Functional and Clinical Outcomes of Upper Extremity Amputation

Investigation of the effectiveness of prehospital amputation devices on cadavers

Amputations take place in the operating rooms. At dangerous sites, circumstances may necessitate on-site amputation to save lives. Currently, there are no evidence-based guidelines for the execution of the amputation or the instruments to be chosen. Furthermore, there are no widely accepted criteria for the standardized characterization of amputation devices. The present study examined the effectiveness of commercially available cutting tools and instruments used by rescue services as possible on-site amputation tools. Five different tools (Holmatro type hydraulic cutter, with two cutting attachments, reciprocating saw, hacksaw, Gigli saw) were used to carry out amputations on designated locations on cadavers (brachial, antebrachial, femoral, and crural regions). During the experiment, the time required for amputation and the number of necessary cutting attempts to detach limbs were recorded. The proximal cut surfaces were analyzed with the help of post-amputation CT scan-based 3D models. An Amputation Index (AI) was determined for each device in each examined region based on the cut surface quality. An Amputation Score (AS) was calculated using the time required for cutting, the number of cutting attempts, and the AI. With the help of AS, the usability of the used devices was determined. According to our scoring system, the reciprocating saw proved the most effective tool. Based on our results, we recommend the consideration and further investigation of the reciprocating saw as a possible on-site amputation device, as well as the introduction of the Amputation Score as an objective and quantitative indicator in the future characterization of on-site amputation devices.

Long-term functional and clinical outcome of combined targeted muscle reinnervation and osseointegration for functional bionic reconstruction in transhumeral amputees: a case series

OBJECTIVE

To describe and evaluate the combination of osseointegration and nerve transfers in 3 transhumeral amputees.

DESIGN

Case series.

PATIENTS

Three male patients with a unilateral traumatic transhumeral amputation.

METHODS

Patients received a combination of osseointegration and targeted muscle reinnervation surgery. Rehabilitation included graded weight training, range of motion exercises, biofeedback, table-top prosthesis training, and controlling the actual device. The impairment in daily life, health-related quality of life, and pain before and after the intervention was evaluated in these patients. Their shoulder range of motion, prosthesis embodiment, and function were documented at a 2- to 5-year follow-up.

RESULTS

All 3 patients attended rehabilitation and used their myoelectric prosthesis on a daily basis. Two patients had full shoulder range of motion with the prosthesis, while the other patient had 55° of abduction and 45° of anteversion. They became more independent in their daily life activities after the intervention and incorporated their prosthesis into their body scheme to a high extent.

CONCLUSION

These results indicate that patients can benefit from the combined procedure. However, the patients' perspective, risks of the surgical procedures, and the relatively long rehabilitation procedure need to be incorporated in the decision-making.

Systematic Review and Meta-Analysis of Global Neuroma Incidence in Upper Extremity Amputees

BACKGROUND

Neuromas substantially decrease a patient's quality of life and obstruct the use of prosthetics. This systematic review and meta-analysis aimed to determine the global incidence of neuroma formation in upper extremity amputees.

METHODS

A literature search was performed using 3 databases: Web of Science, MEDLINE, and Cochrane. Inclusion criteria for the systematic review were those studies investigating only upper extremity amputees and reported postamputation neuroma. A random-effects, inverse-variance analysis was conducted to determine the pooled proportion of neuromas within the upper extremity amputation population. Critical appraisal using the JBI Checklist for Studies Reporting Prevalence Data of each individual article were performed for the systematic review.

RESULTS

Eleven studies met the inclusion criteria collating a total of 1931 patients across 8 countries. More than three-fourth of patients are young men (77%; age range, 19-54 years) and had an amputation due to trauma. The random-effects analysis found the pooled combined proportion of neuromas to be 13% (95% confidence interval, 8%-18%). The treatment of neuroma is highly variable, with some patients receiving no treatment.

CONCLUSIONS

The pooled proportion of neuroma incidence in the 1931 patients was 13%. With the known global prevalence of upper extremity amputees, this translates to nearly 3 million amputees suffering from a neuroma globally. Increasing training in preventative surgical methods could contribute to lowering this incidence and improving the outcomes of this patient population.

The LIBRA NeuroLimb: Hybrid Real-Time Control and Mechatronic Design for Affordable Prosthetics in Developing Regions

Globally, 2.5% of upper limb amputations are transhumeral, and both mechanical and electronic prosthetics are being developed for individuals with this condition. Mechanics often require compensatory movements that can lead to awkward gestures. Electronic types are mainly controlled by superficial electromyography (sEMG). However, in proximal amputations, the residual limb is utilized less frequently in daily activities. Muscle shortening increases with time and results in weakened sEMG readings. Therefore, sEMG-controlled models exhibit a low success rate in executing gestures. The LIBRA NeuroLimb prosthesis is introduced to address this problem. It features three active and four passive degrees of freedom (DOF), offers up to 8 h of operation, and employs a hybrid control system that combines sEMG and electroencephalography (EEG) signal classification. The sEMG and EEG classification models achieve up to 99% and 76% accuracy, respectively, enabling precise real-time control. The prosthesis can perform a grip within as little as 0.3 s, exerting up to 21.26 N of pinch force. Training and validation sessions were conducted with two volunteers. Assessed with the "AM-ULA" test, scores of 222 and 144 demonstrated the prosthesis's potential to improve the user's ability to perform daily activities. Future work will prioritize enhancing the mechanical strength, increasing active DOF, and refining real-world usability.

Use of his prostheses by a double upper limb amputee 6 years after amputation: From aesthetic to functional considerations, a case report

BACKGROUND

Few studies have been published on the prosthetic management of bilateral upper limb amputees. Of particular interest is to study how a patient's use of his upper limb protheses had evolved over a 6-year period in the aim to decrease their rejection rate.

CASE DESCRIPTION AND METHODS

Mr. D had undergone a bilateral upper limb amputation and had been fitted with 7 different prostheses in the past 6 years. Multiple validate instruments and analyses were then used to monitor the patient's fitting and choices.

FINDINGS AND OUTCOMES

Initially, the left prosthesis was regarded as the dominant hand and the right one as the assistive power grip hand. However, the observational results showed that wearing only a left Greifer enabled the prosthetic user to perform the same tasks as with 2 prostheses. He has gained greater satisfaction and quality of life without losing his independence.

CONCLUSION

The patient seemed to make a functional choice over his worrying about his physical appearance in favor of the efficiency of his prosthesis, which was essential for his everyday life, when he decided to wear only nonanthropomorphic prosthesis.

Targeted muscle reinnervation in upper extremity amputation in military hand surgery: A systematic review

INTRODUCTION

Targeted Muscle Reinnervation (TMR) is a surgical technique utilized to alleviate post-amputation neuroma pain, reduce reliance on narcotic pain medication, and enhance control of prosthetic devices. Motor targets for upper extremity TMR vary depending on injury patterns and amputation levels, with conventional transfer patterns serving as general guides. This study aims to summarize the common patterns of TMR in transradial and transhumeral amputations, focusing on anatomic and surgical considerations.

METHODS

A comprehensive systematic review of TMR literature was conducted by two independent physician reviewers (M.H.A. and D.M.G.R.) to identify the prevailing motor targets, while considering injury patterns and amputation levels.

INCLUSION CRITERIA

1) TMR techniques, outcomes, or advancements; 2) Original research, systematic reviews, meta-analyses, or clinical trials; 3) Peer-reviewed journal articles or reputable conference proceedings.

EXCLUSION CRITERIA

non-English resources, editorials, opinion pieces, and case reports. The databases utilized include MEDLINE (PubMed), EMBASE (Scopus) and Cochrane CENTRAL, last searched 01APR2023.

RESULTS

The reviewed literature revealed multiple motor targets described for upper extremity TMR out of our included 51 studies. However, the selection of motor targets is influenced by the availability of viable options based on injury patterns and amputation levels. Conventional transfer patterns provide useful guidance for determining appropriate motor targets in transradial and transhumeral amputations.

DISCUSSION

TMR has played a significant role in military medicine, particularly in addressing the impact of blast-related injuries. The energy associated with such injuries often results in substantial soft tissue defects, higher amputation levels, and increased post-amputation pain. TMR, in conjunction with advancements in prosthetic technology and ongoing military research, offers improved outcomes to help achieve the goals of active-duty service members. The capabilities and applications of TMR continue to expand rapidly due to its high surgical success rate, technological innovations in prosthetic care, and favorable patient outcomes. As technology evolves to include implantable devices, osseointegration techniques, and bidirectional neuroprosthetic devices, the future of amputation surgery and TMR holds immense promise, offering innovative solutions to optimize patient outcomes. It is important to note, this review was limited to the data available in the included resources which was mostly qualitative; thus, it did not involve primary data analysis.

Integration of proprioception in upper limb prostheses through non-invasive strategies: a review

Proprioception plays a key role in moving our body dexterously and effortlessly. Nevertheless, the majority of investigations evaluating the benefits of providing supplemental feedback to prosthetics users focus on delivering touch restitution. These studies evaluate the influence of touch sensation in an attempt to improve the controllability of current robotic devices. Contrarily, investigations evaluating the capabilities of proprioceptive supplemental feedback have yet to be comprehensively analyzed to the same extent, marking a major gap in knowledge within the current research climate. The non-invasive strategies employed so far to restitute proprioception are reviewed in this work. In the absence of a clearly superior strategy, approaches employing vibrotactile, electrotactile and skin-stretch stimulation achieved better and more consistent results, considering both kinesthetic and grip force information, compared with other strategies or any incidental feedback. Although emulating the richness of the physiological sensory return through artificial feedback is the primary hurdle, measuring its effects to eventually support the integration of cumbersome and energy intensive hardware into commercial prosthetic devices could represent an even greater challenge. Thus, we analyze the strengths and limitations of previous studies and discuss the possible benefits of coupling objective measures, like neurophysiological parameters, as well as measures of prosthesis embodiment and cognitive load with behavioral measures of performance. Such insights aim to provide additional and collateral outcomes to be considered in the experimental design of future investigations of proprioception restitution that could, in the end, allow researchers to gain a more detailed understanding of possibly similar behavioral results and, thus, support one strategy over another.

Transhumeral amputation in brachial plexus lesion patients: A multicenter case series

BACKGROUND

A flail limb can be the result of a traumatic complete brachial plexus lesion. Some patients prefer retaining the flail limb, however some patients feel that a flail limb negatively affects daily life. In these circumstances an elective amputation is sometimes elected, however long-term follow-up, with respect to satisfaction and function is unknown. The aim of this study is to evaluate the long-term outcome of this rare and life changing operation.

MATERIALS AND METHODS

8 patients with a transhumeral amputation performed in 2 specialized medical centers were included. Postoperatively, the functional- and psychological outcome and the quality of life were evaluated with standardized patient reported outcome measures (PROMs; DASH, SIP-68, EQ-5D-5L and HADS).

RESULTS

After a median of 9.4 (range 7.5 - 12.8) years follow-up, 7 patients (88%) stated that they would undergo the operation again and were satisfied with the results. At latest follow-up the median DASH score was 37.3 (range 8.3-61.7), the median SIP-68 score was 6.5 (range 0-43) and the median HADS score was 3.0 (range 0-14) for anxiety and 3.0 (range 1-19) for depression. In the EQ-5D-5L patients had most difficulties in self-care, usual activities and pain/discomfort. The median overall health status was 69 (range 20-95).

DISCUSSION

With the right indication a transhumeral amputation is a reasonable option for traumatic complete brachial plexus lesion with satisfying long-term results.

LEVEL OF EVIDENCE

IV, multicenter case series.

Virtual Reality-Based Rehabilitation to Restore Motor Function in People With Amputation: A Systematic Literature Review

ABSTRACT

Virtual reality is an emerging technology with accumulating research and clinical evidence in the field of physical rehabilitation. This study aimed to systematically identify and examine the effects of virtual reality on motor function outcomes in patients with amputation to inform clinical decision making on amputation rehabilitation and inform further research endeavors. Five databases were searched, including PubMed, CINAHL, PsycINFO, Embase, and Scopus. After screening for 1052 records, 10 clinical studies were included in this review: four randomized controlled trials, three pre-post single-arm studies, and three case studies; all studies had fair to good methodological quality. Seven studies were for lower extremity amputation, and three were for upper extremity amputation. Results reveal the positive effects of virtual reality on improving motor function in prosthesis training, including balance, gait, and upper extremity outcomes. Participants also report enjoyment during virtual reality intervention as measured by subjective experience. However, it is unclear whether virtual reality can induce better therapeutic outcomes than conventional rehabilitation, given the limited number of controlled studies and conflicting results reported in the included studies. More properly designed randomized controlled trials with adequately powered sample sizes are warranted to elucidate the benefits of virtual reality-based rehabilitation in the amputation population.

Evaluating the Reliability of a Shape Capturing Process for Transradial Residual Limb Using a Non-Contact Scanner

Advancements in digital imaging technologies hold the potential to transform prosthetic and orthotic practices. Non-contact optical scanners can capture the shape of the residual limb quickly, accurately, and reliably. However, their suitability in clinical practice, particularly for the transradial (below-elbow) residual limb, is unknown. This project aimed to evaluate the reliability of an optical scanner-based shape capture process for transradial residual limbs related to volumetric measurements and shape assessment in a clinical setting. A dedicated setup for digitally shape capturing transradial residual limbs was developed, addressing challenges with scanning of small residual limb size and aspects such as positioning and patient movement. Two observers performed three measurements each on 15 participants with transradial-level limb absence. Overall, the developed shape capture process was found to be highly repeatable, with excellent intra- and inter-rater reliability that was comparable to the scanning of residual limb cast models. Future work in this area should compare the differences between residual limb shapes captured through digital and manual methods.

Understanding Implications of Residual Limb Length, Strength, and Range-of-Motion Impairments of Veterans With Upper Limb Amputation

OBJECTIVE

The aim of the study was to describe and quantify the relationship between limb impairment variables to key functional outcomes.

DESIGN

This was an observational study of 107 participants with unilateral above/at-elbow or below-elbow/wrist amputation. Demographics, prosthesis characteristics, residual limb length, and prevalence of passive range-of-motion restrictions, and strength impairments were described. Correlations between impairment variables were estimated. Linear regressions examined associations between impairment variables and activity performance, health-related quality of life, disability, and prosthesis satisfaction.

RESULTS

Prevalence of short/very short below- and above-elbow residua was 25.7% and 12.5%, respectively. Shorter below-elbow/wrist residual limb length was correlated with elbow flexion weakness (r = 0.30) and prevalence of passive range of motion (r = 0.25). Shoulder prevalence of passive range-of-motion restrictions were correlated with shoulder (r = 0.27-0.51) and elbow weakness (r = 0.25-0.46). In regressions, activity performance was worse for those with shoulder flexion prevalence of passive range-of-motion restrictions (B = -5.0, P = 0.03) and better for those with flexion restrictions (B = 3.3, P = 0.04) compared with normal prevalence of passive range of motion. Prosthetic satisfaction was lower for those with limited elbow prevalence of passive range of motion.

CONCLUSIONS

Short below-elbow residual limb length was correlated with impairment of elbow flexion strength and prevalence of passive range of motion. Prevalence of passive range-of-motion restrictions were most prevalent at the shoulder and were strongly correlated with weakness in the same planes of motion. Few significant associations were found between impairment variables and outcomes.

Degree of Soft Tissue Injury is a Major Determinant of Successful Arterial Repair in the Extremity: A New Classification of Extremity Arterial Injury?

BACKGROUND

This study aimed to investigate outcomes after extremity arterial injury repair and examined the association between outcomes and the degree of soft tissue injury and vascular repair methods.

METHODS

A retrospective study was conducted on 106 patients (108 cases) who underwent emergent microsurgical repair of extremity arterial injury due to trauma and non-perfusion of the affected extremity. The cases were divided into three groups by degree of associated soft tissue injuries: (A) adequate soft tissue coverage over the injured major vessels after radical debridement, (B) inadequate soft tissue coverage over the injured major vessels after radical debridement, and (C) radical debridement was not feasible due to unclear extent of injured soft tissue. Differences in vascular repair methods and outcomes among the three groups were analyzed.

RESULTS

In Group A (n = 61), microvascular suture and vessel graft achieved 95.1% and 85.0% successful limb reperfusion, respectively. In Group B (n = 31), vessel reconstruction with flap coverage achieved 100% successful reperfusion. Vessel graft achieved 28.6% successful limb reperfusion, while there were no cases of successful reperfusion using microvascular sutures. In Group C (n = 16), no vascular repair method achieved successful reperfusion. There were significant differences among the three groups in successful reperfusion (p < 0.001) and limb salvage (p < 0.001).

CONCLUSION

The extent of associated soft tissue injury was associated with different vascular repair methods and outcomes. We propose a new system for classifying these injuries according to the degree of associated soft tissue injury.

Long-Term Consequences of Major Extremity Trauma: A Pilot Study

SUMMARY

Limited data are available on the longer-term physical and psychosocial consequences after major extremity trauma apart from literature on the consequences after major limb amputation. The existing literature suggests that although variations in outcome exist, a significant proportion of service members and civilians sustaining major limb trauma will have less than optimal outcomes or health and rehabilitation needs over their life course. The proposed pilot study will address this gap in current research by locating and consenting METRC participants with the period of 5-7 years postinjury, identifying potential participation barriers and appropriate use of incentives, and conducting the follow-up examination at several data collection sites. The resulting data will inform the primary objective of refining and developing specific hypotheses to determine the design, scope, and feasibility of the main long-term consequences of major extremity trauma. Three METRC enrollment centers will contact past participants to achieve the goal of completing an interview, select patient-reported outcomes, perform a medical record review, and conduct an in-person clinic visit that will consist of a physical examination, blood draw, and x-ray of the study injury area. If successful, it will be possible to design studies to further examine these effects and develop future therapeutic interventions.

Transradial Amputation With Pedicled Pronator Quadratus Interposition and Advanced Neuroma-Prevention Techniques

Transradial amputation is a reconstructive option for upper-extremity trauma, infection, malignancy, and ischemia. The possible postoperative complications include residual radioulnar impingement and the development of a painful neuroma. In this report, a pedicled pronator quadratus flap interposition between the distal radius and ulna has been described. Additionally, various techniques to mitigate the development of symptomatic neuromas have been described.

Comparison of health state utility measures and disabilities of arm, shoulder and hand questionnaire scores in bilateral hand amputees

Bilateral hand amputation (BHA) is a life-changing event that can result in a great degree of loss of function. Prosthetic limb replacement and composite tissue allotransplantation are the treatment options. Understanding the BHA in terms of economic utility will help direct future research and upgrading in healthcare delivery. This is a cross-sectional study in 32 BHA who have completed a minimum of six months after wound healing. The primary objective was to assess the convergent validity of three different health utility (HU) derivation methods, namely the time trade-off (TTO), EuroQol questionnaire (EQ-5D-5L), and EuroQol visual analog scale (EQ-VAS) among BHA. The secondary objective was to correlate the disabilities of arm, shoulder and hand (DASH) scores with the HU scores and see whether the DASH score predicts the HU scores derived by different methods. The mean (SD) HU scores for TTO, VAS, and EQ-5D-5L were 0.34 (0.25), 0.61 (0.25), and 0.46 (0.20), respectively. HU derived by the TTO method displayed a weak correlation with EuroQol-based derivatives (EQ-VAS & EQ-5D-5L). But there was a moderate correlation between values by EQ-VAS & EQ-5D-5L. Hence, the EuroQol HU derivative is preferable to TTO. The mean (SD) of the DASH score was 48.4 (22.9). There was a strong correlation between the DASH scores and HU derived by different methods. Also, the DASH score is seen to be a good predictor of HU scores. This study is the first to derive HU and correlate the DASH with HU scores in the BHA scenario .

Development of overuse musculoskeletal conditions after combat-related upper limb amputation: a retrospective cohort study

STUDY DESIGN

Retrospective cohort study INTRODUCTION: Service members who have sustained traumatic amputations are typically young and otherwise healthy. Beyond standard care, these individuals desire long, highly active, and relatively pain-free lifestyle, whether that is returning to active duty or transitioning to civilian life. Development of overuse musculoskeletal conditions could have a significant influence on quality of life for Service members with traumatic upper limb amputation.

PURPOSE OF THE STUDY

Compare one-year incidence of overuse musculoskeletal injuries in Service members with different levels of combat-related upper limb amputation to Service members with minor combat-related upper limb injuries.

METHODS

Service members with deployment-related upper limb injury (N = 519), 148 major upper limb amputation (55 with amputation at or above elbow, 93 with amputation below elbow) and 371 minor upper limb injury were included in the study. Outcomes of interest clinical diagnosis codes associated with overuse conditions of the upper limb, neck and upper back, lower limb, low back pain, and all regions combined, one year before and one year after injury.

RESULTS

Overall, the one-year incidence of developing at least one musculoskeletal overuse condition after upper limb amputation was between 60% and 65%. Service members with upper limb amputations were 2.7 to 4.7 times more likely to develop an overuse upper limb condition, 3.6 to 3.8 times more likely to develop a neck and upper back condition, 2.8 to 4.4 times more likely to develop a lower limb condition, and 3.3 to 3.9 times more likely to develop low back pain as compared those who sustained minor combat-related injuries. No significant differences in the odds of developing a musculoskeletal condition was found between the above elbow and below elbow amputation groups.

CONCLUSIONS

Incidence of secondary overuse conditions is elevated in Service members with upper limb amputation and warrants focused research efforts toward preventative and rehabilitative interventions.

High-Energy Blast Injury Requiring Transradial Amputation with Associated Essex Lopresti and Terrible Triad Injuries of the Elbow: A Rare Presentation

Case

Blast injuries to the upper extremity can be devastating and emotionally stressful injuries. We describe a case of a high-energy blast injury to an upper extremity from an explosive. The transfer of energy caused severe soft tissue/bony damage to the hand, but also led to associated Essex Lopresti and terrible triad injuries. The patient required emergent transradial amputation by hand surgery as well as definitive fixation by our orthopaedic team.

Conclusion

We describe a unique salvage operation that established forearm pronosupination, elbow flexion, and proper prosthetic fitting. We feel that describing our technique could help others in treating this injury if encountered.

Complex Microsurgical Reconstruction After Tumor Resection in the Trunk and Extremities

Reconstruction of soft tissue defects following tumor ablation procedures in the trunk and extremities can challenge the microsurgeon. The goal is not just to provide adequate soft tissue coverage but also to restore form and function and minimize donor site morbidity. Although the principles of the reconstructive ladder still apply in the trunk and extremities, free tissue transfer is used in many cases to optimally restore form and function. Microsurgery has changed the practice in soft tissue tumors, and amputation is less frequently necessary.

Design and development of a novel 3D-printed non-metallic self-locking prosthetic arm for a forequarter amputation

BACKGROUND

Upper limb, in particular forequarter amputations, require highly customised devices that are often expensive and underutilised.

OBJECTIVES

The objective of this study was to design and develop a comfortable 3D-printed cosmetic forequarter prosthetic device, which was lightweight, cool to wear, had an elbow that could lock, matched the appearance of the contralateral arm and was completely free of metal for a specific user's needs.

STUDY DESIGN

Device design.

TECHNIQUE

An iterative user-centred design approach was used for digitising, designing and developing a functional 3D-printed prosthetic arm for an acquired forequarter amputation, while optimising the fit and function after each prototype.

RESULTS

The cost of the final arm was 20% less expensive than a traditionally-made forequarter prostheses in Singapore. The Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST) 2.0 survey was administered, with results indicating that the 3D-printed arm was preferred due to its overall effectiveness, accurate size, ease of use and suspension. However, durability had a lower score, and the weight of the arm was 100 g heavier than the user's current prosthesis. The technique described resulted in a precise fitting and shaped forequarter prosthesis for the user. Using the user's feedback in the iterations of the design resulted in improved QUEST survey results indicating the device was effective, easy to use, perceived as lighter and more secure than the user's traditionally-made device.

CONCLUSION

A fully customised cosmetic forequarter prosthesis was designed and developed using digital scanning, computer-aided design modelling and 3D printing for a specific user. These technologies enable new avenues for highly complex prosthetic design innovations.

Limb Salvage for Musculoskeletal Tumors in the Austere Environment: Review of the Literature With Illustrative Cases Regarding Considerations and Pitfalls

Although there is literature discussing the treatment of acute and chronic trauma in austere environments, no literature or guidelines for the treatment of musculoskeletal tumors exist. This series discusses case examples with considerations and pitfalls of performing limb-salvage surgery in an underserved location. Cases of limb-salvage surgery performed by the same orthopaedic oncologist in Haiti and the Dominican Republic are discussed with a review of the literature on limb salvage for musculoskeletal tumors in developing nations. All patients successfully underwent limb-salvage surgery after considering multiple factors including tumor type and location. Patients with metastatic disease, likelihood of substantial blood loss, and poor health were not candidates for limb-salvage surgery. Medical missions and the development of partnerships with established training programs make limb salvage a greater possibility. Knowledge of the facility, anesthesia support, and instrumentation available is vital. Advanced imaging, blood products, and allograft are likely unavailable or difficult to obtain. Established continuity of care is necessary, and training of the local surgeon should be provided. Surgery should only be considered if it is safe and provides more of a benefit to the patient than an amputation.

Gamification in Rehabilitation of Patients With Musculoskeletal Diseases of the Shoulder: Scoping Review

Background

Gamification has become increasingly important both in research and in practice. Particularly in long-term care processes, such as rehabilitation, playful concepts are gaining in importance to increase motivation and adherence. In addition to neurological diseases, this also affects the treatment of patients with musculoskeletal diseases such as shoulder disorders. Although it would be important to assist patients during more than one rehabilitation phase, it is hypothesized that existing systems only support a single phase. It is also unclear which game design elements are currently used in this context and how they are combined to achieve optimal positive effects on motivation.

Objective

This scoping review aims to identify and analyze information and communication technologies that use game design elements to support the rehabilitation processes of patients with musculoskeletal diseases of the shoulder. The state of the art with regard to fields of application, game design elements, and motivation concepts will be determined.

Methods

We conducted a scoping review to identify relevant application systems. The search was performed in 3 literature databases: PubMed, IEEE Xplore, and Scopus. Following the PICO (population, intervention, comparison, outcome) framework, keywords and Medical Subject Headings for shoulder, rehabilitation, and gamification were derived to define a suitable search term. Two independent reviewers, a physical therapist and a medical informatician, completed the search as specified by the search strategy. There was no restriction on year of publication. Data synthesis was done by deductive-inductive coding based on qualitative content analysis.

Results

A total of 1994 articles were screened; 31 articles in English, published between 2006 and 2019, were included. Within, 27 application systems that support patients with musculoskeletal diseases of the shoulder in exercising, usually at home but also in inpatient or outpatient rehabilitation clinics, were described. Only 2 application systems carried out monitoring of adherence. Almost all were based on in-house developed software. The most frequently used game components were points, tasks, and avatars. More complex game components, such as collections and teams, were rarely used. When selecting game components, patient-specific characteristics, such as age and gender, were only considered in 2 application systems. Most were described as motivating, though an evaluation of motivational effects was usually not conducted.

Conclusions

There are only a few application systems supporting patients with musculoskeletal diseases of the shoulder in rehabilitation by using game design elements. Almost all application systems are exergames for supporting self-exercising. Application systems for multiple rehabilitation phases seem to be nonexistent. It is also evident that only a few complex game design elements are used. Patient-specific characteristic are generally neglected when selecting and implementing game components. Consequently, a holistic approach to enhance adherence to rehabilitation is required supporting patients during the entire rehabilitation process by providing motivational game design elements based on patient-specific characteristics.

Targeted Muscle Reinnervation and Osseointegration for Pain Relief and Prosthetic Arm Control in a Woman with Bilateral Proximal Upper Limb Amputation

BACKGROUND

Bilateral proximal upper limb loss is a dramatic life-changing event. Replacement of the lost function with prosthetic arms, including multiple mechatronic joints, has remained a challenge from the control, comfort, and pain management perspectives. Targeted muscle reinnervation (TMR) is a peripheral nerve surgical procedure proposed to improve the intuitive control of the prosthetic arm and for neuroma and phantom pain management. Moreover, osseointegrated percutaneous implants (OPIs) allow for direct skeletal attachment of the prosthetic arm, ensuring freedom of movement to the patient's residual articulations.

CASE DESCRIPTION

We have reported the first combined application of TMR and an OPI to treat a 24-year-old woman with a bilateral amputation at the shoulder level on the right side and at the very proximal transhumeral level on the left side. TMR was performed bilaterally in a single day, accounting for the peculiar patient's anatomy, as preparatory stage to placement of the OPI, and considering the future availability of implantable electromyographic sensors. The 2 OPI surgeries on the left side were completed after 8.5 months, and prosthetic treatment was completed 17 months after TMR.

CONCLUSIONS

The use of TMR resolved the phantom pain bilaterally and the right-side neuroma pain. It had also substantially reduced the left side neuroma pain. The actual prosthetic control result was intuitive, although partially different from expectations. At 2 years after TMR, the patient reported improvement in essential activities of daily living, with a remarkable preference for the OPI prosthesis. Only 1 suspected case of superficial infection was noted, which had resolved. Overall, this combined treatment required a highly competent multidisciplinary team and exceptional commitment by the patient and her family.

Occupational Therapy Practice Patterns for Military Service Members With Upper Limb Amputation

INTRODUCTION

Military Service Members (SMs) with upper limb (UL) amputation have unrestricted access to occupational therapy (OT) services. Identifying OT interventions used based on clinical rationale and patient needs can provide insight toward developing best practice guidelines. The purpose of this retrospective observational study was to identify preferred OT practice patterns for U.S. Military SMs treated in Military Treatment Facilities, who have sustained various levels of deployment-related UL amputation.

METHODS

The study sample was ascertained from the Expeditionary Medical Encounter Database housed at the Naval Health Research Center in San Diego, California. SMs with an immediate (within 24 hours of injury) deployment-related unilateral major UL amputation (partial hand and proximal), occurring between January 2001 and December 2014 were identified. SMs with concurrent major lower limb amputation (partial foot and proximal) were excluded. Frequency of OT outpatient visits and units of treatment received were quantified in 3-month increments during the first year after amputation and compared for individuals with above elbow (at or proximal to elbow joint) and below elbow (distal to the elbow joint including partial hand) amputation. This study was approved by the Naval Health Research Center Institutional Review Board.

RESULTS

A total of 29,878 encounters occurred during first year after amputation in 148 patients, who had sustained UL loss during the first year after amputation. Active treatments were included in 79.2% of all treatments, followed by manual therapy (13.7%) and modalities (13.5%). A higher number of OT encounters occurred in the above elbow amputation group-the first year of treatment with significantly higher mean number of treatments months 4 to12. A similar pattern in OT encounters was observed in the active therapy category with significantly higher mean number of treatments occurring in above elbow limb loss group in months 10 to 12.

CONCLUSION

Findings of the current study suggest SMs with UL amputation utilize OT services often within the first year after injury and those who have sustained amputation proximal to the elbow received more therapy visits than their below elbow counterparts during months 4 to 12. Prosthetic training, therapeutic activities, and therapeutic exercise can be expected to be the highest used active interventions in the first year following UL amputation. Further research is needed to determine details on types and frequency of therapy utilization and recommended therapy strategies.

Blast injury of the hand related to warfare explosive devices: experience from the French Military Health Service

INTRODUCTION

The objective was to report on the experience of the French Army Health Service in the management of blast injury of the hands related to warfare explosive devices.

METHODS

A retrospective study was conducted in the Percy Military Hospital (role 4 medical treatment facility) among French soldiers who presented with a combat-related blast injury of the hand between 2002 and 2018. The functional result was assessed by the disabilities of the arm, shoulder and hand (DASH) and the Orthotics and Prosthetics User Survey (OPUS, upper extremity functional status) scores. Proximal amputations (PAs) and distal amputations (DAs) were distinguished for the analysis.

RESULTS

Fifteen patients with a mean age of 31±8 years were included. They totalised 20 blasted hands. There were 16 traumatic amputations: 8 in each of the PA and DA groups. Twelve patients had additional injuries, four of which were polytraumatic. Skin closure time and flap use were higher in the DA group. Only one thumb reconstruction was performed. At a mean follow-up of 6.5±4 years, the number of amputees wearing a prosthesis was higher in the PA group. The mean DASH and OPUS scores were 35.5%±24.0% and 64.0%±19.0%, respectively, with no difference between the two groups.

CONCLUSION

The severity of hand blasts related to warfare explosive devices requires the systematic application of damage control surgery. PAs are frequent and secondary reconstruction options are limited. The functional result is poor and similar between proximal and distal amputees.

Conception, design, and fabrication of novel cost-effective partial-hand prosthetic devices for a quadrilateral individual with limb loss

BACKGROUND AND AIM

The author designed customized upper-limb prosthetic devices for a 22-year-old man with quadrilateral limb loss. The devices were created to meet his functional requirements, while remaining cost-effective. What made this solution unique was that it utilized low-cost items that were easily sourced and maintained.

TECHNIQUE

Devices with polypropylene sockets, wooden positional fingers from an artist's wooden hand and a metal extension plate were conceptualized and manufactured. The patient gave written consent to the publication of information and photographs in this report.

DISCUSSION

The devices allowed the individual to complete tasks he desired to be able to perform independently, which included using a computer mouse, aided by the devices. The devices utilized were low-cost and easily accessible materials, such as polypropylene and wood, to cater to financial constraints. The final design had positional fingers and an extension plate to restore surface area for grip, support, and opposition to enable the execution of daily tasks of living.

CLINICAL RELEVANCE

A cost-effective method of fabricating partial-hand devices with easily accessible materials is described. The resulting devices were successful at restoring the upper-limb surface area for improved grip, support, and opposition for performance of daily tasks.

Current Concepts in Upper-Extremity Amputation

Advances in motor vehicle safety, trauma care, combat body armor, and cancer treatment have enhanced the life expectancy and functional expectations of patients with upper-extremity amputations. Upper-extremity surgeons have multiple surgical options to optimize the potential of emerging prosthetic technologies for this diverse patient group. Targeted muscle reinnervation is an evolving technique that improves control of myoelectric prostheses and can prevent or treat symptomatic neuromas. This review addresses current strategies for the care of patients with amputations proximal to the wrist with an emphasis on recent advancements in surgical techniques and prostheses.

Targeted Muscle Reinnervation for Transradial Amputation: Description of Operative Technique

Targeted muscle reinnervation (TMR) is a revolutionary surgical technique that, together with advances in upper extremity prostheses and advanced neuromuscular pattern recognition, allows intuitive and coordinated control in multiple planes of motion for shoulder disarticulation and transhumeral amputees. TMR also may provide improvement in neuroma-related pain and may represent an opportunity for sensory reinnervation as advances in prostheses and haptic feedback progress. Although most commonly utilized following shoulder disarticulation and transhumeral amputations, TMR techniques also represent an exciting opportunity for improvement in integrated prosthesis control and neuroma-related pain improvement in patients with transradial amputations. As there are no detailed descriptions of this technique in the literature to date, we provide our surgical technique for TMR in transradial amputations.

Complex Microsurgical Reconstruction After Tumor Resection in the Trunk and Extremities

Reconstruction of soft tissue defects following tumor ablation procedures in the trunk and extremities can challenge the microsurgeon. The goal is not just to provide adequate soft tissue coverage but also to restore form and function and minimize donor site morbidity. Although the principles of the reconstructive ladder still apply in the trunk and extremities, free tissue transfer is used in many cases to optimally restore form and function. Microsurgery has changed the practice in soft tissue tumors, and amputation is less frequently necessary.

[Limb salvage and amputation after trauma : Decision criteria and management algorithm]

The clinical decision-making process for patients with severe trauma of the extremities for primary amputation or to initiate extensive reconstructive measures for limb salvage in the best interests of the patient can be complex and difficult. The many factors influencing the decision-making process, such as local anatomical, pathomechanical, physiological, psychosocial and general factors are demonstrated and discussed. In the past, the role of scores supporting the decision-making process for amputation or limb salvage has been overestimated. In the LEAP study it could clearly be demonstrated that none of the sometimes highly complex scores could fulfill the expectations to predict successful limb salvage or the need for amputation. In this article it is shown that initiators and authors of scores achieved much higher sensitivity and specificity in the inaugural studies compared to the standardized and controlled conditions used in the LEAP study. For a long time, a lack of feeling in the feet was considered a safe and reliable criterion for amputation but the LEAP study has made a substantial contribution to demythologizing this as a lead symptom. Patients with severe trauma of the ankle or foot requiring a free flap or ankle arthrodesis have a significantly worse outcome compared to patients with a below knee amputation. Taking all these influencing factors into consideration, a comprehensive algorithm is presented that facilitates, strengthens and standardizes decision-making for amputation or limb salvage. This algorithm consists of four modules: 1) decision-making, 2) emergency treatment, 3) definitive treatment and 4) fine tuning. In the decision-making module not only local and general injury severity are addressed but the expected result, the general condition, comorbidities, compliance and the will of the patient are also included.