heterogenous group of subjects in terms of amputation level, baseline activity level and comorbidities. We used a procedure that was registered in PROSPERO (CRD42022345556) to perform this systematic review of systematic reviews. There is a necessity of good quality research for concluding a consensus of exercise intervention.

Rehabilitation of a Patient after a Transtibial Amputation: A Case Report

Amputation is the surgical removal of a body part or limb caused by excessive tightness, pathological conditions, or a surgical procedure on an extremity. Transtibial amputation involves removing the feet, ankle, distal part of the tibia, and fibula with the surrounding structures like connective tissues and other structures surrounding the distal part of the bone. This type of surgery has a high rate of contraindications but has adequate indications; it maintains a therapeutic technique with a high clinical price and, in general, lifesaving value. The primary objectives of rehabilitation are to improve normal and affected extremity power, patient mobility, aerobic capacity, coordination and balance, and independence in performing activities of daily living. In this case, the patient was a 50-year-old man who complained of pain in his left lower limb and had an ulcer on his left foot. Initially, it was small in size when noticed by the patient but gradually progressed to a large wound of 7x6cm over the medial side, with foul-smelling discharge, associated with blackish discoloration. Walking aggravated foot pain, which was relieved by standing still, medications, and rest. On investigation, the patient was diagnosed with gangrene in the left lower limb and referred for rehabilitation to the physiotherapy department after surgery. This case study provides information on the recovery of a patient with the help of prosthetic devices.

The association between body mass index and skin problems in persons with a lower limb amputation: an observational study

Background

Obesity is common in persons with a lower limb amputation, an amputation can also lead to further weight gain. Data regarding the prevalence of obesity in the Dutch population with a lower limb amputation are lacking. Furthermore, the impact of obesity on skin problems of the residual limb and the need of prosthetic repairs is unknown. The aim of this study was to determine the prevalence of obesity in Dutch persons with a lower limb amputation and to investigate the relationship between body weight, body mass index and skin problems of the residual limb and the frequency of prosthetic repairs.

Methods

A survey was performed among adults with a unilateral lower limb amputation due to any cause, and who are user of a prosthesis. The survey consisted of measurement of the subjects’ body height and weight, a questionnaire which assessed self-reported skin problems in the previous month and factors potentially associated with these skin problems, and assessment of the frequency of visits to the orthopedic workshop.

Results

In total, 413 persons were enrolled. Of them, 39% (95 % confidence interval 35;44) were overweight and 28% (95% confidence interval 24;33) were obese. A total of 77% (95% confidence interval 73;81) reported one or more skin problems in the past month. Body weight and body mass index were neither associated with the presence of skin problems in general nor with the number of prosthetic repairs. Persons with severe skin problems had a slightly lower body mass index (26.6 kg/m² vs. 28.0 kg/m², p = 0.012). Persons with skin problems were younger than those without (difference in means 6.0 years (95% confidence interval 3.0;8.9)).

Conclusions

Our findings show that obesity is common in the Dutch ambulant population with a lower limb amputation, with a prevalence being higher than in the general Dutch adult population. However, its negative impact on the presence of skin problems and the frequency of prosthetic repairs may be limited.

Investigation of Orthopedic Prosthesis Socket Management after Transfemoral Amputation by Expert Survey

Prosthesis treatment requires the close interaction of different actors. In fitting prostheses to patients, special attention is given to the manufacturing of the socket. The continuous development of the technologies involved in the fitting and optimization of prostheses is shown in the literature. The assessment of orthopedic technicians and their influence in the process is thus far largely unexplored. Ten orthopedic technicians were interviewed about the socket fitting process after transfemoral amputation. The research goal was to clarify the socket treatment process with regards to the German context. The results showed that the orthopedic technicians focussing on the patient during the fitting process. This study underlines the importance of interaction and empathy. Volume fluctuations are decisive within the treatment process and are interactively influenced by various factors. Furthermore, the research emphasizes the need for appropriate assistive technologies and the potential for the further development of existing systems.

Recommendations of protective measures for orthopedic surgeons during COVID-19 pandemic

PURPOSE

It was the primary purpose of the present systematic review to identify the optimal protection measures during COVID-19 pandemic and provide guidance of protective measures for orthopedic surgeons. The secondary purpose was to report the protection experience of an orthopedic trauma center in Wuhan, China during the pandemic.

METHODS

A systematic search of the PubMed, Cochrane, Web of Science, Google Scholar was performed for studies about COVID-19, fracture, trauma, orthopedic, healthcare workers, protection, telemedicine. The appropriate protective measures for orthopedic surgeons and patients were reviewed (on-site first aid, emergency room, operating room, isolation wards, general ward, etc.) during the entire diagnosis and treatment process of traumatic patients.

RESULTS

Eighteen studies were included, and most studies (13/18) emphasized that orthopedic surgeons should pay attention to prevent cross-infection. Only four studies have reported in detail how orthopedic surgeons should be protected during surgery in the operating room. No detailed studies on multidisciplinary cooperation, strict protection, protection training, indications of emergency surgery, first aid on-site and protection in orthopedic wards were found.

CONCLUSION

Strict protection at every step in the patient pathway is important to reduce the risk of cross-infection. Lessons learnt from our experience provide some recommendations of protective measures during the entire diagnosis and treatment process of traumatic patients and help others to manage orthopedic patients with COVID-19, to reduce the risk of cross-infection between patients and to protect healthcare workers during work.

LEVEL OF EVIDENCE

IV.