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PubMed1999

Patient-prosthesis mismatch is negligible with modern small-size aortic valve prostheses.

BACKGROUND: Concern has been raised about residual significant gradients when small aortic prostheses are used, particularly in patients with large body surface areas. We studied the performance of six types of small aortic prostheses using dobutamine stress echocardiography. METHODS: Sixty-three patients (mean age, 67 +/- 7 years) who had undergone aortic valve replacement 17 +/- 6 months previously were studied. Two bileaflet mechanical prostheses (St. Jude Medical and CarboMedics: sizes, 19 mm and 21 mm) and two biological prostheses (Medtronic Intact and St. Jude BioImplant: size, 21 mm) were evaluated. A graded infusion of dobutamine was given and Doppler studies of valve performance were carried out. RESULTS: All prostheses except one biological valve had acceptable hemodynamic performance under stress. Using regression modeling, gradient at rest was the only variable found to predict gradient under stress (p < 0.001). Moreover, the most important predictor of gradient at rest was valve design, which accounted for 72% of the variance (p < 0.001). This relationship was independent of valve size (19 mm or 21 mm) or material (ie, mechanical or biological). Body surface area accounted for 4% of the variance in gradient only. CONCLUSIONS: The main predictor of transprosthetic gradient is the inherent characteristics of each particular prosthesis, with relatively insignificant contribution from variations in body surface area. Patient-prosthesis mismatch is not a problem of clinical significance when certain modern valve prostheses are used.

Aged↗
PubMed2000

Gait evaluation of a transfemoral prosthetic simulator.

OBJECTIVE: To test a prosthetic simulator developed to allow persons without amputation to walk like a person with a transfemoral (TF) amputation. PATIENTS: Five able-bodied subjects; comparison with data from the literature on persons with TF amputations. SETTING: Motion analysis laboratory. DESIGN: Two 45- to 60-minute gait training sessions before subjects walked along a 10-meter walkway. There were 6 trials: 3 walking with a cane, 3 without a cane. MAIN OBJECTIVE MEASURES: Sagittal plane kinematic and kinetic analysis of ankle, knee, and hip: angular velocity, joint moment, and power. RESULTS: Kinematic and kinetic analyses showed that joint mechanics during walking were similar between the test subjects and comparative results from persons with TF amputations (reported in the literature). Test subjects walked slower and moved their hip and knee joints faster (higher angular velocity values during the terminal swing) than the TF amputee subjects, although these results were not statistically significant (p < .05). These findings were consistent with new prosthetic users who are more tentative during gait training. However, a perfect simulation would show no difference in kinematic results. CONCLUSION: These results support the use of a TF prosthetic simulator to help health care professionals experience the process of fitting the prosthesis from the client's perspective.

Adult↗
PubMed2003

Bursitis, adventitious bursa, localized soft-tissue inflammation, and bone marrow edema in tibial stumps: the contribution of magnetic resonance imaging to the diagnosis and management of mechanical stress complications.

OBJECTIVE: To assess the contribution of magnetic resonance imaging (MRI) in the diagnosis of tibial stump bursitis, in the establishment of differential diagnosis, and in the therapeutic management prosthetic-stump interface, mainly by adaptation of the prosthetic device. DESIGN: Two-year, prospective, consecutive series. SETTING: University-affiliated prosthetic and rehabilitation center and university department of radiology. PARTICIPANTS: A group of 17 persons with stump problems identified from a total of 139 consecutive below-knee amputees with prosthesis problems. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Clinical symptoms and MRI. RESULTS: Clinical symptoms (variable stump volume, fluctuating mass at palpation with or without mechanical pain) were suggestive of bursitis in 10 patients. MRI confirmed bursitis in 9 and identified 1 in whom clinical signs suggested neuroma, giving an incidence of 10 of 139 amputees (7.2%). MRI identified 13 sites of bursitis (adventitious bursa, 11; synovial bursitis, 2) and 5 localized areas of soft tissue inflammation. MRI showed diffuse muscular edema at 1 site of clinically suspected bursitis, and bursitis at another site of suspected neuroma. Calcified bursitis was observed in 1 case. Bone abnormalities associated with bursitis (n=7) included osteophytes or fracture (n=4) or bone marrow edema (n=3). Two asymptomatic neuromas were also identified. MRI-guided modifications of the prosthetic interface led to favorable outcome in all cases. CONCLUSION: Bursitis, adventitious bursae, and areas of localized soft-tissue inflammation are different aspects of the same disorder resulting from a mechanical conflict between the stump and the prosthesis socket. Besides contributing to diagnosis, MRI provides a precise assessment necessary for correcting the prosthesis-stump interface in a way that reduces mechanical stress and subsequently cures bursitis.

Adolescent↗
PubMed1995

Bilateral gait patterns in subjects fitted with a total hip prosthesis.

OBJECTIVES: The purpose of this report was to determine whether the muscle powers and the mechanical energies developed during the push-off period of the gait cycle of patients having a total hip prosthesis were different from able-bodied subjects as well as the effect on the nonoperated limb. DESIGN: Case control study. SETTING: All patients where independent and functional. PATIENTS: Four patients participated in the study. The indication for surgery was degenerative arthritis of the hip. There was also an able-bodied group. INTERVENTION: A Harris-Galante total hip prosthesis was used to restore hip stability and function. The patients were all operated on by the same orthopedic surgeon and had the same type of total hip replacement. MAIN OUTCOME MEASURE: Gait analyses showed that not only the hips of the surgical group were affected but also the knees. RESULTS: Peak power did not show any significant difference except for a decrease in the frontal plane of the operated hip power absorption. The operated hip developed 35% and 48% less energy than that of the able-bodied group in the sagittal and frontal planes, respectively. The nonoperated hip was also affected and developed 35% more energy in the sagittal plane than the operated limb but 20% less than that of the able-bodied group. There was a reduction of 47% in the energies developed in the knees of the surgical patient group. CONCLUSION: These results confirmed the presence of some mechanical dysfunction in the nonoperated limb.

Aged↗
PubMed1996

Precision of surface measurements for below-knee residua.

OBJECTIVE: To determine the absolute and relative precision of geometric measurements made of below knee (BK) residua and their BK plaster positive casts using calipers, electromagnetic digitizer, optical surface scanner (OSS), and spiral x-ray computed tomography (SXCT). DESIGN: The experimental measurement protocol for a single measurement session was as follows: Dot markers were placed on the residuum, and volume and distances were measured using water displacement and calipers; residuum was measured using electromagnetic digitizer; residuum was scanned using three-dimensional (3D) OSS; a negative plaster cast of subject's residuum was made; the residuum was scanned using SXCT scanner. These steps were repeated at a second measurement session. Plaster positive casts were constructed and subsequently measured using the same protocol. PARTICIPANTS: Thirteen adult below-knee amputee volunteers (subjects) participated in the study, and nine subjects returned for a second measurement session. The study group consisted of 9 men and 4 women; 10 Caucasians and 3 African Americans. RESULTS: Distance measurements for all measurement devices were repeatable within 1% in vivo and within 0.5% on plaster casts; and volumes were within 1% in vivo and within 0.1% on plaster casts. Distance measurements for each device were precise within 3% in vivo and within 1% on plaster casts; and volumes were within 5% in vivo and within 6% on plaster casts when compared with caliper and water displacement measures. CONCLUSION: These measurement systems were found to be substantially equivalent in terms of repeatability and precision for measurement of lower extremity residua.

Adult↗
PubMed1996

Rehabilitation in limb deficiency. 1. Gait and motion analysis.

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on rehabilitation in limb deficiency in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses normal gait, the influence of prosthetic alignment on amputee function, and the effects of prosthetic components on the metabolic costs and the biomechanical function of the amputee. The biomechanics of normal ambulation are presented as a background to enable the practitioner to gain an understanding of the typical gait adaptations that occur in below-knee and above-knee amputees. The effects of newer prosthetic components and socket designs on the biomechanical adaptations are reviewed. The metabolic costs of amputee ambulation are significantly greater than normal. The theoretical mechanisms for this are discussed, and the effects of newer socket designs, ultra-light-weight components, and energy-storing prosthetic components are presented.

Adaptation, Physiological↗
PubMed1996

Rehabilitation in limb deficiency. 2. The pediatric amputee.

This self-directed learning module highlights advances in the evaluation and management of the pediatric amputee. It is part of the chapter on rehabilitation in limb deficiency in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses the etiology and terminology of childhood limb deficiency. Developmental milestones are used as a guide to prescribing prosthetic devices for children, and tables suggesting such guidelines are included. Specific clinical examples are provided to illustrate management issues. Advances that are covered include limb-sparing procedures in the management of lower extremity malignancy.

Adolescent↗
PubMed1996

Rehabilitation in limb deficiency. 3. The geriatric amputee.

This self-directed learning module highlights advances in the evaluation and management of the geriatric amputee. It is part of the chapter on rehabilitation in limb deficiency in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses the impact of aging and comorbid factors on the function of the geriatric amputee. Specific clinical examples are provided to illustrate management issues. Advances that are covered include prosthetic management and modifications for the elderly.

Age Factors↗
PubMed1998

Total surface bearing below-knee prosthesis: advantages, disadvantages, and clinical implications.

OBJECTIVE: To investigate the total surface bearing (TSB) prosthesis for below-knee amputee patients and to determine its clinical indications. DESIGN: Case series. SETTING: University hospital and the Welfare Center for the Disabled. PATIENTS: Thirty-two subjects who could walk with the TSB prosthesis and had already used the patellar-tendon bearing (or Kondylen-Bettung Münster) socket. MAIN OUTCOME MEASURE: Subjective assessment of the TSB socket, consisting of an overall rating and ratings of 13 individual items, was performed, and results were analyzed with Fisher's exact test. RESULTS: Seventy-five percent of the subjects were satisfied overall with the TSB socket. Of the 13 items, comfort, ease to swing, pain, piston movement, tightness, skin irritation, appearance, and durability were regarded as good by more than 75% of the patients. Donning, perspiration, odor, and staining were regarded as poor by more than 20%. Items that were significantly related with overall satisfaction with the TSB socket were comfort, ease to swing, and piston movement, while donning was significantly related to dissatisfaction. CONCLUSION: The TSB socket is suitable for and preferred by many amputee subjects, but some problems remain to be solved.

Adult↗
PubMed1998

Wrist-driven prehension prosthesis for amputee patients with disarticulation of the thumb and index finger.

Partial hand amputations may leave significant functional limitations that are difficult to ameliorate by either orthoses or prostheses. Disarticulation of the thumb and index finger at the metacarpophalangeal joint level and the range of motion of the three remaining fingers would be insufficient to provide any type of grasp. In cases like this, a cosmetic hand usually seems to be the best solution. This report describes the design and use of a wrist-driven prehension prosthesis that was applied to a patient and provided a considerable improvement in function and cosmesis.

Amputation, Traumatic↗
PubMed1999

Anterior ankle-foot orthosis effects on postural stability in hemiplegic patients.

OBJECTIVES: To evaluate the effects of an anterior ankle-foot orthosis (AFO) on static and dynamic postural stability in hemiplegic patients. DESIGN: A cross-sectional assessment of hemiplegic subjects with and without an AFO. SETTING: Outpatient department of a rehabilitation hospital. PATIENTS: A convenience sample of 24 subjects who had been prescribed an anterior AFO. OUTCOME MEASURES: Postural sway index and postural symmetry (body weight distribution through the affected leg) when standing were measured as static postural stability. Maximal balance range in anterior-posterior and lateral directions and the affected leg's weight bearing after weight shift to affected side were measured as dynamic postural stability. RESULTS: When wearing the anterior AFO, there was no significant difference and small effect size (r<0.3) in postural sway index (p = .35), postural symmetry (p = .21), and maximal balance range in anterior-posterior direction (p = .46). There was a significant improvement and large effect size (r>0.5) in lateral weight shifting (p<.01) and weight bearing through the affected leg after weight shifted to the affected side (p<.01). CONCLUSIONS: The significant effects of the anterior AFO in long-term hemiplegic patients were on lateral weight shifting and weight bearing through affected leg after weight shifted to the affected side. Postural sway, postural symmetry, and anterior-posterior weight shifting were not significantly affected.

Adult↗
PubMed2000

Determination of the minimum number of marginal gap measurements required for practical in-vitro testing.

STATEMENT OF PROBLEM: Gap measurements along margins are frequently used to assess the quality of single crowns. However, the number of gap measurements required for clinically relevant results in laboratory studies is not known. PURPOSE: This study estimated the minimum number of gap measurements on margins of single crowns to produce relevant results for gap analysis. METHODS AND MATERIAL: Ten all-ceramic crowns were fabricated on a master steel die. Gaps along crown margins were investigated in a scanning electron microscope on the master steel die without cementation and on replica dies after conventional cementation. Measurements were made in 100 microm steps according to 3 gap definitions. The initial number of measurements per crown (n = 230) was reduced to smaller subsets using both systematic and random approaches to determine the impact on the quality of results. RESULTS: On the data of gap definition 1, reduction from 230 to about 50 measurements caused less than +/-5 microm variability for arithmetic means. Analysis of standard errors showed slowly increasing values smaller than 3 microm, both indicating no relevant impact on the quality of results. Smaller data sizes yielded accelerated increase of standard errors and divergent variabilities of mean. The minimum of 50 measurements did not depend on gap definition or on cementation condition. CONCLUSION: Fifty measurements are required for clinically relevant information about gap size regardless of whether the measurement sites are selected in a systematic or random manner, which is far more than what current in vitro studies use.

Aluminum Oxide↗
PubMed2000

Use of palatal lift and palatal augmentation prostheses to improve dysarthria in patients with amyotrophic lateral sclerosis: a case series.

STATEMENT OF PROBLEM: Amyotrophic Lateral Sclerosis (ALS) is a progressive, adult onset neurodegenerative disorder manifesting itself as a loss of motor capabilities and untimely death. The dysarthria seen in patients with ALS who have bulbar symptoms causes severe problems with communication. The struggle to be understood comes at a time when progressive cumulative disabilities make communication with family, friends, and healthcare workers vital. The use of palatal lift/augmentation prostheses for dysarthria in ALS is not a frequently requested procedure by neurologists. PURPOSE: The purpose of this retrospective outcomes study was to evaluate the effectiveness of this treatment on improving speech function and intelligibility in this group of patients. This study also reviews the history, incidence, pathogenesis, and speech characteristics of the patient with ALS. METHODS: A retrospective study of 25 patients treated with a prosthesis was performed using chart reviews and phone/office interviews to evaluate the efficacy of a palatal lift and/or augmentation prosthesis to improve speech in ALS patients. RESULTS: Twenty-one patients (84%) treated with a palatal lift demonstrated improvement in their dysarthria, specifically in reduction of hypernasality, with 19 (76%) benefiting at least moderately for 6 months. Of the 10 patients treated with a combination palatal lift and augmentation prosthesis, 6 (60%) demonstrated improvement in articulation. A majority of patients indicated it was easier to speak with less effort involved when wearing the prosthesis. CONCLUSION: On the basis of this preliminary retrospective study, the use of a palatal lift/augmentation prosthesis should be considered in ALS patients with dysarthria.

Adult↗
PubMed2003

A preplanned surgical obturator prosthesis for alternative resection lines in the anterior region.

A technique is described that enables adaptation of a surgical obturator to accommodate anterior teeth that may or may not be resected with the lesion at surgery. This is designed and fabricated by placing additional clasps on the teeth in question and providing for a clasp on one of the anterior teeth that can be determined at the time of surgery, thereby allowing anterior retention of the obturator immediately postoperatively. This technique is cost-effective and useful, especially if no prosthodontist is available at the time of surgery to perform obturator modifications.

Humans↗
PubMed1995

A multiple tray technique for implant-retained orbital prostheses.

The use of implants in retaining orbital prostheses has gained favor in recent years. Not all patients may be candidates for use of medical adhesives or anatomic retention as advocated by some. Osseointegrated implants offer an alternative method for retaining an orbital prosthesis. Because of the confining nature of an orbital defect, it may be difficult to reproduce the spatial arrangement of implants accurately with one impression. The technique presented here accomplishes the objectives of minimal trauma to the tissues, accuracy, and elimination of consecutive impression technique.

Humans↗
PubMed1995

Technique for magnet replacement in silicone facial prostheses.

Magnets are often used in silicone facial prostheses for retention. However, these magnets may need to be replaced or repositioned as a result of loss, wear, or poor initial placement. Replacement can be easily accomplished by use of a nylon mesh material and a simple laboratory technique.

Humans↗