Clinical Outcome of Transfemoral Direct Socket Interface (Part 2)

Is the subischial socket better than others in subjects with transfemoral amputation? A systematic review of randomized and controlled clinical trials

Rehabilitation is often complex for persons with transfemoral amputation, and poor socket fit is one of the main factors affecting gait re-education, rehabilitation, and quality of life. The present study systematically reviewed the literature to test whether the subischial socket provides better outcomes in comfort, quality of life, and mobility than other transfemoral sockets. Systematic review and meta-analysis. We searched MEDLINE, Physical Therapy Evidence Database Scale, Epistemonikos, Cochrane, BIREME, Web of Science, and Scopus from inception to January 2024 to identify randomized and controlled trials. Two authors independently screened records and assessed the risk of bias. We performed a narrative synthesis of the evidence and used the standardized mean difference and mean difference for meta-analyses and the Grading of Recommendations, Assessment, Development, and Evaluation approach for recommendations. We identified 7 randomized and controlled clinical trials. Five studies compared the subischial socket with the ischial containment socket (IC), 1 study compared the IC with the Marlo anatomical socket, and 1 study compared the IC with the quadrilateral. Very low certainty showed a difference in comfort (1 study: mean difference = 1.4 [95% CI 0.61, 2.19]), but no in quality of life (2 studies: standardized mean difference = 1.28 (95% CI -1.04, 3.59), and mobility (2 studies: mean difference = 0.11 (95% CI -1.08, 1.29). We observed differences between the subischial socket and the IC in comfort but not in quality of life, mobility, and stability. Furthermore, we found a very low certainty that the subischial socket provides better outcomes than the IC in comfort, quality of life, and mobility.

Innovations in Amputation Rehabilitation and Prosthetic Design

This article reviews emerging surgical techniques and prosthetic innovations related to amputation rehabilitation. Osseointegration is discussed from conception to modern implant designs. Motor and sensory reinnervation techniques are reviewed and compared. Prosthetic socket casting, interface, and design innovations are discussed, including direct molded sockets, water casting, adjustable sockets, and magnetic suspension. Advanced components with hydraulic and microprocessor control, power and crossover prosthetic feet are described.

Detecting Changes in Comfort, Pain, and Mobility Over Clinical Milestones for Individuals With Lower Limb Loss

BACKGROUND

Functional mobility, comfort and the absence of pain are key goals of prosthetic treatment. Outcome measures (OMs) evaluate the impact of treatment and normative and minimal detectable change (MDC) values are key to interpreting these scores and measuring treatment outcomes.

OBJECTIVES

This study seeks to 1) present practice-based normative values of four commonly used OMs at four prosthetic milestones and 2) explore the MDC of the measures over the treatment period.

METHODOLOGY

A chart review was conducted of OMs collected with individuals with lower limb loss between January 1, 2015, and December 31, 2023. This included data for individuals with unilateral transtibial (TT), transfemoral (TF) and rotationplasty (RP) amputations and bilateral transtibial amputation (BTT). OMs included the Socket Comfort Score (SCS), Pain Scale (PS), 2 Minute Walk Test (2MWT), and Prosthetic Limb Users Survey of Mobility (PLUS-M). Data were collected at four milestone time points: (1) Baseline and (2) Discharge from Rehabilitation for those in initial prosthetic rehabilitation, and (3) Initial Evaluation and (4) Definitive Delivery for those receiving a replacement socket. Normative values and MDC values were calculated.

FINDINGS

Data from 30 individuals undergoing in-patient rehabilitation and 74 individuals receiving a replacement socket were included. Practice-based normative data were different for each level of amputation and milestone and had the following ranges: SCS: 5.7 - 9.1, PS: 0.8 - 3.7, 2MWT: 68.4 - 146.3 m and PLUS-M: 38.9 - 57.3. MDC values also varied based on time in treatment (Rehabilitation: SCS = 2.5, PS = 1.6, 2MWT = 32.6, PLUS-M = 8.8; Replacement Socket: SCS = 3.1, PS = 2.6, 2MWT = 38.9, PLUS-M = 4.0). All measures had a statistically significant change over the intervention, however, no average scores changed by greater than the MDC.

CONCLUSIONS

The normative data and MDC scores demonstrate the PS & PLUS-M are useful measures of pain and mobility at all points within treatment. The 2MWT is indicated for individuals in rehabilitation, while the SCS is indicated for those receiving a replacement socket, as both effectively measure treatment goals that are particularly important for each phase of rehabilitation. This provides clinicians with practice-based evidence that enables them to interpret OM scores, a critical part of the decision-making process along the treatment journey.

Moisture mitigation using a vented liner and a vented socket system for individuals with transfemoral amputation

Sweating and heat buildup at the skin-liner interface is a major challenge for persons with limb loss. Liners made of heat-non-conducting materials may cause sweating of the residual limb and may result in liners slipping off the skin surface especially on a warm day or during high activity, causing skin breakdown and affecting limb health. To address this, we evaluated the efficacy of the vented liner-socket system (VS, Össur) compared to Seal-In silicone liner and non-vented socket (nVS, Össur) in reducing relative humidity (RH) during increased sweat. Nine individuals with limb loss using nVS were randomized to VS or nVS and asked for activity in a 20-min treadmill walk. RH was significantly attenuated (p = 0.0002) and perceived sweating, as reported by prosthesis users, improved (p = 0.028) with VS, patient-reported comprehensive lower limb amputee socket survey (CLASS) outcomes to determine the suspension, stability, and comfort were not significantly different between VS and nVS. There are limited rigorous scientific studies that clearly provide evidence-based guidelines to the prosthetist in the selection of liners from numerous available options. The present study is innovative in clearly establishing objective measures for assessing humidity and temperatures at the skin-liner interface while performing activity. As shown by the measured data and perceived sweat scores provided by the subjects based on their daily experience, this study provided clear evidence establishing relative humidity at the skin-liner interface is reduced with the use of a vented liner-socket system when compared to a similar non-vented system.