Epidemiology of limb loss

[Medical-surgical complications and their impact on patients' return to work whilst follow-up major lower-limb amputations in Hospital del Trabajador in Santiago (HTS)]

INTRODUCTION

The presence of different complications whilst follow-up amputee patients reaches 10-80%. The main objective of this research is to assess the impact of these in the return-to-work of lower-limb traumatic amputation cases.

MATERIALS AND METHODS

A retrospective cohort research was carried out. Clinic-demographic variables information was recollected in order to assess its linkage to different medical-surgical complications and functional outcomes. Survival curves were created to evaluate the return-to-work of patients with and without complications.

RESULTS

A total of 46 patients, on average aged 45.7 years old (91.3% men, 71.7% without comorbidities), were included on this research. The most frequent level of amputation was transtibial (65.2%). Residual limb pain, phantom pain, dermatological-infectious complications and painful neuroma were registered in 80.4%, 58.7%, 50% y 30.4% of the cases respectively. Half of the patients had returned to their workplace after 2years of post-surgical follow-up. The return-to-work rates were significantly lower in patients suffering from residual limb pain (p=0.0083) and from painful neuroma (p=0.0051).

CONCLUSION

Complications are frequent during traumatic-amputee patients' follow-up and, some of them, may impact on the return-to-work rate.

A scoping review on upper extremity prostheses: Satisfaction, barriers, and their implications in resource-limited countries

The rates of prosthetic abandonment are not extensively understood especially in resource-limited countries. A scoping review was conducted to examine the literature on the satisfaction with and barriers to using specifically upper limb prostheses. A systematic search of the literature identified 425 studies. After reviewing the articles using predetermined inclusion and exclusion criteria, 7 cross-sectional studies were included in the final review. Barriers to the use of upper limb prostheses include the characteristics of the prosthesis (type, comfort, weight, functionality, price, and availability) and individual patient factors (recent prosthetic user, level of amputation, congenital and accidental limb loss, pain, and duration between amputation and prosthetic fitting). Considering tailored prosthetic design and funding may result in improved prosthetic adherence.

Association between blood markers and the progression of osseointegration in percutaneous prostheses patients-A pilot study

Patients implanted with osseointegrated (OI) prosthetic systems have reported vastly improved upper and lower extremity prosthetic function compared with their previous experience with socket-suspension systems. However, OI systems have been associated with superficial and deep-bone infections and implant loosening due, in part, to a failure of the osseointegration process. Although monitoring the osseointegration using circulating biomarkers has clinical relevance for understanding the progression of osseointegration with these devices, it has yet to be established. Ten patients were enrolled in this study. Blood samples were collected at pre-selected times, starting before implantation surgery, and continuing to 12 months after the second surgery. Bone formation markers, bone resorption markers, and circulating amino acids were measured from blood samples. A linear mixed model was generated for each marker, incorporating patient ID and age with the normalized marker value as the response variable. Post hoc comparisons were made between 1 week before Stage 1 Surgery and all subsequent time points for each marker, followed by multiple testing corrections. Serial radiographic imaging of the residual limb containing the implant was obtained during follow-up, and the cortical index (CI) was calculated for the bone at the porous region of the device. Two markers of bone formation, specifically bone-specific alkaline phosphatase (Bone-ALP) and amino-terminal propeptide of type I procollagen (PINP), exhibited significant increases when compared with the baseline levels of unloaded residual bone prior to the initial surgery, and they subsequently returned to their baseline levels by the 12-month mark. Patients who experienced clinically robust osseointegration experienced increased cortical bone thickness at the porous coated region of the device. A medium correlation was observed between Bone-ALP and the porous CI values up to PoS2-M1 (p = .056), while no correlation was observed for PINP. An increase in bone formation markers and the lack of change observed in bone resorption markers likely reflect increased cortical bone formation induced by the end-loading design of the Utah OI device used in this study. A more extensive study is required to validate the correlation observed between Bone-ALP and porous CI values.

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

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

Selective peripheral nerve recording using simulated human median nerve activity and convolutional neural networks

BACKGROUND

It is difficult to create intuitive methods of controlling prosthetic limbs, often resulting in abandonment. Peripheral nerve interfaces can be used to convert motor intent into commands to a prosthesis. The Extraneural Spatiotemporal Compound Action Potentials Extraction Network (ESCAPE-NET) is a convolutional neural network (CNN) that has previously been demonstrated to be effective at discriminating neural sources in rat sciatic nerves. ESCAPE-NET was designed to operate using data from multi-channel nerve cuff arrays, and use the resulting spatiotemporal signatures to classify individual naturally evoked compound action potentials (nCAPs) based on differing source fascicles. The applicability of this approach to larger and more complex nerves is not well understood. To support future translation to humans, the objective of this study was to characterize the performance of this approach in a computational model of the human median nerve.

METHODS

Using a cross-sectional immunohistochemistry image of a human median nerve, a finite-element model was generated and used to simulate extraneural recordings. ESCAPE-NET was used to classify nCAPs based on source location, for varying numbers of sources and noise levels. The performance of ESCAPE-NET was also compared to ResNet-50 and MobileNet-V2 in the context of classifying human nerve cuff data.

RESULTS

Classification accuracy was found to be inversely related to the number of nCAP sources in ESCAPE-NET (3-class: 97.8% ± 0.1%; 10-class: 89.3% ± 5.4% in low-noise conditions, 3-class: 70.3% ± 0.1%; 10-class: 52.5% ± 0.3% in high-noise conditions). ESCAPE-NET overall outperformed both MobileNet-V2 (3-class: 96.5% ± 1.1%; 10-class: 84.9% ± 1.7% in low-noise conditions, 3-class: 86.0% ± 0.6%; 10-class: 41.4% ± 0.9% in high-noise conditions) and ResNet-50 (3-class: 71.2% ± 18.6%; 10-class: 40.1% ± 22.5% in low-noise conditions, 3-class: 81.3% ± 4.4%; 10-class: 31.9% ± 4.4% in high-noise conditions).

CONCLUSION

All three networks were found to learn to differentiate nCAPs from different sources, as evidenced by performance levels well above chance in all cases. ESCAPE-NET was found to have the most robust performance, despite decreasing performance as the number of classes increased, and as noise was varied. These results provide valuable translational guidelines for designing neural interfaces for human use.

Evaluation of an interphalangeal-joint prosthetic hand in trans-radial prosthesis users

BACKGROUND

A body-powered functional and cosmetically appeasing hand with moving interphalangeal joints (IPJ-Hand) was created. Function and satisfaction with the IPJ-Hand, conventional hand (CH) and functional hook (FH) in trans-radial prosthesis users were evaluated.

METHODS

Eight participants with trans-radial amputations were provided with three prosthetic hands and performed the Nine Hole Peg Test (NHPT), Brief Activity Measure of Upper Limb Amputees (BAM-ULA) and Quebec User Evaluation of Satisfaction with Assistive Technology QUEST).

RESULTS

The data are shown as the median and interquartile range (IQR) due to skewed data distribution. Differences across hands were seen in NHPT with CH 57 (13.3), FH 49.5 (26.5), IPJ-H and 49 (14.8) seconds respectively. BAM-ULA, 10 (1.5), FH 10 (0.7), and IPJ-Hand 10 (1.7). QUEST scores, FH 28.5 (7.2) with the highest score, IPJ-Hand 26 (6.8), and lastly CH 25.5 (9.2).

CONCLUSION

Individual participant results varied, with some participants performing better on the NHPT when using the IPJ-Hand when compared to the CH and FH. No differences between hands on the BAM-ULA were seen, and although no large differences in QUEST were observed, users performed best using IPJ-Hand.Key messagesAn interphalangeal joint prosthetic hand (IPJ-Hand) offers the similar function of a prosthetic hook, and the appearance of a conventional hand, but with improved dexterity.Minimal resources are needed to create the IPJ-Hand for prosthesis wearers.

Current Concepts in Lower Extremity Amputation: A Primer for Plastic Surgeons

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the goals of lower extremity reconstruction and identify clinical scenarios favoring amputation. 2. Understand lower extremity amputation physiology and biomechanics. 3. Review soft-tissue considerations to achieve durable coverage. 4. Appreciate the evolving management of transected nerves. 5. Highlight emerging applications of osseointegration and strategies to improve myoelectric prosthetic control.

SUMMARY

Plastic surgeons are well versed in lower extremity reconstruction for traumatic, oncologic, and ischemic causes. Limb amputation is an increasingly sophisticated component of the reconstructive algorithm and is indicated when the residual limb is predicted to be more functional than a salvaged limb. Although plastic surgeons have traditionally focused on limb salvage, they play an increasingly vital role in optimizing outcomes from amputation. This warrants a review of core concepts and an update on emerging reconstructive techniques in amputee care.

Altered cortical thickness and structural covariance networks in upper limb amputees: A graph theoretical analysis

BACKGROUND

The extensive functional and structural remodeling that occurs in the brain after amputation often results in phantom limb pain (PLP). These closely related phenomena are still not fully understood.

METHODS

Using magnetic resonance imaging (MRI) and graph theoretical analysis (GTA), we explored how alterations in brain cortical thickness (CTh) and structural covariance networks (SCNs) in upper limb amputees (ULAs) relate to PLP. In all, 45 ULAs and 45 healthy controls (HCs) underwent structural MRI. Regional network properties, including nodal degree, betweenness centrality (BC), and node efficiency, were analyzed with GTA. Similarly, global network properties, including global efficiency (Eglob), local efficiency (Eloc), clustering coefficient (Cp), characteristic path length (Lp), and the small-worldness index, were evaluated.

RESULTS

Compared with HCs, ULAs had reduced CThs in the postcentral and precentral gyri contralateral to the amputated limb; this decrease in CTh was negatively correlated with PLP intensity in ULAs. ULAs showed varying degrees of change in node efficiency in regional network properties compared to HCs (p < 0.005). There were no group differences in Eglob, Eloc, Cp, and Lp properties (all p > 0.05). The real-worldness SCN of ULAs showed a small-world topology ranging from 2% to 34%, and the area under the curve of the small-worldness index in ULAs was significantly different compared to HCs (p < 0.001).

CONCLUSION

These results suggest that the topological organization of human CNS functional networks is altered after amputation of the upper limb, providing further support for the cortical remapping theory of PLP.

[Objective measurement tools that predict success in the fitting of major unilateral lower limb amputations patients]

The profile of the patient who most frequently suffers lower limb amputations is usually an elderly patient with high comorbidity. Physiatrists need objective tools in the assessment of these patients that predict the results of prosthetic programs to increase patient safety and efficiency of prosthetic rehabilitation programs. Given the need to update scientific knowledge in this field, we have carried out a review of the literature with the aim of defining a proposal for tools that facilitate decision-making in the indication of prosthetic rehabilitation in these patients. A bibliographic search strategy has been carried out using the scientific databases PubMed, Web of Science, Scopus and Cochrane Library. The quality of the selected articles has been assessed according to the tools proposed by CASPe.

Hand Surgeons' Understanding of Partial Hand Prostheses: Results of a National Survey Study

PURPOSE

Partial hand amputations are devastating injuries that often negatively affect individuals and communities. Partial hand prostheses can mitigate the burdens of living with an amputation, especially when reconstruction alone cannot restore form or function. However, hand surgeons may be unfamiliar with these newer devices because the prosthetic field is rapidly progressing.

METHODS

An electronic survey was distributed to hand surgeon members of the American Association for Hand Surgery with the intent of assessing surgeons' familiarity with partial hand prosthetic devices and their clinical applications. Survey items used Likert 5-point scales, rank order, multiple-choice, and yes/no question formats. Responses were compared by training background (orthopedic or plastic surgery) and by years of experience (≤10 years in practice or >10 years in practice).

RESULTS

Overall, hand surgeons are unfamiliar with modern partial hand prosthetic devices. Most of the cohort denied working within a multidisciplinary hand team (76.2%) or consulting with a prosthetist prior to revisional surgeries (71.4%). Restoring gross motor function and reducing pain were important outcomes to the cohort (4.42 and 4.17, respectively). Plastic trained hand surgeons were more likely to list toe-to-hand transfers as treatment options for multilevel digital amputations (P = .03) and transmetacarpal amputations (P = .02). Senior hand surgeons were more likely to suggest no treatment for partial thumb amputations (P = .02).

CONCLUSIONS

Expanding surgeon knowledge and encouraging collaboration within a multidisciplinary team may enhance amputee care.

Lower extremity amputations (LEAs) in a tertiary hospital in Togo: a retrospective analysis of clinical, biological, radiological, and therapeutic aspects

BACKGROUND

We analysed the clinical, biological, radiological profiles, and therapeutic patterns of the patients who underwent a surgical lower extremity amputation (LEA) in Togo from 2010 to 2020.

METHODS

Retrospective analysis of clinical files of adult patients who underwent an LEA at a single centre (Sylvanus Olympio Teaching Hospital) from 1st January 2010 to 31st December 2020. Data were analysed by CDC Epi Info Version 7 and Microsoft Office Excel 2013 software.

RESULTS

We included 245 cases. The mean age was 59.62 years (15.22 SD) (range: 15-90 years). The sex ratio was 1.99. The medical history of diabetes mellitus (DM) was found in 143/222 (64.41%) files. The amputation level found in 241/245 (98.37%) files was the leg in 133/241 (55.19%) patients, the knee in 14/241 (5.81%), the thigh in 83/241 (34.44%), and the foot in 11/241 (4.56%). The 143 patients with DM who underwent LEA had infectious and vascular diseases. Patients with previous LEAs were more likely to have the same limb affected than the contralateral one. The odds of trauma as an indication for LEA were twice as high in patients younger than 65 years compared to the older (OR = 2.095, 95% CI = 1.050-4.183). The mortality rate after LEA was 17/238 (7.14%). There was no significant difference between age, sex, presence or absence of DM, and early postoperative complications (P = 0.77; 0.96; 0.97). The mean duration of hospitalization marked in 241/245 (98.37%) files was 36.30 (1-278) days (36.20 SD). Patients with LEAs due to trauma had a significantly longer hospital admission than those with non-traumatic indications, F (3,237) = 5.505, P = 0.001.

CONCLUSIONS

Compared to previous decades, from 2010 to 2020, the average incidence of LEAs for all causes at Sylvanus Olympio Teaching Hospital (Lomé, Togo) decreased while the percentage of patients with DM who underwent LEAs increased. This setting imposes a multidisciplinary approach and information campaigns to prevent DM, cardiovascular diseases, and  relative complications.

Gait Alteration in Individual with Limb Loss: The Role of Inertial Sensors

Amputation has a big impact on the functioning of patients, with negative effects on locomotion and dexterity. In this context, inertial measurement units represent a useful tool in clinical practice for motion analysis, and in the development of personalized aids to improve a patient's function. To date, there is still a gap of knowledge in the scientific literature on the application of inertial sensors in amputee patients. Thus, the aim of this narrative review was to collect the current knowledge on this topic and stimulate the publication of further research. Pubmed, Embase, Scopus, and Cochrane Library publications were screened until November 2022 to identify eligible studies. Out of 444 results, we selected 26 articles focused on movement analysis, risk of falls, energy expenditure, and the development of sensor-integrated prostheses. The results showed that the use of inertial sensors has the potential to improve the quality of life of patients with prostheses, increasing patient safety through the detection of gait alteration; enhancing the socio-occupational reintegration through the development of highly technologic and personalized prosthesis; and by monitoring the patients during daily life to plan a tailored rehabilitation program.

Epidemiology and Outcome of Nontraumatic Lower Limb Amputations

Background

In order to create a solid evidence base for the development of improved management methods, this study was performed to describe the epidemiology and outcome of nontraumatic lower limb amputations (LLAs).

Methods

This descriptive case series was conducted over a period of 4 years. It included all patients of both sexes and all ages who underwent LLAs for nontraumatic indications.

Results

There were a total of 217 patients with 136 (62.67%) men and 81(37.32%) women. The age range was 7 to 71 years, with a mean of 54.25 ± 11.49 years. The most common indication for amputation (41.47%) was diabetic foot gangrene. The most common level of amputation (48.29%) was below knee amputation.

Conclusion

Patients with diabetic foot gangrene, malignant tumors, and chronic neuropathic ulcers with osteomyelitis constituted the bulk of the amputees. Diabetes mellitus, obesity, and hypertension were the commonest comorbidities identified among them. Public awareness and education would ensure prompt and early health seeking at the appropriate time and help to prevent the need for major amputations in many instances. The amputees' improved reintegration into society and ability to become contributing members of society would be ensured by the provision of vigorous rehabilitation.

Feasibility of Magnetic Resonance-Guided High-Intensity-Focused Ultrasound (MRgHIFU) Ablation of Stump Neuromas for the Relief of Chronic Postamputation Neuropathic Pain

Up to 70% of limb amputees develop chronic postamputation neuropathic pain (CPANP) which includes phantom pain and residual limb neuropathic pain due to neuroma formation. CPANP often requires invasive procedures aimed at neuroma ablation. Five amputees received 6 noninvasive magnetic resonance-guided high-intensity-focused ultrasound MRgHIFU treatments ExAblate®, Insightec, Tirat-Carmel, Israel). Although ablative temperature (>65°C) at the neuroma was reached in only 1 patient, pain intensity dropped from 5.7 at baseline to 4.3 and back to 5.6 at 3 and 6 month follow-up. Post-treatment bone necrosis was demonstrated in 1 patient. Although no firm conclusion about the effectiveness of MRgHIFU for CPANP could be drawn, further studies are warranted.

Common fall-risk indicators are not associated with fall prevalence in a high-functioning military population with lower limb trauma

BACKGROUND

Persons with lower limb trauma are at high risk for falls. Although there is a wide range of measures used to assess stability and fall-risk that include performance measures, temporal-spatial gait parameters, and nonlinear dynamic stability calculations, these measures are typically derived from fall-prone populations, such as older adults. Thus, it is unclear if these commonly used fall-risk indicators are effective at evaluating fall-risk in a younger, higher-functioning population of Service members with lower limb trauma.

METHODS

Twenty-one Service members with lower limb trauma completed a battery of fall-risk assessments that included performance measures (e.g., four-square-step-test), and gait parameters (e.g., step width, step length, step time) and dynamic stability measures (e.g., local divergence exponents) during 10 min of treadmill walking. Participants also reported the number of stumbles and falls over the previous 4 weeks. Negative Binomial and Quasibinomial Regressions were used to evaluate the strength of associations between fall-risk indicators and self-reported falls.

FINDING

Participants reported on average stumbling 6(4) times and falling 2(3) times in the previous 4 weeks. At least one fall was reported by 62% of the participants. None of the fall-risk indicators were significantly associated with fall prevalence in this population of Service members with lower limb trauma (p > 0.1).

INTERPRETATION

Despite the high number of reported falls in this young active population, none of the fall-risk indicators investigated effectively captured and quantified the fall-risk. Further research is needed to identify appropriate fall-risk assessments for young, high-functioning individuals with lower limb trauma.

Prosthetic vascular graft management in above-knee amputations

OBJECTIVE

Critical limb ischaemia (CLI) is the most severe state of peripheral arterial disease and is one of the major causes of lower-limb amputations. One of the treatment choices is prosthetic vascular grafts. Despite treatment, CLI may lead to amputation owing to infection or progressive ischaemia. The aim of this study was to show that multidisciplinary planning and surgery for CLI patients with prosthetic grafts decreased the duration of hospital stay, costs, risk of infection and ascending conversion of the amputation level.

METHODS

Forty-two above-knee amputation patients with grafts were retrospectively evaluated. Group A patients (n = 24) had partial excision and group B patients ( n = 18) total excision with or without saphenous patch-plasty, according to the patency of the deep femoral artery. Growth in wound culture, antibiotic therapy duration, conversion to hip disarticulation and hospitalisation periods were compared.

RESULTS

Differences in growth of wound culture (p = 0.007), antibiotic duration (p = 0.003), hip disarticulation (p = 0.029) and duration of hospital stay (p = 0.0001) between the two groups were found to be statistically significant (p < 0.05).

CONCLUSIONS

Management of CLI patients is a complex process, and a multidisciplinary approach is key to avoiding undesirable outcomes. Meticulous planning, including excision of the total graft, while ensuring the vascular supply, is essential.

[Practice of perioperative phantom limb pain prevention in Germany: a nationwide survey]

BACKGROUND

The prevalence of phantom limb pain after major amputation remains high and affected patients suffer from relevant impairments in the quality of life. Perioperative treatment strategies may prevent phantom limb pain. This study aims to assess the state of the perioperative anesthesiological pain management for major amputations. Furthermore, it analyzes potentials for optimization and barriers towards a better treatment of patients with amputations.

MATERIAL AND METHODS

This online survey was distributed by the German Society of Anesthesiology and Intensive Care Medicine (DGAI) mailing list of anesthesiological consultants. It was approved by the Charité ethics board.

RESULTS

Overall, 402 persons participated in this survey. Mostly, general anesthesia (85%), regional anesthesia (63%) and neuraxial anesthesia (49%) were performed in different combinations. Furthermore, 72% of participants reported using i.v. opioids postoperatively, mostly applied via patient-controlled analgesia (PCA). In contrast, preoperative regional anesthesia (74%) and gabapentinoids (67%) were seen as potential methods to improve treatment; however, barrier analysis revealed that treatment options are limited especially by organizational aspects and intrinsic patient factors.

CONCLUSION

This survey describes the current practice of phantom limb pain prevention in Germany. It shows an unmet need for specialized perioperative pain treatment. As the evidence regarding treatment recommendations is limited, further research questions can be deduced from this study.

A Technical Guide for Sciatic Nerve Targeted Muscle Reinnervation in a Transfemoral Amputee

There are approximately 2 million people living with the loss of a major limb in America. It is estimated that 95% of these will have some form of pain associated with their amputation. Phantom limb pain, related to symptomatic neuromas, contributes to amputation morbidity and can be difficult to treat. Studies have shown that targeted muscle reinnervation (TMR), by giving symptomatic neuromas “somewhere to go and something to do,” can be an effective therapy. However, a large proportion of surgeons still treat symptomatic neuromas by burying them in nearby tissue.

Mobility Analysis of AmpuTees (MAAT 7): Normative Mobility Values for Lower Limb Prosthesis Users of Varying Age, Etiology, and Amputation Level

OBJECTIVE

The aim of the study was to establish normative values of lower limb amputation mobility across primary etiologies based on age and amputation level.

DESIGN

This study is a cross-sectional observational analysis of outcomes. A total of 11,995 lower limb prosthesis users were included in the analysis. Participants were grouped by etiology into four categories: cancer, congenital, trauma, and diabetes/dysvascular. Mobility was assessed by using the Prosthetic Limb Users Survey of Mobility.

RESULTS

Mobility across seven age groups for the four etiologies was established for both above-the-knee amputation and below-the-knee amputation. Differences were found between age groups for individuals: above-the-knee amputation: cancer (χ 2 (6) = 40.97, P < 0.001), congenital (χ 2 (3) = 9.41, P = 0.024), trauma (χ 2 (6) = 18.89, P = 0.004), and dysvascular (χ 2 (5) = 39.73, P < 0.001; below-the-knee amputation: cancer (χ 2 (6) = 29.77, P < 0.001), trauma (χ 2 (6) = 28.22, P < 0.001), and dysvascular (χ 2 (6) = 144.66, P < 0.001).

CONCLUSIONS

The awareness of differences across amputation etiologies extending across the lifespan of ages can assist the goal-setting process as part of prosthetic rehabilitation. In addition, refined normative values provide the ability to benchmark new and innovative changes in clinical practice.

Microprocessor-Controlled Prostheses for a Bilateral Transtibial Amputee with Gait Analysis and Satisfaction: A 1-Year Followup Case Report

Bilateral amputees are disadvantaged as they lack healthy leg support. We present the rare case of a bilateral transtibial amputee (BTA), in which we compared the first South Korean-made microprocessor-controlled prosthesis (MPA) to a conventional prosthetic ankle (CPA) with gait analysis and a patient questionnaire for long-term outcomes. A 70-year-old man presented with bilateral transtibial amputations from injury. Assessments were performed after wearing an MPA for 1 month and 1 year with three-dimensional gait analysis. Satisfaction, mobility, and pain were evaluated using the Korean version of the Prostheses Evaluation Questionnaire (K-PEQ). The spatiotemporal parameters of both sides showed increased stability from the CPA to 1 month (mMPA) and 1 year (yMPA). We observed an increased single support time, decreased step width, and almost normal stance-swing time ratio. In kinematic parameters, the ankle range of motion (ROM) was bilaterally increased at mMPA and yMPA. Unfortunately, the MPA gait showed insufficient ankle plantarflexion during the terminal stance that failed to generate push-up power. As the MPA adaptation time increased, the symmetry ratio improved to a balanced value. The questionnaire-based investigations of satisfaction, mobility, and pain revealed excellent results. The MPA proved helpful for ankle mobility in the BTA, and the questionnaire showed good satisfaction and mobility in varied terrain.

Identification of Secondary Biomechanical Abnormalities in the Lower Limb Joints after Chronic Transtibial Amputation: A Proof-of-Concept Study Using SPM1D Analysis

SPM is a statistical method of analysis of time-varying human movement gait signal, depending on the random field theory (RFT). MovementRx is our inhouse-developed decision-support system that depends on SPM1D Python implementation of the SPM (spm1d.org). We present the potential application of MovementRx in the prediction of increased joint forces with the possibility to predispose to osteoarthritis in a sample of post-surgical Transtibial Amputation (TTA) patients who were ambulant in the community. We captured the three-dimensional movement profile of 12 males with TTA and studied them using MovementRx, employing the SPM1D Python library to quantify the deviation(s) they have from our corresponding reference data, using “Hotelling 2” and “T test 2” statistics for the 3D movement vectors of the 3 main lower limb joints (hip, knee, and ankle) and their nine respective components (3 joints × 3 dimensions), respectively. MovementRx results visually demonstrated a clear distinction in the biomechanical recordings between TTA patients and a reference set of normal people (ABILITY data project), and variability within the TTA patients’ group enabled identification of those with an increased risk of developing osteoarthritis in the future. We conclude that MovementRx is a potential tool to detect increased specific joint forces with the ability to identify TTA survivors who may be at risk for osteoarthritis.

Test-retest reliability of the Arabic translation of the Lower Extremity Functional Status of the Orthotics and Prosthetics Users' Survey

BACKGROUND

The number of amputations secondary to diverse factors in Arabic countries is expected to rise in the coming years. Therefore, there is a need for high-quality service that can be monitored by the use of standardized patient-reported outcome measures of amputee patients' functional status. This study aimed to translate the Lower Extremity Functional status Orthotics and Prosthetics Users' Survey (OPUS-LEFS) to Arabic and test its reliability in a sample of Arabic-speaking people with amputation.

METHODS

Standard forward and backward translation, followed by an examination by a team of experts, and then preliminary testing were conducted on the final translation. The OPUS-LEFS was cross-culturally validated, and its test-retest reliability was examined in patients with lower extremity amputations (N = 67).

RESULTS

No issues were observed concerning the patients' understanding or the meaning of the items on the Arabic translation of the OPUS-LEFS. The intraclass correlation coefficient was 0.99 (95% confidence interval [CI]: 0.985 to 0.995), and the mean difference was -0.278 (95% CI: -5.83 to 5.28), indicating excellent test-retest reliability.

CONCLUSIONS

The study's results suggest that the Arabic translation of the OPUS-LEFS is a reliable tool that can be recommended for future use as an outcome measure for patients from Arabic-speaking nations with little knowledge of the English language.

Predictors of amputation-free survival after endovascular intervention for chronic limb-threatening ischemia in the modern era

OBJECTIVE

Chronic limb-threatening (CLTI) is associated with 25% limb loss and 25% mortality at 1-year. Its lethality increases to 45% in patients subjected to a major amputation. Percutaneous peripheral intervention (PPI) constitutes an attractive and less morbid treatment option for patients with CLTI. The purpose of this study was to assess amputation-free survival in a contemporary cohort treated with endovascular recanalization and assess its predictors.

METHODS

Patients with CLTI undergoing endovascular revascularization at a single regional hospital between 2015-2019 were reviewed. Baseline demographic characteristics, Wound, Ischemia, and foot Infection (WIfI) stage, technical details, and clinical outcomes were tabulated. The primary endpoint was amputation-free survival; a p-value < 0.05 was used for univariate screening and inclusion in a multivariable model.

RESULTS

137 limbs in 111 patients were studied. Comorbidities were prevalent and included diabetes (65%), congestive heart failure (21%), and dialysis dependence (18%). The majority of revascularized limbs presented with advanced wounds (66% WIfI stages 3-4; 47% Rutherford category 6). Presenting WIfI stages were similar across races (p=0.26). Peripheral interventions most commonly targeted femoropopliteal disease (69%) although 26% were multilevel. Percutaneous atherectomy, stenting and paclitaxel-coated or eluting devices were utilized in 68%, 28%, and 15% of cases, respectively. After a median follow-up of 16 months (IQR=4-29 months), significant independent predictors of reduced AFS included non-white race (HR=2.96 [1.42-6.17]; p=0.004) and WIfI stage 4 wounds (HR=2.23 [1.10-4.52]; p=0.026). At one year following successful revascularization, only 59%±1% of patients were alive with their limb intact.

CONCLUSIONS

Despite considerable and consistent advances in urban health care delivery and the techniques of PPI, CLTI remains a morbid and deadly disease. Even in the endovascular era, nearly half of all patients presenting with CLTI will lose their limb and/or life within the first year. Unfortunately, late-stage presentation continues to be commonplace. Although endovascular intervention can reliably restore patency to affected arteries, this appears insufficient to restore most patients to health.

Advances in Upper Extremity Prosthetic Technology: Rehabilitation and the Interprofessional Team

Purpose of Review

The aim of this paper is to explore current trends and advancements that lead to improved practitioner knowledge and patient care resulting in better outcomes. It is common for the physiatrist to lead the team of interprofessional practitioners in the care of individuals with upper limb absence. The focus of the care is to understand and access prosthetic options, but there are often other health factors and relevant issues to consider.

Recent Findings

Some of the latest updates offer solutions to pain management, prosthetic control, access to relevant evidence, and outcomes-related data. An interesting finding was the influence of telehealth service delivery on multiple issues faced by this population. These issues include lack of information, pain management, monitoring skin breakdown and peripheral vascular disease, prosthetic training, and access to peers and specialized practitioners.

Summary

The diverse technology advancements in surgical techniques, materials, outcome measures, and data management, as well as telehealth, work together to assist the collaborative interprofessional team to provide contemporary and comprehensive care to this unique population.

Osseointegration Amputation Reconstruction

Purpose of Review

To review the topic of osseointegration amputation reconstruction, which inserts a transcutaneous metal implant into the remaining intramedullary bone of a person with an amputation to facilitate a direct bone-anchored connection to an external prosthesis, eliminating the molded socket interface.

Recent Findings

Evidence continues to build that patients function better and have a higher quality of life with osseointegration implants compared with traditional socket prosthetics. The indications for osseointegration are expanding to additional patient populations and the long-term outcomes available are favorable which supports the continued refinement and utilization of the technology.

Summary

Osseointegration implants offer people with amputations freedom from burdensome socket prosthetics while improving function and quality of life. Mild infections at the skin interface are common but managed effectively with oral antibiotics and rarely lead to deep infection and implant removal. Other serious complications like hip or implant fracture are also uncommon. Additional long-term outcomes are needed along with technologic refinements, especially at the skin implant interface.

The reliability of four standardized concern for falling scales among adults with a major lower extremity amputation

INTRODUCTION

More than 52.4% of people with a lower extremity amputation (PLEA) will fall at least once each year. Previously established standardized scales which evaluate a concern for falling (CFF) were primarily developed among community dwelling older adults. The reliability of commonly used scales to evaluate a CFF among PLEA is needed.

OBJECTIVE

To evaluate test-retest relative and absolute reliability, and agreement of the Modified Survey of Activities and Fear of Falling in the Elderly (mSAFFE), Falls Efficacy Scale - International (FES-I), Consequences of Falling (COF) Scale, Perceived Control Over Falling (PCOF) Scale, and Perceived Ability to Manage Falls (PAMF) Scale among PLEA.

DESIGN

Web-based cross-sectional repeated measures study.

SETTING

Rehabilitation hospital.

PARTICIPANTS

Regularly scheduled appointments (N = 22, mean age ± SD, 63.5 ± 12.9 years) with a transtibial or transfemoral level amputation, completed a prosthetic rehabilitation program, and at minimum of one year using a prosthesis for ambulation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Initial and re-test scores on the mSAFFE, FES-I, COF, PAMF, and PCOF.

RESULTS

Intraclass correlation coefficients (ICC) demonstrated excellent relative reliability of the mSAFFE [ICC = 0.92 (95% CI: 0.82-0.97)], good relative reliability of the FES-I [ICC = 0.87 (95% CI: 0.70-0.94)], and fair relative reliability of the COF [ICC = 0.78 (95% CI: 0.53-0.90)] and PAMF [ICC = 0.73 (95% CI: 0.46-0.88)] scales. The ICC value of the PCOF scale could not be validly calculated and was not further analyzed. Calculated SE of measurement values for the mSAFFE, FES-I, COF, and PAMF scales were small in magnitude and Bland-Altman graphs demonstrated good agreement of initial and re-test scores for all scales.

CONCLUSION

This study provides initial evidence on the suitability and reliable use of the mSAFFE, FES-I, COF, and PAMF scales within this population. Further evaluation of the validity of these scales is needed. This article is protected by copyright. All rights reserved.

Loss of independence as a metric for racial disparities in lower extremity amputation for diabetes: A National Surgery Quality Improvement Program (NSQIP) analysis

INTRODUCTION

This study assessed the association between race/ethnicity and amputation with mortality and loss of independence (LOI) for diabetic gangrene.

METHODS

We analyzed the American College of Surgeons National Surgery Quality Improvement Program database from 2016 to 2019. Chi-squared tests were performed to evaluate differences in baseline characteristics and complications. Multivariable logistic regression was performed to model LOI and 30-day mortality.

RESULTS

5250 patients with diabetes underwent lower extremity amputation as treatment for gangrene. Hispanic patients were more likely to undergo below the knee amputation (BKA) (P = 0.006). Guillotine amputation (GA) was associated with age > 65 (P < 0.0001), independent functional status prior to admission (P < 0.0001), and mortality (OR 1.989, 95%CI 1.29-3.065), but was not associated with LOI. Mortality was less frequent in Black patients (OR 0.432, 95%CI 0.207-0.902), but loss of independence (LOI) was more frequent in Black patients (OR 1.373, 95%CI 1.017-1.853). Hispanic patients were less likely to experience LOI (OR 0.575, 95%CI 0.477-0.693).

CONCLUSIONS

LOI and mortality provide contrasting perspectives on outcomes following lower extremity amputation. Further assessment of risk factors may illuminate healthcare disparities.

Retrospective observational study of characteristics of persons with amputations accessing International Committee of the Red Cross (ICRC) rehabilitation centres in five conflict and postconflict countries

OBJECTIVES

Limb amputation incidence is particularly high in fragile contexts due to conflict, accidents and poorly managed diabetes. The study aim was to analyse (1) demographic and amputation characteristics of persons with any type of acquired amputation (PwA) and (2) time between amputation and first access to rehabilitation in five conflict and postconflict countries.

DESIGN

A retrospective, observational study analysing differences in demographic and clinical factors and time to access rehabilitation between users with traumatic and non-traumatic amputations.

SETTING

Five countries with the highest numbers of PwA in the global International Committee of the Red Cross database (Afghanistan, Cambodia, Iraq, Myanmar, Sudan). Cleaned and merged data from 2009 to 2018 were aggregated by sex; age at amputation and registration; cause, combination and anatomical level of amputation(s); living environment.

PARTICIPANTS

All PwA newly attending rehabilitation.

RESULTS

Data for 28 446 individuals were included (4329 (15.2%) female). Most were traumatic amputations (73.4%, 208 90); of these, 48.6% (138 01) were conflict related. Average age at traumatic amputation for men and women was 26.9 and 24.1 years, respectively; for non-traumatic amputation it was 49.1 years and 45.9 years, respectively. Sex differences in age were statistically significant for traumatic and non-traumatic causes (p<0.001, p=0.003). Delay between amputation and rehabilitation was on average 8.2 years for those with traumatic amputation, significantly higher than an average 3 years for those with non-traumatic amputation (p<0.001).

CONCLUSIONS

Young age for traumatic and non-traumatic amputations indicates the devastating impact of war and fragile health systems on a society. Long delays between amputation and rehabilitation reveal the mismatch of needs and resources. For rehabilitation service providers in fragile settings, it is an enormous task to manage the diversity of PwA of various causes, age, sex and additional conditions. Improved collaboration between primary healthcare, surgical and rehabilitation services, a prioritisation of rehabilitation and increased resource provision are recommended to ensure adequate access to comprehensive rehabilitation care for PwA.

Effective assessments to identify overuse injuries in unaffected limbs of persons with unilateral upper limb amputations

STUDY DESIGN

Cross-sectional study.

INTRODUCTION

Overuse injuries (OI) present major health problems and oftentimes, permanent disability. Persons with unilateral upper limb diagnoses, such as amputation, are at-risk for developing OI in their unaffected limbs. Measures to identify high-risk populations are needed.

PURPOSE OF THE STUDY

Scores on 6 OI-assessments were compared for persons with unilateral upper limb amputations (UULA) and healthy participants. Cutoff values were proposed.

METHODS

Sixty-two persons with UULA and 62 healthy controls completed this study. Scores for hand volume (HV), visual analogue scale (VAS), multi-site Semmes Weinstein Monofilament for median and ulnar nerves (SWM-M/SWM-U), torque range of motion for wrist/finger extension and flexion (TROM-E/TROM-F), intrinsic tightness (IT), and differential flexor tendon gliding (DFTG) were collected before and after 15 minutes of repetitive and resistive exercise. When analyzing collected data, descriptive statistics, and ANOVA were used to identify differences between groups. Receiver operating characteristic curves (ROC), area under the curve (AUC), sensitivity, and specificity were calculated to determine acceptable cutoff scores. Cutoff values with significant AUC ≥ 0.60 and sensitivity ≥ 0.80 were accepted.

RESULTS

Statistically significant differences were found between HV by gender in both pre-exercise and post-exercise conditions. Gain scores for whole sample HV, female HV, and TROM-E were statistically different although differences were small and not meaningful. Significant AUC and acceptable pre-exercise cutoff values included 375 ml. for female HV (sensitivity 89%, specificity 87%), 505 ml. for male HV (sensitivity 81%, specificity 70%), 82 degrees for TROM-E (sensitivity 92%, specificity 71%), and 73 degrees of TROM-F (sensitivity 90%, specificity 89%).

CONCLUSIONS

Potential at-risk OI-related populations, especially unaffected limbs of UULA persons, are best identified by pre-exercise cutoff values using HV by gender, TROM, and single-site SWM 2.83.

Skin adhesion to the percutaneous component of direct bone anchored systems: systematic review on preclinical approaches and biomaterials

Nowadays, direct bone anchored systems are an increasingly adopted approach in the therapeutic landscape for amputee patients. However, the percutaneous nature of these devices poses a major challenge to obtain a stable and lasting proper adhesion between the implant surface and the skin. A systematic review was carried out in three databases (PubMed, Scopus, Web of Science) to provide an overview of the innovative strategies tested with preclinical models (in vitro and in vivo) in the last ten years to improve the skin adhesion of direct bone anchored systems. Fifty five articles were selected after screening, also employing PECO question and inclusion criteria. A modified Cochrane RoB 2.0 tool for the in vitro studies and the SYRCLE tool for in in vivo studies were used to assess the risk of bias. The evidence collected suggests that the implementation of porous percutaneous structures could be one of the most favorable approach to improve proper skin adhesion, especially in association with bioactive coatings, as hydroxyapatite, and exploiting the field of nanostructure. Some issues still remain open as (a) the identification and characterization of the best material/coating association able to limit the shear stresses at the interface and (b) the role of keratinocyte turnover on the skin/biomaterial adhesion and integration processes.

Early Experience with Femoral and Tibial Bone-Anchored Osseointegration Prostheses

Background:

The use of bone-anchored osseointegration implants for amputation reconstruction continues to expand throughout the world. Benefits are thought to include the elimination of socket-related problems and improved control and proprioception of the prosthetic limb. Reported outcomes have been positive, but skepticism remains with regard to the risk of infection and implant failure. Further results from early adopters are therefore needed prior to widespread acceptance and regulatory approval.

Methods:

A retrospective review of the first 31 consecutive patients who underwent implantation of a press-fit osseointegration implant of the femur or tibia with follow-up of at least 6 months was performed. The primary outcome was the patient-reported Questionnaire for persons with a Transfemoral Amputation (Q-TFA) measured preoperatively and 6 to 12 months postoperatively. Patient-Reported Outcomes Measurement Information System (PROMIS) and Limb Deformity-Scoliosis Research Society (LD-SRS) scores, 2-minute and 6-minute walk tests, and complications were also recorded.

Results:

In this study, 18 femoral reconstructions and 13 tibial reconstructions were performed, with a mean follow-up (and standard deviation) of 21.1 ± 9.2 months. Twenty-eight reconstructions were single-stage implantations. All Q-TFA domains improved significantly (p < 0.001) from preoperatively to postoperatively, including the global score (25.0 ± 17.4 to 81.2 ± 17.6 points), prosthetic use (50.2 ± 39.9 to 91.2 ± 18.7 points), prosthetic mobility (49.7 ± 26.9 to 81.4 ± 21.5 points), and prosthetic problems (46.4 ± 17.5 to 9.1 ± 6.6 points). The overall and functional outcome domains of the PROMIS and LD-SRS and the 2-minute walk test (243 ± 107 to 369 ± 151 ft [74 ± 33 to 112 ± 46 m]; p = 0.022) and 6-minute walk test (609 ± 323 to 1,054 ± 555 ft [186 ± 98 to 321 ± 169 m]; p = 0.016) also improved significantly. Serious adverse events included 2 periprosthetic hip fractures, 1 explantation for septic loosening, and 1 explantation for aseptic loosening, with an overall implant retention of 93%. The most common complication was low-grade, soft-tissue infection requiring oral antibiotics.

Conclusions:

Similar to the early experience of other international centers, osseointegration implants improved the overall and functional experience of patients compared with socket prosthetics. Complications were present but manageable and were not a deterrent to ongoing support of the technology.

Level of Evidence:

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

A guillotine amputation at the ankle level-how to quickly remove a septic foot: a case report

As of 2014, diabetes is estimated to affect 422 million people globally. It is well recognised that lower extremity amputations secondary to diabetes have a high mortality rate perioperatively. The purpose of this article is to provide a simple, step-by-step guide to surgeons who need to perform a transtibial amputation. The case report of a 62-year-old female patient with poorly controlled diabetes who developed necrotising fasciitis of the lower extremity and systemic sepsis is used to illustrate the procedure. Knowing how to complete this operation is essential due to its effectiveness in quickly eliminating a source of pedal sepsis.

A Scoping Review of Physical Activity in People With Lower-Limb Loss: 10,000 Steps Per Day?

OBJECTIVE

After amputation, people with lower-limb loss (PLL) face challenges to regain their previous physical activity level. Assessing the scope of evidence regarding physical activity in PLL can identify sources of evidence and gaps within the literature that can influence amputation-related research, outcome assessment choices, and wellness activities. The purpose of this scoping review was to map the evidence regarding steps per day as a physical activity measure for PLL. Specific aims were to (1) identify research designs, (2) catalog population subgroups, (3) document steps per day measurement methods, and (4) provide descriptive data for steps per day in PLL.

METHODS

The MEDLINE, CINAHL, Embase, Web of Science, and AMED databases; and the Journal of Prosthetics and Orthotics archive were searched without language or time limits. Exclusion criteria included no PLL subjects, not peer-reviewed, and no direct step count measure. Inclusion criteria allowed any sample size, nonprosthetic use, and self-reported step count. As a scoping review, only descriptive statistics were compiled, and no methodologic quality assessment was performed.

RESULTS

Twenty-one articles using crossover (8), cohort (4), cross-section (8), and case-study (1) designs were included that reported accelerometer (19) or pedometer (2) data. Studies often mixed amputation etiologies (15/21) and most (13/21) excluded transfemoral amputations. Studies primarily examined people with transtibial amputations (81.2%) and people at independent community walking levels (Medicare functional classifications: K3 = 49.2%, K4 = 36.3%). All 21 studies had fewer than 100 participants, and overall included 515 subjects (343, 66.6% male), mean (SD) age 53.2 (22.1) years. Mean (SD) number of pooled steps per day for PLL was 5087 (2998): 5929 (3047) for transtibial amputations and 3553 (2030) for transfemoral amputations.

CONCLUSIONS

Most PLL have low activity levels compared with the 10,000 steps per day generally recommended or 6000 common in people with diabetes. Research with larger samples, defined subgroups, and data along the recovery continuum would enhance knowledge of physical activity level in PLL.

IMPACT

This scoping review has identified gaps in the research related to steps per day as a measure of physical activity in people with lower-limb loss to guide future research.

LAY SUMMARY

People with lower-limb loss take fewer steps per day than suggested for general health. Increasing steps per day may be a useful goal for this population, and this study is a first step in improving knowledge of physical activity levels in people with lower-limb loss.

Fascicle-Specific Targeting of Longitudinal Intrafascicular Electrodes for Motor and Sensory Restoration in Upper-Limb Amputees

Multichannel longitudinal intrafascicular electrode (LIFE) interfaces provide optimized balance of invasiveness and stability for chronic sensory stimulation and motor recording/decoding of peripheral nerve signals. Using a fascicle-specific targeting (FAST)-LIFE approach, where electrodes are individually placed within discrete sensory- and motor-related fascicular subdivisions of the residual ulnar and/or median nerves in an amputated upper limb, FAST-LIFE interfacing can provide discernment of motor intent for individual digit control of a robotic hand, and restoration of touch- and movement-related sensory feedback. The authors describe their findings from clinical studies performed with 6 human amputee trials using FAST-LIFE interfacing of the residual upper limb.

Parietal Lobe Reorganization and Widespread Functional Connectivity Integration in Upper-Limb Amputees: A rs-fMRI Study

The right parietal lobe plays an important role in body image, and disorders of body image emerge after lesions in the parietal lobe or with parietal lobe epilepsy. Body image disorder also often accompanies upper-limb amputation, in which the patient misperceives that their missing limb is still part of their body. Cortical reorganization is known to occur after upper-limb amputation, but it is not clear how widespread and to what degree functional connectivity (FC) is reorganized post-amputation, nor whether such changes might be related to misperceptions of body image. Twenty-four subjects who had a traumatically upper-limb amputees (ULAs) and 24 age-matched healthy controls (HCs) underwent resting-state functional magnetic resonance imaging (rs-fMRI) scans. Regions of interest (ROIs) in the right superior parietal gyrus (SPG_R) and right inferior parietal lobule (IPL_R) were defined using BrainNet Viewer. We calculated the amplitude of low-frequency fluctuations (ALFF) in ROIs and correlated the ROI mean amplitude of low-frequency fluctuations (mALFF) and mean scores on the phantom limb sensation (PLS) scale and beck depression index (BDI). We also calculated ROIs and whole-brain FC. Compared to the HC group, we observed significantly increased activation (mALFF) in ROIs of the ULA group. Moreover, correlation analyses revealed a significant positive correlation between ROI mALFF and scores on the PLS. There was a significant negative correlation between the SPG_R mALFF and BDI scores. Seed-based, whole-brain FC analysis revealed that FC in the ULA group significantly decreased in many brain regions across the entire brain. The right parietal lobe appears to be involved in some aspect of body awareness and depression in amputation patients. Upper-limb amputation results not only in reorganization in the local brain area formerly representing the missing limb, but also results in more widespread reorganization through FC changes in whole brain.

Psychosocial Factors Influence Physical Activity after Dysvascular Amputation: A Convergent Mixed-Methods Study

BACKGROUND

Physical function is a common target of rehabilitation intervention to improve disability and physical activity after dysvascular lower-limb amputation (LLA); yet, the influence of psychosocial factors on physical activity is unclear.

OBJECTIVE

To identify psychosocial factors with potential to influence clinically relevant measures of physical activity, physical function, and disability in light of participants' narratives.

DESIGN

Convergent mixed-methods.

SETTING

General community.

PARTICIPANTS

Twenty participants with dysvascular LLA were enrolled if their most recent LLA was at least 1 year prior, they were ambulating independently with a prosthesis, and were between 45 and 88 years old.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Quantitative data included physical activity (activPAL; steps/d), physical function (Timed Up-and-Go; TUG), and disability (World Health Organization Disability Assessment Schedule 2.0; WHODAS 2.0). Qualitative data were collected via semistructured interviews.

RESULTS

Higher steps/d was moderately correlated with better TUG time (r = -.58, P < .01), but was not correlated with WHODAS 2.0 score (r = -0.18; P > .10). Qualitative analysis of interviews, using an inductive, team-based, phenomenological approach, identified four themes: (1) perceptions of their prosthesis, (2) fear during mobility, (3) influence of LLA on life activities, and (4) positive outlook within social interactions. Mixed-methods analysis used an iterative approach to interpret and describe how psychosocial factors influence physical activity in four exemplar cases.

CONCLUSIONS

Physical activity in people with dysvascular LLA results from an interaction among perceptions of their prosthesis, fear during mobility, influence of LLA on life activities, and positive outlook within social interactions. The overlapping nature of these themes suggests that interventions targeting psychosocial factors may be associated with improved physical activity, physical function, and subsequent disability after dysvascular LLA.

COVID-19: A catalyst for change in virtual health care utilization for persons with limb loss

The dramatic uptake of virtual care, or telehealth, utilization because of COVID‐19 restrictions for persons with limb loss has led to a much greater understanding of this health care delivery method for this complex patient population. However, much is still unknown. Therefore, the authors provide a comprehensive literature review of existing evidence for virtual care delivery across the phases of amputation rehabilitation, as well as anecdotal evidence, to provide a platform for further discussion and development of research and innovative opportunities. Evidence reveals that virtual care serves as a complement to in‐person health care for individuals with limb loss because it allows for increased accessibility to these services. The authors conclude that continued use of telehealth beyond the COVID‐19 restrictions to optimize outcomes across the continuum of care for persons with limb loss is warranted.

[Correlation among tests and functional assessment scales in the follow-up of prosthetic adaptation in people with lower limb amputation]

INTRODUCTION

There is a wide variety of functional tests and scales for the assessment of different aspects in the adaptation of amputees, but there is still no consensus on which are the most appropriate.

OBJECTIVES

To describe the measures of correlation and association among three functional tests for lower-limb amputees and to define the most appropriate for this assessment. To assess general satisfaction in lower-limb prostheses users and its association with the functional tests.

METHODS

We included 83 unilateral lower-limb amputees who were users of low-cost exoskeletal prostheses. The instruments employed were the Houghton scale, the Prosthesis Evaluation Questionnaire - Mobility Scale (PEQ-MS) and the 2-minute walk test (2MWT). The statistical analysis was performed using the chi-square test and Spearman's correlation coefficient.

RESULTS

The functional tests evaluated had an acceptable correlation and association with each other, but the Spearman correlation between the Houghton scale and the 2MWT was of greater significance (whole sample: r=0.56; below-knee amputees: r=0.53). The association measures did not achieve statistically significant results for above-knee amputees or for general satisfaction.

CONCLUSIONS

The Houghton Scale and the 2MWT showed a good correlation and association with each other, becoming possible first-line instruments for the follow-up of exoskeletal lower limb prosthesis users. No significant association was identified between satisfaction and the instruments measured.

Restoring Form and Function to the Partial Hand Amputee: Prosthetic Options from the Fingertip to the Palm

Partial hand amputations are the most common upper extremity amputations and affect individuals across a spectrum of socioeconomic and geographic backgrounds. Prosthetic devices can provide straightforward solutions to the devastating aesthetic, functional, psychological, and social deficits caused by these injuries. However, because of the recent development of multiple partial hand prosthetic devices, many hand providers remain unaware of their applicability in practice. This article highlights the various classes of partial hand prostheses currently available, including passive functional, body-powered, and externally powered options. Familiarity with these partial hand prostheses will better enable providers to care for partial hand amputees.

Psychometric Assessment of the Connor-Davidson Resilience Scale for People With Lower-Limb Amputation

OBJECTIVE

The purpose of this study was to (1) determine the psychometric properties of the 25- and 10-item Connor-Davidson Resilience Scales (CD-RISC25, CD-RISC10) for people with lower-limb amputation (LLA) in middle age or later, and (2) describe relationships of the CD-RISC with biopsychosocial, sociodemographic, and health variables.

METHODS

Participants were included if their most recent LLA was 1 or more years prior, if they were independently walking with a prosthesis, and if they were between 45 and 88 years of age (N = 122; mean = 62.5 years of age [SD = 8]; 59.5 [mean = 58] months since LLA; 88.5% male; 82.0% with dysvascular etiology; 68.0% with unilateral transtibial LLA). Psychometric analyses included assessment of skewness, floor and ceiling effects, internal consistency, and agreement between versions. Correlation analyses were used to determine associations between the CD-RISC with disability, perceived functional capacity, falls efficacy, life-space, anxiety, depression, self-efficacy, social support, sociodemographic, and health variables. Additionally, quartiles of participants were identified using CD-RISC25 and CD-RISC10 scores and compared using ANOVA and post-hoc comparisons for disability, perceived functional capacity, falls efficacy, and life-space.

RESULTS

Skewness, floor, and ceiling effects of both CD-RISC versions were acceptable. Both versions of the CD-RISC were internally consistent (CD-RISC25: α = .92; CD-RISC10: α = .89). The CD-RISC25 and CD-RISC10 were highly correlated with disability, perceived functional capacity, falls efficacy, anxiety, depression, and self-efficacy (r = 0.52-0.67). CD-RISC25 and CD-RISC10 quartile differences, especially the lowest quartile, were identified for disability, perceived functional capacity, falls efficacy, and life-space.

CONCLUSION

The CD-RISC25 and CD-RISC10 have acceptable psychometric properties for use with people who have LLA. CD-RISC scores are associated with clinically relevant biopsychosocial measures targeted by physical therapist intervention following LLA.

IMPACT

The CD-RISC may be an appropriate tool to measure resilience following LLA.

Indirect Endovascular Revascularization via Collaterals: A New Classification to Predict Wound Healing and Limb Salvage

BACKGROUND

In the setting of chronic limb ischemia, lower extremity (LE) wounds require revascularization of source arteries for wound healing and limb salvage. Direct revascularization of the source artery is preferred but cannot always be performed. Our objective was to analyze the influence of arterial-arterial connections on clinical outcomes after angiosome-directed endovascular revascularization.

METHODS

Consecutive LE wounds in patients with isolated infra-popliteal disease revascularized endovascularly from 2012 to 2016 within a single center were retrospectively reviewed. Treatment was classified as direct revascularization (DR) if the source artery supplying the wound angiosome was treated, indirect revascularization via collaterals (IR-C) if the source artery angiosome was revascularized by another major artery via arterial connections, or indirect revascularization (IR) if direct revascularization of the source artery angiosome was not possible. Demographics, comorbidities, and patient outcomes were collected.

RESULTS

Of 105 patients with 106 LE wounds, there were 35, 38, and 33 patients in the DR, IR-C, and IR groups, respectively. The mean age was 65.8 years old (standard deviation (SD) 11.9) with 81 males (77.1%) and 24 females (22.9%). Average follow-up was 21.0 months (SD 14.0). Overall wound healing rates were 80.0%, 92.1%, and 63.6% for DR, IR-C, and IR, respectively (P = 0.009). Significant differences were found between all 3 group comparisons, DR versus IR-C (P = 0.010), DR versus IR (P = 0.013), IR-C versus IR (P = 0.008). Overall major amputation-free survival was 85.7%, 89.5%, and 69.7% in DR, IR-C, and IR groups, respectively, with statistically significant differences between the IR-C and IR groups (P = 0.036).

CONCLUSIONS

Treating diseased infra-popliteal arteries and improving blood flow via arterial-arterial connections as per the angiosome model improved wound healing and amputation-free survival in this cohort. Although DR is still the gold standard, revascularization using IR-C may give superior healing results even in highly comorbid patients. This offers an additional avenue for treatment, especially when DR is not possible.

Patterns of Sitting, Standing, and Stepping After Lower Limb Amputation

OBJECTIVE

The objectives of this study were to describe sitting, standing, and stepping patterns for people with lower limb amputation (LLA) and to compare sitting, standing, and stepping between people with dysvascular LLA and people with traumatic LLA.

METHODS

Participants with dysvascular or traumatic LLA were included if their most recent LLA was at least 1 year earlier, they were ambulating independently with a prosthesis, and they were between 45 and 88 years old. Sitting, standing, and stepping were measured using accelerometry. Daily sitting, standing, and stepping times were expressed as percentages of waking time. Time spent in bouts of specified durations of sitting (<30, 30-60, 60-90, and >90 minutes), standing (0-1, 1-5, and >5 minutes), and stepping (0-1, 1-5, and >5 minutes) was also calculated.

RESULTS

Participants (N = 32; mean age = 62.6 [SD = 7.8] years; 84% men; 53% with dysvascular LLA) spent most of the day sitting (median = 77% [quartile 1 {Q1}-quartile 3 {Q3} = 67%-84%]), followed by standing (median = 16% [Q1-Q3 = 12%-27%]) and stepping (median = 6% [Q1-Q3 = 4%-9%]). One-quarter (median = 25% [Q1-Q3 = 16%-38%]) of sitting was accumulated in bouts of >90 minutes, and most standing and stepping was accrued in bouts of <1 minute (standing: median = 42% [Q1-Q3 = 34%-54%]; stepping: median = 98% [Q1-Q3 = 95%-99%]). Between-etiology differences included proportion of time sitting (traumatic: median = 70% [Q1-Q3 = 59%-78%]; dysvascular: median = 79% [Q1-Q3 = 73%-86%]) and standing (traumatic: median = 23% [Q1-Q3 = 16%-32%]; dysvascular: median = 15% [Q1-Q3 = 11%-20%]).

CONCLUSION

Participants had high daily volumes of long durations of sitting. Further, these individuals accumulated most physical activity in bouts of <1 minute.

IMPACT

High levels of sedentary behavior and physical inactivity patterns may place people with LLA at greater mortality risk relative to the general population. Interventions to minimize sedentary behaviors and increase physical activity are potential strategies for improving poor outcomes of physical therapy after LLA.

Biomimetic Approaches for Separated Regeneration of Sensory and Motor Fibers in Amputee People: Necessary Conditions for Functional Integration of Sensory-Motor Prostheses With the Peripheral Nerves

The regenerative capacity of the peripheral nervous system after an injury is limited, and a complete function is not recovered, mainly due to the loss of nerve tissue after the injury that causes a separation between the nerve ends and to the disorganized and intermingled growth of sensory and motor nerve fibers that cause erroneous reinnervations. Even though the development of biomaterials is a very promising field, today no significant results have been achieved. In this work, we study not only the characteristics that should have the support that will allow the growth of nerve fibers, but also the molecular profile necessary for a specific guidance. To do this, we carried out an exhaustive study of the molecular profile present during the regeneration of the sensory and motor fibers separately, as well as of the effect obtained by the administration and inhibition of different factors involved in the regeneration. In addition, we offer a complete design of the ideal characteristics of a biomaterial, which allows the growth of the sensory and motor neurons in a differentiated way, indicating (1) size and characteristics of the material; (2) necessity to act at the microlevel, on small groups of neurons; (3) combination of molecules and specific substrates; and (4) temporal profile of those molecules expression throughout the regeneration process. The importance of the design we offer is that it respects the complexity and characteristics of the regeneration process; it indicates the appropriate temporal conditions of molecular expression, in order to obtain a synergistic effect; it takes into account the importance of considering the process at the group of neuron level; and it gives an answer to the main limitations in the current studies.

Improved Self-Reported Comfort, Stability, and Limb Temperature Regulation with an Immediate Fit, Adjustable Transtibial Prosthesis

Objective

The purpose of this investigation was to assess participants’ self-reported satisfaction with an adjustable, immediate fit transtibial prosthetic system as compared to their conventionally fabricated prosthetic device.

Design

A prospective study involving a 2-week single-group pre-post intervention design.

Setting

Physical medicine and rehabilitation clinic of a university hospital.

Participants

Adults (N=27) with transtibial limb loss.

Intervention

Participants were fit with the iFIT prosthetic system and instructed to wear it for a 2-week evaluation period.

Main Outcome Measure

A modified Prosthetic Evaluation Questionnaire (PEQ) scale was completed on the participant’s conventional prosthetic during the initial visit and the iFIT system after 2 weeks.

Results

Twenty-seven persons with lower limb loss were enrolled. Three were lost to follow-up leaving 24 participants with completed data. Three participants had recent amputations with no conventional device for comparison. The modified PEQ scores were significantly higher for the iFIT prosthetic in comparison to their conventional device (29.18±4.63 vs 23.82±6.38, P<.01). Participants were also found to perceive significantly better temperature control with the iFIT prosthetic system (4.19±0.68 vs 2.97±1.02, P<.001). Participants did not report any skin breakdown, prosthetic issues, or falls.

Conclusion

This immediate fit, adjustable transtibial prosthesis demonstrated significantly better patient satisfaction and temperature perception compared to conventional devices. These results are consistent with previous findings and further support the efficacy of an immediate fit adjustable transtibial prosthetic system. Longer-term studies in the United States and internationally are underway to assess the durability and efficacy of this new prosthesis in different populations and settings.

Blood Cell Count Biomarkers, Risk, and Outcomes of Ischemia-Related Lower Limb Amputations: Systematic Review

Lower limb amputations due to ischemia represent an important health care and social issue. However, there are currently no specific biomarkers able to predict the risk of amputation and postamputation complications and prognosis. We conducted a systematic review of studies investigating whether blood cell count indexes of systemic inflammation are linked to the risk and the outcome of lower limb amputations due to ischemia. Overall, in 22 studies involving 8832 patients selected for review, several blood cell count indexes, particularly the neutrophil lymphocyte ratio, showed some promise in terms of predicting amputations and general outcomes of conservative and surgical treatments, as well as postamputation complications and prognosis. However, largely due to methodological limitations, further prospective studies are required to establish the clinical utility and applicability of blood cell indexes in the routine management of patients with ischemia-related lower limb amputations.

Self-Efficacy and Social Support are Associated with Disability for Ambulatory Prosthesis Users After Lower-Limb Amputation

BACKGROUND

Interventions targeting psychosocial factors may improve rehabilitation outcomes for prosthesis users after lower-limb amputation (LLA), but there is a need to identify targeted factors for minimizing disability.

OBJECTIVE

To identify psychosocial factors related to disability for prosthesis users after LLA in middle age or later.

DESIGN

Cross-sectional study.

SETTING

General community.

PARTICIPANTS

Participants with LLA (N = 122) were included in this cross-sectional study if their most recent LLA was at least 1 year prior, they were ambulating independently with a prosthesis, and they were between 45 and 88 years old.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Disability, the primary outcome, was measured using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS). Candidate psychosocial variables included self-efficacy, social support, and motivation, measured using the Self-Efficacy of Managing Chronic Disease questionnaire (SEMCD), Multidimensional Scale of Perceived Social Support questionnaire (MSPSS), and modified contemplation ladder (mCL), respectively. The hypothesis was that greater self-efficacy, social support, and motivation would be associated with lower disability when controlling for covariates.

RESULTS

The covariate model, including etiology, age, sex, U.S. military veteran status, LLA characteristics, time since LLA, medical complexity, and perceived functional capacity, explained 66.1% of disability variability (WHODAS 2.0). Backward elimination of candidate psychosocial variables stopped after removal of motivation (P = .10), with self-efficacy (P < .001) and social support (P = .002) variables remaining in the final model. The final model fit was statistically improved (P < .001) and explained an additional 6.1% of disability variability when compared to the covariate model.

CONCLUSIONS

Greater self-efficacy and social support are related to lower disability after LLA. Findings suggest there may be a role for interventions targeting increased physical function, self-efficacy, and social support for ambulatory prosthesis users after LLA in middle age or later, especially when complicated by multiple chronic conditions.

Technological Advances in Prosthesis Design and Rehabilitation Following Upper Extremity Limb Loss

PURPOSE OF REVIEW

The complexity of the human extremity, particularly the upper extremity and the hand, allows us to interact with the world. Prosthetists have struggled to recreate the intuitive motor control, light touch sensation, and proprioception of the innate limb in a manner that reflects the complexity of its native form and function. Nevertheless, recent advances in prosthesis technology, surgical innovations, and enhanced rehabilitation appear promising for patients with limb loss who hope to return to their pre-injury level of function. The purpose of this review is to illustrate recent technological advances that are moving us one step closer to the goal of multi-functional, self-identifiable, durable, and intuitive prostheses.

RECENT FINDINGS

Surgical advances such as targeted muscle reinnervation, regenerative peripheral nerve interfaces, agonist-antagonist myoneural interfaces, and targeted sensory reinnervation; development of technology designed to restore sensation, such as implanted sensors and haptic devices; and evolution of osseointegrated (bone-anchored) prostheses show great promise. Augmented and virtual reality platforms have the potential to enhance prosthesis design, pre-prosthetic training, incorporation, and use. Emerging technologies move surgeons, rehabilitation physicians, therapists, and prosthetists closer to the goal of creating highly functional prostheses with elevated sensory and motor control. Collaboration between medical teams, scientists, and industry stakeholders will be required to keep pace with patients who require durable, high-functioning prostheses.