Oxygen consumption and gait dynamics in transfemoral bone-anchored prosthesis users compared to socket-prosthesis users: A cross-sectional study

Comparing the mechanical energetics of walking among individuals with unilateral transfemoral limb loss using socket and osseointegrated prosthetic interfaces

Osseointegration (OI), or bone-anchoring, of a prosthesis is a transformative procedure for addressing issues of socket fit among individuals with lower limb loss. Mechanically, the removal of the socket interface substantially alters the transmission of load and the flow of energy through the prosthetic limb. Here, we compared the mechanical energetics of walking between socket and OI interfaces using biomechanical data and custom models of 8 service members pre- and ~24-months post-OI. Relative to a socket interface, an OI interface shifted loads toward the intact limb, which increased collision losses, while the net mechanical work of both the prosthetic and intact limbs remained minimal for both interfaces. At the joint level, despite the removal of the socket interface potentially saving ~ 6 J of work per stride, these reduced collision losses were transmitted to the center of mass instead of altering joint work. The principal change in prosthetic limb joint mechanics with an OI interface was a decrease in negative prosthetic limb hip work during late stance, driven by a decreased hip flexion moment and prosthetic limb offloading. Our findings suggest that despite previously reported improvements in walking economy, after OI individuals likely walk with increased mechanical energetic asymmetry.

The influence of prosthetic suspension on gait and cortical modulations is persons with a transfemoral amputation: socket-suspended versus bone-anchored prosthesis

BACKGROUND

Persons with a transfemoral amputation (TFA) often experience difficulties in daily-life ambulation, including an asymmetrical and less stable gait pattern and a greater cognitive demand of walking. However, it remains unclear whether this is effected by the prosthetic suspension, as eliminating the non-rigid prosthetic connection may influence stability and cortical activity during walking. Spatiotemporal and stability-related gait parameters, as well as cortical activity during walking, were evaluated between highly active individuals (MFC-level K3-4) with a TFA and able-bodied (AB) persons, and between persons with a bone-anchored prosthesis (BAP) and those with a socket-suspended prosthesis (SSP).

METHODS

18 AB persons and 20 persons with a unilateral TFA (10 BAP-users, 10 SSP-users) walked on a treadmill at their preferred speed. Spatiotemporal and margin of stability parameters were extracted from three-dimensional movement recordings. In addition, 126-channel electroencephalogram (EEG) was recorded. Brain-related activity from several cortical areas was isolated using independent component analysis. Source-level data were divided into gait cycles and subjected to time-frequency analysis to determine gait-cycle dependent modulations of cortical activity.

RESULTS

Persons with TFA walked with smaller and wider steps and with greater variability in mediolateral foot placement than AB subjects; no significant differences were found between BAP- and SSP-users. The EEG analysis yielded four cortical clusters in frontal, central (both hemispheres), and parietal areas. No statistically significant between-group differences were found in the mean power over the entire gait cycle. The event-related spectral perturbation maps revealed differences in power modulations (theta, alpha, and beta bands) between TFA and AB groups, and between BAP- and SSP-users, with largest differences observed around heel strike of either leg.

CONCLUSIONS

The anticipated differences in gait parameters in persons with TFA were confirmed, however no significant effect of the fixed suspension of a BAP was found. The preliminary EEG findings may indicate more active monitoring and control of stability in persons with TFA, which appeared to be timed differently in SSP than in BAP-users. Future studies may focus on walking tasks that challenge stability to further investigate differences related to prosthetic suspension.

Transfemoral limb loss modestly increases the metabolic cost of optimal control simulations of walking

Background

In transtibial limb loss, computer simulations suggest that the maintenance of muscle strength between pre- and post-limb loss can maintain the pre-limb loss metabolic cost. These results are consistent with comparable costs found experimentally in select cases of high functioning military service members with transtibial limb loss. It is unlikely that similar results would be found with transfemoral limb loss, although the theoretical limits are not known. Here we performed optimal control simulations of walking with and without an above-knee prosthesis to determine if transfemoral limb loss per se increases the metabolic cost of walking.

Methods

OpenSim Moco was used to generate optimal control simulations of walking in 15 virtual "subjects" that minimized the weighted sum of (i) deviations from average able-bodied gait mechanics and (ii) the gross metabolic cost of walking, pre-limb loss in models with two intact biological limbs, and post-limb loss with one of the limbs replaced by a prosthetic knee and foot. No other changes were made to the model. Metabolic cost was compared between pre- and post-limb loss simulations in paired t-tests.

Results

Metabolic cost post-limb loss increased by 0.7-9.3% (p < 0.01) depending on whether cost was scaled by total body mass or biological body mass and on whether the prosthetic knee was passive or non-passive.

Conclusions

Given that the post-limb loss model had numerous features that predisposed it to low metabolic cost, these results suggest transfemoral limb loss per se increases the metabolic cost of walking. However, the large differences above able-bodied peers of ∼20-45% in most gait analysis experiments may be avoidable, even when minimizing deviations from able-bodied gait mechanics. Portions of this text were previously published as part of a preprint (https://www.biorxiv.org/content/10.1101/2023.06.26.546515v2.full.pdf).

Musculoskeletal model of osseointegrated transfemoral amputees in OpenSim

This study presents a generic OpenSim musculoskeletal model of people with an osseointegrated unilateral transfemoral amputation wearing a generic prosthesis. The model, which consists of seventy-six musculotendon units and two ideal actuators at the knee and ankle joints of the prosthesis, is tested by designing an optimal control strategy that guarantees the tracking of experimental amputee data during level-ground walking while finding the actuators' torques and minimizing the muscle forces. The model can be made subject-specific and, as such, is able to reproduce the kinematics and dynamics of both healthy and amputee subjects. The model provides a tool to analyze the biomechanics of level-ground walking and to understand the contribution of the muscles and of the prosthesis' actuators. The proposed OpenSim musculoskeletal model is released as support material to this study.