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Paysant J, Andre J-M, Martinet N, Beis J-M, Datie A-M, Henry S, Dap F. Transcranial magnetic stimulation for diagnosis of residual limb neuromas. Arch Phys Med Rehabil 2004;85:737–42. Objective To analyze the mechanism and examine the potential diagnostic contribution of transcranial magnetic stimulation (TMS) in diagnosing painful, clonic, and/or autonomic manifestations in amputees' residual limbs. Design Prospective study. Setting Regional rehabilitation institute at a medical school in France. Participants Thirty-four amputees (24 with myoclonus, stump pain, or trophic skin disorders; 10 controls with no stump symptoms). Interventions Not applicable. Main Outcomes Measures TMS performed before and after correcting prosthesis adaptation. Results TMS induced pain in 12 amputees, clonic manifestations in 4, and autonomic manifestations in 2. Twelve patients underwent magnetic resonance imaging that showed neuromas in all 12. After neuroma resection in 9 amputees, TMS no longer provoked abnormal manifestations. TMS did provoke abnormal manifestations after resection in 3 patients who had postoperative recurrent neuromas. The response to TMS was negative in subjects with a clinically silent neuroma (n=7). The response was also negative in all patients with other stump anomalies whose clinical manifestations fully regressed after conservative treatment. There was a highly significant correlation between the presence of a pathologic neuroma and TMS-induced abnormal manifestations ( P Conclusions TMS can provoke symptoms in patients who experience spontaneous or evoked symptoms related to a neuroma. Induced symptoms are proportional to spontaneous symptoms. Removing the neuroma can stop stump symptoms and reverse the TMS effect. The response to TMS was negative in the control subjects with clinically silent neuromas; conservative treatment was successful in these cases. TMS-induced abnormal manifestations underlying mechanisms are discussed (ephaptic transmission in neuromas).

Foisneau-Lottin A, Martinet N, Henrot P, Paysant J, Blum A, Andre J-M. 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. Arch Phys Med Rehabil 2003;84:770-7 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.

Mâaref K, Martinet N, Grumillier C, Ghannouchi S, Andre JM, Paysant J. Kinematics in the terminal swing phase of unilateral transfemoral amputees: microprocessor-controlled versus swing-phase control prosthetic knees. Objectives To analyze the spatiotemporal parameters in the terminal swing phase of the prosthetic limb in unilateral transfemoral amputees (TFAs) compared with a group of asymptomatic subjects, and to identify a latency period (LP) in the TFA between the full extension of the prosthetic knee and the initial ground contact of the ipsilateral foot. To study the correlation between the LP and the duration of the swing phase. To evaluate the influence of the type of knee, the time since amputation, and the amputation level on the latency period. Design Three-dimensional gait analysis with an optoelectronic device. Setting Gait analysis laboratory of a re-education and functional rehabilitation service. Participants TFA (n=29) and able-bodied (n=15) subjects. Interventions Not applicable. Main Outcome Measures Spatiotemporal and kinematics gait parameters. Results The swing phase and the LP of the prosthetic limb, associated with a consequently longer single-limb stance phase in the intact limb, were significantly longer than those measured in the intact limbs of these subjects, as well as those measured on both lower limbs of the able-bodied subjects ( P P r 2 =.58 between the LP and the swing phase on the TFA's prosthetic side. The LP measured in the prosthetic limb of TFA with a swing-phase control prosthetic knee is significantly greater than in those using the microprocessor-controlled prosthetic knee ( P Conclusions Of negligible duration in able-bodied subjects and in the intact limb of TFA, the LP is significantly greater in the prosthetic limb. It can explain the lengthened swing phase on the prosthetic side of those subjects. The use of a microprocessor-controlled prosthetic knee allows the LP to be reduced. This LP appears to be necessary to insure the stability of the prosthetic knee. We suggest calling this time "confidence time."

To analyze the mechanism and examine the potential diagnostic contribution of transcranial magnetic stimulation (TMS) in diagnosing painful, clonic, and/or autonomic manifestations in amputees' residual limbs.Prospective study.Regional rehabilitation institute at a medical school in France.Thirty-four amputees (24 with myoclonus, stump pain, or trophic skin disorders; 10 controls with no stump symptoms).Not applicable.TMS performed before and after correcting prosthesis adaptation.TMS induced pain in 12 amputees, clonic manifestations in 4, and autonomic manifestations in 2. Twelve patients underwent magnetic resonance imaging that showed neuromas in all 12. After neuroma resection in 9 amputees, TMS no longer provoked abnormal manifestations. TMS did provoke abnormal manifestations after resection in 3 patients who had postoperative recurrent neuromas. The response to TMS was negative in subjects with a clinically silent neuroma (n=7). The response was also negative in all patients with other stump anomalies whose clinical manifestations fully regressed after conservative treatment. There was a highly significant correlation between the presence of a pathologic neuroma and TMS-induced abnormal manifestations (P.0001).TMS can provoke symptoms in patients who experience spontaneous or evoked symptoms related to a neuroma. Induced symptoms are proportional to spontaneous symptoms. Removing the neuroma can stop stump symptoms and reverse the TMS effect. The response to TMS was negative in the control subjects with clinically silent neuromas; conservative treatment was successful in these cases. TMS-induced abnormal manifestations underlying mechanisms are discussed (ephaptic transmission in neuromas).