The influence of falling, fear of falling, and balance confidence on prosthetic mobility and social activity among individuals with a lower extremity amputation

OBJECTIVE

To assess in amputee patients the relationship between having fallen in the past 12 months, fear of falling, and balance confidence on mobility capability, mobility performance, and social activity.

DESIGN

Population-based survey and chart review.

SETTING

Two university-affiliated outpatient amputee programs in southwestern Ontario.

PARTICIPANTS

Community-living individuals (n = 435) with a unilateral lower limb amputation.

INTERVENTIONS

Patient chart review and a survey questionnaire.

MAIN OUTCOME MEASURES

Self-report assessment of prosthetic capability and performance and social activity participation was assessed with the Prosthetic Evaluation Questionnaire mobility subscale, the Houghton Scale, and the Frenchay Activities Index.

RESULTS

Falling experiences in the past 12 months were not significantly associated with any outcomes. Fear of falling was important in univariate relationships in all 3 outcomes, but not when balance confidence was included in multivariable modeling. Balance confidence was statistically significant with each of the outcomes and remained significant with inclusion of the covariates. There was statistical interaction (balance confidence x automatism; balance confidence x medication count) in modeling mobility capability and in modeling mobility performance (balance confidence x pain + balance confidence x amputation level). The final models accounted for 70%, 60%, and 55% of the variation in mobility capability, mobility performance, and social activity, respectively.

CONCLUSION

Balance confidence was the only factor associated with mobility capability and performance and social activity in the final adjusted models. Clinicians and researchers should consider this variable in the rehabilitation of amputee patients.

Prosthesis use in persons with lower- and upper-limb amputation

This study identified clinical (e.g., etiology) and demographic factors related to prosthesis use in persons with upper- and lower-limb amputation (ULA and LLA, respectively) and the effect of phantom limb pain (PLP) and residual limb pain (RLP) on prosthesis use. A total of 752 respondents with LLA and 107 respondents with ULA completed surveys. Factors related to greater use (hours per day) for persons with LLA included younger age, full- or part-time employment, marriage, a distal amputation, an amputation of traumatic etiology, and an absence of PLP. Less use was associated with reports that prosthesis use worsened RLP, and greater prosthesis use was associated with reports that prosthesis use did not affect PLP. Having a proximal amputation and reporting lower average PLP were related to greater use in hours per day for persons with an ULA, while having a distal amputation and being married were associated with greater use in days per month. Finally, participants with LLA were significantly more likely to wear a prosthesis than those with ULA. These results underscore the importance of examining factors related to prosthesis use and the differential effect that these variables may have when the etiology and location of amputation are considered.

Left tactile extinction following visual stimulation of a rubber hand

In close analogy with neurophysiological findings in monkeys, neuropsychological studies have shown that the human brain constructs visual maps of space surrounding different body parts. In right-brain-damaged patients with tactile extinction, the existence of a visual peripersonal space centred on the hand has been demonstrated by showing that cross-modal visual-tactile extinction is segregated mainly in the space near the hand. That is, tactile stimuli on the contralesional hand are extinguished more consistently by visual stimuli presented near the ipsilesional hand than those presented far from it. Here, we report the first evidence in humans that this hand-centred visual peripersonal space can be coded in relation to a seen rubber replica of the hand, as if it were a real hand. In patients with left tactile extinction, a visual stimulus presented near a seen right rubber hand induced strong cross-modal visual-tactile extinction, similar to that obtained by presenting the same visual stimulus near the patient's right hand. Critically, this specific cross-modal effect was evident when subjects saw the rubber hand as having a plausible posture relative to their own body (i.e. when it was aligned with the subject's right shoulder). In contrast, cross-modal extinction was strongly reduced when the seen rubber hand was arranged in an implausible posture (i. e. misaligned with respect to the subject's right shoulder). We suggest that this phenomenon is due to the dominance of vision over proprioception: the system coding peripersonal space can be 'deceived' by the vision of a fake hand, provided that its appearance looks plausible with respect to the subject's body.

Self-Contained Neuromusculoskeletal Arm Prostheses

We report the use of a bone-anchored, self-contained robotic arm with both sensory and motor components over 3 to 7 years in four patients after transhumeral amputation. The implant allowed for bidirectional communication between a prosthetic hand and electrodes implanted in the nerves and muscles of the upper arm and was anchored to the humerus through osseointegration, the process in which bone cells attach to an artificial surface without formation of fibrous tissue. Use of the device did not require formal training and depended on the intuitive intent of the user to activate movement and sensory feedback from the prosthesis. Daily use resulted in increasing sensory acuity and effectiveness in work and other activities of daily life. (Funded by the Promobilia Foundation and others.).

Dermatologic conditions associated with use of a lower-extremity prosthesis

OBJECTIVES

To document the frequency of skin problems among lower-limb prosthesis users and to assess for factors associated with skin problems among patients using a prosthesis.

DESIGN

Six-year retrospective chart review.

SETTING

An outpatient amputee clinic at a regional, referral rehabilitation hospital in Canada.

PARTICIPANTS

Seven hundred forty-five subjects with a total of 828 lower-extremity amputations participated. Subjects were included if they had a lower-extremity amputation and used a prosthesis for ambulation or transfers.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The presence or absence of a skin problem. Descriptive and nonparametric statistics were used to analyze data.

RESULTS

Three hundred thirty-seven residual limbs (40.7%) had at least 1 skin problem. Adjusted odds ratios showed that amputation level, being employed, type of walking aid, and absence of peripheral vascular disease (as a comorbidity) were independently associated with the presence of at least 1 skin problem ( P <.05). CONCLUSIONS; Dermatologic conditions are a frequent complication for the lower-extremity amputee who uses a prosthesis. The results suggest that more active amputees have an increased risk for developing skin problems. Further study in this area is warranted.

Reliability of the two-minute walk test in individuals with transtibial amputation

OBJECTIVE

To determine inter- and intrarater reliability of the two-minute walk test (2MWT) in individuals with transtibial amputation.

DESIGN

Prospective; test-retest method by a pair of trained physical therapists.

SETTING

Two regional amputee rehabilitation centers in Canada.

PARTICIPANTS

Thirty-three subjects (23 men, 10 women; mean age +/- standard error, 63.6+/-2.0y) with transtibial amputation; 6 in outpatient rehabilitation, 27 in inpatient rehabilitation. The most common primary diagnoses were peripheral vascular disease (n=15) and diabetes (n=11).

INTERVENTIONS

Each subject performed a total of four 2MWTs, 1 test for each rater, on 2 consecutive days at approximately the same time of day. Subjects were given at least a 20-minute rest between tests. The order of raters was randomized on the first day and reversed for the next day. The walk tests were performed in the same enclosed corridors with the same starting point for all tests. The subjects were familiar with the test or were given 1 or more practice tests at least 1 day before testing. Subjects were allowed to walk with a mobility aid of their choice. Raters used a digital stopwatch to time the tests and a calibrated wheel with a counter to measure the distance walked in meters. The raters were blinded to each other's scores.

MAIN OUTCOME MEASURE

Distance walked in 2 minutes (in meters).

RESULTS

Within-rater reliability was high (intraclass correlation coefficient [ICC],.90-.96). Between rater reliability was also high (ICC.98-.99). Analysis of variance (ANOVA) showed a significant effect for day of test (P<.001) in the inpatient group but no effect for therapist (P=.098) or for interaction of day and therapist (P=.710). Similarly, in the outpatient group, ANOVA showed a significant effect for day (P=.013) but no effect for therapist (P=.259) or interaction of day and therapist (P=.923).

CONCLUSION

Although the 2MWT showed evidence of inter- and intrarater reliability in individuals with unilateral below-knee amputation, the distance walked in 2 minutes continued to improve over time. This improvement was not solely the result of a training and learning effect.

Skin disorders in amputees

BACKGROUND

Dermatologic problems restrict the normal use of a prosthetic limb. The importance of contact dermatitis to skin morbidity in a population of amputees and the selection criteria for patch testing have not been clearly defined.

OBJECTIVE

We describe the range of dermatoses seen in a population of amputees and examine the incidence, causes, and patterns of contact dermatitis.

METHODS

This is a questionnaire-based, cross-sectional study of 210 amputees. Those with a skin problem were assessed by a dermatologist. Patch testing was undertaken in patients with persistent dermatitis.

RESULTS

A total of 34% of amputees experienced a skin problem. Lesions resulting from friction, pressure, and occlusion are common. Allergic contact dermatitis is seen in a third of patients with stump dermatitis. There are no features that distinguish allergic from irritant (chemical or physical) dermatitis.

CONCLUSION

Dermatologic problems are common in prosthetic limb users. Allergic contact dermatitis is a significant problem, and all patients with dermatitis on the residual limb should be patch tested.

Imaging of the painful lower limb stump

Several postoperative complications associated with pain may develop in the stump of an amputated lower limb. Clinical findings are often nonspecific; however, radiologic evaluation, especially with magnetic resonance (MR) imaging, is useful in the early diagnosis of these complications, thereby helping minimize physical disability with its psychologic and socioeconomic implications. Conventional radiography can demonstrate evidence of osseous origins of pain (eg, aggressive bone edge, heterotopic ossification, osteomyelitis) and should be the first imaging study performed after clinical examination. Videofluoroscopy can help evaluate improper prosthetic fit by demonstrating abnormal residual limb motion, piston action, rolling of soft tissues, and abnormal angle between the limb axis and the prosthesis during gait. Ultrasonography can demonstrate inflammatory changes in the stump as well as soft-tissue fluid collections. However, MR imaging is the modality of choice when clinical and other imaging findings are indeterminate. Because of its high spatial and contrast resolution, MR imaging can demonstrate subtle inflammatory changes, fluid collections, cancers, neuromas, and subtle traumatic bone lesions. Knowledge of various surgical and rehabilitation techniques is required for accurate diagnosis of complications associated with stump pain. Correct diagnosis allows choice of the most appropriate therapy, which may involve treating the stump, remodeling the prosthesis, or both.

The ICEROSS concept: a discussion of a philosophy

Prefabricated ICEROSS (Icelandic Roll On Silicone Socket) sockets have been in use in Iceland since early 1986. Use of custom-made silicone sockets began several years earlier, and a paper devoted to the subject was presented at the 1984 AOPA Assembly by the author of this article. The ICEROSS system is primarily used for suspension. At the same time the author believes it considerably improves the weight-bearing capability of the prosthesis and the interface between prosthesis and user. After being turned inside out and rolled over the stump, the silicone sleeve forces skin in a distal direction, stabilising soft tissue and minimising pistoning. Both prosthetist and user may experience some problems initially, although most can be overcome by careful socket design and skin care.

Skin problems of the stump in lower limb amputees: 1. A clinical study

Use of a prosthesis in lower limb amputees can lead to skin problems of the amputation stump. However, little is known about the epidemiology and type of problems experienced. We conducted a cross-sectional survey consisting of a questionnaire and a clinical assessment of the amputation stump. The aims of the study were to estimate the prevalence of skin problems of the amputation stump, to evaluate the impact of these skin problems and to evaluate differences between clinically observed skin problems and skin problems reported by the amputee. Participants (n = 124) were recruited from among lower limb amputees who visited an orthopaedic workshop. The prevalence of skin problems was 36%. Problems identified were: reduction in prosthesis use, and reduction in walking distance without a break. Significantly more skin problems were reported than observed (p = 0.011). Cold skin and excessive perspiration in particular were significantly more reported than observed.

Skin problems in lower limb amputees: an overview by case reports

The stump in lower limb amputees is prone to skin problems because it is exposed to several unnatural conditions (shear and stress forces and increased humidity) when a prosthesis is used. This study reviews the literature on case reports of lower limb amputees with skin problems on the stump. In total, 56 reports comprising 76 cases were identified in the literature. The main disorders are acroangiodermatitis, allergic contact dermatitis, bullous diseases, epidermal hyperplasia, hyperhidrosis, infections, malignancies and ulcerations.

Painful neuromata following upper limb amputation

Painful neuromata occurring after upper limb amputation are a significant cause of stump pain and limit the success of prosthetic training and use. There is little information in the literature regarding incidence, consequences or outcomes of painful neuromata subsequent to upper limb amputation. This article reports an analysis of thirty-two consecutive upper limb amputees. Of these 25% had moderate-to-severe stump pain and clinical signs suggestive of neuromata. All patients with neuromata were limited in their ability to use a prosthesis prior to surgery and following failure of conservative measures, were referred for surgical opinion. Six patients have undergone surgical management. The results of surgery, with respect to pain and prosthetic usage, are discussed.

Upper limb prosthetic use in Slovenia

The article deals with the use of different types of upper limb prostheses in Slovenia. Four hundred and fourteen upper limb amputees were sent a questionnaire on the type of their prosthesis, its use and reasons for non-use, respectively. The replies were subject to statistical analysis. Most of the questioned upper limb amputees (70%) wear a prosthesis only for cosmesis. The use of a prosthesis depends on the level of upper limb amputation, loss of the dominant hand, and time from amputation. Prosthetic success appears to be unrelated to age at the time of amputation and the rehabilitation programme. The most frequent reason for not wearing a prosthesis is heat and consequent sweating of the stump. More than a third of amputees are dissatisfied with their prostheses.

Residual-limb skin temperature in transtibial sockets

The insulated environment of the lower-limb prosthesis can result in elevated residual-limb skin temperatures that may contribute to skin irritation, blistering, and a reduced quality of life. The design and materials of the prosthetic socket, suspension system, and liner can potentially alleviate these conditions, but the thermal load may vary with activity and location within the socket. To characterize the thermal environment at the skin-prosthesis interface, we made temperature measurements on five transtibial amputees at 14 locations on the residual limbs. After the participants donned their prosthesis and rested in the seated position for 15 min, the mean skin temperatures of their residual limbs increased by 0.8 degrees Celcius. Subsequent walking for 10 min resulted in a 1.7 degrees Celsius total increase in mean skin temperature. Thermal contour maps revealed the skin was coolest at the anterior proximal location and warmest across the posterior section, correlating with areas of low and high perfusion. From the results, we determined that residual-limb skin temperature depends on activity and locality. This information may aid in understanding where and why skin problems develop on lower-limb residual limbs and may provide design requirements for new prosthetic socket systems intended to alleviate temperature-related discomfort.

Cross-Sectional Assessment of Factors Related to Pain Intensity and Pain Interference in Lower Limb Prosthesis Users

OBJECTIVE

To determine relationships between pain sites and pain intensity/interference in people with lower limb amputations (LLAs).

DESIGN

Cross-sectional survey.

SETTING

Community.

PARTICIPANTS

Lower limb prosthesis users with unilateral or bilateral amputations (N=1296; mean time since amputation, 14.1y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity (1 item to assess average pain), PROMIS pain interference (4-item short form to assess the consequences of pain in desired activities), and questions that asked participants to rate the extent to which each of the following were a problem: residual limb pain (RLP), phantom limb pain (PLP), knee pain on the nonamputated side, back pain, and shoulder pain.

RESULTS

Nearly three quarters (72.1%) of participants reported problematic pain in 1 or more of the listed sites. Problematic PLP, back pain, and RLP were reported by 48.1%, 39.2%, and 35.1% of participants, respectively. Knee pain and shoulder pain were less commonly identified as problems (27.9% and 21.7%, respectively). Participants also reported significantly (P<.0001) higher pain interference (T-score ± SD, 54.7±9.0) than the normative sample based on the U.S. population (T-score ± SD, 50.0±10.0). Participants with LLAs rated their pain intensity on average ± SD at 3.3±2.4 on a 0-to-10 scale. Pain interference (ρ=.564, P<.0001) and intensity (ρ=.603, P<.0001) were positively and significantly correlated with number of pain sites reported.

CONCLUSIONS

Problematic pain symptoms, especially RLP, PLP, and back pain, affect most prosthetic limb users and have the potential to greatly restrict participation in life activities.

Hygiene problems of residual limb and silicone liners in transtibial amputees wearing the total surface bearing socket

OBJECTIVE

To determine whether washing the residual limb and silicone liner reduces the associated skin problems in transtibial amputees who wear a total surface bearing (TSB) socket.

DESIGN

Case series.

SETTING

General community.

PATIENTS

Eighty-three transtibial amputees (65 men, 18 women; mean age, 53.4 yr) in western Japan who used or had used a TSB socket with a silicone liner in the previous 5 years.

INTERVENTION

Participants took a self-administered questionnaire that included items concerning their personal profile, daily life activities, period of TSB use (yr), hours of TSB use daily, washing frequency of the residual limb and silicone liner, the method of washing, and any associated hygiene problems.

MAIN OUTCOME MEASURES

Logistic regression analysis was applied to examine factors related to hygiene problems. Predicted values include hygiene problems (perspiration, eruptions, itching, odor) and explanatory values include TSB use, daily life activity, and washing of limb and prosthetic.

RESULTS

Fifty-five subjects washed the residual limb, and 44 subjects washed the silicone liner every day. Itching, perspiration, eruption, and odor were frequent hygiene problems. Perspiration was noted less by women, eruption more by older subjects, and itching and odor more by younger subjects. Washing the silicone liner every day was associated with fewer reports of skin eruption.

CONCLUSION

Keeping the residual limb and silicone liner clean is important to reduce skin problems, but hygiene problems of the residual limb and silicone liner still remain to be resolved.

Skin problems in an amputee clinic

OBJECTIVE

To document the type and frequency of individual residual limb skin problems among patients using a lower extremity prosthesis, including the suggested etiology and management of each type of skin problem.

DESIGN

This is a 6-yr retrospective chart review of skin lesions diagnosed in patients examined in an outpatient amputee clinic at a regional, referral rehabilitation hospital in Ottawa, Canada. Skin lesions were included if they were on a lower extremity residual limb for a patient who functionally used a prosthesis. Descriptive statistics were used to analyze data.

RESULTS

A total of 528 skin problems were documented in 337 lower extremity residual limbs. Ulcers, irritations, inclusion cysts, calluses, and verrucous hyperplasia were the five most common skin problems representing 79.5% of all documented skin disorders.

CONCLUSIONS

This study demonstrated that a wide variety of dermatologic conditions occurred frequently in the lower extremity amputee who functionally used a prosthesis. Five types of skin problems accounted for nearly 80% of the skin lesions identified. Future studies are required to evaluate prevention and management of the most frequent skin problems.

Safety and Performance of Bone-Anchored Prostheses in Persons with a Transfemoral Amputation: A 5-Year Follow-up Study

BACKGROUND

For almost 30 years, bone-anchored prostheses have offered an alternative solution to prosthetic sockets by attaching the artificial limb directly to the femoral residuum by means of an osseointegration implant. Osseointegration implant surgery was introduced in our center in 2009. The aim of the present study is to report on safety, prosthesis-wearing time, and health-related quality-of-life (HRQoL) for patients with femoral bone-anchored prostheses during a 5-year follow-up period.

METHODS

All patients who underwent implantation of a press-fit osseointegration implant between May 2009 and November 2013 were eligible for the present study. Implantation was performed in 2 stages. Adverse events included infectious complications (grade 1 to 4), aseptic loosening, breakage, stoma-redundant tissue, and stoma hypergranulation. Prosthesis-wearing time and HRQoL were measured with the Questionnaire for Persons with a Transfemoral Amputation (Q-TFA) prosthetic use score and global score, respectively.

RESULTS

Thirty-nine of 42 eligible patients were included. Thirty patients (77%) presented with some kind of infection (156 events in total), with 148 (95%) events being classified as grade 1 or 2 and 8 events (5%) being classified as grade 3; the latter 8 events occurred in 4 patients. There were no instances of septic loosening. The intramedullary stem of the osseointegration implant broke in 2 patients. In total, soft-tissue refashioning had to be done 30 times in 14 patients. The Q-TFA median prosthetic use and global scores improved significantly from 71 to 100 and from 33 to 75, respectively (p < 0.001).

CONCLUSIONS

Despite the adverse events, patient prosthetic use and HRQoL improved significantly. Grade-1 and 2 infections were frequent but could mostly be treated with nonoperative measures. Most infections seemed to occur in the first 2 years and did not lead to deep infections. Two broken intramedullary stems were revised successfully. Current developments focus on reduction of infectious complications and prevention of osseointegration implant breakage.

LEVEL OF EVIDENCE

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

Stump ulcers and continued prosthetic limb use

Stump ulcers are common problems in amputees. Temporary discontinuation of prosthetic limb use is frequently employed to facilitate healing. Inevitably, this limits activity and may, for instance, prevent an amputee from going to work. A survey of clinical practice was carried out based on the premise that controlled continued prosthetic limb use in patients with stump ulcers will not adversely affect the ulcer nor prevent healing. The survey would also form a basis for developing future guidelines in the management of stump ulcers. All consecutive patients attending the Chapel Allerton Hospital prosthetic clinic between January 2003 and May 2004 with stump ulcers were recruited into the study. Primary outcome measures were changes in the surface area of the ulcers and in clinical photographs taken on 2 occasions 6 weeks apart. Some 102 patients with a mean age 60 years (range 18 - 88 years) were recruited. Eight patients who were established prosthetic limb users did not complete the study and were excluded from the analysis. Of the patients 52 were newly referred patients with delayed surgical wound healing while 42 were established prosthetic limb users for at least 1 year. Continued prosthetic limb was associated with a significant reduction in ulcer size (p < 0.05). Mean sizes of the ulcers at first and second observations were 3.30 cm2 (range 0.06 - 81) and 0.70 cm2 (range 0.00 - 13.00) respectively. The ulcers improved in 83 cases while two were unchanged. Deterioration was observed in nine cases. The current clinical practice is to allow most of the patients to commence or continue prosthetic limb wearing despite the presence of stump ulceration. This observational study found that, despite prosthetic use, 60 (64%) cases healed completely within the six-week study period and 23 (25%) ulcers reduced in size. The ulcers were unchanged in 2% of the cases. Deterioration was observed in nine (9%) cases. This survey suggests that the current practice of allowing patients to use their prostheses is safe. A clinical trial is now needed to establish whether this practice alters healing rate or has any other disadvantages for new or established amputees.

Outcome of fitting an ICEROSS prosthesis: views of trans-tibial amputees

A report of the outcome of fitting ICEROSS prostheses to trans-tibial amputees from a subregional amputee rehabilitation centre is presented. This work has mainly concentrated on obtaining patients' own views to judge advantages and disadvantages of ICEROSS compared to their previous patellar-tendon-bearing (PTB) prostheses. Sixty-nine patients were entered for this study, but the results of the study are based on 54 patients who responded. Fifteen patients (27.7%) had rejected their ICEROSS prosthesis at the time of the study. Provision of ICEROSS prostheses did not improve indoor and outdoor walking abilities in terms of distance or use of other walking aids, nor were they more comfortable to wear. An increase in sweating in the first 3 months of wearing ICEROSS was significant, but settled afterwards. The amputees considered that the rate of stump skin breakdown with ICEROSS compared to their PTB prostheses was significantly less. Walking up and down stairs was more comfortable and in general overall rating of ICEROSS prostheses they were scored significantly higher by the amputees themselves. It is concluded that appropriate patient selection is vital and in certain cases ICEROSS will provide considerable benefits to the amputees.

Femoral prosthesis implantation induces changes in bone stress that depend on the extent of porous coating

The objective of this study was to evaluate the effect of implantation of porous-coated anatomic medullary fitting prostheses on stress in the proximal femur. Three-dimensional finite element models of a cadaveric femur before and after implantation were used to evaluate the resulting changes in stress in the bone. Models of the femur were generated automatically from computed tomographic scan data with use of an innovative mesh-generation technique. The models were analyzed for three levels of porous coating (proximal, 5/8, and full), with the assumption of ideal ingrowth (perfect bonding) over porous areas and a frictionless, tension-free surface on smooth areas. All models were loaded and restrained to represent conditions of normal gait. The stresses predicted in the implanted femur are consistent with clinical observations of proximal cortical atrophy (normal stress reduced to 6-9% of normal at the calcar and 50-55% at mid-prosthesis) and of hypertrophy at the porous coating junctions (normal stress at the 5/8-coating junction, 123% of stress proximal to the junction) and hypertrophy near the distal tip of the prosthesis (anterior and posterior normal stresses 200-800% of normal). The fully coated prosthesis induced stresses in the bone near the tip of the prosthesis that were most like stresses in the normal femur (medial and lateral normal stress 105 and 102% of the stress in the normal femur). Below the collar, the normal stress associated with the proximally coated prosthesis was 6% greater than that produced with the other two levels of coating but still was only 2% of normal. The 5/8-coated prosthesis appeared to combine the worst features of the fully coated and proximally coated prostheses--greater stress-shielding at the calcar and higher stress near the tip of the prosthesis.

Experiences with respect to the ICEROSS system for trans-tibial prostheses

This article describes the authors' initial experiences and those of their patients with respect to the ICEROSS system for trans-tibial prostheses. Up to October 1992, 54 patients attending the "Hoensbroeck" Rehabilitation Centre received such a prosthesis. With the aid of patients' records an all-round evaluation has been made. In addition, a survey was undertaken and an examination made amongst the 43 patients who responded to a written request. For 26 patients who were provided with the ICEROSS as a second appliance after having used an older kind of prosthesis a comparison was made with the old system. In general these patients considered the new prosthesis as providing a clear improvement.

ICEROSS--a consensus view: a questionnaire survey of the use of ICEROSS in the United Kingdom

The management of the individual with a trans-tibial amputation has been strongly influence by the increasing use of the ICEROSS socket system over recent years. Despite this growth in clinical experience, there has been very little research into its place in current prosthetic practice, and prescribing activity is largely determined by personal experience. In order to formulate the current consensus view on the use of ICEROSS, questionnaire were sent to 42 doctors and 43 senior prosthetists around the UK. The influence of 38 different factors on prescribing activity was assessed using a grading system (ranging from "primary indication" to "absolute contraindication"). An 85% response rate was achieved and no significant differences in response between the two professional groups were identified. Those factors considered by most to be positive indications for using ICEROSS were "pistoning", "shear-sensitive skin/split-skin grafts", "patient unsuccessful with supracondylar (s/c) or cuff suspension" and "insufficient suspension due to change in type or level of activity". Those considered by most to be absolute contra-indications were "ulceration/unhealed scars", "poor patient hygiene" and "poor commitment to prosthetic rehabilitation". This consensus of opinion is in keeping with the results of the few published adults of ICEROSS usage. There was a lack of consensus, however, about the use of ICEROSS in some situations, including skin complications. Whilst some consensus does exist about the use of ICEROSS, the results of this survey indicate significant variations in clinical practice with serve to illustrate the urgent need for data from prospective clinical trials.

Satisfaction and problems experienced with transfemoral suspension systems: a comparison between common suction socket and seal-in liner

OBJECTIVE

To compare a seal-in liner with the common suction socket with regards to patient satisfaction and problems experienced with the prosthesis.

DESIGN

Retrospective survey.

SETTING

A medical and engineering research center and a department of biomechanical engineering.

PARTICIPANTS

Men (N=90) with traumatic transfemoral amputation who used both suspension systems participated in the study.

INTERVENTION

Two prosthetic suspension systems: a seal-in liner and common suction socket.

MAIN OUTCOME MEASURES

Two questionnaires were completed by each subject to evaluate their satisfaction and problems experienced with the 2 suspension systems. Satisfaction and problems with the prosthetic suspension systems were analyzed in terms of fitting, donning and doffing, sitting, walking, stair negotiation, appearance, sweating, wounds, pain, irritation, pistoning, edema, smell, sound, and durability.

RESULTS

The study revealed that the respondents were more satisfied with a seal-in liner with regards to fitting, sitting, and donning and doffing. Overall satisfaction increased with the use of a seal-in liner compared with the suction socket (P<.05). However, satisfaction with the prosthesis showed no significant differences in terms of walking (flat and uneven surfaces), appearance, and stair negotiation. Furthermore, problems experienced differed significantly between the 2 suspension systems (P<.05). Sweating, wounds, pain, irritation, pistoning, edema, smell, and sound were less problematic with the use of a seal-in liner, whereas durability was significantly better with the suction socket.

CONCLUSIONS

The results of the survey suggest that satisfaction and problems with prosthetic suspension in persons with transfemoral amputation can be improved with a seal-in liner compared with the suction socket, provided that the durability of the liner is enhanced.