The Knud Jansen lecture. Amputation revisited

Optimisation of the prescription for trans-tibial (TT) amputees

The great diversity of prosthetic mechanisms available nowadays leads to the question of which type of artificial foot would be the most advisable for a particular person. To answer correctly, it is necessary to establish, in an objective way, the performance of each type of prosthetic mechanism. This knowledge is obtained by means of the study of the subject-prosthesis interaction, both in static and dynamic conditions. This paper, based on the analysis of 8 trans-tibial (TT) amputees, presents a quantitative method for the study of human gait which allows the determination of the influence of four different prosthetic ankle-foot mechanisms (SACH, Single-axis, Greissinger and Dynamic) on gait. To do this, 1341 gait trials at different cadences were analysed (383 with normal subjects and 958 with amputees, using the four prosthetic feet under study). From all the variables available for study only those which offered interpretable clinical information were chosen for analysis. A total of 18 variables (kinetic, kinematic and time-related) were selected. A covariance analysis (ANOVA) of these variables was made, which showed that the factors influencing TT amputee gait were, in order of importance, cadence and leg studied (sound or prosthetic), inter-individual variability and, finally, the prosthetic mechanism used. When looking at the performance during gait of the 4 prosthetic mechanisms studied it can be observed that there are similarities in the kinetic study between SACH and Dynamic feet on one hand and Single-axis and Greissinger feet on the other. These results seem to support the classification criteria of articulated and non-articulated prosthetic mechanisms.

Standing balance in trans-tibial amputees following vascular disease or trauma: a comparative study with healthy subjects

Standing balance measured as sway and standing time both on one and two legs, was studied by use of a stable force platform (Kistler) in 36 patients aged 48-87 years with trans-tibial amputation and 27 healthy subjects matched for age. The aim of the study was to compare postural function in standing in two groups with unilateral trans-tibial amputations, separating vascular disease from trauma. Results revealed that the vascular group had a significantly increased sway in the lateral direction compared with the healthy group, when standing on both feet close together for 30 seconds, looking straight ahead or blindfolded (p values ranging from 0.003 to 0.02). In the sagittal direction the trauma amputees had a significantly decreased sway when looking straight ahead, compared to the vascular and healthy groups (p values = 0.03). No significant differences in the lateral or sagittal direction were seen among the three groups when comparing standing on one leg. There was a significant difference, however, in the standing time in the one-leg standing test of the vascular group when compared with the trauma and healthy groups (p values ranging from 0.0009 to 0.02). In contrast to the vascular group, all subjects in the trauma and healthy groups from 48 to 59 years could stand on the healthy leg for 30 seconds when looking straight ahead, and from 60 to 79 years they could stand for 5 seconds. None in the vascular or trauma group older than 80 years could stand on the healthy leg for 5 seconds.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of introducing the team approach to the care of the amputee: the Dulwich study

The effects of introducing the Team Approach to the management of the lower limb amputee has been assessed in a consecutive series of 233 patients over a five year period. During the first year, baseline data was collected and during the subsequent yearly phases the effects of introducing a physiotherapist co-ordinator, visiting prosthetist and medical officer from the local Artificial Limb and Appliance Centre (ALAC), and finally trained surgeons were studied. During the final phases of the study, the effects of changing team staff were monitored. The results have shown that only when the full Team Approach is adopted are the best results achieved, but that, once this approach is established, staff changes can be made without serious reductions in effectiveness. The study has shown that the team can reduce in-patient stay by 20 days; reduce the need for post-discharge physiotherapy by 94%; increase the proportion of patients discharged with a prosthesis more than fivefold and increase the effectiveness of long term rehabilitation threefold.