Prosthetic interventions for people with transtibial amputation: Systematic review and meta-analysis of high-quality prospective literature and systematic reviews

The nonsalvageable tibia: amputation and prosthetics

Mangled extremities are a challenging problem for the orthopaedic surgeon. The decision for salvage versus amputation is multifactorial. Several work groups have attempted to create scoring systems to guide treatment, but each case must be regarded individually. As surgical technique and prosthetics continue to improve, amputations should be seen as a viable reconstructive option, rather than failure. This article reviews scoring systems for the mangled extremity, outcomes on salvage versus amputation, amputation surgical technique, and prosthetic options.

Reconstruction of Soft Tissues of the Postamputation Lower Leg Stump with a Free Anterolateral Thigh Flap for Optimal Prosthesis

Patients without proper covering of the bone stump with soft tissues after below-knee amputation have limited opportunities for prosthesis. The resulting high degree of disability severely restricts their proper functioning in social and professional life. The commonly used significant reduction of the bone length for local coverage limits rehabilitative options to the less comprehensive prosthesis. We aimed to describe a delayed reconstruction with soft tissues of the lower leg stump using free anterolateral thigh flap as an alternative surgical method allowing for optimal prosthesis. A 20-year-old patient was consulted because of right lower leg stump, covered only with a skin graft following posttraumatic amputation. Previously, the patient had ineffective attempts of using a prosthesis. He asked to determine the possibility of recovering the functionality of the lower limb. We performed reconstruction of soft tissues of the stump with a free anterolateral thigh flap. Postoperatively, the patient achieved good coverage of the remaining part of the tibia with a thick layer of soft tissues, allowing the subsequent adequate forming of the stump. Therefore, a fixed prosthesis with the dynamic foot could be implemented. A significant increase in physical activity contributed to a full return to the patient's professional and private life. In conclusion, the free anterolateral thigh flap provides a robust amount of good-quality tissues for supportive function of the lower limb stump. The resulting adaptation of the stump to numerous modern prosthetic devices significantly increases the range of physical activity and contributes to the full return of the patient to their professional and private life.

Outcomes of Patients with Lower Limb Loss after Using a Training Prosthesis: A Retrospective Case Series Study

The aim of this retrospective case series study was to investigate outcomes in patients with lower limb loss based on whether or not they used a training prosthesis (TP) during rehabilitation. The medical records of 171 consecutive patients admitted to rehabilitation hospitalization between January 2014 and December 2018 following a major amputation of the lower limb were reviewed. Patients were categorized into two groups: patients who underwent rehabilitation with a TP and patients who did not use a TP. Outcomes (i.e., discharge destination, length of stay, number of sockets required, and number of the size adaptation of each socket, as well as functional level) were compared between groups. Of the 171 patients, 126 underwent rehabilitation with a TP, and 45 patients underwent rehabilitation without any TP. In conclusion, we found that patients who used a TP had a significantly shorter hospital length of stay when compared to those who did not. This length of stay for patients with TP was not influenced by age but was lowered by a higher body mass index (BMI), tibial instead of femoral amputation, and the male gender. No association was found between the use of TP and discharge destination, functional level, number of socket modifications, and number of sockets required.

Effectiveness of telerehabilitation-based structured exercise program in individuals with unilateral transtibial amputation: a randomized controlled study

PURPOSE

The study aimed to compare the effects of home exercise alone and telerehabilitation combined with home exercise in individuals with transtibial amputation.

MATERIALS AND METHODS

The telerehabilitation group (n = 24) received telerehabilitation combined with home exercise, while the control group (n = 24) received home exercise alone. Outcomes included the timed up-and-go (TUG) test and the 30-second chair-stand test (30CST), the Activities-specific Balance Confidence (ABC) Scale, the Trinity Amputation and Prosthesis Experience Scales (TAPES), the Amputee Body Image Scale (ABIS), and the Nottingham Health Profile (NHP). The analysis used a 2 × 2 mixed repeated measures ANOVA.

RESULTS

The group-by-time interactions were significant for TUG (p = 0.002, F[1;41] = 10.74) and 30CST (p = 0.001, F[1;41] = 11.48). The mean difference (6th week-baseline) was -0.49 for TUG and 0.95 for 30CST in the telerehabilitation group and -0.14 for TUG and 0.13 for 30CST in the control group. There were statistically meaningful group-by-time interactions on the ABC (p = 0.0004, F[1;41] = 14.47), the TAPES-activity restriction (p = 0.0001, F[1;41] = 28.96), TAPES-prosthesis satisfaction (p = 0.004, F[1;41] = 9.19), and the NHP (p = 0.0002, F[1;41] = 16.07) favoring the telerehabilitation group.

CONCLUSIONS

Telerehabilitation combined with home exercise can offer greater benefits in improving gait, muscle strength, balance confidence, activity restriction, prosthesis satisfaction, and quality of life compared to home exercise alone for individuals with transtibial amputation.Implications for rehabilitationExercise helps individuals with lower limb amputation overcome their physical limitations and enables them to use their prostheses effectively.Physiotherapy and rehabilitation after amputation are not at the desired level, and individuals with lower limb amputation encounter various difficulties in accessing physiotherapy.Telerehabilitation has great potential to facilitate access to physiotherapy for individuals with amputation and reduce resource utilization.In a relatively small sample of amputees, this study shows that telerehabilitation-based exercise improves physical health and quality of life.

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.

PROClass: The Development and Validation of a Novel Prosthetic Component Sophistication Classification System

Objective

To develop a lower limb prosthesis (LLP) sophistication classification system that categorizes prosthetic component prescriptions into "basic," "intermediate," and "advanced" and assess its content validity, reliability, and accuracy.

Design

Classification development and validation study.

Setting

The Veterans Affairs (VA) Corporate Data Warehouse database and National Prosthetics Patient Database were used to identify patients undergoing their first amputation at the transtibial or transfemoral level due to diabetes or peripheral artery disease and to identify the associated codes for each LLP.

Participants

An expert panel of 6 nationally recognized certified prosthetists, a national expert in VA prosthetics data and coding, a physical medicine and rehabilitation physician, and an epidemiologist developed an LLP classification system (PROClass) using 30 transfemoral and transtibial lower limb amputees.

Main Outcome Measures

The expert panel reviewed 20 consecutive participants meeting study criteria for the development of the PROClass system and a subsequent 30 consecutive cases for assessing the inter- and intra-rater reliability and accuracy.

Results

The interrater and intrarater reliability was almost perfect with Gwet's AC1 values ranging from .82 to .96 for both expert panel members and research assistants. The accuracy of the research assistant's classifications to the "criterion standard" was excellent with Gwet's AC1 values ranging between .75 and .92.

Conclusions

PROClass is a pragmatic, reliable, and accurate prosthetic classification system with strong face validity that will enable the classification of prosthetic components used for large data set research aimed at evaluating important clinical questions such as the effects of sophistication on patient outcomes.

Characterization of initial ankle-foot prosthesis prescription patterns in U.S. Service members following unilateral transtibial amputation

Introduction

The purpose of this study was to explore relationships between patient-specific characteristics and initial ankle-foot prosthesis prescription patterns among U.S. Service members with unilateral transtibial limb loss.

Methods

A retrospective review of health records identified 174 individuals with unilateral transtibial limb loss who received care at Walter Reed National Military Medical Center between 2001 and 2019. We examined patient-specific factors such as demographics, participant duty status at injury and amputation, amputation etiology, and timing between injury, amputation, and initial prescription. The type of first prescribed ankle-foot prosthesis was categorized as energy storing and return - nonarticulating, energy storing and return - articulating, or computer controlled.

Results

Sex, amputation etiology, time from injury to initial prescription, and time from amputation to initial prescription differed by type of initial ankle-foot prosthesis prescription. Service members with shorter intervals between injury-initial prescription and amputation-initial prescription, and those injured by combat blast, were more likely to receive a non-articulating device. Incorporating sex, time from injury-initial prescription, time from amputation-initial prescription, and amputation etiology as predictors of prosthesis type, we were able to correctly classify 72% of all first prostheses prescribed.

Discussion

Patient-specific characteristics such as sex, the time between injury-initial prescription, time from amputation-initial prescription and amputation etiology are essential characteristics that influence initial ankle-foot prosthesis prescription patterns in U.S. Service members.

Transtibial prosthetic socket fitting: Australian prosthetist perspectives on primary challenges, management strategies, and opportunities for workflow and technological innovation

BACKGROUND

Following transtibial amputation, a custom-built socket is the most common interface between the prosthesis and residual limb. Desire from both prosthetists and prosthesis users for improved socket fitting processes have been well documented. However, there is currently limited information available about prosthetists' experiences of how prosthetic manufacturing workflow can contribute to socket fit problems.

OBJECTIVES

This study aims to determine how socket fit problems are currently detected and managed by prosthetists and to identify challenges, management strategies, and opportunities for workflow and technological innovation during prosthesis manufacture and socket fitting.

STUDY DESIGN

Mixed-method (quantitative and qualitative) survey.

METHODS

An online survey was developed and piloted in consultation with members of the Australian Orthotic Prosthetic Association. The final 25-question survey was distributed through their membership database. Mixed methods were used to analyze survey items. Qualitative items were grouped and coded under themes relating to challenges, management strategies, and opportunities. Quantitative data were analyzed using nonparametric descriptive methods.

RESULTS

Twenty-three respondents with a range of experience completed the survey. Seven of eight major Australian states/territories were represented. Primary workflow stages presenting challenges with limited strategies/solutions available to the prosthetists were roll-on liner selection, mold or cast modifications, communication with the client, and check socket fitting. Suggested solutions included improved socket-limb interface monitoring technology.

CONCLUSIONS

This study provides the first insights into prosthetist-identified challenges and limitations at different stages of the socket workflow and presents a starting point for more targeted research into innovation that may assist in these processes.

Biomechanical accommodation to walking with an ankle-foot prosthesis: An exploratory analysis of novice users with transtibial limb loss within the first year of ambulation

BACKGROUND

The way in which a person with limb loss interacts with a prosthesis changes over time; however, there remains a lack of guidance for defining accommodation to walking with a prosthesis, limiting consistency and generalizability of research.

OBJECTIVE

To evaluate accommodations to walking with dynamic elastic response prosthetic ankle-foot devices among novice users with unilateral transtibial limb loss during the first year of ambulation.

STUDY DESIGN

This is a retrospective cohort study.

METHODS

Prosthetic and intact ankle-foot mechanical power profiles and mechanical work during step-to-step transitions were calculated using the Unified Deformable model for 22 male individuals with limb loss at five time points within the first year of independent ambulation (0, 2, 4, 6, and 12 months). Subjects walked at a self-selected walking velocity and controlled walking velocity (CWV). Subjective measures included the Prosthetic Evaluation Questionnaire and the 36-Item Short-Form Health Survey.

RESULTS

Self-selected walking velocity ranged from 1.24 ± 0.06 m/s at 0 month to 1.38 ± 0.04 m/s at 12 months, whereas CWV was 1.20 ± 0.02 m/s. At both velocities, positive work/peak power during prosthetic push-off trended upward until the 4-month time point. In addition, negative peak power during intact foot-strike seemed to qualitatively become less negative until 4 months. Positive work during intact push-off trended downward until 4 months at CWV, whereas positive peak power during intact push-off qualitatively became more positive at self-selected walking velocity.

CONCLUSIONS

These trends may partially indicate (biomechanical) accommodation to walking by appearance of a "plateau" at 4 months after initial ambulation with a prosthesis.

How does ankle power on the prosthetic side influence loading parameters on the sound side during level walking of persons with transfemoral amputation?

BACKGROUND

Increased ankle power on the prosthetic side seems to decrease biomechanical loading parameters on the sound side. This assumption is based on biomechanical comparisons of different foot constructions. However, such study designs could not show whether the amount of ankle power solely influences the sound side.

OBJECTIVE

To analyze the influence of divergent ankle power, resulting from different foot constructions and from different ankle power settings, on the sound side loading parameters.

STUDY DESIGN

Interventional cross sectional study.

METHODS

Level walking of transfemoral amputees with a microprocessor knee joint and Solid Ankle Cushioned Heel (SACH), energy storing and returning (ESR) and powered foot (PF) was analyzed. The PF was adapted in three configurations: without power (np), low power (lp), and optimal power (op). An optoelectronic camera system with 12 cameras and two force plates were used.

RESULTS

The ankle power on the prosthetic side shows significant differences about foot types and different settings of the PF. The knee adduction moment, the knee flexion moment, and the vertical ground reaction forces on the sound side were significantly reduced with PF_op and ESR in comparison to SACH. When analyzing these parameters for the different PF configurations, only some show significant results at normal velocity.

CONCLUSIONS

The additional positive mechanical work for an active push off in the PF tends to have a relieving effect. The biomechanical sound side loading parameters are reduced with PF_op in comparison to SACH and ESR, resulting in a relief of the sound side of lower limb amputees.

Adjustable-Volume Prosthetic Sockets: Market Overview and Value Propositions

The prosthetic socket is commonly considered to be the most important part of the prosthesis and lack of fit can lead to skin breakdown, reduction in wear, reduction in activity, and consequential deleterious health effects. Furthermore, approximately 90% of amputations are due to a vascular etiology, which affect fluid retention regularity, and even small limb volume fluctuations can lead to lack of fit. Adjustability in the socket volume has been suggested as a potential solution to common fit issues but has lacked market penetration mostly due to lack of reimbursement. Despite this there are several adjustable-volume sockets emerging on the market today including prefabricated, modular, custom with adjustable-volume component, custom with adjustable-volume feature, and adjustable-hybrid sockets. Prefabricated sockets are mass produced in common sizes and fit directly to the patient by a prosthetist using pad kits, BOA dials, or straps. Modular sockets are assembled to a patient or model with panels or struts attached to an adjustable base. Custom sockets with adjustable-volume elements are traditionally-fabricated sockets made to a model of a patient's limb with a volume-adjustable component added or volume-adjustable feature built in. Custom-hybrid sockets are made custom to a model of the patient's limb and incorporate several aspects of the previous socket types and include some radically-unique design aspects which cannot be limited to one category. These adjustable-volume sockets offer several advantages to traditional rigid-volume sockets for the patient, prosthetist, and providing clinic. The micro-adjustability for the patient allows them to alter fit without removing the socket, maintaining a more intimate fit throughout the day than traditional sockets. The macro-adjustability for the prosthetist allows for increased options for fit customization including the ability to reverse or undo changes without necessarily re-making the socket. This allows for the most optimal fit for the patient. Adjustable volume also present efficiencies in the fitting process by simplifying or eliminating steps including residual limb shape capture, form modification, diagnostic fabrication, iterative alteration, and definitive fabrication with the different socket types affecting different steps. Due to these factors, adjustable-volume sockets have disrupted the market to the point where reimbursement reform is needed including additional L-codes in the United States and fee-for-service or fee-for-outcome associated with prosthetic follow-up care. Prosthetic care should also be separated from durable medical equipment to allow for alternative reimbursement models. As reimbursement adapts prosthetists must adapt correspondingly to differentiate their skillset from other allied health providers including incorporating more objective methods to show superior care outcomes. This adaptation should include a continued push for state and municipal licensure of prosthetists.

Effects of prosthetic feet on metabolic energy expenditure in people with transtibial amputation: a systematic review and meta-analysis

OBJECTIVE

To assess the effects of different prosthetic feet on energy costs associated with walking and running in people with transtibial amputation.

LITERATURE SURVEY

The Pubmed, CINAHL, and Web-of-Science bibliographic databases were searched for original research published through June 30, 2018. References from identified articles were also reviewed.

METHODOLOGY

Two reviewers screened titles, abstracts, and articles for pertinent studies. Details were extracted with a standardized template. Risk of bias was assessed using domain-based methods. Prosthetic feet were grouped into categories, and compared according to energy costs associated with walking or running over various terrain conditions. Meta-analyses were conducted when data quantity and homogeneity permitted. Evidence statements were formed when results were consistent or undisputed.

SYNTHESIS

15 studies were included. Participants (n = 144) were predominantly male (88.2%), had unilateral amputation (95.8%) from non-dysvascular causes (87.5%), and were classified as unlimited community ambulators or active adults (56.9%). Participants were often young, but varied in age (mean age 24.8-66.6 years). Available evidence indicates that feet with powered dorsiflexion reduce energy costs relative to dynamic response feet in unlimited community ambulators or active adults when walking on level or declined surfaces. Dynamic response feet do not significantly reduce energy costs compared to energy storing, flexible keel, or solid ankle feet when walking on level terrain. Running feet do not reduce energy costs relative to dynamic response in active adults when running. Select feet may reduce energy costs under specific conditions, but additional research is needed to confirm preliminary results.

CONCLUSIONS

The overall body of evidence is based on small samples, comprised mostly of participants who may not well represent the population of prosthesis users, and test conditions that may not well reflect how prostheses are used in daily life. However, evidence suggests energy costs are affected by prosthetic foot type, but only under select conditions. This article is protected by copyright. All rights reserved.

Innovative alignment of sprinting prostheses for persons with transfemoral amputation: Exploratory study on a gold medal Paralympic athlete

BACKGROUND

Recommendations for the alignment of the socket and foot in the sprinting prosthesis of athletes with transfemoral amputation are either based on walking biomechanics or lack public scientific evidence.

OBJECTIVES

To explore the biomechanical changes and the sensations of a gold medal Paralympic sprinter, while running with three bench alignments: a conventional reference (A0), an innovative alignment based on the biomechanics of elite able-bodied sprinters (A2), and an intermediate alignment (A1).

STUDY DESIGN

Single subject with repeated measures.

METHODS

A1 and A2 feature a progressively greater socket tilt and a plantar-flexed foot compared to A0. The 30-year-old female athlete trained with three prostheses, one per alignment, for at least 2 months. We administered a questionnaire to collect her impressions. Then, she ran on a treadmill at full speed (5.5 m/s). We measured the kinematics and moments of the prosthetic side, and the ground reaction forces of both sides.

RESULTS

A2 reduced the prosthetic side hip extension at foot-off while preserving hip range of motion, decreased the impulse of the hip moment, and increased the horizontal propulsion, leaving sufficient margin to prevent knee buckling without increasing sound side braking forces. Biomechanical outcomes matched well with subjective impressions.

CONCLUSIONS

A2 appears promising to improve the performance and comfort of sprinters with transfemoral amputation, without compromising safety.

CLINICAL RELEVANCE

Observation of elite able-bodied sprinters led to the definition of a new specific alignment for the sprinting prosthesis of athletes with transfemoral amputation, which appears promising to improve performance and comfort, without compromising safety. This may constitute a major improvement compared to alignments based on walking biomechanics.

Lower limb prosthetic interfaces: Clinical and technological advancement and potential future direction

The human-prosthesis interface is one of the most complicated challenges facing the field of prosthetics, despite substantive investments in research and development by researchers and clinicians around the world. The journal of the International Society for Prosthetics and Orthotics, Prosthetics and Orthotics International, has contributed substantively to the growing body of knowledge on this topic. In celebrating the 50th anniversary of the International Society for Prosthetics and Orthotics, this narrative review aims to explore how human-prosthesis interfaces have changed over the last five decades; how research has contributed to an understanding of interface mechanics; how clinical practice has been informed as a result; and what might be potential future directions. Studies reporting on comparison, design, manufacturing and evaluation of lower limb prosthetic sockets, and osseointegration were considered. This review demonstrates that, over the last 50 years, clinical research has improved our understanding of socket designs and their effects; however, high-quality research is still needed. In particular, there have been advances in the development of volume and thermal control mechanisms with a few designs having the potential for clinical application. Similarly, advances in sensing technology, soft tissue quantification techniques, computing technology, and additive manufacturing are moving towards enabling automated, data-driven manufacturing of sockets. In people who are unable to use a prosthetic socket, osseointegration provides a functional solution not available 50 years ago. Furthermore, osseointegration has the potential to facilitate neuromuscular integration. Despite these advances, further improvement in mechanical features of implants, and infection control and prevention are needed.

Advanced techniques in amputation surgery and prosthetic technology in the lower extremity

Bone-anchored implants give patients with unmanageable stump problems hope for drastic improvements in function and quality of life and are therefore increasingly considered a viable solution for lower-limb amputees and their orthopaedic surgeons, despite high infection rates.Regarding diversity and increasing numbers of implants worldwide, efforts are to be supported to arrange an international bone-anchored implant register to transparently overview pros and cons.Due to few, but high-quality, articles about the beneficial effects of targeted muscle innervation (TMR) and regenerative peripheral nerve interface (RPNI), these surgical techniques ought to be directly transferred into clinical protocols, observations and routines.Bionics of the lower extremity is an emerging cutting-edge technology. The main goal lies in the reduction of recognition and classification errors in changes of ambulant modes. Agonist-antagonist myoneuronal interfaces may be a most promising start in controlling of actively powered ankle joints.As advanced amputation surgical techniques are becoming part of clinical routine, the development of financing strategies besides medical strategies ought to be boosted, leading to cutting-edge technology at an affordable price.Microprocessor-controlled components are broadly available, and amputees do see benefits. Devices from different manufacturers differ in gait kinematics with huge inter-individual varieties between amputees that cannot be explained by age. Active microprocessor-controlled knees/ankles (A-MPK/As) might succeed in uneven ground-walking. Patients ought to be supported to receive appropriate prosthetic components to reach their everyday goals in a desirable way.Increased funding of research in the field of prosthetic technology could enhance more high-quality research in order to generate a high level of evidence and to identify individuals who can profit most from microprocessor-controlled prosthetic components. Cite this article: EFORT Open Rev 2020;5:724-741. DOI: 10.1302/2058-5241.5.190070.

Factors Associated With Prolonged Length of Stay and Failed Lower Limb Prosthetic Fitting During Inpatient Rehabilitation

Objective

To identify variables associated with rehabilitation length of stay (LOS) and prosthetic fitting success for people with lower limb amputation (LLA).

Design

Retrospective analysis of clinically collected cohort.

Setting

Canadian inpatient rehabilitation hospital.

Participants

Consecutive individuals with LLA (N=103) admitted for prosthetic fitting (mean age, 65.3±10.6y).

Interventions

Not applicable.

Main Outcome Measures

Independent variables included the Lower Limb Amputee Measurement Scale (LLAMS), which is a 31-question tool to predict LOS with items in medical, cognitive, social, physical, activities of daily living, and other subsections; admission FIM; age; sex; level of amputation (below- or above-knee); and time from surgery to admission. LOS was measured as days from admission to discharge. Successful prosthetic fitting was defined as the ability to use a prosthesis on discharge.

Results

The mean LOS was 63.6 ± 33.3 days, and 21.4% of patients failed prosthetic fitting. Higher LLAMS, lower FIM, and above-knee amputation were significantly associated with longer LOS (P<.001, R²=0.36). Age, sex, and time from surgery were not significantly associated with LOS or prosthetic fitting. Higher LLAMS was significantly associated with unsuccessful prosthetic fitting (P=.032). Of the 31 items in the LLAMS, 5 were associated with prolonged LOS and 5 were associated with failed prosthetic fitting (P<.10).

Conclusions

The LLAMS, level of amputation, and admission FIM can be used to predict LOS in lower limb amputees admitted for prosthetic fitting. The LLAMS was weak in identifying patients who failed prosthetic fitting. Future research should consider shortening the LLAMS.

Silicone soft socket system for the treatment of geriatric transtibial amputees

Background

Outfitting geriatric amputees with a suitable prosthesis is a demanding task. The aim of this study was to determine the effect of prostheses outfitted with a silicone suspension interface system on a large group of transtibial amputees regarding walking distance, satisfaction of use and duration of daily use.

Methods

The study included 75 mostly geriatric transtibial amputees fitted with a rigid total contact socket with a silicone interface system called an Icelandic roll-on silicone socket (ICEROSS, Ossur, Reykjavik, Iceland). At follow-up 54 patients remained for assessment. Ambulatory performance was measured by first categorizing the patients into four subgroups regarding their walking capacity: 0–50 m, 50–100 m, 100–500 m and >500 m. The alteration in patient mobility was measured at admission, discharge and follow-up. Satisfaction and duration of daily use as well as use of walking aids were collated with a standard questionnaire.

Results

Between admission and discharge, patients showed significant improvement (p = <0.001) in walking distances. The walking distance diminished again between time of discharge and follow-up (p = <0.001). The parameters satisfaction with device and duration of daily use showed no significant differences and the same applied to male and female subjects.

Conclusions

Geriatric transtibial amputees fitted with prostheses attached via a silicone suction socket system showed significant improvements in walking distances and a high rate of satisfaction with the device. There were no statistically significant gender-specific differences among users of the ICEROSS system.

Clinical Practice Guidelines for the Rehabilitation of Lower Limb Amputation: An Update from the Department of Veterans Affairs and Department of Defense

Between 2015 and 2017, the US Department of Veterans Affairs and the US Department of Defense developed a clinical practice guideline for rehabilitation of lower limb amputation to address key clinical questions. A multidisciplinary workgroup of US Department of Veterans Affairs and US Department of Defense amputation care subject matter experts was formed, and an extensive literature search was performed which identified 3685 citations published from January 2007 to July 2016. Articles were excluded based on established review criteria resulting in 74 studies being considered as evidence addressing one or more of the identified key issues. The identified literature was evaluated and graded using the National Academies of Science GRADE criteria. Recommendations were formulated after extensive review. Eighteen recommendations were confirmed with four having strong evidence and workgroup confidence in the recommendation. Key recommendations address patient and caregiver education, consideration for the use of rigid and semirigid dressings, consideration for the use of microprocessor knees, and managed lifetime care that includes annual transdisciplinary assessments. In conclusion, this clinical practice guideline used the best available evidence from the past 10 yrs to provide key management recommendations to enhance the quality and consistency of rehabilitation care for persons with lower limb amputation.

Reported physical activity and quality of life in people with lower limb amputation using two types of prosthetic suspension systems

BACKGROUND

Vacuum-assisted suspension systems provide better suspension than non-vacuum systems, but data are limited on whether they improve physical activity levels and quality of life for people with amputation.

OBJECTIVES

To compare the physical activity and quality of life levels of people with transtibial amputation using PIN/LOCK suspension system or vacuum-assisted suspension systems with those of able-bodied controls and to investigate parameters associated with physical activity levels.

STUDY DESIGN

A cross-sectional observational study.

METHODS

Fifty-one people with amputation and 51 controls participated. The International Physical Activity Questionnaire Short Form and Short Form 36 were used to measure the physical activity and quality of life, respectively.

RESULTS

The total physical activity and Short Form 36 scores were significantly lower in the participants with amputation than the controls. There were no significant differences between the two types of suspension systems in terms of physical activity levels and quality of life. The vacuum-assisted suspension system users reported significantly more bodily pain on the Short Form 36 questionnaire than the controls (p = 0.003). The only parameter that correlated significantly with the total physical activity was the Short Form 36 physical functioning subscale (r = 0.302, p = 0.031).

CONCLUSION

Contrary to our expectations, vacuum-assisted suspension system users compared to PIN/LOCK users did not report greater levels of physical activity or improved quality of life or levels closer to comparable controls.

CLINICAL RELEVANCE

A better understanding of the effects of different prosthetic suspension systems on physical activity and quality of life may help clinicians when prescribing prostheses, as well as setting appropriate prosthetic expectations. This study suggests that vacuum-assisted suspension systems and PIN/LOCK suspension systems provide equal benefit to users with regards to physical activity and quality of life.

Low back pain in persons with lower extremity amputation: a systematic review of the literature

BACKGROUND CONTEXT

Lower extremity amputation (LEA) is associated with an elevated risk for development and progression of secondary health conditions. Low back pain (LBP) is one such condition adversely affecting function, independence, and quality of life.

PURPOSE

The purpose of this study was to systematically review the literature to determine the strength of evidence relating the presence and severity of LBP secondary to LEA, thereby supporting the formulation of empirical evidence statements (EESs) to guide practice and future research.

STUDY DESIGN/SETTING

Systematic review of the literature.

METHODS

A systematic review of five databases was conducted followed by evaluation of evidence and synthesis of EESs.

RESULTS

Seventeen manuscripts were included. From these, eight EESs were synthesized within the following categories: epidemiology, amputation level, function, disability, leg length, posture, spinal kinematics, and osseointegrated prostheses. Only the EES on epidemiology was supported by evidence at the moderate confidence level given support by eight moderate quality studies. The four EESs for amputation level, leg length, posture, and spinal kinematics were supported by evidence at the low confidence level given that each of these statements had some evidence not supporting the statement but ultimately more evidence (and of higher quality) currently supporting the statement. The remaining three EESs that addressed function, disability and osseointegrated prosthetic use were all supported by single studies or had comparable evidence that disagreed with study findings rendering insufficient evidence to support the respective EES.

CONCLUSIONS

Based on the state of the current evidence, appropriate preventative and, particularly, treatment strategies to manage LBP in persons with LEA remain a knowledge gap and an area of future study.

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

INTRODUCTION

This guideline was developed to present current evidence and to provide associated clinical recommendations on prosthetic foot selection for individuals with lower-limb amputation.

MATERIALS

NA.

METHODS

The guideline is based upon the best available evidence as it relates prosthetic foot selection during the provision of definitive lower-limb prostheses. Where possible, recommendations are drawn from Cochrane Review, meta-analysis, systematic and narrative literature reviews, and published evidence-based guidelines. Where this standard is unavailable, alternate academic literature has been used to support individual recommendations.

RESULTS

Recommendation 1: For patients ambulating at a single speed who require greater stability during weight acceptance because of weak knee extensors or poor balance, a single-axis foot should be considered. Recommendation 2: Patients at elevated risks for overuse injury (i.e., osteoarthritis) to the sound-side lower limb and lower back are indicated for an energy-storage-and-return (ESAR) foot to reduce the magnitude of the cyclical vertical impacts experienced during weight acceptance. Recommendation 3: Neither patient age nor amputation etiology should be viewed as primary considerations in prosthetic foot type. Recommendation 4: Patients capable of variable speed and/or community ambulation are indicated for ESAR feet.

CONCLUSIONS

These clinical practice guidelines summarize the available evidence related to prosthetic foot selection for individuals with lower limb amputation. The noted clinical practice guidelines are meant to serve only as "guides." They may not apply to all patients and clinical situations.

The role of exercise testing in predicting successful ambulation with a lower extremity prosthesis: a systematic literature review and clinical practice guideline

BACKGROUND

Growing discontent with the k-level system for functional classification of patients with limb loss and movement of healthcare toward evidence-based practice has resulted in the need for alternative forms of functional classification and development of clinical practice guidelines to improve access to quality prosthetic interventions. The purpose of this project was to develop and present a clinical practice recommendation for exercise testing in prosthetic patient care based on the results and synthesis of a systematic literature review.

METHODS

Database searches of PubMed, Google Scholar, Web of Science, and Cochrane were conducted and articles reviewed. Of the potential 1386 articles 10 met the criteria for inclusion. These articles were assessed using the critical appraisal tool of the United Kingdom National Service Framework for Long-Term Conditions. Of the 10 included articles eight were of high, one of medium, and one of low, quality. Data from these articles were synthesized into 6 empirical evidence statements, all qualifying for research grade A. These statements were used to develop the proposed clinical practice guideline.

RESULTS

While the results of this systematic review were not able to support the direct connection between cardiorespiratory performance and K-levels, the literature did support the ability of exercise testing results to predict successful prosthetic ambulation in some demographics. Both continuous maximum-intensity single lower extremity ergometer propelled by a sound limb and intermittent submaximal upper extremity ergometer protocols were found to be viable evaluation tools of cardiorespiratory fitness and function in the target population.

CONCLUSION

The ability to sustain an exercise intensity of ≥50% of a predicted VO2max value in single leg cycle ergometry testing and achievement of a sustained workload of 30 W in upper extremity ergometry testing were found to be the strongest correlates to successful ambulation with a prosthesis. VO2 values were found to increase in amputee subjects following a 6-week exercise program. These synthesized results of the systematic literature review regarding exercise testing in patients with loss of a lower extremity were used to develop and a present a clinical treatment pathway.

A systematic review of shock-attenuating componentry for lower limb amputees

BACKGROUND

Shock-attenuating pylons are commonly fitted to prostheses in order to compensate for the anatomical and biomechanical shock-absorbing features of the lower limb removed upon amputation. However, studies concerning their shock-attenuating capacity are highly variable and, to date, have not yet been reviewed, making them difficult to interpret and apply in clinical practice.

OBJECTIVES

To synthesise and appraise the available literature examining the effectiveness of shock-attenuating pylons in attenuating shock upon limb loading compared to rigid pylons among lower limb amputees.

STUDY DESIGN

Systematic review.

METHODS

A comprehensive search of seven databases was conducted using search terms concerning amputation level, shock-attenuating and rigid pylons as well as measures of shock attenuation. All studies yielded were screened against established inclusion and exclusion criteria before eligible articles were appraised using the Quality Assessment Standard for Crossover Studies adapted from the Cochrane handbook.

RESULTS

Nine articles were eligible for inclusion. While there was a trend among studies to indicate only a limited positive effect of shock-attenuating pylons in attenuating transient impact forces, limitations to the study designs, namely, in sampling, poor reporting of methodological details and heterogeneity of outcomes made conclusive interpretation of results difficult.

CONCLUSION

While the current body of literature does not reconcile with claims made by manufacturers of shock-attenuating pylons, it is insufficient to conclusively determine how effective shock-attenuating pylons are, in comparison with conventional rigid pylons, in attenuating transient impact forces among lower limb amputees. Higher quality research is required to better guide decisions regarding prescription of shock-attenuating componentry in clinical practice. Clinical relevance When delivered well, research can provide clinicians with objective and reliable data that can be applied in their practice to guide prescription of componentry. However, methodological limitations to research may compromise the reliability of findings, thereby producing potentially misleading outcomes. These limitations must be recognised and appreciated such that findings may be interpreted accurately and applied appropriately.

Effects of Test Socket on Pain, Prosthesis Satisfaction, and Functionality in Patients with Transfemoral and Transtibial Amputations

BACKGROUND The aim of this retrospective study was to investigate the frequency of admissions, reason for admissions, and test socket satisfaction in patients who received a lower-limb prosthesis with or without a test socket in our unit. MATERIAL AND METHODS A total of 88 patients (54 men, 34 women) were included in the study. Patients were divided into 2 groups: the group with test socket (Group I, 44 patients) and the group without test socket (Group II, 44 patients). Variables related to the functional status, frequency of complaints, and test socket satisfaction were investigated in the 2 groups. The Trinity Amputation and Prosthesis Experience Scales (TAPES) and Beck Depression Inventory (BDI) were used to assess the level of patient satisfaction with their prosthesis. The VAS (Visual Analogue Scale) was used to assess pain at rest and during walking. RESULTS We found that the TAPES values were more significant in Group 1 in both transtibial and transfemoral amputations (P<0.05). However, prosthesis delivery time was more significant in Group 2 in both transtibial and transfemoral amputations (P<0.001) whereas the frequency of admissions within 3 months was more significant in Group 1 in both transtibial and transfemoral amputations (P<0.001). There was no statistically significant difference between the 2 groups in terms of other parameters (P>0.05). CONCLUSIONS Although the use of a test socket increases the cost of prosthesis units, we showed that patients with transtibial and transfemoral amputations have fewer complaints related to prosthesis increases patient functionality, and that it reduces pain and increases patient satisfaction with the prosthesis.

Comparison between three types of prosthetic feet: a randomized double-blind single-subject multiple-rater trial

There are many prosthetic feet (Pfeet) on the market, and those in the same category do not necessarily have the same properties. We assessed three different Pfeet in terms of gait patterns on various terrains, balance and walking speed in a randomized double-blind controlled single-subject multiple-rater clinical trial. The patient was a 43-year old man who was an active prosthesis user and was amputated at transtibial level because of injury 17 years ago. One Solid Ankle Cushion Heel and two Dynamic Elastic Response (DER) Pfeet were tried six times in random order. The patient walked on flat, uneven, sloped terrain and stairs. Gait pattern was rated in comparison with the patient's previous prosthetic foot (Pfoot) by a physiatrist, physiotherapist, prosthetist and the patient; one-leg standing test on the prosthesis and 10-m walking test were also performed. The ratings differed significantly between the raters on each terrain, and there was no agreement among the raters regarding the ranking order of the Pfeet. All the Pfeet were generally rated as worse than the patient's previous one. The patient gave lower ratings on average than the professionals and recognized the order of the tested Pfeet. The results of one-leg standing test with one DER and the Solid Ankle Cushion Heel Pfoot were statistically significant better than with the other DER and the patient's previous Pfoot. Our study therefore indicates that rehabilitation professionals, when blinded, cannot always reliably observe differences in walking on different terrains with different Pfeet. The patient may feel the differences, but those may not match what the manufacturers declare.

Clinically Relevant Outcome Measures Following Limb Osseointegration; Systematic Review of the Literature

OBJECTIVES

The current standard of care for an amputee is a socket-based prostheses. An osseointegrated implant (OI) is an alternative for prosthetic attachment. Osseointegration addresses reported problems related to wearing a socket interface, such as skin issues, discomfort, diminished function, quality of life, prosthetic use, and abandonment. The purpose of this report is to systematically review current literature regarding OI to identify and categorize the reported clinically relevant outcome measures, rate the quality of available evidence, and synthesize the findings.

DATA SOURCES

A multidisciplinary team used PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methods. Search methodology was based on identifying clinically relevant articles. Three databases were searched: PubMed, CINAHL, and Web of Science.

STUDY SELECTION

Clinical studies with aggregated data reporting at least 1 clinically relevant outcome measure were included.

DATA EXTRACTION

The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criterion was used for critical appraisal and recommendations.

CONCLUSIONS

This review identified 21 clinically relevant observational studies. Outcome measures were categorized into the following 9 categories: vibratory stimulation, complications, biomechanics, economics, patient-reported outcome measures, electromyography, x-ray, physical functional performance, and energy consumption. This systematic review consisted of Level III and IV observational studies. Homogeneous outcome measures with strong psychometric properties across prospective studies do not exist to date. Higher-level, prospective, randomized, long-term, clinically relevant trials are needed to prove efficacy of OI compared with socket prosthetic attachment. Osseointegration was at least equivalent to sockets in most studies. In some cases, it was superior. Osseointegration represents a promising alternative to socket prosthetic attachments for extremity amputees.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Sphygmomanometer test to evaluate muscle strength in individuals with lower limb amputation: validity and reliability

Abstract Introduction: The sphygmomanometer test is an alternative and inexpensive method for assessment of muscle strength. This instrument was considered valid and reliable to measure the isometric strength in different health conditions, however, in individuals with limb amputations the properties of this instrument for this purpose, have not been investigated. Objective: To investigate the concurrent criterion validity, test-retest and inter-rater reliabilities of the aneroid sphygmomanometer test (AST) without modification, for assessment of the strength of subjects with lower limb amputations. Methods: Twenty-two subjects (57.6 ± 15.2 years) with lower limb amputations were included in this study. Maximum isometric force was assessed with a handheld dynamometer (microFet2®) and the AST. To identify differences between trials, one-way ANOVA was applied. To assess the concurrent criterion validity, test-retest and inter-rater reliabilities of the AST, Pearson’s correlation coefficients of determination and intra-class correlation coefficient (ICC) were calculated. Results: For all muscle groups, no differences were observed between the trials (0.00001 ≤ F ≤ 0.10; 0.90 ≤ p ≤ 0.99). Significant, positive, and high to very high correlations were found between the HHD and the AST measures for the different numbers of trials for all assessed muscles (0.76 ≤ r ≤ 0.93; p ≤ 0.02). Test-retest (0.67 ≤ ICC ≤ 0.97) and inter-rater reliabilities (0.78 ≤ ICC ≤ 0.97) were adequate. The values obtained with the AST were good predictors of those obtained with HHD (0.58 ≤ r2 ≤ 0.85). Conclusion: For individuals with lower limb amputation, the AST showed adequate concurrent criterion validity, test-retest reliability and inter-rater reliability for the assessment of lower limbs muscle strength.

Comprehensive Rehabilitation Following Combat Extremity Trauma: Evolution and Its Impact on Outcomes

Recent military combat operations have resulted in a high burden of extremity-related long-term disability due to limb amputation and persistent deficits despite limb reconstruction. The US Army amputee care programs, established at focused centers with interdisciplinary care teams, have redefined the standard of how rehabilitation following limb loss is undertaken as the limb reconstruction is just one part of the entire patient's restoration of wellness and reintegration. Inspired by this approached, comprehensive rehabilitation programs designed for patients with limb reconstruction have also excelled rehabilitation following a spectrum of severe limb trauma. These programs, which include advances in orthotics and orthosis training, have improved function and military retention among the limb salvage patient population. Lessons learned from comprehensive rehabilitation efforts emphasize the value of highly skilled, interprofessional care teams and the overall wellness of the patients. Although this approach is resource intensive and not available in all health care systems, civilian trauma counterparts can learn from the example of holistic attention to the patient's recovery.

COMPARATIVE EFFECTIVENESS OF AN ADJUSTABLE TRANSFEMORAL PROSTHETIC INTERFACE ACCOMMODATING VOLUME FLUCTUATION: CASE STUDY

The socket-limb interface is vital for functionality and provides stability and mobility for the amputee. Volume fluctuation can lead to compromised fit and function. Current socket technology does not accommodate for volume fluctuation. An adjustable interface may improve function and comfort by filling this technology gap. The purpose of this study was to compare the effectiveness of the standard of care (SOC) ischial ramus containment to an adjustable transfemoral prosthetic interface socket in the accommodation of volume fluctuation. A prospective experimental case study using repeated measures of subjective and performance outcome measures between socket conditions was employed. In the baseline volume condition, the adjustable socket improved subjective and performance measures 19% to 37% over SOC, whereas the two-minute walk test demonstrated equivalence. In the volume loss condition, the adjustable socket improved all subjective and performance measures 22% to 93%. All aggregated data improved 16% to 50% compared with the SOC. In simulated volume gain, the SOC socket failed, while the subject was able to complete the protocol using the adjustable socket. In this case study, the SOC socket was inferior to the comparative adjustable transfemoral amputation interface in subjective and performance outcomes. There is a lack of clinical trials and evidence comparing socket functional outcomes related to volume fluctuation.

THE EFFECT OF TRANSFEMORAL INTERFACE DESIGN ON GAIT SPEED AND RISK OF FALLS

Falls and diminished walking capacity are impairments common in persons with transfemoral amputation (TFA). Reducing falls and optimizing walking capacity through such means as achieving a more normal gait speed and community ambulation should be considered when formulating the prosthetic prescription. Because walking capacity and balance confidence are compromised with TFA, these outcomes should be considered when evaluating interfaces for transfemoral prosthetic users. The purpose of this study was to compare the effect of TFA interface design on walking capacity and balance confidence A retrospective cohort design was utilized involving unilateral TFA patients who used ischial ramus containment (IRC) and High-Fidelity (HiFi) interfaces (independent variables). Dependent variables included the Activity-specific Balance Scale (ABC) and the two-minute walk test (2MWT). Complete records were available for 13 patients (n = 13). The age range was 26 to 58 years. Three patients functioned at the K4 activity level, whereas all others functioned at the K3 level. Mean ABC scores were significantly different (p ≤ 0.05) at 77.2 (±16.8; 35.6 to 96.9) for IRC and 90.7 (±5.7; 77.5 to 98.7) for HiFi. The mean distance walked on the 2MWT was 91.8 m (±22.0, 58.3 to 124.7) for IRC compared to 110.4 m (±28.7; 64.7 to 171.1) for the HiFi socket (p ≤ 0.05). Alternative transfemoral interface design, such as the HiFi socket, can improve walking capacity and balance confidence in higher-functioning TFA patients.

ECONOMIC EVALUATIONS OF INTERVENTIONS FOR TRANSTIBIAL AMPUTEES: A SCOPING REVIEW OF COMPARATIVE STUDIES

Transtibial amputation (TTA) is life-altering emotionally, functionally, and economically. The economic impact to all stakeholders is largely unknown, as is the cost-effectiveness of prosthetic intervention. This scoping report's purpose was to determine if there is sufficient evidence to conduct a formal systematic review or meta-analysis in any particular prosthetic intervention area and to determine if any evidence statements could be synthesized relative to economic evaluation of interventions provided to patients with TTA. The scoping review revealed six articles representing three topical areas of transtibial care: Care Models, Prosthetic Treatment, and Prosthetic Sockets. All six articles were cost-identification or cost-consequence design and included a total of 704 subjects. Presently, it can be concluded with moderate confidence that specific weight-bearing and total-contact sockets for transtibial amputees are functionally and economically equivalent in the short term when costs, delivery time, and all stakeholder perspectives are considered. Long-term socket outcomes are relatively unexplored. Further primary research is needed beyond this to determine cost-effectiveness for other areas of transtibial prosthetic care although clinical outcomes are somewhat established through systematic review and meta-analysis in other areas of care. Conversely, evaluation of narrative economic reports relative to transtibial care may be sufficient to warrant further analysis. Guidance from the profession may also be useful in devising a strategy for how to assure economic analyses are a routine element of future prosthetic science.