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

Assessing Phase-Change Materials as Effective Long-Term Biosensors in Limb Prosthetics

Monitoring and controlling the microclimate at the skin-socket interface of limb prostheses is an important, yet unresolved, clinical problem. Phase-change materials (PCMs) represent a promising biosensor technology that holds the potential to both detect and alter (i.e., stabilize) changes in the temperature of a hybrid biological/mechanical system, such as a prosthesis. The biologically inspired sensor capabilities of PCMs can enhance the internal socket conditions and offer improved comfort and suspension while minimizing skin injuries for prosthesis users. This study investigated how prosthetic liners equipped with PCM biosensors affected the long-term outcomes for prosthesis users. In this double-blinded longitudinal crossover study, a cohort of transtibial prosthesis users wore regular conventional liners for six months and PCM liners for another six months. Prosthesis utilization, physical performance, and gait symmetry were studied using Modus StepWatch, the 2-minute walk test, and the TekScan F-Scan gait test, respectively. Measured parameters from these various tests, acquired at multiple timepoints during the study, were compared pairwise between the two liners per individual. While the obtained quantitative data trends, such as the gait symmetry, favored the PCM liners, no statistically significant differences were found between the PCM and conventional gel liners in any of the study parameters.

The experience of self-managing from the perspective of persons with lower limb loss, prosthetists, and physical therapists

PURPOSE

Persons with lower limb loss (PwLLL) must self-manage their residual limb and their prosthesis to prevent self-management related complications (SMRC). However, the experience of PwLLL as it relates to self-management has not been reported. Thus, the purpose of this study was to explore the experience of self-management from the perspective of PwLLL, prosthetists, and physical therapists.

METHODS

This study had a qualitative design. Twenty-three participants were interviewed (PwLLL = 10, prosthetists = 7, physical therapists = 6). Interviews were transcribed and then coded using constant comparison.

RESULTS

Four prominent themes were developed from the transcripts: (1) embodying the duty of self-management, (2) being a vigilant self-advocate, (3) setting goals collaboratively, and (4) making informed decisions. Each of the four themes were influenced by the health beliefs of the PwLLL, specifically motivation and presence of an internal locus of control.

CONCLUSION

Clinicians should emphasize the therapeutic relationship, including open communication, collaborative goal setting, and promoting an internal locus of control in interactions with PwLLL, as it may play a role in decreasing SMRC and improving clinical outcomes.Implications for rehabilitationSelf-management is a crucial aspect of preventing secondary complications associated with limb loss and prosthesis use.Self-management requires an internal locus of control, problem-solving abilities, and foundational knowledgeClinicians can promote self-management through collaborative goal setting and systematic education.

Development and validation of the Self-Management Assessment for the Residuum and prosThesis system designed for persons with limb loss (SMART)

OBJECTIVE

To develop a system of reliable and valid knowledge assessments of self-management in persons with lower limb loss, along with the accompanying targeted educational interventions (TEIs), known as the Self-Management Assessment for the Residuum and prosThesis (SMART) system.

DESIGN

This 2-phase study used mixed methodology. Phase 1 was development, face validation, and content validation of the 60-item knowledge assessment measure (SMART 60) and the TEI. Phase 2 assessed internal consistency reliability using Kuder-Richardson Formula 20 and the creation of the SMART system, consisting of modules developed from the SMART 60. Validity of the measures using known groups' comparison was analyzed by comparing clinicians (prosthetists and physical therapists) with persons with lower limb loss. Participants were recruited from the Amputee Coalition National Conference in 2018 and 2019.

RESULTS

A total of 140 participants completed this study. Four modules from the SMART 60 were created and designed to integrate as a system. Face validity survey average scores found that 9/10 participants either agreed or strongly agreed that the SMART system has high readability, perceived usefulness, and value for both new and experienced prosthetic users. Measure length ranged from 10 to 45 items with a reliability ranging from Kuder-Richardson Formula 20 = 0.70-0.82. The SMART system demonstrated known-groups validity ( p < 0.05).

CONCLUSION

The SMART system is an integrated series of self-management knowledge assessments with reasonable to good internal consistency reliability and known-groups validity. The TEIs provide directed solutions to identified knowledge gaps on the assessments.

Does socket liner material affect clinical outcomes in lower limb prosthesis users? Insights from a randomized control trial

Among the noted disadvantages of prosthesis suspension by flexible liner is the increased rate of perspiration within the socket, which has the potential to cause discomfort, suspension issues, and tissue damage. In recent years, phase change material technology has been adopted for the use in prosthesis liners. These promise to improve temperature control and, consequently, reduce sweating. Previous work has demonstrated that this approach is effective in slowing the temperature increase at the limb-socket interface, but it was not clear how this would translate to clinical outcomes. This study had the aim to compare conventional and phase change material liners regarding prosthesis utilization, physical performance, and patient-reported outcome measures. A randomized double-blind cross-over study design with 6-month intervention periods was used. Of the 42 enrolled participants, only 50% completed the protocol. The high attrition was in large part because of the COVID-19 pandemic that started disrupting daily life and thereby the data collection midway through the study period. The findings indicate that the temperature control liners were, by trend, associated with better prosthesis utilization. The found effects did not reach the level of statistical significance, which is likely a result of the unduly reduced sample size.

Toward improving residual limb climate within prostheses for persons with lower limb loss: a technical note

BACKGROUND

Individuals with lower limb loss often wear a gel liner and enclosed socket for connecting to a terminal prosthetic device. Historically, a significant limitation to traditional liners and sockets is that they are thermal insulators, thereby trapping heat and moisture within, which can lead to numerous deleterious issues, including loss of suspension and residual limb skin problems, and, in turn, reductions in mobility, function, and overall quality of life. To mitigate these issues, new approaches are therefore needed to enhance the residual limb climate (e.g. breathability and air permeability), allowing the dispersal of heat and moisture from within the liner and socket.

METHODS

In this study, a multidisciplinary team sought to establish the feasibility of an innovative prosthetic liner-socket system, designed to improve residual limb climate by capitalizing on passive (i.e. nonpowered) ventilation to reduce temperature/moisture and improve socket comfort for persons with transtibial amputations. Focus group meetings, along with an iterative design approach, were implemented to establish innovative design and development concepts that led to a passively ventilated liner-socket system.

CONCLUSIONS

Ex vivo design has supported the feasibility of developing a passively ventilated liner-socket. To build on these successes, future development and human subjects testing are needed to finalize a commercially viable system. Implementing a passively ventilated liner-socket system that improves residual limb health and comfort, without compromising function or mobility of the user, into standard clinical care may encourage a more active lifestyle and enhance the quality of life for individuals after lower limb loss.

Measuring discomfort-An objective method for quantifying peak pressure discomfort and improved fit in adults with transtibial amputation

BACKGROUND

Prosthetic socket coupling with the residual limb should be comfortable without causing skin breakdown or excessive pressure. However, users report socket discomfort, and there is a scarcity of objective measurements available to assess this feeling of discomfort. Quantifying the specific pressure may enable clinicians and users to determine and improve comfort levels objectively.

OBJECTIVES

(1) To evaluate if a peak pressure reduction assists in resolving wounds, redness, and pain inside prosthetic sockets in people with transtibial amputation. (2) To determine if peak pressures measured inside the prosthetic socket due to external forces could be used to quantify the level of improvement in socket discomfort.

DESIGN

In this cohort study, we used a pressure sensor to quantify and facilitate adjustments to the prosthetic socket, correlating this information to the user's socket comfort.

SETTING

Outpatient clinic in a tertiary hospital in Singapore.

PARTICIPANTS

People (N = 16) with unilateral transtibial lower limb amputation using a prosthesis.

INTERVENTIONS

NA.

MAIN OUTCOME MEASURES

Peak pressure and socket comfort score (SCS).

RESULTS

The peak pressure value showed a statistically significant reduction across all participants following adjustments at a 50% delta change in pressure (p = .001). This was achieved with a mean number of 2.6 ± 1.4 adjustments per participant. Following the adjustments, the paired t-test results showed a mean increase between the first SCS and final SCS was 2.6 (p = .001).

CONCLUSION

The wound, redness, and pain resolved in 15 of 16 participants regardless of diabetic status following socket adjustments. Although the peak pressures values did not correlate to the SCS score, the reduction in peak pressure saw significant improvement to the SCS. The use of a portable sensor is a fast and efficient means to quantify adjustments inside the prosthetic socket and could potentially be considered as part of future care delivery.

Issues faced by people with amputation(s) during lower limb prosthetic rehabilitation: A thematic analysis

BACKGROUND

Successful rehabilitation is essential to improve the physical and mental outcomes of people with lower limb amputation(s). Individuals have different goals and expectations of successful rehabilitation and experience issues that affect their quality of life.

OBJECTIVES

To determine factors affecting lower limb prosthetic rehabilitation from people with amputation(s), important for studies focusing on prosthetic and socket design and fitting because they provide context of need and user issues.

STUDY DESIGN

Thematic analysis of semistructured interviews.

METHODS

Ten people with amputation(s) were self-selected from a survey identifying factors affecting lower limb prosthetic rehabilitation. The telephone interviews were semistructured exploring the biggest impactors on and frustrations with rehabilitation and the socket. A thematic analysis was completed by following the undermentioned steps: familiarization, coding, generating themes, reviewing themes, defining and naming themes, and reporting.

RESULTS

Five distinct but interrelated themes were identified: External to Prosthesis, Body Impactors, Consequences of Ill-Fit, Prosthesis Irritants, and Work and Social Impact. Those living with amputation(s) mentioned prosthetic-related issues affecting their work and social life, including difficulties wearing their prosthesis all day, the socket's rigidity, and the ability to participate in hobbies.

CONCLUSIONS

The study provides new insights into the issues experienced during prosthetic rehabilitation, highlighting impacts beyond just physical health consequences. The study provides an evidence base for areas of the rehabilitation journey which could be improved to improve the quality of life of people with amputation(s).

Issues Faced by Prosthetists and Physiotherapists During Lower-Limb Prosthetic Rehabilitation: A Thematic Analysis

Successful prosthetic rehabilitation is essential to improve the physical and mental outcomes of people with lower-limb amputation. Evaluation of prosthetic services from a prosthesis user perspective have been published and commissioned by the national bodies, however, the perspectives of clinicians working with service users during rehabilitation have not to date been sought. We sought to determine factors impacting lower-limb prosthetic rehabilitation from a clinician's perspective to inform studies focusing on prosthetic and socket design and fitting. Six clinician (2 prosthetists, 4 physiotherapists) interviewees were self-selected from a survey exploring issues and frustrations during lower-limb prosthetic rehabilitation. Semi-structured interviews explored the impactors on and frustrations with rehabilitation and the prosthetic socket. A thematic analysis was subsequently conducted to identify themes in the responses. Five themes were identified: Service Disparity, Body Impactors, Consequences of Ill-Fit, Prosthesis Irritants, and Limitations of Practice. Each theme, though distinct, relates to the others either as a cause or consequence and should be viewed as such. Addressing the themes will have benefits beyond the issues addressed but also expand into the other themes. This study provides an insight into the clinician perspectives on lower-limb prosthetic rehabilitation, which has not been formally documented to date.

Hyperhidrosis of the residual limb: a narrative review of the measurement and treatment of excess perspiration affecting individuals with amputation

BACKGROUND

Hyperhidrosis (HH) is a relatively common disorder involving excessive sweating, typically of the palms or axilla. HH can also frequently occur after limb amputation, where the remaining residual limb excessively perspires, leading to an increased risk of dermatological disorders and functional limitations, such as the inability to comfortably or safely wear a prosthesis. Although many treatments have been proposed to treat HH within the dermatology community, they are not widely known by healthcare providers typically involved in caring for individuals with acquired limb loss.

OBJECTIVES

To appraise the current state of quantitative and qualitative assessment of HH within the residual limb and examine existing and future treatment strategies for this problem.

STUDY DESIGN

Narrative Literature Review.

METHODS

A literature review focused on the assessment and treatment of excessive sweating of residual limbs.

RESULTS

There is currently no objective or subjective standard to assess or diagnose HH of the residual limb. Conventional therapies for HH do not always translate to the population of individuals with limb loss. Emerging modalities for treating HH show promise toward a permanent resolution of excess perspiration but require additional studies within people with amputation.

CONCLUSIONS

Further research is needed to quantify standard values to objectively and subjectively assess and diagnose hyperhidrosis of the residual limb. New and developing treatments for hyperhidrosis require additional studies to assess efficacy and safety in the residual limb.

Deleterious Musculoskeletal Conditions Secondary to Lower Limb Loss: Considerations for Prosthesis-Related Factors

Significance: The intent of this work was to summarize the existing evidence of, and highlight knowledge gaps specific to, prosthetic devices/componentry and training regimes, particularly in the context of the human-device interaction and deleterious musculoskeletal conditions secondary to lower limb loss. Recent Advances: With the recent and evolving technological advancements in prostheses, there are numerous devices available to individuals with lower limb loss. Current literature demonstrates the importance of expanding the knowledge of all prosthetic device-specific factors and the significance of proper prescription, fit, and alignment, along with adequate device-/activity-specific training, to enhance human-device interaction, reduce gait abnormalities and compensatory motions, and as a result, mitigate risk for secondary musculoskeletal conditions. Critical Issues: Inadequate device prescription, fit, alignment, and training are evident owing to the lack of knowledge or awareness of the many device-specific properties and factors, leading to suboptimal use, as well as, biomechanical compensations, which collectively and adversely affect the function, activity level, and overall health of the prosthesis user. Future Directions: To maximize optimal outcomes after lower limb loss, it is essential to better appreciate the factors that affect both prosthesis use and satisfaction, particularly any modifiable factors that might be targeted in rehabilitation interventions such as device prescription, fit/alignment, and training regimes. A better understanding of such device-specific factors will help enhance the human-device interaction and resulting functional performance, thereby reducing secondary musculoskeletal conditions, allowing for the readiness of the fighting force (return-to-duty/redeployment) and/or improved reintegration into civilian society/work, and overall enhancing quality of life after lower limb loss.

Design of a Single Layer Metamaterial for Pressure Offloading of Transtibial Amputees

While using a prosthesis, transtibial amputees can experience pain and discomfort brought on by large pressure gradients at the interface between the residual limb and the prosthetic socket. Current prosthetic interface solutions attempt to alleviate these pressure gradients using soft homogenous liners to reduce and distribute pressures. This research investigates an additively manufactured metamaterial inlay with a tailored mechanical response to reduce peak pressure gradients around the limb. The inlay uses a hyperelastic behaving metamaterial (US10244818) comprised of triangular pattern unit cells, 3D printed with walls of various thicknesses controlled by draft angles. The hyperelastic material properties are modeled using a Yeoh third-order model. The third-order coefficients can be adjusted and optimized, which corresponds to a change in the unit cell wall thickness to create an inlay that can meet the unique offloading needs of an amputee. Finite element analysis simulations evaluated the pressure gradient reduction from (1) a standard homogenous silicone liner, (2) a prosthetist's inlay prescription that utilizes three variations of the metamaterial, and (3) a metamaterial solution with optimized Yeoh third-order coefficients. Compared to a traditional homogenous silicone liner for two unique limb loading scenarios, the prosthetist prescribed inlay and the optimized material inlay can achieve equal or greater pressure gradient reduction capabilities. These preliminary results show the potential feasibility of implementing this metamaterial as a method of personalized medicine for transtibial amputees by creating a customizable interface solution to meet the unique performance needs of an individual patient.

Synthesis and characterization of a silver nanoparticle-containing polymer composite with antimicrobial abilities for application in prosthetic and orthotic devices

Background

The presence of skin problems in patients using external lower limb prosthesis is recurrent. This has generated the need to develop interfaces for prosthesis with the ability to control microbial growth. Silver nanoparticles (AgNPs) have been implemented in the development of biomaterials because of their high antimicrobial activity. This article discusses the development of an AgNP-containing polymer composite with antimicrobial activity for developing prosthetic liners.

Methods

AgNPs were synthesized using a photochemical method and certain physicochemical properties were characterized. Furthermore, the antimicrobial activity of AgNPs against Staphylococcus aureus ATCC 25923 and methicillin-resistant Staphylococcus aureus (MRSA), was assessed on the basis of their minimum inhibitory concentrations (MICs). AgNPs were incorporated into a silicon elastomer to assess certain physicomechanical properties, antimicrobial activity and cytotoxic effect of the material.

Results

The maximum antimicrobial activity of the material against Staphylococcus aureus ATCC 25923 and MRSA was 41.58% ±2.97% at AgNP concentration of 32.98 μg/mL and 14.85% ±5.94% at AgNP concentration of 16.49 μg/mL, respectively. Additionally, the material exhibited tensile yield strength, rupture tensile strength, and tensile modulus of elasticity of 0.70 - 1.10 MPa, 0.71–1.06 MPa, and 0.20 - 0.30 MPa, respectively. The mechanical characteristics of the material were within the acceptable range for use in external lower limb prosthetic and orthotic interfaces.

Conclusions

It was possible to incorporate the AgNPs in a silicone elastomer, finding that the composite developed presented antimicrobial activity against Staphylococcus aureus ATCC 25923 and MRSA when compared to non-AgNP material samples.

Predictive prosthetic socket design: part 1-population-based evaluation of transtibial prosthetic sockets by FEA-driven surrogate modelling

It has been proposed that finite element analysis can complement clinical decision making for the appropriate design and manufacture of prosthetic sockets for amputees. However, clinical translation has not been achieved, in part due to lengthy solver times and the complexity involved in model development. In this study, a parametric model was created, informed by variation in (i) population-driven residuum shape morphology, (ii) soft tissue compliance and (iii) prosthetic socket design. A Kriging surrogate model was fitted to the response of the analyses across the design space enabling prediction for new residual limb morphologies and socket designs. It was predicted that morphological variability and prosthetic socket design had a substantial effect on socket-limb interfacial pressure and shear conditions as well as sub-dermal soft tissue strains. These relationships were investigated with a higher resolution of anatomical, surgical and design variability than previously reported, with a reduction in computational expense of six orders of magnitude. This enabled real-time predictions (1.6 ms) with error vs the analytical solutions of < 4 kPa in pressure at residuum tip, and < 3% in soft tissue strain. As such, this framework represents a substantial step towards implementation of finite element analysis in the prosthetics clinic.

Effect of temperature-control liner materials on long-term outcomes of lower limb prosthesis use: a randomized controlled trial protocol

Background

In people living with limb loss, addressing the resulting functional deficit with prostheses increases the risk for secondary conditions such as pressure sores, impaired blood perfusion, and injuries from accidental falls. Any of those occurrences can render the prosthesis temporarily useless, making it challenging for users to engage in many activities of daily life, including work, exercise, and social participation. Many of the described issues originate at the interface between residual limb and prosthetic socket, where the objectives of sufficient weight distribution and suspension are conflicting with the necessity to facilitate heat exchange and limit contact pressure and friction.

Recently, prosthesis liners that contain phase-change material have become commercially available, holding the promise that the micro climate at the interface between the residual limb skin and the prosthetic socket can be regulated to reduce the users’ tendency to sweat. Preliminary studies on these liners indicate that the socket temperatures inside the socket stayed lower and rose slower than in conventional liners. However, the clinical relevance of those findings remains unclear.

The purpose of this study is to investigate whether longer (6+ months) periods of use of phase-change material based temperature-control liners have clinically meaningful effects.

Methods

The protocol is a double-blind longitudinal cross-over research design. A sample of trans-tibial prosthesis users are wearing their regular gel or silicone liners for six months and phase-change material liners for another six months in a randomized sequence. Their prostheses is equipped with activity monitors to detect days when they could not wear their prosthesis. In six-week intervals, individuals’ activity, physical performance, and overall prosthesis assessment is recorded using standardized methods.

Discussion

Expected results will inform prescription and reimbursement practice of phase-change material-based prosthesis liners and will help improve and economize prosthetic fitting for people with limb loss. The design and duration of the protocol, including randomization, blinding, and within-subject comparison, will generate scientific evidence of a comparably high level. Inclusion of a comparably large sample and different climates, e.g. across all four seasons, will make findings applicable to a large number of prosthesis users.

Trial registration

Clinicaltrials.gov, NCT03428815. Registered on 12 February 2018.

Reliability and Validity of Measurement Tools for Residual Limb Volume in People With Limb Amputations: A Systematic Review

BACKGROUND

Measurements of residual limb volume often guide decisions on the type and timing of prosthetic prescription. To help inform these decisions, it is important that clinicians use measurement tools that are reliable and valid.

PURPOSE

The aim of this systematic review was to investigate the reliability and validity of measurement tools for residual limb volume in people with limb amputations.

DATA SOURCES

A comprehensive search on MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science was performed on July 11, 2016.

STUDY SELECTION

Studies were included if they examined the reliability or validity of measurement tools for residual limb volume, were conducted on humans, and were published in English.

DATA EXTRACTION

Data were extracted from 11 reliability and 4 validity studies and included study characteristics, volumetric estimates, and reliability and validity estimates. The quality of the studies was also rated.

DATA SYNTHESIS

Data from 2 studies (38 participants) indicated good to excellent intrarater (intraclass correlation coefficient [ICC] ≥0.88) and interrater (ICC ≥0.88) reliability and high between-session reliability (coefficient of variation [CV] = 10%) for water displacement volumetry. One study (28 participants) reported excellent intrarater and interrater reliability (ICC ≥0.93) for the circumferential method, and data from 2 studies (19 participants) indicated high between-session reliability for the optical surface scanner (CV ≤9.8%). Three studies (26 participants) indicated good to excellent between-session reliability results for computed tomography (CV = 9.2%-10.9%). One study (7 participants) showed moderate within-session reliability (CV = 50%). Using water displacement volumetry as the gold standard, 2 studies (79 participants) indicated excellent validity for the circumferential method ( r ≥0.92; ICC ≥0.92). All studies reporting measures of reliability or validity were performed with people who had transtibial amputations.

LIMITATIONS

Only studies published in English and in which water displacement volumetry was used as the gold standard were included in this review. The reliability and validity of the quality rating scale used in this review have not been tested.

CONCLUSIONS

On the basis of a limited number of moderate- to high-quality studies with small sample sizes, circumferential and water displacement methods were found to be reliable, and the circumferential method was found to be valid in people with transtibial amputations. There are inadequate data for drawing conclusions about volume measurement methods in people with other types of limb amputations.

Materials for lower limb prosthetic and orthotic interfaces and sockets: Evolution and associated skin problems

Introduction: Sockets and interfaces are important elements for lower limb orthoses and prostheses, as they allow for proper contact and fit between the devices and the affected limb or stump.Objective: To review the different polymers used in the development of lower limb sockets and external prosthetic and orthotic interfaces, their functional requirements and the possible skin problems caused by their use.Materials and methods: A literature review was conducted using the databases EBSCO, Embase, LILACS, SciELO, ScienceDirect and Scopus.Results: 47 articles and papers that met the inclusion criteria were retrieved. Thermoplastics, thermosets, foams, gels and elastomers are among the polymers used for manufacturing prosthetic and orthotic interfaces and sockets. However, studies estimate that between 32% and 90.9% of the population that use these devices have experienced skin problems on the affected stump or limb, such as excessive sweating, wounds and irritation.Conclusion: There is a clear need for further research to develop prosthetic and orthotic interfaces and sockets for lower limbs that can prevent or control damage to the skin of users.

Sockets for Limb Prostheses: A Review of Existing Technologies and Open Challenges

In the prosthetics field, one of the most important bottlenecks is still the human-machine interface, namely the socket. Indeed, a large number of amputees still rejects prostheses or points out a low satisfaction level, due to a sub-optimal interaction between the socket and the residual limb tissues. The aim of this paper is to describe the main parameters (displacements, stress, volume fluctuations and temperature) affecting the stump-socket interface and reducing the comfort/stability of limb prostheses. In this review, a classification of the different socket types proposed in the literature is reported, together with an analysis of advantages and disadvantages of the different solutions, from multiple viewpoints. The paper then describes the technological solutions available to face an altered distribution of stresses on the residual limb tissues, volume fluctuations affecting the stump overtime and temperature variations affecting the residual tissues within the socket. The open challenges in this research field are highlighted and the possible future routes are discussed, towards the ambitious objective of achieving an advanced socket able to self-adapt in real-time to the complex interplay of factors affecting the stump, during both static and dynamic tasks.

Systematic review of effects of current transtibial prosthetic socket designs--Part 2: Quantitative outcomes

This review is an attempt to untangle the complexity of transtibial prosthetic socket fit and perhaps find some indication of whether a particular prosthetic socket type might be best for a given situation. In addition, we identified knowledge gaps, thus providing direction for possible future research. We followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, using medical subject headings and standard key words to search for articles in relevant databases. No restrictions were made on study design and type of outcome measure used. From the obtained search results (n = 1,863), 35 articles were included. The relevant data were entered into a predefined data form that included the Downs and Black risk of bias assessment checklist. This article presents the results from the systematic review of the quantitative outcomes (n = 27 articles). Trends indicate that vacuum-assisted suction sockets improve gait symmetry, volume control, and residual limb health more than other socket designs. Hydrostatic sockets seem to create less inconsistent socket fittings, reducing a problem that greatly influences outcome measures. Knowledge gaps exist in the understanding of clinically meaningful changes in socket fit and its effect on biomechanical outcomes. Further, safe and comfortable pressure thresholds under various conditions should be determined through a systematic approach.

The Evaluation of Daily Life Activities after Application of an Osseointegrated Prosthesis Fixation in a Bilateral Transfemoral Amputee: A Case Study

Individuals with a transfemoral amputation (TFA) may experience limitations in daily life due to reduced mobility and prosthesis-related problems. An osseointegrated prosthesis fixation (OPF) procedure in amputees might contribute to a solution for patients with short stumps or socket-related problems. To date, no study has specifically described the application of an OPF procedure in individuals with a TFA. This study evaluated the level of daily life activities of a 21-year old service member with a bilateral TFA and cerebral trauma. Due to a short stump length and coordination problems, an OPF procedure was deemed the most suitable option.The result of this procedure and the rehabilitation program showed an increased mobility and satisfaction as obtained by the assessment of life habits questionnaire (LIFE-H) and lower extremity functional scale. The participant was able to walk short distances and the Genium knee provided a stance position. Stair ambulation is impossible because of inadequate muscle capacity.In this specific case we conclude that the quality of life improved through the use of an OPF. However, OPF might not be the appropriate device for every individual with TFA, due to varying bone compositions, co-morbidities, and limited clinical experience and unknown long-term effects.

Incidence, severity, and impact of hyperhidrosis in people with lower-limb amputation

To assess the incidence and severity of self-reported hyperhidrosis in patients with amputation and understand its effects on prosthetic fit or function, a cross-sectional survey of patients at two amputee clinics was performed. Responses from 121 subjects with lower-limb amputation were analyzed. Of these subjects, 66% reported sweating to a degree that it interfered with daily activities, as measured by the Hyperhidrosis Disease Severity Scale. There was a significant association between sweating and interference with prosthetic fit and function. Sweating was more severe in cases of transtibial amputations, patients under the age of 60, warm weather, and vigorous activity. There was no relationship between severity of sweating and time since amputation, etiology of amputation, duration of daily prosthetic use, or reported ability to perform functional tasks. Subjects reported trying multiple interventions, but the self-reported effectiveness of these treatments was low. Hyperhidrosis, a common problem associated with prosthetic usage, varies in severity and often interferes with daily activities. Sweating severity is associated with poor prosthetic fit and function. Risk factors include younger age and transtibial amputation status. Treatment strategies generally lack efficacy. The results of this study may provide guidance for future interventions and treatment options.

Biomedical and psychosocial factors influencing transtibial prosthesis fit: a Delphi survey among health care professionals

PURPOSE

We aimed to reach consensus among professionals caring for prosthesis users, on definitions of biomedical and psychosocial factors, to assess their influence on fit of transtibial prosthesis and to identify new factors.

METHOD

A three-round, internet-based, Delphi survey was conducted among experts recruited via the Dutch National Amputee and Prosthesis Work Group. The main outcome measure was consensus among care professionals on statements concerning new and presented biomechanical and psychosocial factors that influence transtibial prosthesis fit.

RESULTS

Fifty-four experts participated in the survey, and consensus was reached on 67% (46/69) of all statements. Consensus on statements relevant for good prosthesis fit was reached in most of the statements concerning psychosocial factors and on statements concerning the biomedical factors "prosthesis support and suspension". Least consensus was reached on statements concerning the biomedical factor "skin problems and pain in the residual limb".

CONCLUSIONS

Biomedical and psychosocial factors influence transtibial prosthesis fit. Consensus was reached among care professionals in a majority of the presented statements concerning these factors. Implications for Rehabilitation Prosthesis fit and comfort is suboptimal in many prosthesis users. Both biomedical and psychosocial factors influence fit. Biomedical and psychosocial factors should be checked during transtibial prosthesis prescription to achieve and maintain an optimal fit. Consensus on many factors influencing prosthesis fit is achieved among care professionals. Consensus was largest regarding prosthesis support and suspension and least regarding skin problems and pain in the residual limb. This consensus contributes to systematic assessment of prosthesis fit.

Prosthetic options available for the diabetic lower limb amputee

Although the rate of lower limb amputation in patients with diabetes is decreasing, amputation still remains a major complication of diabetes. Prosthetics have been long used to help amputees ambulate. The last decade has seen many advances in prostheses with the enhanced understanding of the mechanics of ambulation and improved use of technology. This review describes the different types of prosthetic options available for below knee, ankle, and foot amputees, emphasizing the latest advances in prosthetic design.

Transtibial prosthesis suspension systems: systematic review of literature

BACKGROUND

Today a number of prosthetic suspension systems are available for transtibial amputees. Consideration of an appropriate suspension system can ensure that amputee's functional needs are satisfied. The higher the insight to suspension systems, the easier would be the selection for prosthetists. This review attempted to find scientific evidence pertaining to various transtibial suspension systems to provide selection criteria for clinicians.

METHODS

Databases of PubMed, Web of Science, and ScienceDirect were explored to find related articles. Search terms were as follows: "Transtibial prosthesis (32), prosthetic suspension (48), lower limb prosthesis (54), below-knee prosthesis (58), prosthetic liner (20), transtibial (193), and prosthetic socket (111)". Two reviewers separately examined the papers. Study design (case series of five or more subjects, retrospective or prospective), research instrument, sampling method, outcome measures and protocols were reviewed.

FINDINGS

Based on the selection criteria, 22 articles (15 prospective studies, and 7 surveys) remained. Sweat control was found to be a major concern with the available suspension liners. Donning and doffing procedures for soft liners are also problematic for some users, particularly those with upper limb weakness. Moreover, the total surface bearing (TSB) socket with pin/lock system is favored by the majority of amputees.

INTERPRETATION

In summary, no clinical evidence is available to suggest what kind of suspension system could have an influential effect as a "standard" system for all transtibial amputees. However, among various suspension systems for transtibial amputees, the Iceross system was favored by the majority of users in terms of function and comfort.

Prosthetic liners for lower limb amputees: a review of the literature

Prosthetic liners exist to improve amputee safety and comfort by adding a cushioning layer between the residual limb and the prosthetic socket. Many choices in liner technology are available, and clinicians often rely on personal intuition and experience to choose which liners are appropriate for which patients. The purpose of this study was to examine the literature to find what scientific evidence exists to inform prescription practices. 'Prosthetic liner' was used as a search term in the Web of Science and PubMed research databases. Fourteen scientific articles met the eligibility criteria and are discussed in this review. The results of this review suggest that there is little scientific evidence to inform prosthetic liner prescription practices. Liner material properties have been well-studied, but their influence on in vivo performance is not well understood. Understanding liner effect on function would be an area of great usefulness.

Skin problems in lower limb amputees: A systematic review

PURPOSE

Skin problems of the stump in lower limb amputees are relative common in daily rehabilitation practice, possibly impeding prosthetic use. This impediment may have great impact in daily life. Our objective was to review literature systematically concerning incidence and prevalence of skin disorders of the stump in lower limb amputees.

METHOD

A literature search was performed in several medical databases (MEDLINE, CINAHL, EMBASE, RECAL) using database specific search strategies. Reference lists in the identified publications were used as threads for retrieving more publications missed in the searches. Only clinical studies and patient surveys were eligible for further assessment.

RESULTS

545 publications were initially found. After selection, 28 publications were assessed for research methodology. Only one publication fulfilled the selection criteria. The prevalence of skin problems in a series of 45 lower leg amputees of 65 years and older was 16%.

CONCLUSIONS

Prevalence and incidence of skin problems of the stump in lower limb amputees are mainly unknown.

Literature review of the possible advantages of silicon liner socket use in trans-tibial prostheses

The silicon liner socket has been used in the trans-tibial prosthesis since the 1980s. Silicon liner sockets are sleeves of silicon material that are rolled onto the stump and fix the prosthesis to it. The producers of the liners propagate many advantages in their use i.e. better suspension of the prosthesis, protection of the stump skin and improved cosmetic appearance. This review was performed to find objective documentation in the literature in support of the advantages in prosthetic fitting and use of silicon liners. A medline search was performed with the key words: "silicon liner socket, Icelandic Roll On Silicon Socket (ICEROSS), trans-tibial prosthesis, lower leg prosthesis and stump sockets". Six articles remained after application of the selection criteria. In two studies clinical examination was done while in the rest questionnaires were used to collect data. The indication for amputation varied from vascular insufficiency, diabetes mellitus and infection to trauma. Most studies mentioned improved prosthetic suspension compared to the conventional supracondylar fitting. Also the walking performance improved with less use of walking aids. There were reports of positive but also negative effects on the skin such as excessive perspiration and itching. Patients had a general preference in prosthetic appearance in favour of the prosthesis with a silicon liner. Further research is needed with the use of objective clinical parameters and a homogenous study group objectively to find advantages in the use of the silicon liner socket in the trans-tibial prosthesis.

A randomized controlled trial comparing functional outcome and cost efficiency of a total surface-bearing socket versus a conventional patellar tendon-bearing socket in transtibial amputees

OBJECTIVE

To compare functional outcome and cost efficiency of a total surface-bearing (TSB) socket with a conventional patellar tendon-bearing (PTB) socket in transtibial amputees.

DESIGN

Prospective randomized controlled trial.

SETTING

Outpatient rehabilitation clinic of a general hospital, rehabilitation research department of a university hospital, and certified prosthetics and orthotics workplace.

PARTICIPANTS

Twenty-six adult unilateral transtibial amputees walking with a prosthesis for at least 1 year.

INTERVENTION

Subjects were randomly assigned to 2 groups: one receiving an ICEX TSB socket, the other a conventional PTB socket.

MAIN OUTCOME MEASURES

Prosthetic Evaluation Questionnaire (PEQ) score, mobility-related activities of daily life, and gait characteristics at baseline and 3 months after initial socket fitting, as well as cost of materials, manufacturing time, and number of visits and interventions.

RESULTS

No significant differences were found between both groups in terms of changes in socket function (PEQ scores, mobility-related activities, gait characteristics). In the TSB sockets, cost of materials was significantly larger, but the manufacturing time was significantly shorter and the number of visits was significantly less than in the PTB sockets.

CONCLUSIONS

Both sockets performed equally well in terms of patient satisfaction, mobility-related activities performed during daily life, and gait performance. Material costs were higher in the TSB group, whereas the manufacturing time in the TSB group was lower.