A long-term review of children with congenital and acquired upper limb deficiency

Functional Outcomes and Health-Related Quality of Life of Adults With Congenital Below-Elbow Amputation in North America

PURPOSE

Congenital below-elbow amputation (BEA) is a common upper-extremity anomaly and generally encompasses 2 diagnoses, symbrachydactyly and transverse deficiency. Little is known about the physical, mental, and social well-being of adults with congenital BEA. A deeper understanding of longitudinal outcomes within this population may help guide family conversations and counseling for patients with congenital BEA.

METHODS

The Shriners Hospitals for Children Health Outcomes Network was queried to identify all patients currently >18 years of age who had been seen as a child between 1975 and 2019 for congenital BEA at 1 of 20 Shriners Hospitals across North America. A unique health survey examining physical functioning, mental health, social outcomes, and health-related quality of life was constructed and sent by mail or in electronic form to eligible patients.

RESULTS

A total of 64 questionnaires were completed. Patients ranged between 18 and 34 years of age, and 70% were female. Nearly two-thirds of patients (64%) reported that a prosthesis was not required and only 14% reported daily prosthetic use. Although respondents reported below-average Patient-Reported Outcomes Measurement Information System (PROMIS) upper-extremity scores, there were no differences in Short-Form 12 or Quick Disabilities of the Arm, Shoulder, and Hand scores relative to the US general population. Study participants had lower PROMIS Pain Intensity and higher PROMIS satisfaction with social roles and activities scores than the US general population, translating to clinically meaningful differences.

CONCLUSIONS

Although adults with congenital BEA report lower upper-extremity functional scores than the general population, they report no clear differences from normative values in self-efficacy, psychosocial well-being, health-related quality of life, or global life satisfaction.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Patient-reported function, quality of life and prosthesis wear in adults born with one hand: a national cohort study

We invited individuals aged above 16 years with a congenital transverse reduction deficiency at and above the wrist born in Norway between 1970 and 2006 to complete the short version of the Disabilities of the Arm, Shoulder and Hand Outcome Measure, the 5-Level EuroQoL-5-Dimension instrument, the RAND 36-Item Short Form Health Survey and a single-item questionnaire on arm function, appearance, pain and prosthesis wear. Of 154 eligible participants, 58 (38%) responded. Their scores were not different from the general population. All had been offered prostheses, and 56 (97%) had been fitted at a median age of 1 year (interquartile range 0-2.8). Of the participants, 37 (64%) were still prosthesis wearers, while 21 (36%) were non-wearers or using gripping devices only. Prosthesis wearers had higher levels of 'vitality' as assessed by the RAND-36 and rated their arm appearance higher, but there were no other score differences, indicating that prosthesis rejection is not associated with worse functional outcomes.Level of evidence: III.

Prenatal radiographic evaluation of congenital transverse limb deficiencies: A scoping review

BACKGROUND

Congenital transverse deficiencies are horizontal deficiencies of the long bones that occur with a reported incidence as high 0.38%. They can occur alone or represent a manifestation of a various clinical syndromes. Diagnosis has traditionally comprised of conventional radiography and prenatal imaging studies. There has been much advancement regarding prenatal imaging modalities to allow for early diagnosis and appropriate treatment.

AIM

To summarize the current state of knowledge on congenital transverse limb deficiencies and to provide an update regarding the radiographic evaluation of congenital transverse limb deficiencies.

METHODS

This IRB-exempt scoping review followed the PRISMA-ScR checklist for scoping reviews strictly. Five search engines were searched for a total of 265 publications. Four authors reviewed these during the screening process. Of these, 51 studies were included in our article. Prenatal magnetic resonance imaging (MRI), 3D Ultrasound, and multidetector Computed tomography (CT) exist are emerging modalities that have the potential to improve diagnosis.

RESULTS

Use of the appropriate classification system, three-dimensional ultrasonography with a maximum intensity projection, and appropriate use of prenatal MRI and prenatal CT can improve diagnosis and inter-provider communication.

CONCLUSION

Further scholarly efforts are required to develop improve standardized guidelines regarding the pre-natal radiographic evaluation of congenital limb deficiencies.

Evolving 3D-Printing Strategies for Structural and Cosmetic Components in Upper Limb Prosthesis

The evolution of prosthetic limbs continues to develop, with novel manufacturing techniques being evaluated, including additive manufacturing. Additive manufacturing (AM), or 3D-printing, holds promise for enabling personalized and tailored medical device options. The requirements for personalized medicine, coupled with the limitations of small-batch manufacturing, have made the technique viable for exploration. In this manuscript, an approach is presented for incorporating additive manufacturing for prostheses, both as a final part and in applications as an intermediate manufacturing step. As a result, through the use of these methods a multi-gesture capable electromyographic prosthesis was designed and manufactured, currently being evaluated in clinical trials for pediatric patients. This paper explored the results of this unique method of applying additive manufacturing techniques, and assessed how the blend of different manufacturing techniques improved performance and reduced device weight. Creating unique and aesthetic cosmetic coverings for the device was achieved through using additive manufacturing as an intermediate manufacturing component and, then, applying thermoforming. Cosmesis components saw a 33% reduction in weight from this change in manufacturing. The approach is explored to blend multiple manufacturing techniques to create cosmesis components and structural components for the prosthesis. The techniques serve the design intent to reduce reported challenges with upper limb prosthesis devices and to encourage device retention. Recommendations for manufacturing strategies are discussed, including the limitations.

Age-dependent Upper Limb Myoelectric Control Capability in Typically Developing Children

Research in EMG-based control of prostheses has mainly utilized adult subjects who have fully developed neuromuscular control. Little is known about children's ability to generate consistent EMG signals necessary to control artificial limbs with multiple degrees of freedom. As a first step to address this gap, experiments were designed to validate and benchmark two experimental protocols that quantify the ability to coordinate forearm muscle contractions in typically developing children. Able-bodied, healthy adults and children participated in our experiments that aimed to measure an individual's ability to use myoelectric control interfaces. In the first experiment, participants performed 8 repetitions of 16 different hand/wrist movements. Using offline classification analysis based on Support Vector Machine, we quantified their ability to consistently produce distinguishable muscle contraction patterns. We demonstrated that children had a smaller number of highly independent movements (can be classified with >90% accuracy) than adults did. The second experiment measured participants' ability to control the position of a cursor on a 1-DoF virtual slide using proportional EMG control with three different visuomotor gain levels. We found that children had higher failure rates and slower average target acquisitions than adults did, primarily due to longer correction times that did not improve over repetitive practice. We also found that the performance in both experiments was age-dependent in children. The results of this study provide novel insights into the technical and empirical basis to better understand neuromuscular development in children with upper-limb loss.

Hierarchical Human-Inspired Control Strategies for Prosthetic Hands

The abilities of the human hand have always fascinated people, and many studies have been devoted to describing and understanding a mechanism so perfect and important for human activities. Hand loss can significantly affect the level of autonomy and the capability of performing the activities of daily life. Although the technological improvements have led to the development of mechanically advanced commercial prostheses, the control strategies are rather simple (proportional or on/off control). The use of these commercial systems is unnatural and not intuitive, and therefore frequently abandoned by amputees. The components of an active prosthetic hand are the mechatronic device, the decoding system of human biological signals into gestures and the control law that translates all the inputs into desired movements. The real challenge is the development of a control law replacing human hand functions. This paper presents a literature review of the control strategies of prosthetics hands with a multiple-layer or hierarchical structure, and points out the main critical aspects of the current solutions, in terms of human's functions replicated with the prosthetic device. The paper finally provides several suggestions for designing a control strategy able to mimic the functions of the human hand.

Treatment approaches for congenital transverse limb deficiency: Data analysis from an epidemiological national survey in Japan

BACKGROUND

Congenital limb deficiency is a rare anomaly that impairs limb function. Transverse deficiency accounts for approximately half of congenital limb deficiency cases. In Japan, there have been no detailed data of clinical features, especially treatment approaches, of this disorder. The present study aimed to investigate the status of treatment approaches of congenital transverse limb deficiency in Japan.

METHODS

From the national epidemiological survey of congenital limb deficiency undertaken in Japan in 2016, all the data of 200 patients with congenital transverse limb deficiencies were extracted. These data were analysed to reveal the treatment approaches of congenital transverse limb deficiency and its basic clinical features.

RESULTS

Surgical treatments and prosthetic or orthotic intervention had been implemented or planned for about one-quarter of patients, respectively. In the upper limb deficiencies, prosthetic or orthotic intervention was likely chosen in cases of deficiency at the metacarpal or proximal to metacarpal level. Surgical treatment was chosen only in cases of deficiency at the carpal or distal to carpal level. Although the number of patients with transverse lower limb deficiencies was small, prosthetic or orthotic intervention was likely chosen in proximal deficiencies, and surgical treatment was likely chosen in distal deficiencies.

CONCLUSIONS

Herein, we revealed the status of treatment approaches for congenital transverse limb deficiency in Japan. Approximately half of the patients had no history of-and no plans for-surgical, prosthetic, or orthotic interventions. Further treatment advances may enable patients with congenital limb deficiencies to increase their participation in daily activities.

STUDY DESIGN

Cross-sectional survey.

Suitability of the Openly Accessible 3D Printed Prosthetic Hands for War-Wounded Children

The field of rehabilitation and assistive devices is being disrupted by innovations in desktop 3D printers and open-source designs. For upper limb prosthetics, those technologies have demonstrated a strong potential to aid those with missing hands. However, there are basic interfacing issues that need to be addressed for long term usage. The functionality, durability, and the price need to be considered especially for those in difficult living conditions. We evaluated the most popular designs of body-powered, 3D printed prosthetic hands. We selected a representative sample and evaluated its suitability for its grasping postures, durability, and cost. The prosthetic hand can perform three grasping postures out of the 33 grasps that a human hand can do. This corresponds to grasping objects similar to a coin, a golf ball, and a credit card. Results showed that the material used in the hand and the cables can withstand a 22 N normal grasping force, which is acceptable based on standards for accessibility design. The cost model showed that a 3D printed hand could be produced for as low as $19. For the benefit of children with congenital missing limbs and for the war-wounded, the results can serve as a baseline study to advance the development of prosthetic hands that are functional yet low-cost.

Effect of prostheses on children with congenital upper limb deficiencies

BACKGROUND

Individual weaknesses in motor skills are a characteristic of children with congenital upper limb deficiencies. These weaknesses increase with age. In Japan, however, prosthetic prescription and subsequent rehabilitation approaches for children with upper limb deficiencies are insufficient and often delayed. This study aimed to elucidate whether rehabilitation approaches, including prostheses prescription and occupational therapy, improve these children's adaptive behaviors, especially their motor skills.

METHODS

The study included nine children, aged 0-6 years, with unilateral transradial or transcarpal upper limb deficiencies. We measured their adaptive behaviors and motor skills at the beginning of prosthetic therapy and after 1.5 years, using the Vineland Adaptive Behavior Scales - Second Edition.

RESULTS

The score for the motor skills domain was significantly lower than the median score of the domains at the beginning of prosthetic therapy. The motor skill weaknesses significantly improved after 1.5 years of prosthetic therapy.

CONCLUSIONS

Although children with congenital upper limb deficiencies have individual weaknesses in their motor skill behavior, it was shown that these weaknesses can be improved through rehabilitation approaches, including occupational and prosthetic therapies. Issuing the appropriate prostheses and implementing the appropriate training to use the prostheses for congenital upper limb deficiencies are reasonable and meaningful interventions to improve quality of life.

Design of a myoelectric 3D-printed prosthesis for a child with upper limb congenital amputation

For an early intervention with children, a prosthetic hand that is affordable, light-weight, and easy to wear and use is vital. Commercial prosthetic hands for children are often too expensive, burdensome and difficult to use. In this research, we attempt to address these issues with a novel design for a prosthetic hand for children. The proposed prosthesis implements two important features: the use of sound biofeedback and a soft socket with in-liner electrodes. We hypothesize that these features will make the hand prosthesis easy to use, lightweight and affordable, improving the control performance and increasing the acceptance rate. Preliminary experiments showed that the proposed prosthesis can be successfully controlled by a congenital amputation.

Perceptions of ability among adults with upper limb absence: impacts of learning, identity, and community

Aims: The purpose of this research was to examine the lived experiences of adults with upper limb absence, specifically the interplay of device use, ability, and quality of life through semi-structured interviews. We sought to draw insight from these experiences to improve the practice and perceptions of adults with upper limb absence, prosthetists, and technology designers.Methods: Semi-structured interviews were conducted and interpreted with phenomenological analysis for fourteen individuals with acquired or congenital limb absence. Through an interpretive phenomenological analysis approach, researchers employed an inductive approach to coding and identification of central themes.Results: Participants shared high perceptions of ability and function, regardless of prosthesis or assistive technology use. Life experiences related to three dimensions strongly influenced perceptions of ability: (1) learning to live with upper limb absence, (2) developing their identity, and (3) connecting with their community. The diversity of experiences across participants highlighted the limitations of identifying "normative" pathways of recovery or device use, emphasizing the need for flexible and adaptable systems that can creatively support personal goals and needs.Conclusions: Integration of novel platforms for professional practice, supportive communities, and technology innovation can support the evolving needs and care of individuals with upper limb absence.Implications for rehabilitationIn this study, perceptions of ability were largely independent of prosthetic use and each individual developed a unique toolkit of devices and strategies to support function in daily life.Clinicians can support perceptions of ability by promoting opportunities for community development and life-long learning.Informal communities, such as online networks, can provide novel device designs, resources for learning, and societal awareness to empower individuals with limb absence.

Coactivation index of children with congenital upper limb reduction deficiencies before and after using a wrist-driven 3D printed partial hand prosthesis

Background

Co-contraction is the simultaneous activation of agonist and antagonist muscles that produces forces around a joint. It is unknown if the use of a wrist-driven 3D printed transitional prostheses has any influence on the neuromuscular motor control strategies of the affected hand of children with unilateral upper-limb reduction deficiencies. Thus, the purpose of the current investigation was to examine the coactivation index (CI) of children with congenital upper-limb reduction deficiencies before and after 6 months of using a wrist-driven 3D printed partial hand prosthesis.

Methods

Electromyographic activity of wrist flexors and extensors (flexor carpi ulnaris and extensor digitorum) was recorded during maximal voluntary contraction of the affected and non-affected wrists. Co-contraction was calculated using the coactivation index and was expressed as percent activation of antagonist over agonist. Nine children (two girls and seven boys, 6 to 16 years of age) with congenital upper-limb deficiencies participated in this study and were fitted with a wrist-driven 3D printed prosthetic hand. From the nine children, five (two girls and three boys, 7 to 10 years of age) completed a second visit after using the wrist-driven 3D printed partial hand prosthesis for 6 months.

Results

Separate two-way repeated measures ANOVAs were performed to analyze the coactivation index and strength data. There was a significant main effect for hand with the affected hand resulting in a higher coactivation index for flexion and extension than the non-affected hand. For wrist flexion there was a significant main effect for time indicating that the affected and non-affected hand had a significantly lower coactivation index after a period of 6 months.

Conclusion

The use of a wrist-driven 3D printed hand prosthesis lowered the coactivation index by 70% in children with congenital upper limb reduction deficiencies. This reduction in coactivation and possible improvement in motor control strategies can potentially improve prosthetic rehabilitation outcomes.

Adaptive behaviour and motor skills in children with upper limb deficiency

BACKGROUND

The dysfunction of individuals with upper limb deficiencies affects their daily lives and social participation.

OBJECTIVES

To clarify the adaptive behaviours and motor skills of children with upper limb deficiencies.

STUDY DESIGN

Cross-sectional survey.

METHODS

The subjects were 10 children ranging from 1 to 6 years of age with unilateral upper limb deficiencies at the level distal to the elbow who were using only cosmetic or passive prostheses or none at all. To measure their adaptive behaviour and motor skills, the Vineland Adaptive Behavior Scales, Second Edition was used. They were evaluated on the domains of communication, daily living skills, socialization and motor skills. We also examined the relationship of the scores with age.

RESULTS

There were no statistically significant scores for domains or subdomains. The domain standard score of motor skills was significantly lower than the median scores of the domains and was negatively correlated with age.

CONCLUSION

Children with upper limb deficiencies have individual weaknesses in motor skill behaviours, and these weaknesses increase with age. It may be helpful in considering approaches to rehabilitation and the prescription of prostheses to consider the characteristics and course of children's motor skill behaviours. Clinical relevance Even if children with unilateral upper limb deficiencies seem to compensate well for their affected limb function, they have or will experience individual weaknesses in motor skills. We should take this into consideration to develop better strategies for rehabilitation and prostheses prescriptions.

Case-study of a user-driven prosthetic arm design: bionic hand versus customized body-powered technology in a highly demanding work environment

BACKGROUND

Prosthetic arm research predominantly focuses on "bionic" but not body-powered arms. However, any research orientation along user needs requires sufficiently precise workplace specifications and sufficiently hard testing. Forensic medicine is a demanding environment, also physically, also for non-disabled people, on several dimensions (e.g., distances, weights, size, temperature, time).

METHODS

As unilateral below elbow amputee user, the first author is in a unique position to provide direct comparison of a "bionic" myoelectric iLimb Revolution (Touch Bionics) and a customized body-powered arm which contains a number of new developments initiated or developed by the user: (1) quick lock steel wrist unit; (2) cable mount modification; (3) cast shape modeled shoulder anchor; (4) suspension with a soft double layer liner (Ohio Willowwood) and tube gauze (Molnlycke) combination. The iLimb is mounted on an epoxy socket; a lanyard fixed liner (Ohio Willowwood) contains magnetic electrodes (Liberating Technologies). An on the job usage of five years was supplemented with dedicated and focused intensive two-week use tests at work for both systems.

RESULTS

The side-by-side comparison showed that the customized body-powered arm provides reliable, comfortable, effective, powerful as well as subtle service with minimal maintenance; most notably, grip reliability, grip force regulation, grip performance, center of balance, component wear down, sweat/temperature independence and skin state are good whereas the iLimb system exhibited a number of relevant serious constraints.

CONCLUSIONS

Research and development of functional prostheses may want to focus on body-powered technology as it already performs on manually demanding and heavy jobs whereas eliminating myoelectric technology's constraints seems out of reach. Relevant testing could be developed to help expediting this. This is relevant as Swiss disability insurance specifically supports prostheses that enable actual work integration. Myoelectric and cosmetic arm improvement may benefit from a less forgiving focus on perfecting anthropomorphic appearance.

Building blocks system for a prosthesis training of a child with congenital amputee

Our objective is to provide a novel habilitation experience using play to children with special needs, in particular to those with congenital defects of the upper limbs. Our concept is a device-assisted motivational training session using tangible building block devices. In order to verify the feasibility of our concept with used bioToys in a clinical training session with occupational therapists. Our participant was a one-year-old girl with congenital amputation of the right upper limb. We verified that bioToys could be used in clinical training for a prosthesis, and could assist with both playful training and quantitative therapeutic evaluation.

Upper Limb Sensation in Children with Congenital Limb Deficiencies: Implications for Function and Prosthetic Use

Little is known about sensation in children with upper limb congenital deficiencies. Is sensation different in the deficient limb? If so, does sensation influence function and determine whether or not a prosthesis is used? This study was undertaken to measure sensation in children with transradial congenital limb deficiencies and to explore possible associations with function and prosthetic use.

Twenty-four children and adolescents were evaluated on touch pressure and kinaesthesia measurement tools. The participants' parents were required to rate their child's performance on everyday functional activities and, where appropriate, report on their child's patterns of prosthetic use. The results revealed that most participants had better touch pressure sensation at the stump circumference of the deficient limb, not only compared with the same level on the intact limb (p = 0.06) but also compared with the hand (p = 0.008). All the participants demonstrated perfect scores for kinaesthetic awareness for both limbs. No strong association was found between touch pressure and performing functional activities or prosthetic use patterns.

This study is an important contribution to understanding upper limb sensation in children with congenital limb deficiencies and the implications for function and prosthetic use. Further research involving multiple centres would provide an adequate sample size to explore more fully sensation in children with congenital upper limb deficiencies and its possible association with function and prosthetic use.

Upper Limb Absence: Predictors of Work Participation and Work Productivity

OBJECTIVES

To analyze work participation, work productivity, contributing factors, and physical work demands of individuals with upper limb absence (ULA).

DESIGN

Cross-sectional study: postal survey (response rate, 45%).

SETTING

Twelve rehabilitation centers and orthopedic workshops.

PARTICIPANTS

Individuals (n=207) with unilateral transverse upper limb reduction deficiency (RD) or acquired amputation (AA), at or proximal to the carpal level, between the ages of 18 and 65 years, and a convenience sample of control subjects (n=90) matched on age and sex.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Employment status, self-reported work productivity measured with the Quality-Quantity method, and self-reported upper extremity work demands measured with the Upper Extremity Work Demands scale.

RESULTS

Seventy-four percent of the individuals with RD and 57% of the individuals with AA were employed (vs 82% of the control group and 66% of the general population). Male sex, younger age, a medium or higher level of education, prosthesis use, and good general health were predictors of work participation. Work productivity was similar to that of the control group. Higher work productivity was inversely related to musculoskeletal complaint-related pain. When having predominantly mentally demanding work, individuals with ULA perceived higher upper extremity work demands compared with controls.

CONCLUSIONS

Work participation of individuals with RD was slightly higher compared with that of the general population, whereas employment rates of individuals with AA were slightly lower. Furthermore, work productivity did not differ between individuals with RD, AA, and controls.

Use of Powered Prosthesis for Children with Upper Limb Deficiency at Hyogo Rehabilitation Center

Background

There has been no research investigating the use of powered prosthetic for children in Japan.

Objective

To gain better insight into the state of powered prosthesis usage and identify a ratio of rejection among children.

Methods

Subjects were 37 unilateral below elbow amputees between the ages of 0 and 16 at the time of their first experienced fitting with a powered prosthesis at our Center. The information was collected from medical records and through face-to-face interviews, and we examined rejection rate and the factors affecting the use of powered prosthesis.

Results

The rate of discontinuation was 21.6% as 8 of the 37 children stopped using powered prosthesis. All of them were fitted their prosthesis after 2 years of age, and they rejected prosthesis between 5 to 19 years. We found that the level of amputation had no influence on the use of a powered prosthesis.

Conclusions

Children fitted before 2 years of age tend to accept their powered prosthesis than those fitted after 2 years. Multidisciprinary team approach, adequate rehabilitation, detailed follow-up and involvement of parents are quite important for introducing powered prosthesis for children.

A custom bicycle handlebar adaptation for children with below elbow amputations

As hand therapists, we are always using our creativity to help our patients participate in functional, desired activities. These authors share their expertise in adapting bicycles for children with below elbow amputations.

Cyborg beast: a low-cost 3d-printed prosthetic hand for children with upper-limb differences

BACKGROUND

There is an increasing number of children with traumatic and congenital hand amputations or reductions. Children's prosthetic needs are complex due to their small size, constant growth, and psychosocial development. Families' financial resources play a crucial role in the prescription of prostheses for their children, especially when private insurance and public funding are insufficient. Electric-powered (i.e., myoelectric) and body-powered (i.e., mechanical) devices have been developed to accommodate children's needs, but the cost of maintenance and replacement represents an obstacle for many families. Due to the complexity and high cost of these prosthetic hands, they are not accessible to children from low-income, uninsured families or to children from developing countries. Advancements in computer-aided design (CAD) programs, additive manufacturing, and image editing software offer the possibility of designing, printing, and fitting prosthetic hands devices at a distance and at very low cost. The purpose of this preliminary investigation was to describe a low-cost three-dimensional (3D)-printed prosthetic hand for children with upper-limb reductions and to propose a prosthesis fitting methodology that can be performed at a distance.

RESULTS

No significant mean differences were found between the anthropometric and range of motion measurements taken directly from the upper limbs of subjects versus those extracted from photographs. The Bland and Altman plots show no major bias and narrow limits of agreements for lengths and widths and small bias and wider limits of agreements for the range of motion measurements. The main finding of the survey was that our prosthetic device may have a significant potential to positively impact quality of life and daily usage, and can be incorporated in several activities at home and in school.

CONCLUSIONS

This investigation describes a low-cost 3D-printed prosthetic hand for children and proposes a distance fitting procedure. The Cyborg Beast prosthetic hand and the proposed distance-fitting procedures may represent a possible low-cost alternative for children in developing countries and those who have limited access to health care providers. Further studies should examine the functionality, validity, durability, benefits, and rejection rate of this type of low-cost 3D-printed prosthetic device.

Prognostic factors of a satisfactory functional result in patients with unilateral amputations of the upper limb above the wrist that use an upper limb prosthesis

PURPOSE

The purpose of this study is to determine the prognostic factors of a satisfactory functional outcome in patients using upper extremity prosthetics with a proximal third forearm stump, and above, level of amputation.

MATERIALS AND METHODS

All patients with longitudinal deficiencies and traumatic amputations of upper extremity with a level of amputation of proximal third forearm and above were included. A total of 49 patients with unilateral upper extremity amputations that had used the prosthetic for a minimum of 2 years were included in the protocol. The Disability arm shoulder hand (DASH) scale was used to determine a good result with a cut-off of less than 40%. The independent variables were the level of amputation, the etiology for its use, initial age of use and number of hours/day using the prosthesis.

RESULTS

It was found that patients with a congenital etiology and those that started using the prosthetic before 6 years of age had better functional results.

DISCUSSION

It was found that when adapting a patient with an upper extremity prosthetic, which has a high rejection rate of up to 49%, better functional outcomes are found in those who started using it before 6 years of age, and preferably because of a congenital etiology. It was also found that the number of hours/day strongly correlates with a favorable functional outcome.

Use of an iliac crest growth plate for the development of a neo-articulation for congenital transverse deficiencies at the wrist

PURPOSE

Terminal congenital transverse deficiencies of the wrist and hand are rare malformations. They are usually treated with prosthetic devices. We describe here a surgical technique to create a neo-articulation that could provide mobility distal to the forearm and help children with terminal transverse deficiencies use orthotic devices.

METHODS

This procedure involved an autologous, nonvascularized graft from the immature iliac crest. The graft was placed with its cartilaginous side facing the radial and ulnar articular surfaces. We studied the clinical, radiological, and functional outcomes of this technique in 2 pediatric cases 5 and 14 years after this procedure.

RESULTS

The x-rays showed a mobile graft distally in the forearm. Magnetic resonance imaging showed a space between the graft and the radius and an intermediate signal on either side of the space highly suggestive of articular cartilage. These various elements were organized into a neo-articulation between the forearm and the graft. The functional ability at follow-up was greater compared with the absence of a graft.

CONCLUSIONS

The results of basic research work on cartilage and chondrocytes may help explain the presence of persistent cartilaginous tissue on the articulated part of the graft. The good functional outcome provided by our surgical procedure may translate into reduced need for prosthesis acceptance. Our surgical procedure does not restore limb length, but does add a new functional ability.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Age at first prosthetic fitting and later functional outcome in children and young adults with unilateral congenital below-elbow deficiency: a cross-sectional study

The objective of this study was to evaluate whether prosthetic fitting before the age of one year is associated with better outcomes in children with unilateral congenital below-elbow deficiency compared to children fitted after the age of one. Twenty subjects aged 6-21 years were recruited (five prosthetic users and 15 non-users). The Child Amputee Prosthetics Project-Prosthesis Satisfactory Inventory (CAPP-PSI) and the Prosthetic Upper Extremity Functional Index (PUFI) were used to assess patient satisfaction and functional use of the prosthesis. Videotapes were used to assess motor performance. Initial prosthetic fitting before one year of age was related to use of a prosthesis for at least four years. Age at first fitting was not associated with satisfaction with the prosthesis, functional use of the prosthesis or motor skills. Discrepancies between ease of performance with prosthesis and usefulness of the prosthesis as well as between capacity and performance of activities were found. The video assessments showed impaired movement adaptation to some tasks in six subjects. In conclusion, early prosthetic fitting seems to have a limited impact on prosthesis use during later stages of life.

Comparison of clinical test and questionnaires for the evaluation of upper limb prosthetic use in children

PURPOSE

The aim of the present study was to find out if there was a correlation between an observational clinical test and a questionnaire for the evaluation of upper limb prosthetic use in children and to determine which one was better and easier to use in clinical practice.

METHOD

Twenty children who were patients of the children's prosthetic clinic at the Rehabilitation Institute in Ljubljana, Slovenia, and had a functional prosthesis were included in the study. The age appropriate subtest of the University of New Brunswick Test of Prosthetic Function (the UNB test) was assessed by an occupational therapist. Parents completed either the Child Amputee Prosthetics Project-Functional Status Inventory for Preschool children (CAPP-FSIP) or the Child Amputee Prosthetics Project-Functional Status Inventory (CAPP-FSI), depending on which was appropriate for the child's age. Information was limited to the upper extremity items.

RESULTS

We found a significant correlation between UNB spontaneity and skill score (r = 0.956, p = 0.000) and also between the parental CAPP score and UNB test (UNB spontaneity--CAPP activities r = 0.634, p = 0.003; UNB spontaneity--CAPP prosthetic use r = 0.542, p = 0.014, UNB skill--CAPP activities r = 0.559, p = 0.010, UNB skill--CAPP prosthetic use r = 0.597, p = 0.005).

CONCLUSIONS

We concluded that both instruments can be used for assessing upper limb prosthetic use in children but neither is an optimal choice.

The roles of predisposing characteristics, established need, and enabling resources on upper extremity prosthesis use and abandonment

PURPOSE

Prosthesis use and abandonment is a complex function of variables defining the contextualized individual. This review presents a comprehensive panoramic of these factors as related to the management of upper limb deficiency. Me

METHOD

nderson's model for health service utilization was used to frame prosthesis use and abandonment as a function of (1) predisposing characteristics of the individual (e.g. gender or level of limb loss); (2) established need, as characterized by lifestyle- and age-related demands; and (3) enabling resources (e.g. clinical and social). English-language articles pertaining to these components were identified in a search of Ovid, PubMed, ISI Web of Science and www.scholar.google.com (1980-November 2006) for key words upper limb and prosthesis. Approximately 90 articles were included as evidence in this review. Re

RESULTS

ersonal and contextual factors are critical determinants of prosthesis acceptance. While the influence of some factors (i.e. lifestyle, level of limb loss), is strongly supported in the literature, the impact of others, (i.e. age of fitting, efficacy of training protocols), remain controversial. Co

CONCLUSIONS

nhanced understanding of these factors is required to optimize clinical practices, guide design efforts, and satiate demand for evidence-based measures of intervention. Future research should comprise of controlled, multifactor studies adopting standardized outcome measures and providing comprehensive descriptions of population characteristics.

Upper-limb prosthetics: critical factors in device abandonment

OBJECTIVE

To investigate the roles of predisposing characteristics, established need, and enabling resources in upper-limb prosthesis use and abandonment.

DESIGN

A self-administered, anonymous survey was designed to explore these factors. The questionnaire was available online and in paper format and was distributed through healthcare providers, community support groups, and one prosthesis manufacturer. Two hundred forty-two participants of all ages and levels of upper-limb absence completed the survey.

RESULTS

Of participants, 20% had abandoned prosthesis use. Predisposing factors, namely, origin of limb absence, gender, bilateral limb absence, and, most importantly, level of limb absence, proved influential in the decision not to wear prostheses. Enabling resources such as the availability of health care, cost, and quality of training did not weigh heavily on prosthesis rejection, with the exception of the fitting time frame and the involvement of clients in the prosthesis selection. Conversely, the state of available technology was a highly censured factor in abandonment, specifically in the areas of comfort and function. Perceived need emerged as a predominant factor in prosthesis use.

CONCLUSIONS

Future research should focus on continued development of more comfortable and functional prostheses, particularly for individuals with high-level or bilateral limb absence. Improved follow-up, repair, and information services, together with active involvement of clients in the selection of prostheses meeting their specific goals and needs, is recommended.

Allogreffe de main chez le nouveau-né agénésique: étude de faisabilité

Would a newborn with a single hand benefit from hand allograft? Transantebrachial aplasia is the chosen clinical form of agenesia in our interrogation. The feasibility study presents several aspects: 1) ethical and psychological aspects. Is this a desired surgery for agenesic population? Which are the functional, psychological and social situations of agenesic patient? Is the hand transplantation in newborn ethically acceptable? What is the parents' attitude toward agenesia? Can we envisage organ donation in neonatal period? 2) immunological aspects. The non-vital character of this condition and its' good functional tolerance cannot make accepting the risk of adverse effects of hand allotransplantation. Hence, one may consider this surgery only without immunosuppression. Can the peculiarities of the neonate "immature" immune system represent an opportunity of easier tolerance obtaining, avoiding immunosuppression? 3) anatomical and technical aspects. The proximal tissues at the level of amputation are all hypoplastic in agenesic patients. Can we efficaciously suture those structures with donor eutrophic tissues? 4) cognitive aspects. Is a neonate born with only one hand is able to use two? A feasibility study on such a subject needs to take into account all these aspects. This research is useful because, even if hand allograft in agenesic newborn will never be done, the provided information will allow to progress in the vaster domain of composite tissue allotransplantation in perinatology.

Upper limb prosthesis use and abandonment: a survey of the last 25 years

This review presents an analytical and comparative survey of upper limb prosthesis acceptance and abandonment as documented over the past 25 years, detailing areas of consumer dissatisfaction and ongoing technological advancements. English-language articles were identified in a search of Ovid, PubMed, and ISI Web of Science (1980 until February 2006) for key words upper limb and prosthesis. Articles focused on upper limb prostheses and addressing: (i) Factors associated with abandonment; (ii) Rejection rates; (iii) Functional analyses and patterns of wear; and (iv) Consumer satisfaction, were extracted with the exclusion of those detailing tools for outcome measurement, case studies, and medical procedures. Approximately 200 articles were included in the review process with 40 providing rates of prosthesis rejection. Quantitative measures of population characteristics, study methodology, and prostheses in use were extracted from each article. Mean rejection rates of 45% and 35% were observed in the literature for body-powered and electric prostheses respectively in pediatric populations. Significantly lower rates of rejection for both body-powered (26%) and electric (23%) devices were observed in adult populations while the average incidence of non-wear was similar for pediatric (16%) and adult (20%) populations. Documented rates of rejection exhibit a wide range of variance, possibly due to the heterogeneous samples involved and methodological differences between studies. Future research should comprise of controlled, multifactor studies adopting standardized outcome measures in order to promote comprehensive understanding of the factors affecting prosthesis use and abandonment. An enhanced understanding of these factors is needed to optimize prescription practices, guide design efforts, and satiate demand for evidence-based measures of intervention.

Dielectric elastomers as actuators for upper limb prosthetics: challenges and opportunities

Recent research has indicated that consumers of upper limb prostheses desire lighter-weight, anthropomorphic devices. The potential of dielectric elastomer (DE) actuators to better meet the design priorities of prosthesis users is explored. Current challenges are critically reviewed with respect to (1) durability, (2) precision control, (3) energy consumption, and (4) anthropomorphic implementation. The key points arising from the literature review are illustrated with empirical examples of the strain performance and durability of one of the most popular DEs, VHB 4910. Practical application of DE actuators in powered upper extremity prosthetics is at present impeded by poor durability and susceptibility to air-borne contaminants, unreliable control owing to viscoelasticity, hysteresis, stress relaxation and creep mechanisms, high voltage requirements, and insufficient stress and strain performance within the confines of anthropomorphic size, weight, and function. Our review suggests that the implementation of DE actuators in powered upper extremity prosthetics is not feasible at present but worthy of reevaluation as the materials advance.

[Management of upper limb deformities. Treatment concepts through the years]

The provision of aids and prostheses for patients with upper limb deficiencies has to be based on comprehensive knowledge in the field of orthopaedic technology. Taking into account the patient's complete background, evaluation of the possible functional benefit is mandatory in order to achieve good acceptance of a prosthesis in the long term. The extent of extremity "loss" and the remaining function of the deficient limb have an impact on the success of prosthetic fitting. Furthermore, there is a trend towards myoelectric prostheses, which seem to improve prosthetic acceptance. Bilateral congenital deficiency of the upper limbs cannot be equated with amputations. Most people affected do not push for a prosthesis, but should be provided with one, if the need arises. Decades of overuse of the deficient limbs often take their toll in terms of decreasing function as degenerative changes occur. As a consequence, artificial upper limbs may be obligatory to prevent loss of independence.

Prescription of the first prosthesis and later use in children with congenital unilateral upper limb deficiency: A systematic review

BACKGROUND

The prosthetic rejection rates in children with an upper limb transversal reduction deficiency are considerable. It is unclear whether the timing of the first prescription of the prosthesis contributes to the rejection rates.

OBJECTIVE

To reveal whether scientific evidence is available in literature to confirm the hypothesis that the first prosthesis of children with an upper limb deficiency should be prescribed before two years of age. We expect lower rejection rates and better functional outcomes in children fitted at young age.

METHODS

A computerized search was performed in several databases (Medline, Embase, Cinahl, Amed, Psycinfo, PiCarta and the Cochrane database). A combination of the following keywords and their synonyms was used: "prostheses, upper limb, upper extremity, arm and congenital". Furthermore, references of conference reports, references of most relevant studies, citations of most relevant studies and related articles were checked for relevancy.

RESULTS

The search yielded 285 publications, of which four studies met the selection criteria. The methodological quality of the studies was low. All studies showed a trend of lower rejection rates in children who were provided with their first prosthesis at less than two years of age. The pooled odds ratio of two studies showed a higher rejection rate in children who were fitted over two years of age (pooled OR = 3.6, 95% CI 1.6 - 8.0). No scientific evidence was found concerning the relation between the age at which a prosthesis was prescribed for the first time and functional outcomes.

CONCLUSION

In literature only little evidence was found for a relationship between the fitting of a first prosthesis in children with a congenital upper limb deficiency and rejection rates or functional outcomes. As such, clinical practice of the introduction of a prosthesis is guided by clinical experience rather than by evidence-based medicine.

Demography and function of children with limb loss

This retrospective study was designed for the period 1982-2002 to collect the basic data on the demography, level and side of the amputation, involved limbs, age, gender, and prosthetic functional level in children with limb loss. A total of 232 children were assessed through their prosthetic records. Seventy-two percent (195 children) presented lower-limb involvement, and 28% (77 children) had upper-limb loss. The age of the children varied between 1 and 15 years with a mean age of 9.90 +/- 2.32 years. Results of the study revealed that the leading amputation cause in children was congenital limb absence. The most frequent levels were determined as trans-tibial and trans-radial in lower and upper limbs, respectively. Findings showed that more boys (60%) were affected, and 84% of all amputations were found to be unilateral. It was also seen that right-side amputations (54%) were more common than left-side amputations (46%). The outcome of the study showed that 96% of children with lower-limb loss reached a functional gait pattern without any aids, while the percentage of independence in activities of daily living was found to be 88% in upper-limb loss.

Prosthetic management of children in The Netherlands with upper limb deficiencies

The aim of the study was to assess which children with congenital and acquired upper limb deficiencies were fitted with prostheses, what types of prostheses were prescribed as first, second and third prostheses, at what age prostheses were first prescribed and how long the children wore their prostheses. The design was a retrospective chart review at De Hoogstraat Rehabilitation Centre, Utrecht (The Netherlands). Medical files of all patients with congenital or acquired upper limb deficiencies who visited the outpatient clinic between 1972 and 1996 were reviewed, collecting data on patient characteristics, prosthesis prescription and use of prostheses. The group included 224 children, of whom 206 (92%) had congenital deficiencies. Of all children with unilateral congenital deficiencies, 54% had been fitted with prostheses, against 3% of all children with bilateral congenital deficiencies and 67% of all children with acquired deficiencies. In the congenital group, it was children with transverse defects of one-third or two-thirds of the forearm who had most frequently had prostheses fitted (85% of the children). Most of the children with unilateral congenital deficiencies had received passive prostheses as their first prostheses (80 of the 90 prescribed prostheses); children with acquired defects usually had active prostheses (8 of the 12 prescribed prostheses). Body-powered prostheses were most commonly prescribed as the second type of prosthesis. In the group of 119 children who had been seen before the age of 4 years and had been followed for at least three years, 63 had been fitted with one or more prostheses at a mean age of 2.6 (SD 2.5) years. Of the 46 children with congenital defects, 30 had been fitted with prostheses, and at the age of 12, two-thirds of them still used their prostheses (63%, 19/30). "De Hoogstraat" rehabilitation centre uses a restrained prosthesis prescription policy, depending on the type of deficiency and the expected functional benefits. Data on prosthesis use are encouraging, although a follow-up study is required to determine the functional outcome for prosthesis users and non-users.

Clinical results of an investigation of paediatric upper limb myoelectric prosthesis fitting at the Quebec Rehabilitation Institute

This study was designed to investigate the satisfaction level of young users of myoelectric prostheses who received an upper limb myoelectric prosthesis, to assess their dropout rate and to identify which factors influence the use or non-use of the upper limb myoelectric prosthesis in the eastern part of Quebec (Canada). The users were fitted between 1990 and 1999 at the Quebec Rehabilitation Institute, a major rehabilitation centre located in the province of Quebec. This rehabilitation centre provides cutting-edge expertise not only for the eastern part of Quebec, but also across the entire province, because it is one of only two highly specialised centres serving all of Quebec. A literature review was completed to compile the results obtained in other rehabilitation centres and to identify factors influencing the use or non-use of paediatric upper limb myoelectric prostheses. The Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST) was used in order to assess the degree to which the children were satisfied with their prostheses. Eighteen (18) children were fitted and trained to use an upper limb myoelectric prosthesis. A total of 10 children and parents agreed to participate. Some 80% of participants said that they were satisfied with their prostheses. A dropout rate of 53% for the overall group (participants and non-participants) seems high compared with that of other studies. Recommendations linked to factors identified in the literature are made. The authors conclude that a multidisciplinary team and structured training and follow-up can improve the clinical results pertaining to all the factors proposed in the literature.

Prosthesis rejection in children with a unilateral congenital arm defect

OBJECTIVE

To determine the rate of rejection for prosthetic use in children and to investigate reasons for this rejection.

DESIGN

Cross-sectional study of a cohort of children.

SETTING

Rehabilitation centre, St Maartenskliniek, Nijmegen, The Netherlands.

SUBJECTS

Thirty-two children (0-18 years) with a unilateral congenital arm defect who visited the clinic between September 1991 and December 1996.

METHODS

Parents of all children and 19 children (> or =6 years) completed a questionnaire.

RESULTS

Eleven children (34%) rejected the prosthesis. A survival function shows that the rejection can be characterized by three periods: 0-40 months, 40-162 months and after 162 months. In the first and last period a high rate of rejection is seen, while in the second period a low rate exists. Fitting for the first time after 2 years of age seems to be related with higher rejection rate. Lack of functional gain with the prosthesis, as perceived by the subjects and the parents, is significantly associated with increased rejection rate. Increased rejection rate is associated with the parents' disappointment, insufficient involvement of the parents in treatment, and dissatisfaction pertaining to emotional and social guidance.

CONCLUSIONS

Rejection seems to occur in two main periods: within 3.5 years after being provided with a prosthesis and after 13.5 years of prosthetic use, when most children experience puberty. Fitting before the age of 2 years seems to reduce rejection rate. Preventing the parents' disappointment about prosthetic benefits as well as providing them with sufficient involvement in treatment and adequate guidance are essential for optimal results of prosthetic rehabilitation.

Laterality, gender and age differences in estimated frequency and actual registration of people with congenital upper limb absences

Initial analyses from a survey of people with unilateral upper limb congenital absence registered with the Cambridge Disablement Services Centre (DSC) indicated differences related to laterality and gender. A postal survey of all DSCs in the UK was conducted and support for these findings was provided from the analysis of the information supplied by the 25 DSCs who could provide data in the format requested. Comparing statistics for the UK population with those gained from the 25 DSCs, estimates for the number of children and adults who should be registered with DSCs in the UK are made. From these figures it is suggested that the non-registration rate for adults with a congenital absence of an upper limb could be as high as 64%.

Myoelectric prostheses for below-elbow amputees: the Trent experience

Experience of myoelectric prostheses for unilateral below-elbow amputees in a large region of Great Britain is presented. Of the cases considered, 14 were adults and 29 were 16 years of age or less. The rejection rate was 25% overall but it was lower in adults, at 17%. Comparisons with published data and other aspects of myoelectric prostheses are discussed. Just over half the 37 amputees interviewed were independent in activities of daily living; independence was more common in the adults, at 77%. A very large proportion of myoelectric prosthesis users also used body-powered prostheses, demonstrating a need for both types of prosthesis for optimum rehabilitation. It is recommended that myoelectric prosthetic programmes should be carried out from specialized centres with comprehensive facilities for this expensive rehabilitation aid.

Body-powered hand prosthesis with low operating power for children

For unilateral below-elbow amputated children a new elbow-controlled hand prosthesis has been developed. Since the triceps of young children have insufficient power to activate normal spring-closing hands, a special mechanism with low operating power has been developed for this prosthesis. A stiff spring gives a good gripping force. When the elbow is slightly extended this spring is switched off, and by further extension the hand is opened against a weak spring. So far, six children have used this special prosthesis. Their initial enthusiasm resulted in an improved system, which is now being designed.

The Free Limb Scheme and the limb-deficient child in Australia

A review was undertaken of computerized data on 547 children aged 0-14 years, treated under the Free Limb Scheme in Australia in the years 1981-85, and of children in New South Wales, Queensland and South Australia having major amputations in some of these years. The male/female ratio was 1.8:1. There were 171 children with upper limb deficits and 376 children with lower limb deficits. The distribution of the limb deficits of the children treated under the free limb scheme is shown. The ratio of congenital:acquired limb deficiency is known for New South Wales and was 3.7:1. The prevalence of prosthetic use in Australian children is 14.8/100,000 children.