Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Symposium: Recent Advances in Amputation Surgery and Rehabilitation 20 articles


Does Activity Affect Residual Limb Skin Temperatures?

Glenn K. Klute PhD, Elizabeth Huff MS, William R. Ledoux PhD

Many lower limb amputees experience thermal discomfort as a result of wearing a prosthesis. The development of new prosthetic technology to address thermal discomfort requires an understanding of how activity (or inactivity) affects residual limb skin temperatures and how skin temperatures are mapped across the skin-prosthesis interface.

Implant Survival, Adverse Events, and Bone Remodeling of Osseointegrated Percutaneous Implants for Transhumeral Amputees

Georgios Tsikandylakis MD, Örjan Berlin MD, PhD, Rickard Brånemark MD, PhD

Osseointegrated percutaneous implants provide direct anchorage of the limb prosthesis to the residual limb. These implants have been used for the rehabilitation of transhumeral amputees in Sweden since 1995 using a two-stage surgical approach with a 6-month interval between the stages, but results on implant survival, adverse events, and radiologic signs of osseointegration and adaptive bone remodeling in transhumeral amputees treated with this method are still lacking.

Task-specific Fall Prevention Training Is Effective for Warfighters With Transtibial Amputations

Kenton R. Kaufman PhD, PE, Marilynn P. Wyatt MA, PT, Pinata H. Sessoms PhD, Mark D. Grabiner PhD

Key factors limiting patients with lower extremity amputations to achieve maximal functional capabilities are falls and fear of falling. A task-specific fall prevention training program has successfully reduced prospectively recorded trip-related falls that occur in the community by the elderly. However, this program has not been tested in amputees.

Does Intact Limb Loading Differ in Servicemembers With Traumatic Lower Limb Loss?

Alison L. Pruziner DPT, Kathryn M. Werner BS, Timothy J. Copple MS, Brad D. Hendershot PhD, Erik J. Wolf PhD

The initiation and progression of knee and hip arthritis have been related to limb loading during ambulation. Although altered gait mechanics with unilateral lower limb loss often result in larger and more prolonged forces through the intact limb, how these forces differ with traumatic limb loss and duration of ambulation have not been well described.

How Does Ankle-foot Orthosis Stiffness Affect Gait in Patients With Lower Limb Salvage?

Elizabeth Russell Esposito PhD, Ryan V. Blanck CPO, Nicole G. Harper MS, Joseph R. Hsu MD, Jason M. Wilken PT, PhD

Ankle-foot orthoses (AFOs) are commonly prescribed during rehabilitation after limb salvage. AFO stiffness is selected to help mitigate gait deficiencies. A new custom dynamic AFO, the Intrepid Dynamic Exoskeletal Orthosis (IDEO), is available to injured service members but prescription guidelines are limited.

Does Use of a Powered Ankle-foot Prosthesis Restore Whole-body Angular Momentum During Walking at Different Speeds?

Susan D’Andrea PhD, Natalie Wilhelm BA, Anne K. Silverman PhD, Alena M. Grabowski PhD

Whole-body angular momentum (H) influences fall risk, is tightly regulated during walking, and is primarily controlled by muscle force generation. People with transtibial amputations using passive-elastic prostheses typically have greater H compared with nonamputees.

Transfemoral Amputations: Is There an Effect of Residual Limb Length and Orientation on Energy Expenditure?

Johanna C. Bell MSE, Erik J. Wolf PhD, Barri L. Schnall MPT, John E. Tis MD, Benjamin K. Potter MD

Energy cost of ambulation has been evaluated using a variety of measures. With aberrant motions resulting from compensatory strategies, persons with transfemoral amputations generally exhibit a larger center of mass excursion and an increased energy cost. However, few studies have analyzed the effect of residual femur length and orientation or energy cost of ambulation.

Do Patients With Bone Bridge Amputations Have Improved Gait Compared With Patients With Traditional Amputations?

Trevor Kingsbury MA, Nancy Thesing MS, John David Collins MA, ATC, Joseph Carney MD, Marilynn Wyatt MA, PT

Two surgical techniques for performing a transtibial amputation include a traditional approach and a bone bridge approach. To date, there is no conclusive evidence of superiority of either technique in terms of temporal-spatial, kinetic, and mechanical work parameters.

Can an Integrated Orthotic and Rehabilitation Program Decrease Pain and Improve Function After Lower Extremity Trauma?

Katherine M. Bedigrew MD, Jeanne C. Patzkowski MD, Jason M. Wilken PhD, MPT, Johnny G. Owens MPT, Ryan V. Blanck LCPO, Daniel J. Stinner MD, Kevin L. Kirk DO, Joseph R. Hsu MD

Patients with severe lower extremity trauma have significant disability 2 years after injury that worsens by 7 years. Up to 15% seek late amputation. Recently, an energy-storing orthosis demonstrated improved function compared with standard orthoses; however, the effect when integrated with rehabilitation over time is unknown.

Does a Torsion Adapter Improve Functional Mobility, Pain, and Fatigue in Patients with Transtibial Amputation?

Ava D. Segal MS, Rose Kracht BS, Glenn K. Klute PhD

Turning gait is an integral part of daily ambulation and likely poses a greater challenge for patients with transtibial amputation compared with walking a straight pathway. A torsion adapter is a prosthetic component that can increase transverse plane compliance of the prosthesis and decrease the torque applied to the residual limb, but whether this will improve patients’ mobility, pain, and fatigue remains unknown.

Does Targeted Nerve Implantation Reduce Neuroma Pain in Amputees?

Mitchell A. Pet MD, Jason H. Ko MD, Janna L. Friedly MD, Pierre D. Mourad PhD, Douglas G. Smith MD

Symptomatic neuroma occurs in 13% to 32% of amputees, causing pain and limiting or preventing the use of prosthetic devices. Targeted nerve implantation (TNI) is a procedure that seeks to prevent or treat neuroma-related pain in amputees by implanting the proximal amputated nerve stump onto a surgically denervated portion of a nearby muscle at a secondary motor point so that regenerating axons might arborize into the intramuscular motor nerve branches rather than form a neuroma. However, the efficacy of this approach has not been demonstrated.

Fluid Collections in Amputations Are Not Indicative or Predictive of Infection

Elizabeth M. Polfer MD, Benjamin W. Hoyt BS, Lien T. Senchak MD, Mark D. Murphey MD, Jonathan A. Forsberg MD, Benjamin K. Potter MD

In the acute postoperative period, fluid collections are common in lower extremity amputations. Whether these fluid collections increase the risk of infection is unknown.

Bilateral Transfemoral/Transtibial Amputations Due to Battle Injuries: A Comparison of Vietnam Veterans with Iraq and Afghanistan Servicemembers

Paul J. Dougherty MD, Lynne V. McFarland PhD, Douglas G. Smith MD, Gayle E. Reiber PhD

Multiple limb loss from combat injuries has increased as a proportion of all combat-wounded amputees. Bilateral lower-extremity limb loss is the most common, with bilateral transfemoral amputations being the most common subgroup followed by bilateral amputations consisting of a single transfemoral amputation and a single transtibial amputation (TFTT). With improvements in rehabilitation and prostheses, we believe it is important to ascertain how TFTT amputees from the present conflicts compare to those from the Vietnam War.

Radiographic Evaluation of Bone Adaptation Adjacent to Percutaneous Osseointegrated Prostheses in a Sheep Model

Sujee Jeyapalina PhD, James Peter Beck MD, Kent N. Bachus PhD, Ornusa Chalayon MD, Roy D. Bloebaum PhD

Percutaneous osseointegrated prostheses (POPs) are being investigated as an alternative to conventional socket suspension and require a radiographic followup in translational studies to confirm that design objectives are being met.

Does a Microprocessor-controlled Prosthetic Knee Affect Stair Ascent Strategies in Persons With Transfemoral Amputation?

Jennifer M. Aldridge Whitehead MS, Erik J. Wolf PhD, Charles R. Scoville PT, DPT, Jason M. Wilken MPT, PhD

Stair ascent can be difficult for individuals with transfemoral amputation because of the loss of knee function. Most individuals with transfemoral amputation use either a step-to-step (nonreciprocal, advancing one stair at a time) or skip-step strategy (nonreciprocal, advancing two stairs at a time), rather than a step-over-step (reciprocal) strategy, because step-to-step and skip-step allow the leading intact limb to do the majority of work. A new microprocessor-controlled knee (Ottobock X2) uses flexion/extension resistance to allow step-over-step stair ascent.

Punitive Limb Amputation

Anna Mavroforou MSc, LLM-LAMB, MBA, Konstantinos Malizos MD, Theofilos Karachalios MD, Konstantinos Chatzitheofilou MD, Athanasios D. Giannoukas MSc, MD, PhD, FEBVS

Limb amputation has been carried out through the ages as a punitive method in various parts of the world. This article highlights the historical and societal background associated with the use of punitive limb amputation.

A Model to Predict Limb Salvage in Severe Combat-related Open Calcaneus Fractures

Adam J. Bevevino MD, Jonathan F. Dickens MD, Benjamin K. Potter MD, Theodora Dworak MD, Wade Gordon MD, Jonathan A. Forsberg MD

Open calcaneus fractures can be limb threatening and almost universally result in some measure of long-term disability. A major goal of initial management in patients with these injuries is setting appropriate expectations and discussing the likelihood of limb salvage, yet there are few tools that assist in predicting the outcome of this difficult fracture pattern.

Progression of Bone Ingrowth and Attachment Strength for Stability of Percutaneous Osseointegrated Prostheses

Sujee Jeyapalina PhD, J. Peter Beck MD, Roy D. Bloebaum PhD, Kent N. Bachus PhD

Percutaneous osseointegrated prosthetic (POP) devices have been used clinically in Europe for decades. Unfortunately, their introduction into the United States has been delayed, in part due to the lack of data documenting the progression of osseointegration and mechanical stability.