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Finite element estimates of interface stress in the trans-tibial prosthesis using gap elements are different from those using automated contact.

When compared with automated contact methods of finite element (FE) analyses, gap elements have certain inherent disadvantages in simulating large slip of compliant materials on stiff surfaces. However, automated contact has found limited use in the biomechanical literature. A non-linear, three-dimensional, geometrically accurate, FE analysis of the trans-tibial limb-socket prosthetic system was used to compare an automated contact interface model with a gap element model, and to evaluate the sensitivity of automated contact to interfacial coefficient of friction (COF). Peak normal stresses and resultant shear stresses were higher in the gap element model than in the automated contact model, while the maximum axial slip was less. Under proximally directed load, compared with automated contact, gap elements predicted larger areas of stress concentration that were located more distally. Gap elements did not predict any relative slip at the distal end, and also transmitted a larger proportion of axial load as shear stress. Both models demonstrated non -linear sensitivity to COF, with larger variation at lower magnitudes of COF. By imposing physical connections between interface surfaces, gap elements distort the interface stress distributions under large slip. Automated contact methods offer an attractive alternative in applications such as prosthetic FE modeling, where the initial position of the limb in the socket is not known, where local geometric features have high design significance, and where large slip occurs under load.

Artificial Limbs↗

Upper limb traumatic amputees. Review of prosthetic use.

The prosthetic status of the traumatic upper limb amputees was reviewed. Fifty-five upper limb amputees were reviewed using a detailed questionnaire, telephone or clinic review and by case note study. Twenty-three patients were traumatic amputees and 32 were congenital amputees. The amputees' function, prosthetic use and satisfaction were evaluated and this formed the basis of a scoring system. The traumatic group were less satisfied with their prosthesis and their functional ability was poorer, especially in the use of the myoelectric prosthesis. Traumatic amputees were their prosthesis for an average of 6.5 hours per day compared to 9.3 hours in the atraumatic group. None of the traumatic amputees fitted after 12 weeks returned to gainful employment. Early prosthetic fitting, rehabilitation and post-traumatic counselling are advocated in upper limb traumatic amputees in order to achieve an optimum prosthetic benefit for the patient.

Adolescent↗

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

OBJECTIVE: To determine whether washing the residual limb and silicone liner reduces the associated skin problems in transtibial amputees who wear a total surface bearing (TSB) socket. DESIGN: Case series. SETTING: General community. PATIENTS: Eighty-three transtibial amputees (65 men, 18 women; mean age, 53.4 yr) in western Japan who used or had used a TSB socket with a silicone liner in the previous 5 years. INTERVENTION: Participants took a self-administered questionnaire that included items concerning their personal profile, daily life activities, period of TSB use (yr), hours of TSB use daily, washing frequency of the residual limb and silicone liner, the method of washing, and any associated hygiene problems. MAIN OUTCOME MEASURES: Logistic regression analysis was applied to examine factors related to hygiene problems. Predicted values include hygiene problems (perspiration, eruptions, itching, odor) and explanatory values include TSB use, daily life activity, and washing of limb and prosthetic. RESULTS: Fifty-five subjects washed the residual limb, and 44 subjects washed the silicone liner every day. Itching, perspiration, eruption, and odor were frequent hygiene problems. Perspiration was noted less by women, eruption more by older subjects, and itching and odor more by younger subjects. Washing the silicone liner every day was associated with fewer reports of skin eruption. CONCLUSION: Keeping the residual limb and silicone liner clean is important to reduce skin problems, but hygiene problems of the residual limb and silicone liner still remain to be resolved.

Activities of Daily Living↗

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.

Activities of Daily Living↗

Socket considerations for the patient with a transtibial amputation.

This paper reviews the theory of transtibial prosthetic socket designs from a historic perspective to the present. The patella tendon bearing socket originated in 1959, and is the standard from which the new alternative socket designs have evolved. Although the patella tendon bearing socket is still the most commonly prescribed socket for a transtibial prosthesis, the total surface bearing and hydrostatic sockets are becoming increasingly accepted. The total surface bearing socket still may incorporate the weightbearing characteristics of the patella tendon bearing socket, but often will be accompanied by a shock absorbing gel liner. The hydrostatic socket does not incorporate the standard patella tendon bearing design characteristics, but instead depends on a method of pressure casting that in theory produces a socket with equally distributed pressure over all of the residual limb soft tissue. These three designs are reviewed as current options for the socket portion of the transtibial prosthesis.

Amputation, Surgical↗

Fabrication of a polysar, temporary prosthesis in a hospital setting.

The Physical Therapy Department at Kessler Institute for Rehabilitation has been fabricating temporary prostheses since 1967. Initially, these below-knee limbs were constructed with a plaster socket attached to a modular type prosthesis. Early in 1970, we began to use polysar, a thermoplastic compound. It is nonirritating to the skin, light, durable, easily moldable, relatively inexpensive, retains suspension mechanisms adequately, and allows the production of a cosmetically acceptable training limb. Because we had difficulty with the direct forming method as described by Staros and Gardner, the indirect method was adopted.

Amputation Stumps↗

The causes and treatments of phantom limb pain.

Almost all patients who undergo amputation suffer 'phantom sensations', a sensory perception of the missing limb, possibly caused by a neural imprint or memory of the limb within the brain. The patient may experience abnormal kinaesthetic sensation, such as the feeling that the limb is in an abnormal position. Perceived changes in length, size or temperature of the limb are also common. Some of these people will go on to develop phantom limb pain (PLP). Appropriate aggressive pain management is required immediately postamputation in an attempt to avoid chronic PLP.

Afferent Pathways↗

A methodology for studying the effects of various types of prosthetic feet on the biomechanics of trans-femoral amputee gait.

This paper reports on a methodology developed for studying the effects of various types of prosthetic feet on the gait of trans-femoral amputees. It is shown that an analysis in three planes of motion of not only the prosthetic, but also the sound limb provides important information on the performance of prosthetic feet. Two male trans-femoral amputees were tested with four different prosthetic feet; the Springlite II, Carbon Copy III, Seattle LightFoot and the Multiflex foot. A detailed analysis of the results of one amputee and a summary of the most important results of a second subject is presented. The tests were carried out at normal (1.16 m s(-1)) and fast (1.56 m s(-1)) walking speeds. Three dimensional gait analysis was carried out to derive the time curves of the joint angles, intersegmental moments and power at the ankle, knee and hip joints at both the prosthetic and sound sides. A higher first peak of the ground reaction force at the sound side with the Seattle LightFoot compared to that with the Springlite II, may be the result of the lower late stance dorsiflexion angle with the former. Compared to the other two feet, the Carbon Copy III and the Springlite II showed higher prosthetic dorsiflexing moments and positive power at late stance, which could assist in the push-off. The 3D intersegmental loads at the ankle and knee can be used as a guide for design and for compilation of standards for testing of lower limb prostheses incorporating flexible feet.

Adult↗

Residual-limb shape change: three-dimensional CT scan measurement and depiction in vivo.

PURPOSE: To perform quantitative evaluation of lower-extremity prosthesis fit by using spiral computed tomography (CT). MATERIALS AND METHODS: Two spiral CT scans were obtained at each of two different sessions in seven adult patients who had undergone amputation below the knee. A rigid-body transformation of the tibia was computed and used to align paired (intra- and intersession) spiral CT data sets for each individual in a common coordinate system. Paired scans in each individual were compared to assess registration and precision of soft-tissue change measurement. Clinical prosthesis fit evaluation was demonstrated in an adult amputee volunteer who underwent CT evaluation while wearing two different prostheses. RESULTS: In the seven patients examined, more than 90% of the measured soft-tissue volume displacements between sessions could be explained as true differences. Precision error of soft-tissue volume change was approximately 13 cm3, or approximately 1% error relative to the mean volume. Volumetric changes due to different prostheses were substantially larger than the random error. CONCLUSION: Registration of CT volumetric data sets to quantify residual-limb soft-tissue envelope change in lower-limb prosthetics is precise and can be used to detect the effect of prosthesis shape alterations.

Adult↗

Finite-element analysis to determine effect of monolimb flexibility on structural strength and interaction between residual limb and prosthetic socket.

Monolimb refers to a kind of transtibial prostheses having the socket and shank molded into one piece of thermoplastic material. One of its characteristics is that the shank is made of a material that can deform during walking, which can simulate ankle joint motion to some extent. Changes in shank geometry can alter the stress distribution within the monolimb and at the residual limb-socket interface and, respectively, affect the deformability and structural integrity of the prosthesis and comfort perceived by amputees. This paper describes the development of a finite-element model for the study of the structural behavior of monolimbs with different shank designs and the interaction between the limb and socket during walking. The von Mises stress distributions in monolimbs with different shank designs at different walking phases are reported. With the use of distortion energy theory, possible failure was predicted. The effect of the stiffness of the monolimb shanks on the stress distribution at the limb-socket interface was studied. The results show a trend--the peak stress applied to the limb was lowered as the shank stiffness decreased. This information is useful for future monolimb optimization.

Amputation, Surgical↗

Driving appliances for upper limb amputees.

The advice given to upper limb amputees in the United Kingdom with regard to the use of driving appliances has often been somewhat variable. At best a full rehabilitation package has been provided, including the fitting of the appliances to the person's vehicle and contact with the driver's instructor, to the other extreme of issuing driving appliances to patients with no instruction at all. Though upper limb amputations are not a relevant or prospective disability, all drivers with a "limb disability" are legally required, in the UK, to declare changes in their physical state to the Driver and Vehicle Licensing Agency. This study examines the current usage of driving appliances. It was found that the level of upper limb loss has little effect on where the driving appliance is placed or on any other aspect of driving method used.

Adult↗

Prostheses and the forward reach of sitting lower-limb amputees.

The hypothesis that prostheses improve the forward reach of sitting lower-limb amputees was tested. While sitting with only ischial support, ten unilateral below-knee (BK) amputees could reach farther when they wore their prostheses than when they did not, when reaching at 45 degrees toward or away from the side of the amputation, with mean differences (+/- 1 SD) of 10.7cm (+/- 6.9, p less than 0.0001) and 4.4cm (+/- 4.1, p less than 0.01), respectively. With ten unilateral above-knee (AK) amputees, the differences were not statistically significant. Seven bilateral amputees (mixed levels) were able to reach farther with their prostheses on than off, with mean differences of 41.2cm (+/- 9.5) and 31.5cm (+/- 7.9) for reaches at 0 degrees and 45 degrees, respectively (p less than 0.0001). With the prostheses off, their reach was significantly greater when their thighs were supported than when they were sitting with only ischial support. These findings suggest that (1) prostheses improve the anterolateral reach of unilateral BK amputees, and the straight forward and anterolateral reach of bilateral amputees; (2) when prostheses are not being worn, a sitting surface which provides support through the residual limbs improves forward reach; and (3) the design of AK prostheses should reflect the patient's needs, both standing and sitting.

Adult↗

Ilizarov lengthening of a posttraumatic below elbow amputation stump. A case report.

Lengthening of a nonfunctional posttraumatic below elbow stump via Ilizarov technique is described. Preoperatively, the 5 cm ulna in the residual forearm provided an insufficient lever arm for practical use of a standard below elbow prosthesis. An additional 5 cm of ulnar length was achieved (100% increase) by distraction histogenesis, ultimately limited by impending necrosis of adherent skin covering the tip of the residual limb. Utilizing the Ilizarov technique, ulnar lengthening converted the functional level of the patient's amputation from elbow disarticulation to below elbow status.

Adult↗

[Foot deformities in longitudinal ectromelia of the lower limbs].

We have studied 204 feet in 181 children with congenital limb shortening. There were 17 short femurs in 11 children in whom it was impossible to lengthen the leg. Thirteen feet were abnormal. It was necessary to adapt the foot to fit the chosen prosthesis. In 34 children it was possible to correct the length of the short femur. In 21 the feet were normal. 13 had abnormal feet associated with fibular aplasia and deformities included equinovalgus, hind foot synostosis, and deficient rays. In 72 children with congenital hypoplasia or aplasia of the fibula, 76 feet were affected. The function of the foot depends on attaining a stable position beneath the tibia. In 34 children (35 feet), the feet were in a stable position. There were 22 ball and socket ankle joints. Before carrying out leg lengthening, operation was necessary on 9 feet, and a further 13 required operation after lengthening had been carried out. In 34 children (41 feet) there was fibular aplasia. The feet lay in equinovalgus and were often narrow. Only 5 did not have a degree of synostosis. Twenty-three feet in twenty two children were operated on with early soft tissue release, tendon transfer and tibiotalar arthrodesis. This is our treatment of choice. Twenty-seven children had tibial dysplasia which affected 37 feet. The feet lay in equinovarus and in 5 there was partial diplopodia. In the absence of a tibia (19 feet) disarticulation of the knee was carried out. In 12 there was proximal shortening of the tibia which in 9 cases was treated by tibiofibular union. It was possible to retain only 2 feet in a proper position in a lengthened leg. In 30 children (33 feet) both fibular and tibial hypoplasia was present. The feet functioned well. There were 22 ball and socket ankles, 28 narrow feet and numerous synostoses. In limbs with atypical dysplasia 7 abnormal feet were noted. If it is possible to preserve or lengthen the limb it is vital that the foot is retained in a stable position beneath the tibia in order that satisfactory function be obtained. If limb lengthening is impossible, the foot must be adapted to match the prosthesis.

Adolescent↗

Augmented auditory information in the control of upper-limb prostheses.

The present study compared the effects of augmented auditory information on the linear positioning performance of individuals with natural or prosthetic limbs. Subjects were ten male volunteers, five of whom had above-elbow amputations and had used their prosthetic devices for an average of 8.3 years. The other five subjects were selected from a volunteer pool. Movements were made and measured on a standard linear slide whose cursor had a pulsing infrared diode attached opposite the subject. An infrared camera and microprocessor translated diode movement into a corresponding change in voltage. The voltage was simultaneously applied to an audio device which supplied the augmented feedback. The movement of the cursor by the subject was paralleled by a linearly-related change in audible frequency (Hz). The subjects performed 15 trials at each of three retentions (immediate, 15-sec filled, and 15 sec unfilled), both with and without the augmented feedback, for a total of 90 trials. The results of group X feedback X retention intervals analysis of variance on absolute and variable error indicated both a group X retention and a group X feedback interaction. Subjects using a prosthetic limb to produce the movement were less accurate and more variable than the "normal" subjects when augmented feedback was not concurrent with response.

Adult↗

Outcomes of a contemporary amputation series.

BACKGROUND: The aim of this study was to determine the outcomes of a contemporary amputation series. METHODS: A retrospective audit of 87 cases of major lower limb amputation from January 2000 to December 2002 from the Department of Vascular Surgery, Royal Perth Hospital, was conducted. RESULTS: The mean age of the study population was 70.1 +/- 14.3 years; the male : female ratio was 3.35:1. Comorbid problems included diabetes (49.4%), smoking (81.6%), hypertension (77.0%), ischaemic heart disease (58.6%), stroke (25.3%), raised creatinine level (34.5%) and chronic airway limitation (25.3%). Preamputation vascular reconstructive procedures were common, 34.5% in a previous admission and 23.0% in the same admission. The main indication was critical limb ischaemia (75.9%) followed by diabetic infection (17.2%). There were 51 below-knee (58.6%), 5 through-knee (5.7%) and 31 above-knee (35.6%.) amputations. The below-knee amputation to above-knee amputation ratio was 1.65:1. The overall wound infection rate was 26.4%; the infection rates for below-knee (29.4%) and above-knee (22.6%) amputation did not differ significantly (P = 0.58). Revision rates were 17.6% for below-knee, 20% for through-knee and none for above-knee amputations. Twenty patients (23.0%) underwent subsequent contralateral amputation. Thirty-nine patients (44.8%) were selected as suitable for a prosthesis by a rehabilitation physician; 31 (79.5%) used the prosthesis both indoors and outdoors and 6 (15.4%) used it indoors only within 3 months. Cumulative mortality at 30 days, 6 months, 12 months and 24 months was 10.1, 28.7, 43.1 and 51.7%, respectively. CONCLUSION: This series agrees with the current published work in finding that patients undergoing major lower limb amputation are older, with a high prevalence of comorbid conditions. Successful prosthesis rehabilitation depends on patient selection and a multidisciplinary approach. Despite a low immediate mortality, the overall long-term results of lower limb amputation remain dismal.

Aged↗

An above-knee prosthesis with a system of energy recovery: a technical note.

Knee flexion to 24 degrees during early stance transforms kinetic energy into potential energy of a total center of mass (TCM) position. Flexion is controlled by the musculoligamentous apparatus. Reproduction of such flexion in a new single-axis prosthesis knee unit has minimized the metabolic energy cost to the patient by a more favorable use of gravity acting upon the prosthetic segments and the body as well as of inertia. Potential energy is stored in the spring shock absorber of the knee unit. The coefficient of energy recovery increased by 30% in comparison with a conventional above-knee prosthesis. Energy costs to the patient decrease an average of 35% during gait with the new prosthesis. The same amount of unloading during walking is typical of an intact limb. The knee unit mechanism has a link set on the axle, thus providing two joints with a common axis: a) the main joint for knee flexion to 70 degrees during swing phase and flexion to 135 degrees during sitting; b) the second joint for bending at the beginning of stance phase. Compared with conventional units, gait with the new unit displays several functional advantages: 1) normal knee kinematics with movement of a TCM along a trajectory that contributes to an easy rollover of the foot and smooth and continuous translation of the body; 2) shock absorption during early stance prevents impact from the anterior brim of the socket; 3) at mid-stance, the increase of the TCM position accumulates potential energy that results in a significant increase of the push-off force; 4) during rapid gait, the unit provides adequate resistance to knee flexion; 5) location of the joint axis in front of the line of gravity loads the prosthesis in standing, making possible unimpeded carrying of the prosthesis over the support, the lengths of the prosthetic and the intact limb being equal; in addition, it facilitates flexion before the beginning of the swing phase. Production of the units began in 1992.

Amputation Stumps↗