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Fit and alignment are observable objectives of the prosthesis rendering process for individuals with lower limb amputation. Nevertheless, there is a dearth of validated measures to directly assess the quality of this clinical procedure.The objectives of this scoping review are to evaluate existing measurement parameters and clinical outcomes used in investigations of transtibial socket fit or prosthetic alignment and to identify gaps in the literature regarding tools for evaluation of prosthetic fitting.Scoping literature review.A comprehensive search was conducted in the following databases: MEDLINE (through PubMed), Embase (through Elsevier), Scopus (through Elsevier), and Engineering Village (through Elsevier), resulting in 6107 studies to be screened.Sixty-three studies were included in the review. When measuring fit, studies most frequently reported on patient-reported comfort (n = 22) and socket size compared with the residual limb volume (n = 9). Alignment was most frequently measured by the prosthetists' judgment and/or use of an alignment jig (n = 34). The measurement parameters used to determine alignment or fit varied greatly among the included studies.This review demonstrated that most measures of socket fit rely on a patient's self-report and may vary with biopsychosocial factors unrelated to the socket fitting process. Meanwhile, alignment is determined mostly by the prosthetist's judgment, paired with objective measurements, such as alignment jigs and gait analysis. Efforts to standardize and validate measures of these parameters of prosthetic fitting are vital to improving clinical practice and reporting outcomes.

The human-prosthesis interface is one of the most complicated challenges facing the field of prosthetics, despite substantive investments in research and development by researchers and clinicians around the world. The journal of the International Society for Prosthetics and Orthotics

Previous studies investigating limb volume change with elevated vacuum have shown inconsistent results and have been limited by out-of-socket volume measurements and short, single-activity protocols.To evaluate the effectiveness of elevated vacuum for managing limb fluid volume compared to suction suspension with an in-socket measurement modality during many hours of activity.Fixed-order crossover design with a standardized out-of-laboratory activity protocol.Transtibial electronic elevated vacuum users participated in two sessions. Elevated vacuum was used during the first session, and suction suspension in the second. Participants completed a 5.5-h protocol consisting of multiple intervals of activity. In-socket residual limb fluid volume was continuously measured using a custom portable bioimpedance analyzer.A total of 12 individuals participated. Overall rate of fluid volume change was not significantly different, though the rate of posterior fluid volume change during Cycle 3 was significantly lower with elevated vacuum. Although individual results varied, 11 participants experienced lower overall rates of fluid volume loss in at least one limb region using elevated vacuum.Elevated vacuum may be more effective as a volume management strategy after accumulation of activity. Individual variation suggests the potential to optimize the limb fluid volume benefits of elevated vacuum by reducing socket vacuum pressure for some users.A better understanding of how elevated vacuum (EV) affects residual limb fluid volume will allow prosthetists to make more informed clinical decisions regarding accommodation strategies designed to improve daily socket fit.

BACKGROUND: Loss of residual limb volume degrades socket fit and may require accommodation. OBJECTIVES: To examine if either of two accommodation strategies executed during resting, socket release with full socket size return and socket release with partial socket size return, enhanced limb fluid volume retention during subsequent activity. STUDY DESIGN: Two repeated-measures experiments were conducted to assess the effects of socket release on limb fluid volume retention. METHODS: Limb fluid volume was monitored while participants wore a socket with a single adjustable panel. Participants performed eight activity cycles that each included 10 minutes of sitting and 2 minutes of walking. The socket’s posterior panel and pin lock were released during the 5(th) cycle while participants were sitting. In one experiment (Full Return), the socket was returned to its pre-release size; in a second experiment (Partial Return), it was returned to 102% of its pre-release size. Short-term and long-term limb fluid volume retention were calculated and compared to a projected, No Intervention condition. RESULTS: Partial Return and Full Return short-term retentions and Partial Return long-term retention were greater than those projected under the control condition (p

Wellness activities can benefit health, yet committed adherence is challenging.Identify factors associated with committed participation in an amputee wellness-walking program and determine benefits of committed participation.Prospective longitudinal cohort.Two former Paralympians led the wellness-walking sessions. Participants provided medical history and self-reported balance confidence and prosthetic functional measures. Physiotherapy professionals/paraprofessionals assessed balance and gait. Committed participants-those attending three sessions within 3 years-were compared to one-time-only participants using Fisher's exact and independent t-tests. First and third sessions for committed participants were compared with t-tests. A bootstrapped multivariable logistic regression model was developed using significant univariate predictors.A total of 305 volunteers averaged 55.7 ± 15.2 years, including 68.4% men, 78.4% White race; 51.8% with dysvascular amputations, 40.5% with ⩾1 prosthetic knee; and 49.1% independent community walkers. Committed participants were initially similar to one-time-only participants ( p 0.05) except for fewer years since amputation ( p = 0.007), better balance ability ( p = 0.001), and greater likelihood of dieting ( p = 0.030). The final model-balance ability (odds ratio = 2.4), dieting (odds ratio = 3.3), and years since amputation (odds ratio = 0.94)-identified 88.0% of committed participants ( p = 0.007). Balance confidence and functional improvements after three sessions were not significant ( p 0.07).Committed participants were more likely to diet, have better balance ability, and have more recent amputations than one-time-only participants.Knowing which characteristics identify people most likely to become committed participants-such as people with recent amputations, an interest in dieting, and better balance ability-may help health practitioners from different professions promote consistent participation in wellness activities that may benefit self-reported function.

Low back pain is a common secondary disabling condition in the transfemoral amputee population. Transfemoral amputees are at risk of excessive lumbar lordosis; it has been suggested that increased lumbar lordosis may be associated with low back pain. However, the relationship between lumbar lordosis angle and low back pain has not yet been studied in this population.To determine whether the extent of lumbar lordosis is associated with low back pain in transfemoral amputees.Case-control observational study.Participants included eight transfemoral amputees without low back pain and nine transfemoral amputees with low back pain. Etiology of amputation was primarily trauma. All participants underwent lateral view radiographs of the lumbar spine, from which lumbar lordosis angle and sacral inclination angle were measured.Lumbar lordosis angle mean ± standard deviation was 46.1° ± 12.4° in participants with low back pain and 51.0° ± 12.6° in those without. Sacral inclination angle mean ± standard deviation was 38.3° ± 8.7° in participants with low back pain and 39.1° ± 7.5° in those without. There was no significant difference in lumbar lordosis angle or sacral inclination angle between participants with and without low back pain.This study suggests that increased lumbar lordosis angle and sacral inclination angle are not significantly associated with low back pain in transfemoral amputees of a primarily traumatic etiology.Low back pain (LBP) is a common, disabling condition in transfemoral amputees. In the clinical setting, increased lumbar lordosis is implicated in LBP. This study does not support an association between increased lumbar lordosis and LBP; further study is needed to understand the increased prevalence of LBP in this population.

The 2008 Sichuan Earthquake resulted in many amputees, yet due to the rare incidence, few studies have explored the rehabilitation outcomes and quality of life of bilateral lower limb amputees after major natural disasters.To evaluate rehabilitation outcomes of 17 young and adult bilateral lower limb amputees under the StandTall rehabilitation programme and to identify factors associated with successful functional recovery of bilateral amputees after large-scale disasters.Cross-sectional study.Mobility (amputee mobility predictor), prosthesis use (Houghton Scale) and health-related quality of life (Trinity Amputation and Prosthesis Experience Scale, Short Form 12) were evaluated through questionnaires and performance-based assessments. Means of scores were compared using T-tests.Subjects with bilateral through-knee or transtibial amputations had less activity restriction ( p 0.01) and higher mobility ( p = 0.03). Subjects using prostheses more than 50% waking time had better general adjustment ( p = 0.02) and less functional restriction ( p = 0.01). Exercise and education were associated with higher mobility ( p = 0.06) and mental quality of life, respectively ( p = 0.09).Amputation level and knee joint salvage, prosthesis use, exercise and education were associated with better rehabilitation outcomes including ambulation, adjustment and quality of life in bilateral lower limb amputees from the 2008 Sichuan Earthquake.The study examined a unique group of traumatic bilateral lower limb amputees who were young and healthy before having traumatic amputations from a single episode of natural disaster. The factors associated with better functional recovery after the earthquake were investigated and may support future development of post-disaster rehabilitation strategies for bilateral lower limb amputees.

Background: Gaitography is gait parametrization from center-of-pressure trajectories of walking on an instrumented treadmill. Gaitograms may be useful for prosthetic gait analyses, as they can be rapidly and unobtrusively collected over multiple gait cycles without constraining foot placement. However, its reliability must still be established for prosthetic gait. Objectives: To evaluate (a) within-method test–retest repeatability and (b) between-methods agreement for temporal gait events (foot contact, foot off) and gait characteristics (e.g. step times, single-support duration). Study design: Cohort study with repeated measurements. Methods: Ten male proficient prosthetic walkers with a unilateral trans-femoral or trans-tibial amputation were equipped with a pressure-insole system and were invited to walk on separate days on an instrumented treadmill. Results: We found better between-methods reproducibility than within-method repeatability in temporal gait characteristics. Step times, stride times, and foot-contact events matched well between the two methods. In contrast, insole-based foot-off events were detected one-to-two samples earlier. Likewise, a similar bias was observed for temporal gait characteristics that incorporated foot-off events. Conclusion: Notwithstanding small systematic biases, the good between-methods agreement indicates that temporal gait characteristics may be determined interchangeably with gaitograms and insoles in persons with a prosthesis. However, the relatively poorer test–retest repeatability hinders longitudinal assessments with either method. Clinical relevance: Clinical practice could potentially benefit from gaitography as an efficient, unobtrusive, easy to use, automatized, and patient-friendly means to objectively parametrize prosthetic gait, with immediate availability of test results allowing for prompt clinical decision-making. Temporal gait parameters demonstrate good between-methods agreement, but poorer within-method repeatability hinders detecting prosthetic gait changes.

Different recommendations exist regarding what age is best for first-time fitting of myoelectric hand prostheses in children.To compare prosthetic skill, prosthetic use and risk for rejection over time between children fitted with myoelectric hand prostheses before or after 2½ years of age.Prospective case-control design.The cases were nine children fitted with myoelectric hand prostheses before the age of 2½ years, whereas the controls were 27 children who were fitted with myoelectric hand prostheses after the age of 2½ years. The Skills Index Ranking Scale was used to classify prosthetic skill, and prosthetic use was categorised based on wearing time and pattern. Independent samples tests were used to compare data between groups. To estimate and compare the risk of prosthesis rejection between groups and over time, survival analysis was used.Cases showed prosthetic skill early, but controls had caught up by the age of 3½ years. Cases had a significant ( p = 0.046) decrease in prosthetic use at the age of 9 years. In the long term, cases had a higher percentage of prosthesis rejection.Considering young children's development of prosthetic skill and prosthetic use over time, this study shows no additional advantages from fitting a myoelectric hand prosthesis before 2½ years of age. Clinical relevance Children may be fitted with myoelectric hand prostheses to assist in daily tasks and to prevent future over-use problems. Most children fitted with myoelectric hand prostheses before 4 years of age become regular users. No advantages of fitting myoelectric hand prostheses before 2½ years of age were observed.

Background: Shock-attenuating pylons are commonly fitted to prostheses in order to compensate for the anatomical and biomechanical shock-absorbing features of the lower limb removed upon amputation. However, studies concerning their shock-attenuating capacity are highly variable and, to date, have not yet been reviewed, making them difficult to interpret and apply in clinical practice. Objectives: To synthesise and appraise the available literature examining the effectiveness of shock-attenuating pylons in attenuating shock upon limb loading compared to rigid pylons among lower limb amputees. Study design: Systematic review. Methods: A comprehensive search of seven databases was conducted using search terms concerning amputation level, shock-attenuating and rigid pylons as well as measures of shock attenuation. All studies yielded were screened against established inclusion and exclusion criteria before eligible articles were appraised using the Quality Assessment Standard for Crossover Studies adapted from the Cochrane handbook. Results: Nine articles were eligible for inclusion. While there was a trend among studies to indicate only a limited positive effect of shock-attenuating pylons in attenuating transient impact forces, limitations to the study designs, namely, in sampling, poor reporting of methodological details and heterogeneity of outcomes made conclusive interpretation of results difficult. Conclusion: While the current body of literature does not reconcile with claims made by manufacturers of shock-attenuating pylons, it is insufficient to conclusively determine how effective shock-attenuating pylons are, in comparison with conventional rigid pylons, in attenuating transient impact forces among lower limb amputees. Higher quality research is required to better guide decisions regarding prescription of shock-attenuating componentry in clinical practice. Clinical relevance: When delivered well, research can provide clinicians with objective and reliable data that can be applied in their practice to guide prescription of componentry. However, methodological limitations to research may compromise the reliability of findings, thereby producing potentially misleading outcomes. These limitations must be recognised and appreciated such that findings may be interpreted accurately and applied appropriately.

Epidermolysis bullosa dystrophica is a rare dermatological disease characterized by extreme skin fragility and elevated risk of developing a squamous cell carcinoma. In some cases, amputation of a limb is necessary. Case description and methods: A 37-year-old man with recessive, severe generalized epidermolysis bullosa dystrophica developed a squamous cell carcinoma on the right forearm requiring a below-elbow amputation. Preoperative advice concerning indication and level of amputation was given. Due to potential skin problems, a conventional prosthesis was not feasible. Findings and outcomes: A custom-designed adaptive prosthesis with an upper arm cuff was trialed and was well tolerated. Multiple working tools, attached with a rotation and inclination system, allowed independence and return to work.Despite multiple potential skin problems of the stump, the patient was successfully fitted with a custom-designed adaptive prosthesis. Preparation for this fitting was done by a comprehensive multidisciplinary patient-centered approach. Clinical relevance Despite severe skin fragility, a patient with epidermolysis bullosa dystrophica was successfully fitted with a custom-designed adaptive upper limb prosthesis allowing good functional outcome. This required a multidisciplinary and patient-centered approach.

The microprocessor-controlled foot Meridium is a prosthetic component with adjustable stance-phase characteristics.To investigate subjects' and prosthetists' perception of safety, walking, and satisfaction during first routine fittings.Multicenter, prospective, observational cohort study.Data regarding demographics, fitting process, safety, daily life activities, and satisfaction were obtained through questionnaires. The follow-up period was 7 months.In all, 89% of 70 users were satisfactorily fitted within the first two visits. Compared to previous feet, users reported improvements in walking on level ground (54% of subjects), uneven ground (82%), ascending (97%), and descending ramps (91%). More than 45% of the users perceived an improvement in safety and stability while standing and walking. No difference was observed in concentration, exertion, and pain. Overall user satisfaction with Meridium was 50% and the foot was preferred by 40% of users. Amputation level, age and mobility grade did not influence subjects' preference. Prosthetists recommended Meridium for 59% of subjects. A correlation analysis revealed that transfemoral amputees fitted with Genium and/or having a long residual limb strongly preferred Meridium ( p 0.05).Meridium was appreciated by amputees with a preference for natural walking and requirement to safely and comfortably negotiate uneven terrain and slopes. Clinical relevance Amputees preferring Meridium perceive benefits with safe, comfortable, and natural walking. While the perception of benefits regarding the negotiation of uneven terrain and slopes is very high, the correlation to product preference is moderate. Individual assessment and trial fitting might be essential to identify patients who benefit greatly.

Background: Studies suggest that the energy expenditure of healthy persons (control) during walking with the preferred walking speed in steady-state conditions is dominated by fat oxidation. Conversely, carbohydrate and fat oxidation during walking is little investigated in transfemoral amputees. Objectives: To investigate carbohydrate and fat oxidation, energy cost of walking, and percent utilization of maximal aerobic capacity (%V·O2max) during walking. Study design: Eight transfemoral amputees and controls walked with their preferred walking speed and speeds 12.5% and 25% slower and faster than their preferred walking speed. Methods: Energy expenditure and fuel utilization were measured using a portable metabolic analyzer. Metabolic values are means ± standard deviation. Results: For transfemoral amputees (37.0 ± 10.9 years) and controls (39.0 ± 12.3 years), fat utilization at the preferred walking speed was 44.8% ± 7.2% and 45.0% ± 7.2% of the total energy expenditure, respectively. The preferred walking speed of the transfemoral amputees and controls was close to a metabolic cross-over speed, which is the speed where carbohydrate utilization increases steeply and fat utilization decreases. When walking fast, at 90 m min−1 (preferred walking speed plus 25%), transfemoral amputees utilized 70.7% ± 5.6% of their V·O2max , while the controls utilized 30.9% ± 4.5% (p

In principle, lower limb bone-anchored prostheses could alleviate expenditure associated with typical socket manufacturing and residuum treatments due to socket-suspended prostheses.This study reports (a) the incremental costs and (b) heath gain as well as (c) cost-effectiveness of bone-anchored prostheses compared to socket-suspended prostheses.Retrospective individual case-controlled observations and systematic review.Actual costs were extracted from financial records and completed by typical costs when needed over 6-year time horizon for a cohort of 16 individuals. Health gains corresponding to quality-adjusted life-year were calculated using health-related quality-of-life data presented in the literature.The provision of bone-anchored prostheses costed 21% ± 41% more but increased quality-adjusted life-years by 17% ± 5% compared to socket-suspended prostheses. The incremental cost-effectiveness ratio ranged between -$25,700 per quality-adjusted life-year and $53,500 per quality-adjusted life-year with indicative incremental cost-effectiveness ratio of approximately $17,000 per quality-adjusted life-year. Bone-anchored prosthesis was cost-saving and cost-effective for 19% and 88% of the participants, respectively.This study indicated that bone-anchored prostheses might be an acceptable alternative to socket-suspended prostheses at least from a prosthetic care perspective in Australian context. Altogether, this initial evidence-based economic evaluation provided a working approach for decision makers responsible for policies around care of individuals with lower limb amputation worldwide. Clinical relevance For the first time, this study provided evidence-based health economic benefits of lower limb bone-anchored prostheses compared to typical socket-suspended prostheses from a prosthetic care perspective that is essential to clinicians and decision makers responsible for policies.

Recent literature indicates equivalent costs of walking can be achieved after a transtibial amputation when the individual is young, active, and/or has extensive access to rehabilitative care. It is unknown if a similar cohort with transfemoral amputation can also achieve lower metabolic costs of walking than previously reported.Compare metabolic cost in individuals with a transfemoral amputation to controls and to the literature across a range of walking speeds.Cross-sectional.A total of 14 individuals with a unilateral transfemoral amputation (27 ± 5 years, N = 4 mechanical knee, N = 10 microprocessor knee) and 14 able-bodied controls (26 ± 6 years) walked at self-selected and four standardized speeds. Heart rate, metabolic rate (mL OSelf-selected speed was 8.6% slower in the transfemoral amputation group ( p = 0.031). Across standardized speeds, both metabolic rate and metabolic cost ranged from 44%-47% greater in the transfemoral amputation group ( p 0.001), heart rate was 24%-33% greater ( p 0.001), and perceived exertion was 24%-35% greater ( p 0.009).Although the transfemoral amputation group was relatively young, physically fit, and had extensive access to rehabilitative care, the metabolic cost of walking fell within the ranges of the literature on older or presumably less fit individuals with transfemoral amputation. Clinical relevance Developments in prosthetic technology and/or rehabilitative care may be warranted and may reduce the metabolic cost of walking in individuals with a transfemoral amputation.

Prosthetic feet are prescribed based on their mechanical function and user functional level. Subtle changes to the stiffness and hysteresis of heel, midfoot, and forefoot regions can influence the dynamics and economy of gait in prosthesis users. However, the user's choice of shoes may alter the prosthetic foot-shoe system mechanical characteristics, compromising carefully prescribed and rigorously engineered performance of feet.Observe the effects of footwear on the mechanical properties of the prosthetic foot-shoe system including commonly prescribed prosthetic feet.Repeated-measures, Mechanical characterization.The stiffness and energy return was measured using a hydraulic-driven materials test machine across combinations of five prosthetic feet and four common shoes as well as a barefoot condition.Heel energy return decreased by an average 4%-9% across feet in all shoes compared to barefoot, with a cushioned trainer displaying the greatest effect. Foot designs that may improve perceived stability by providing low heel stiffness and rapid foot-flat were compromised by the addition of shoes.Shoes altered prosthesis mechanical characteristics in the sagittal and frontal planes, suggesting that shoe type should be controlled or reported in research comparing prostheses. Understanding of how different shoes could alter certain gait-related characteristics of prostheses may aid decisions on footwear made by clinicians and prosthesis users. Clinical relevance Shoes can alter function of the prosthetic foot-shoe system in unexpected and sometimes undesirable ways, often causing similar behavior across setups despite differences in foot design, and prescribing clinicians should carefully consider these effects on prosthesis performance.

This novel case report describes the problems of prescribing a prosthetic socket in a left transfemoral amputee secondary to chronic patellofemoral instability compounded by complex regional pain syndrome. Case Description and Methods: Following the amputation, complex regional pain syndrome symptoms recurred in the residual limb, presenting mainly with oedema. Due to extreme daily volume fluctuations of the residual limb, a conventional, laminated thermoplastic socket fitting was not feasible. Findings and Outcomes: An adjustable, modular socket design was trialled. The residual limb volume fluctuations were accommodated within the socket. Amputee rehabilitation could be continued, and the rehabilitation goals were achieved. The patient was able to wear the prosthesis for 8 h daily and to walk unaided indoors and outdoors.An adjustable, modular socket design accommodated the daily residual limb volume fluctuations and provided a successful outcome in this case. It demonstrates the complexities of socket fitting and design with volume fluctuations. Clinical relevance Ongoing complex regional pain syndrome symptoms within the residual limb can lead to fitting difficulties in a conventional, laminated thermoplastic socket due to volume fluctuations. An adjustable, modular socket design can accommodate this and provide a successful outcome.

Background: Current transfemoral prosthetic sockets are problematic as they restrict function, lack comfort, and cause residual limb problems. Development of a subischial socket with lower proximal trim lines is an appealing way to address this problem and may contribute to improving quality of life of persons with transfemoral amputation. Objectives: The purpose of this study was to illustrate the use of a new subischial socket in two subjects. Study design: Case series. Methods: Two unilateral transfemoral prosthesis users participated in preliminary socket evaluations comparing functional performance of the new subischial socket to ischial containment sockets. Testing included gait analysis, socket comfort score, and performance-based clinical outcome measures (Rapid-Sit-To-Stand, Four-Square-Step-Test, and Agility T-Test). Results: For both subjects, comfort was better in the subischial socket, while gait and clinical outcomes were generally comparable between sockets. Conclusion: While these evaluations are promising regarding the ability to function in this new socket design, more definitive evaluation is needed. Clinical relevance Using gait analysis, socket comfort score and performance-based outcome measures, use of the Northwestern University Flexible Subischial Vaccum Socket was evaluated in two transfemoral prosthesis users. Socket comfort improved for both subjects with comparable function compared to ischial containment sockets.

The fit and function of a prosthetic socket depend on the prosthetist's ability to design the socket's shape to distribute load comfortably over the residual limb. We recently developed a sub-ischial socket for persons with transfemoral amputation: the Northwestern University Flexible Sub-Ischial Vacuum Socket.This study aimed to quantify the rectifications required to fit the Northwestern University Flexible Sub-Ischial Vacuum Socket to teach the technique to prosthetists as well as provide a computer-aided design-computer-aided manufacturing option.Development project.A program was used to align scans of unrectified and rectified negative molds and calculate shape change as a result of rectification. Averaged rectifications were used to create a socket template, which was shared with a central fabrication facility engaged in provision of Northwestern University Flexible Sub-Ischial Vacuum Sockets to early clinical adopters. Feedback regarding quality of fitting was obtained.Rectification maps created from 30 cast pairs of successfully fit Northwestern University Flexible Sub-Ischial Vacuum Sockets confirmed that material was primarily removed from the positive mold in the proximal-lateral and posterior regions. The template was used to fabricate check sockets for 15 persons with transfemoral amputation. Feedback suggested that the template provided a reasonable initial fit with only minor adjustments.Rectification maps and template were used to facilitate teaching and central fabrication of the Northwestern University Flexible Sub-Ischial Vacuum Socket. Minor issues with quality of initial fit achieved with the template may be due to inability to adjust the template to patient characteristics (e.g. tissue type, limb shape) and/or the degree to which it represented a fully mature version of the technique. Clinical relevance Rectification maps help communicate an important step in the fabrication of the Northwestern University Flexible Sub-Ischial Vacuum Socket facilitating dissemination of the technique, while the average template provides an alternative fabrication option via computer-aided design-computer-aided manufacturing and central fabrication.

STUDY DESIGN: Retrospective cohort study.BACKGROUND: Persons with a lower limb amputation can regain mobility using a prosthetic device. For fast and adequate prescription of prosthetic components, it is necessary to predict the mobility outcome early in rehabilitation. Currently, prosthetic prescription is primarily based on empirical knowledge of rehabilitation professionals.OBJECTIVE: In this study, we explored motor ability tests, to be completed without a prosthetic device, which have predictive value for mobility outcome at the end of rehabilitation.METHODS: For this study, data of 82 patients with a lower limb amputation were included. The Single-limb standing balance test (Balance test), the Lower-Extremity Motor Coordination Test and the Amputee Mobility Predictor Assessment Tool (AMPnoPRO) were used as measures for motor ability. Mobility outcome was measured using the Timed Up and Go Test, the Two-Minute Walking Test and K levels were used.RESULTS: The explained variance of the Balance test, the Lower-Extremity Motor Coordination Test and the AMPnoPRO was, respectively, 0.603, 0.534 and 0.649 on the Two-Minute Walking Test (linear regression); 0.597, 0.431 and 0.624 on the Timed Up and Go Test (linear regression); and 0.432, 0.420 and 0.526 on the K levels (logistic regression).CONCLUSION: The AMPnoPRO predicted mobility outcome statistically (largest amount of explained variance).CLINICAL RELEVANCE: This study explored the possibility of statistically predicting mobility outcome in lower limb amputees at the end of rehabilitation, using motor ability tests conducted in early rehabilitation. This study suggests the use of the AMPnoPRO to predict mobility outcome in lower limb amputees.

The need for information regarding running-specific prosthetic properties has previously been voiced. Such information is necessary to assist in athletes' prostheses selection.This study aimed to describe the characteristics of two commercially available running-specific prostheses.The running-specific prostheses were tested (in an experimental setup) without the external interference of athlete performance variations.Four stiffness categories of each running-specific prosthetic model (XtendNo statistically significant differences were found between the different setups of the running-specific prostheses. Statistically significant differences were found between the two models for all outcome variables (GRFThese findings suggest that the Xtreme stores more elastic energy than the Xtend, leading to a greater performance response. The specific responsive features of blades could guide sprint athletes in their choice of running-specific prostheses. Clinical relevance Insights into the running-specific prosthesis (RSP) properties and an understanding of its responsive characteristics have implications for athletes' prosthetic choice. Physiologically and metabolically, a short sprint event (i.e. 100 m) places different demands on the athlete than a long sprint event (i.e. 400 m), and the RSP should match these performance demands.

Body composition is important for health screening, but appropriate methods for unilateral lower extremity amputees have not been validated.To compare body mass index adjusted using Amputee Coalition equations (body mass index-Amputee Coalition) to dual-energy X-ray absorptiometry in unilateral lower limb amputees.Cross-sectional, experimental.Thirty-eight men and women with lower limb amputations (transfemoral, transtibial, hip disarticulation, Symes) participated. Body mass index (mass/heightBody mass index-Amputee Coalition increased body mass index (by ~ 1.1 kg/mBody mass index (despite correction) underestimates health risk for obese patients and overestimates lean, muscular individuals with lower limb amputation. Clinical relevance Clinical recommendations for an ideal body mass based on body mass index-Amputee Coalition should not be relied upon in lower extremity amputees. This is of particular concern for obese lower extremity amputees whose health risk might be significantly underestimated based on body mass index despite a "correction" formula for limb loss.

Elevated vacuum suspension systems use a pump to draw air from the socket with the intent of reducing bone-socket motion as compared to passive suction systems. However, it remains unknown if elevated vacuum suspension systems decrease limb displacement uniformly during transitions from unloaded to full-body-weight support.To compare limb-socket motion between elevated vacuum and passive suction suspension sockets using a controlled loading paradigm.Comparative analysis.Persons with transtibial amputation were assessed while wearing either an elevated vacuum or passive suction suspension socket. Digital video fluoroscopy was used to measure axial bone-socket motion while the limb was loaded in 20% body-weight increments. An analysis of variance model was used to compare between suspension types.Total axial displacement (0%-100% body weight) was significantly lower using the elevated vacuum (vacuum: 1.3 cm, passive suction: 1.8 cm; p 0.0001). Total displacement decreased primarily due to decreased motion during initial loading (0%-20%; p 0.0001). Other body-weight intervals were not significantly different between systems.Elevated vacuum suspension reduced axial limb-socket motion by maintaining position of the limb within the socket during unloaded conditions. Elevated vacuum provided no meaningful improvement in limb-socket motion past initial loading.Excessive bone-socket motion contributes to poor residual limb health. Our results suggest elevated vacuum suspensions can reduce this axial displacement. Visual assessment of the images suggests that this occurs through the reduction or elimination of the air pocket between the liner and socket wall while the limb is unloaded.

The socket reaction moments are directly measured at the base of a socket and may be useful for fitting a prosthesis. Previous studies have focused on the effect of prosthetic alignment changes on them. The aim of this study was to explore their range at clinically perceived optimal alignment by investigating the individual differences.In total, 11 amputees using unilateral transtibial prostheses with solid-ankle-cushion-heel (SACH) feet were recruited. The socket reaction moments were measured using a custom instrumented prosthesis alignment component and plotted. Eight variables that were related to their magnitude (N m/kg) and timing (% stance of event) as well as cadence (steps/minute) were calculated for each amputee. Their mean, standard deviation, maximum value, minimum value, and range were subsequently analyzed.This study may serve as a foundation to explore the range of individual differences in socket reaction moments in transtibial prostheses.Socket reaction moments can be conveniently measured in the clinical setting. Prosthetists could potentially use them as one of the criteria to align prosthesis in addition to observational gait analysis and amputees perception.

Harness fitting in the body-powered prosthesis remains more art than science due to a lack of consistent and quantitative evaluation. The aim of this study was to develop a mechanical, human-body-shaped apparatus to simulate body-powered upper limb prosthetic usage and evaluate its capability of quantitative examination of harness configuration.The apparatus was built upon a torso of a wooden mannequin and integrated major mechanical joints to simulate terminal device operation. Sensors were used to register cable tension, cable excursion, and grip force simultaneously.The apparatus allowed the scapula to move up to 127 mm laterally and the load cell can measure the cable tension up to 445 N. Our preliminary evaluation highlighted the needs and importance of investigating harness configurations in a systematic and controllable manner.The apparatus allows objective, systematic, and quantitative evaluation of effects of realistic harness configurations and will provide insightful and working knowledge on harness fitting in upper limb amputees using body-powered prosthesis.

There is limited research on responsiveness of prosthetic rehabilitation outcome measures.To examine responsiveness of the Box and Block test, Jebsen-Taylor Hand Function tests, Upper Extremity Functional Scale, University of New Brunswick skill and spontaneity tests, Activity Measure for Upper Limb Amputation, and the Patient-Specific Functional Scale.This was a quasi-experimental study with repeated measurements in a convenience sample of upper limb amputees.Measures were collected before, during, and after training with the DEKA Arm.Largest effect sizes were observed for Patient-Specific Functional Scale (effect size: 1.59, confidence interval: 1.00, 2.14), Activity Measure for Upper Limb Amputation (effect size: 1.33, confidence interval: 0.73, 1.90), and University of New Brunswick skill test (effect size: 1.18, confidence interval: 0.61, 1.73). Other measures that were responsive to change were Box and Block test, Jebsen-Taylor Hand Function light and heavy can tests, and University of New Brunswick spontaneity test. Responsiveness and pattern of responsiveness varied by prosthetic level.The Box and Block test, Jebsen-Taylor Hand Function light and heavy can tests, University of New Brunswick skill and spontaneity tests, Activities Measure for Upper Limb Amputation, and the Patient-Specific Functional Scale were responsive to change during prosthetic training. These findings have implications for choice of measures for research and practice and inform clinicians about the amount of training necessary to maximize outcomes with the DEKA Arm.Findings on responsiveness of outcome measures have implications for the choice of measures for clinical trials and practice. Findings regarding the responsiveness to change over the course of training can inform clinicians about the amount of training that may be necessary to maximize specific outcomes with the DEKA Arm.

It has long been reported that a range of prosthesis alignments is acceptable in trans-tibial prosthetics. This range was shown to be smaller when walking on uneven surfaces. It has also been argued that findings on gait with prostheses that were obtained under laboratory conditions are limited in their applicability to real-life environments.This study investigated the hypothesis that efforts to compensate for suboptimal alignments by active users of trans-tibial prostheses become less effective when levels of physical exertion increase.A 2 × 2 repeated-measures analysis of variance was conducted to compare the effects of physical exertion and subtle alignment perturbations on gait with trans-tibial prostheses.The gait of eight subjects with trans-tibial amputation was analyzed when walking with two different prosthesis alignments and two different physical exertion levels. The main and interaction effects were statistically evaluated.Bilateral step length symmetry and measures of step variability within the same leg were found to be affected by the intervention. There was no significant effect on index variables that combined kinematic or kinetic measures.Findings showed that persons with trans-tibial prostheses responded heterogeneously to the interventions. For most variables, the research hypothesis could not be confirmed.Findings support the practice of allotting several sessions to the alignment of trans-tibial prostheses, as users' gait responds differently to perturbations when external factors (e.g. exertion) change. Furthermore, the found inhomogeneity in the population of persons with trans-tibial amputation supports the use of technical gait assessment methods in clinical practice.

Few studies have explored the effects of exercise on gait performance in people with lower limb amputations.To (1) summarize the effects of exercise programs on gait performance and (2) assess the overall quality of the evidence for adults ambulating with leg prostheses.Systematic review.Six databases were searched for one- and two-group studies published through June 2013 reporting effects of exercise on gait speed, a universal measure of performance in lower limb prosthetic users. The search adhered to a predetermined protocol following Cochrane Collaboration guidelines.In all, 623 citations were reviewed and eight studies included. The quality level of the combined evidence was low with few randomized control trials and multiple sources of bias evident within the heterogeneous group of studies. The 11 exercise programs, including three control conditions, demonstrated small to large effect size improvements in self-selected gait speed. Use of exercise to improve gait speed was supported by low-quality level evidence, with low-moderate quality evidence to suggest that specific functional exercise programs were more effective than supervised walking.Using exercise to improve gait speed in people with lower limb amputation received a B grade recommendation. Future high-quality research is required.Supervised walking, muscle strengthening, balance exercises, gait training, and functional training programs demonstrated small to large effect size gait performance improvements in people with lower limb amputation. Self-selected gait speed was the most consistent outcome measure. Exercise programs emphasizing resisted gait and functional training were more effective than supervised walking.

The functional performance of currently available body-powered prostheses is unknown.The goal of this study was to objectively assess and compare the functional performance of three commonly used body-powered upper limb terminal devices.Experimental trial.A total of 21 able-bodied subjects (n = 21, age = 22 ± 2) tested three different terminal devices: TRS voluntary closing Hook Grip 2S, Otto Bock voluntary opening hand and Hosmer Model 5XA hook, using a prosthesis simulator. All subjects used each terminal device nine times in two functional tests: the Nine-Hole Peg Test and the Box and Blocks Test.Significant differences were found between the different terminal devices and their scores on the Nine-Hole Peg Test and the Box and Blocks Test. The Hosmer hook scored best in both tests. The TRS Hook Grip 2S scored second best. The Otto Bock hand showed the lowest scores.This study is a first step in the comparison of functional performances of body-powered prostheses. The data can be used as a reference value, to assess the performance of a terminal device or an amputee.The measured scores enable the comparison of the performance of a prosthesis user and his or her terminal device relative to standard scores.

Patients who undergo transfemoral amputation after infection of a total knee arthroplasty do not have good functional outcomes and have major difficulty walking.To evaluate the quality of life and walking ability among patients who underwent amputation and among those who refused to undergo amputation following infection of a total knee arthroplasty.Retrospective case series.Patients who received an indication for amputation following an infection of a total knee arthroplasty were evaluated retrospectively. The patients were divided between those who accepted the amputation procedure and those who refused amputation (four amputee vs four non-amputees). Walking ability and quality of life were evaluated using the Short Form-36 questionnaire.The average physical health was 27.4 for the amputees and 31.3 for the non-amputees. The average mental health was 49.9 for the amputees and 47.1 for the non-amputees. In relation to walking ability, only one (25%) of the amputees was able to walk, as opposed to 100% in the non-amputee groups.Twenty-five percent of the amputee patients continued to be able to walk. The functional outcome of non-amputee patients was better, with 100% being able to walk, though with limitations.This is the first study evaluating patients who refused the amputation procedure and remained with the spacer. Despite the fact that this option is not recommended by the medical community, we believe that these data are useful when discussing, with a patient, quality of life after amputation.

Background and aim: Dynamic alignment of transtibial prostheses is generally performed based on visual interpretation of gait without the benefit of any kinetic analysis in the clinic. The aim of this technical note was to present and discuss the possibilities of assisting dynamic alignment of transtibial prostheses through visualization of socket reaction moments. Technique: Smart Pyramid™ (currently Europa™) was used to measure the socket reaction moments under various alignment conditions from an amputee with transtibial prosthesis. The socket reaction moments were plotted to visualize the effect of alignment changes on them, and they were clinically interpreted. Discussion: Socket reaction moments could complement information available to prosthetists to optimize prosthetic alignment. They could be used to reduce excessive loading on sensitive areas, to improve gait stability, or to communicate the outcome of dynamic alignment with the amputees. Further research is needed to identify the contribution of kinematics and kinetics for optimal alignment. Clinical relevance Dynamic alignment of transtibial prostheses is currently tuned subjectively based on prosthetists' experiences and skills. Socket reaction moments may potentially provide objective information for prosthetists to align transtibial prostheses in the clinic.

In recent years, there has been an increased interest in recording high-quality electromyographic signals from within the sockets of lower-limb amputees. However, successful recording presents major challenges to both researchers and clinicians. This article details and compares four prototypical integrated socket-sensor designs used to record electromyographic signals from within the sockets of transfemoral amputees.Four prototypical socket-sensor configurations were constructed and tested on a single transfemoral amputee asked to perform sitting/standing, stair ascent/descent, and level ground walking. The number of large-amplitude motion artifacts generated using each prototype was quantified, the amount of skin irritation documented, and the comfort level of each assembly subjectively assessed by the amputee subject.Of the four configurations tested, the combination of a suction socket with integrated wireless surface electrodes generated the lowest number of large-amplitude motion artifacts, the least visible skin irritation, and was judged to be most comfortable by the amputee subject.The collection of high-quality electromyographic signals from an amputee's residual limb while maximizing patient comfort holds substantial potential to enhance neuromuscular clinical assessment and as a method of intuitive control of powered lower-limb prostheses.

Daily changes in the shape and size of the residual limb affect prosthetic socket fit. Prosthetic socks are often added or removed to manage changes in limb volume. Little has been published about how persons with transtibial amputations use socks to manage diurnal changes in volume and comfort.To investigate prosthetic sock use with a customized, self-report questionnaire.Cross-sectional survey.Persons with transtibial amputation reported number, thickness, and timing of socks used over a 14-day period.Data from 23 subjects (16 males and 7 females) were included. On average, socks were changed less than once per day (0.6/day) and ply increased over the day (4.8-5.5 ply). Subjects wore prostheses significantly longer (15.0-14.1 h, p = 0.02) and changed socks significantly more often (0.6/day-0.4/day, p = 0.03) on weekdays compared to weekends. Participants were also divided into two subgroups: those who used socks to manage limb volume and those who used socks for socket comfort. Sock use did not differ (p0.05) between subgroups.Sock changes are infrequent among persons with lower limb loss. Initial, verbal reports of sock use were often inconsistent with data measured by logs. Tools (e.g. sock logs or objective instruments) to better understand sock-use habits among persons with limb loss are needed.Knowledge of prosthetic patients' sock use may help practitioners enhance volume management strategies or troubleshoot fitting issues. Results showed that subjects generally added socks to account for volume loss, and end-of-day sock thickness frequently exceeded 5 ply. Use of sock logs in clinical practice may facilitate improved residual limb health.

The objective of this study was to demonstrate how a load cell and force-moment curves can be used outside of a gait lab to directly measure and evaluate the transverse plane loading moment on transtibial residual limbs.A load cell was attached distally to the socket of three transtibial amputees who walked a straight path and a circle of 3.048-m diameter with the prosthetic foot both inside and outside the curved path.Compared to straight path walking, transverse plane moment decreased when the foot was on the outside of the curved path. When the foot was on the inside, the moment did not exceed that for straight path walking for two participants; maximum transverse moment was approximately 0.15 N m/kg of body mass. Force-moment curves indicated that each participant's gait was unique, but underlying similarities were observed with respect to each of the three conditions.A load cell in conjunction with curved and straight path walking and force-moment curves can be used outside of a gait lab to measure and examine the transverse plane loading on the residual limb.

Background:We report our experiences of prosthetic fitting in quadruple amputees. Two patients underwent quadruple amputation after suffering from disseminated intravascular coagulation in conjunction with pneumococcemia with purpura fulminans.Case Description and Methods:The first patient, a 52-year-old man, underwent bilateral transradial, left transtibial, and right transfemoral amputation, and the second patient, a 62-year-old man, underwent bilateral transradial and bilateral transfemoral amputation, both for symmetrical peripheral gangrene subsequent to septic shock.Findings and Outcomes:The amputations were accompanied by skin damage due to ischemic tissue changes both on the stumps and on the nose and/or lips. The combination of the intensive prosthetic rehabilitation program and supportive medical care led to completely independent functioning, including driving a car, with the use of four prosthetic limbs and a wheelchair in both cases.Conclusion:Early initiation of a multidisciplinary approach ...

One of the main indicators of the suspension system efficiency in lower limb prostheses is vertical displacement or pistoning within the socket. Decreasing pistoning and introducing an effective system for evaluating pistoning could contribute to the amputees' rehabilitation process.The main objective of this study was to review existing research studies that examine the occurrence of pistoning in lower limb prosthesis with different techniques in static (standing) and dynamic (walking and jumping) positions.Literature review.Keywords related to slippage, suspension, pistoning and vertical movement in lower limb prosthetics were used to search the literature available in PubMed, ScienceDirect, Web of Science and Google Scholar databases. Sixteen articles were selected for further analysis according to the selection criteria.The following methods have been used to measure the occurrence of pistoning in prosthetic limbs: radiological methods, photographic technique, motion analysis system, sensor and spiral computerized tomography (CT). Pistoning was measured both in standing and walking.The results of this review reveal that further research is needed to develop and evaluate easy, accurate and safe methods of measuring pistoning. Future studies should provide a gold standard for the acceptable range of pistoning in a prosthetic socket.

Background and Aim: Partial ear amputations are one of the forms of ear loss. A user-friendly design of prosthesis with safe suspension and an aesthetic appearance can be helpful to a patient who has lost part of their ear due to congenital absence or trauma. Prosthetic use has social and psychological effects on the patient and their family. The aim of this paper is to describe a technique of ear prosthesis fabrication with self suspension for these patients. Technique: To provide a snugly fitting prosthesis, the only parts of the residual ear that were covered by the prosthesis were accurately manufactured and reduced in thickness to 0.5–1 mm and 10 mm in width, so that the silicone extended over the stumps to provide adequate suspension. Discussion: This paper proposes the designing and constructing of a silicone ear prosthesis which had good suspension, low cost, was easy to use and was acceptable in appearance to the patient.

As part of the process of improving prosthetic arms, it is important to obtain the opinions of the user population.To identify factors that should be focused on to improve prosthesis provision.Postal questionnaire.The questionnaire was sent to 292 adults (aged 18 to 70 years) with upper-limb loss or absence at five centres (four in Europe) Participants were identified as regular attendees of the centres.This questionnaire received a response from 180 users (response rate 62%) of different types of prosthetic devices. Responses showed that the type of prosthesis generally used was associated with gender, level of loss and use for work (Pearson chi-square, p-values below 0.05). The type of prosthesis was not associated with cause, side, usage (length per day, sports or driving) or reported problems. The findings did not identify any single factor requiring focus for the improvement of prostheses or prosthetic provision.Every part of the process of fitting a prosthesis can be improved, which will have an effect for some of the population who use their devices regularly. There is, however, no single factor that would bring greater improvement to all users.Based on information gained from a broad range of prosthesis users, no single aspect of prosthetic provision will have a greater impact on the use of upper limb prostheses than any other. Efforts to improve the designs of prosthetic systems can cover any aspect of provision.

This article proposes a type of transtibial socket composed of an inner layer fabricated by a rapid prototyping (RP) machine and an outer layer coated with unsaturated polyester resin. This work integrates contemporary technologies including a handheld scanner and CAD systems, to design a thin primary socket shape and then manufactures the socket using a fused deposition-modeling machine. To prevent breakage caused by the layer-based forming process and to reinforce flexural strength, the current research coats the preliminary RP socket with a layer of unsaturated polyester resin. After shaping the proximal brim of the resin-reinforced RP socket to match the specific stump, this study assembles and aligns a shank and a prosthetic foot to form a prosthesis set. After completing a trial safety walk wearing the prosthesis, which is satisfactory to the amputee and a registered prosthetist, this research measures interface pressures between the stump and the resin-reinforced RP socket. Experiment results demonstrate that the resin-reinforced RP socket is applicable for transtibial amputees. In addition to strengthening the FDM socket and producing consistent socket fit, this study also demonstrates a feasible procedure that employs current technologies to design and manufacture transtibial sockets without plaster moulds.

From the roots of cross training to the rigorous worldwide events, triathlon has become a means for physical conditioning, competition and socialization that is adaptable to everyone with a desire and commitment to participate. The novelty of athletes with limb loss competing alongside able-bodied has passed. The current expectation is that sport, including triathlon, is well within the reach of any amputee athlete with the physical ability and determination to compete. Commitment by the clinical team to the amputee athlete along with the systematic practice of prosthetic fitting, sport-specific training and accurate record keeping will not only assist today's athletes, but will establish the foundation for future amputee triathletes. This article outlines the prosthetic and training consideration for clinicians working with novice and intermediate amputee triathletes or those interested in swimming, cycling and running. In addition, prosthetic fitting and component selection and race day strategies is discussed.

A sand-casting technique for transtibial sockets was applied to 28 amputees in 2005. Although this meant an improvement in the quality of fitting as compared to historical reports with plaster of Paris casting, a total contact required three (two to five) stump socks. Continuing research leads the inventor, Dr Y. Wu, to replace the sand with micro polystyrene beads and simplify the equipment by eliminating the need for fluidization of silica sand by an air compressor during casting of the amputation stump. In a pilot series of 10 transtibial amputees, socket casting was performed with the new CIR casting technique and compared with the former sand-casting technique conducted by the same Category-I prosthetist. It was possible to obtain a good fit in eight out of 10 cases, which is an improvement from 19 out of 28 in the old series. Furthermore, there was a highly significant reduction in circumference measurements on the positive model with the new technique as compared to sand-casting.

This paper describes a new casting system for transtibial socket fabrication. Like the earlier CIR Sand Casting System, the CIR Casting System is based on the 'dilatancy' principle that is similar to the packaging process for coffee beans by which loose beans become a solid mass when a vacuum is applied. The main difference from the CIR Sand Casting System is that the CIR Casting System uses light-weight, polystyrene beads in place of silica sand as the primary material for casting the negative mold. The formed negative mold can be converted into a positive sand model for modification and socket formation. With the new plaster-less casting system, the prosthetist can fabricate a transtibial prosthesis in about one hour. It reduces the set-up cost, overall weight and size of the casting system, and increases portability for service in remote areas. The System also creates minimal waste and is energy-conserving and environmentally-friendly.

This study investigated the validity of post-amputation application of removable rigid dressings (RRDs) for trans-tibial amputees, regarding preparation for prosthetic management and key rehabilitation timelines. It was hypothesised that the use of RRDs would result in faster preparation of the residual limb for prosthetic management and shorter rehabilitation times, compared with conventional soft dressings. A retrospective case-note audit was conducted, in which consecutive trans-tibial amputees who underwent amputation in the 2 years before RRD implementation (non-RRD group, n = 37) and in the 2 years after RRD implementation (RRD group, n = 28) were eligible for inclusion. There was a significant reduction in the geometric mean time-to-first-prosthetic-casting in the RRD group, compared with the soft-dressing group (36.4 days vs. 27.6 days, respectively, p0.05). A significant reduction in acute length of stay (LOS) for the RRD group was also identified (15.9 days vs. 8.7 days, respectively, p0.001). There were no significant differences in other rehabilitation timeframes, such as rehabilitation LOS, total LOS, outpatient rehabilitation days, and total rehabilitation days between the two groups. This study shows that the application of RRDs reduces acute LOS and time-to-first-prosthetic-casting, thereby providing substantial benefits in preparing the trans-tibial amputee for early rehabilitation and prosthetic intervention.

This study aimed to provide a description of the continuous recording of the true load regime experienced during daily living by the abutment of a trans-femoral amputee fitted with an osseointegrated fixation. The specific objectives: (i) To present an apparatus and a procedure allowing recording of the load regime, and (ii) an example of the raw data and six performance indicators of the usage of the prosthesis obtained with this method. A subject was monitored for a period of 5 hours as he went about his daily activities. The load regime was directly measured and recorded using a commercial transducer and data logger. The overall load profile presented alternative periods of variable length of inactivity (64%) and activity (36%), respectively. The maximum load applied on the mediolateral, anteroposterior and the long axes represented 21%, 21% and 120% of the body weight, respectively. The anteroposterior, mediolateral and long components of the impulse were 395 kN.s, 359 kN.s and 2,323 kN.s, respectively. The amputee generated a total of 2312 gait cycles of the prosthetic leg, giving an approximate overall cadence of 8 stride/min. Preliminary outcomes indicated that the proposed method was an improvement on the current techniques as it provided the true loading and actual usage of the prosthesis during daily living. This study is a stepping stone in the development of future affordable, on-board and user-friendly load recording systems that can be used in evidence-based practice.

There have been a variety of efforts demonstrating the use of solid freeform fabrication (SFF) for prosthetic socket fabrication though there has been little effort in leveraging the strengths of the technology. SFF encompasses a class of technologies that can create three dimensional objects directly from a geometric database without specific tooling or human intervention. A real strength of SFF is that cost of fabrication is related to the volume of the part, not the part's complexity. For prosthetic socket fabrication this means that a sophisticated socket can be fabricated at essentially the same cost as a simple socket. Adding new features to a socket design becomes a function of software. The work at The University of Texas Health Science Center at San Antonio (UTHSCSA) and University of Texas at Austin (UTA) has concentrated on developing advanced sockets that incorporate structural features to increase comfort as well as built in fixtures to accommodate industry standard hardware. Selective laser sintering (SLS) was chosen as the SFF technology to use for socket fabrication as it was capable of fabricating sockets using materials appropriate for prosthetics. This paper details the development of SLS prosthetic socket fabrication techniques at UTHSCSA/UTA over a six-year period.

Stump ulcers are common problems in amputees. Temporary discontinuation of prosthetic limb use is frequently employed to facilitate healing. Inevitably, this limits activity and may, for instance, prevent an amputee from going to work. A survey of clinical practice was carried out based on the premise that controlled continued prosthetic limb use in patients with stump ulcers will not adversely affect the ulcer nor prevent healing. The survey would also form a basis for developing future guidelines in the management of stump ulcers. All consecutive patients attending the Chapel Allerton Hospital prosthetic clinic between January 2003 and May 2004 with stump ulcers were recruited into the study. Primary outcome measures were changes in the surface area of the ulcers and in clinical photographs taken on 2 occasions 6 weeks apart. Some 102 patients with a mean age 60 years (range 18 - 88 years) were recruited. Eight patients who were established prosthetic limb users did not complete the study and were excluded from the analysis. Of the patients 52 were newly referred patients with delayed surgical wound healing while 42 were established prosthetic limb users for at least 1 year. Continued prosthetic limb was associated with a significant reduction in ulcer size (p < 0.05). Mean sizes of the ulcers at first and second observations were 3.30 cm2 (range 0.06 - 81) and 0.70 cm2 (range 0.00 - 13.00) respectively. The ulcers improved in 83 cases while two were unchanged. Deterioration was observed in nine cases. The current clinical practice is to allow most of the patients to commence or continue prosthetic limb wearing despite the presence of stump ulceration. This observational study found that, despite prosthetic use, 60 (64%) cases healed completely within the six-week study period and 23 (25%) ulcers reduced in size. The ulcers were unchanged in 2% of the cases. Deterioration was observed in nine (9%) cases. This survey suggests that the current practice of allowing patients to use their prostheses is safe. A clinical trial is now needed to establish whether this practice alters healing rate or has any other disadvantages for new or established amputees.

A high degree of gait symmetry is characteristic of healthy gait. The aim of this study is to examine the symmetry of various gait parameters in subjects with unilateral trans-tibial amputation over a range of acceptable anteroposterior translational and tilt alignments, and further to examine if a consistent alignment of highest symmetry can be found. Acceptable alignments were determined by bench, static and dynamic testing on level and non-level surfaces. A total of 15 kinetic and kinematic parameters were then measured in the seven subjects participating in this study. Results indicate that some parameters show consistently higher symmetries, particularly the vertical ground reaction force parameters and the stance duration, step length and time to full knee flexion during the swing phase. Symmetries in other parameters such as knee flexion at loading response, acceleration impulse, and peak anteroposterior propulsive force seem to have little relevance in determining whether the gait pattern for that prosthetic alignment is acceptable or not. While analysis of the symmetry of more relevant gait parameters may assist the prosthetist in consistently and objectively identifying a most symmetrical alignment within the acceptable range, further clinical study is required before any conclusions can be drawn regarding evaluation of symmetry as a tool in defining any optimum alignment.

A prospective study was carried out on the clinical application and features of a carbon fibre reinforced plastic leg orthosis (carbon orthosis) for polio survivors. The subjects comprised 9 polio survivors, and 11 carbon knee-ankle-foot orthoses (KAFOs) were prescribed, fabricated, and checked out at the authors' post-polio clinic. Walking was classified based on the functional ambulatory category, and the features of walking with a carbon orthosis were self-evaluated by using a visual analogue scale. The period from modelling a cast to completion was 55 +/- 25 days; the weight of a carbon KAFO was 27.8% lighter than that of the ordinary KAFO; the standard carbon KAFO was 50% more expensive than the ordinary KAFO. The carbon KAFO remained undamaged for at least 2 years. It improved the scores in the functional ambulation categories, but there was no difference between walking with an ordinary and with a carbon KAFO. The self-evaluation of walking with a carbon KAFO revealed that the subjects using a carbon KAFO were satisfied with their carbon KAFO. The carbon KAFO is lightweight, durable, slim and smart, and is positively indicated for polio survivors.

The objective of this study is to investigate the accuracy of the TracerCAD system in measuring a model of known dimensions and volumes. A cylindrical nylon 6.6 model was prepared. Landmarks were added to indicate proximal, distal, anterior, medial, and lateral. Four additional landmarks were added at regular intervals along the length of the cylinder with a view to calculating diameters and volumes relative to these landmarks. The model was measured using a comparator with a guaranteed accuracy of 0.01 mm and was traced using the TracerCAD system (Test 1). The test was repeated with the model rotated by 90 degrees (Test 2), to determine whether there were any effects related to the orientation of the model in relation to the transmitter. The difference in average volume between measured results and TracerCAD scans was between 0.20% and -1.96%. Individual trace volumes varied between -0.0085% and -4.50%. In all volumes measured in Tests 1 and 2, all maximum volume percentage differences measured greater than 3%.