Jonathan D. Day

Assessment of Pressures Within the Prosthetic Socket of a Person With Osteomyoplastic Amputation During Varied Walking Tasks

In this article, we report the pilot evaluation of the interfacial contact forces produced inside the prosthetic socket of a transtibial “Ertl amputee” while walking at varied speeds, directions, and elevations. In addition to the contact forces, the temporal-spatial parameters for the different gaits were also studied. Although the goal of osteomyoplastic transtibial amputation, i.e., “Ertl Procedure,” is to provide an “end-bearing” limb for prosthetic wear, such “end bearing” could not be verified or quantified in the past. In this study, a sensor kit and a data acquisition system were developed to monitor the internal loads between the residual limb and prosthetic socket in a transtibial amputee. The subject, an otherwise healthy individual, had undergone right osteomyoplastic amputation. The interfacial loads within the socket and the gait parameters were evaluated during different types of gaits under normal ambulation. The study shows that although the weight was transferred almost uniformly to the proximal regions of the prosthetic socket, significant end bearing was achieved during all the tests.

Effect of prosthetic foot on residuum-socket interface pressure and gait characteristics in an otherwise healthy man with transtibial osteomyoplastic amputation

ABSTRACT This article elucidates the effect of prosthetic foot on the residuum-socket interface (RSI) pressure and gait characteristics in a man with transtibial osteomyoplastic amputation (TOA). The study evaluates the effect of three prosthetic feet, including 1) Renegade Foot® from Freedom Innovations (Irvine, CA), 2) Venture Foot™ from College Park (Fraser, MI), and 3) Proprio Foot® from Össur (Reykjavik, Iceland) in six gait activities: walking forward at “normal” pace, walking forward at fast pace, ascending and descending a staircase, and ascending and descending a ramp. Force resistive sensors were placed at six locations, including distal anterior end-bearing, middle posterior, and four proximal points inside the prosthetic socket, to capture real-time RSI pressures. Whereas nominal values of pressure were observed in the proximal region, greater pressure was observed at the distal anterior end-bearing region of the socket, which confirmed one of the intended outcomes of the TOA procedure. Of 36 statistical tests (t-test, p < 0.05), 35 tests (97.2%) confirmed the hypothesis that when the same prosthetic foot was used in the same gait activity, peak and mean pressures are greater at the distal anterior end-bearing location than at other locations. Furthermore, 182 of 216 (84.2%) statistical tests (t-test, significance level of 0.05) supported the hypothesis that at the same measured location during the same gait activity, different prosthetic feet result in different peak (or mean) RSI pressures. Coefficients of variation of the mean sustained pressures showed that when the gait activity was changed, each prosthetic foot affected the sustained pressure differently, even at the same measured location. Each prosthetic foot also had a direct effect on temporal gait parameters such as stance phase and gait cycle durations. These results elucidate the importance for clinicians to understand the characteristics of different prosthetic foot designs to match with the specific needs of the client with amputation.

Residual muscle contraction and residuum socket interface force in men with transtibial osteomyoplastic amputation

ABSTRACT In the transtibial osteomyoplastic amputation (TOA) technique, the distal ends of the tibia and fibula are surgically joined to form a “bone bridge” to stabilize the bony anatomy of the distal residuum. The distal-most muscles also are secured to reestablish a length-tension relationship. Unlike conventional amputation techniques in which the muscles are not secured and do not retain length-tension relationship, the TOA procedure is anticipated to allow muscles to actively contract and retain normal physiological function. In this case series, outcomes of the TOA procedure were investigated by measuring electromyography signals from the tibialis anterior and gastrocnemius muscles in the residuum and forces at the residuum socket interface (RSI) in unilateral transtibial amputees with TOA during three types of gait activities (self-paced walking, brisk 2-minute walking, and walking over a distance of 25 ft while carrying various loads). Results confirmed the presence of loadings at the distal residuum and the activity in the residuum muscles during these gaits. Furthermore, statistical analysis showed that when the distal RSI force variation was higher, the residual tibialis anterior muscle was more active compared with its activity at lower distal RSI force variation.

Barriers and Facilitators to Physical Activity Participation for Men with Transtibial Osteomyoplastic Amputation: A Thematic Analysis

Background Lower-limb amputation (LLA) results in participation restrictions in major life activities in personal, work, and leisure environments. By participating in significantly less physical activity (PA) than those who are otherwise healthy, people with LLA are at risk for developing secondary chronic health conditions. Barriers and facilitators to PA participation for those with conventional LLA are well documented. However, these factors are not well understood for those with transtibial osteomyoplastic amputation (TOA). Purpose The aim of this study was to qualitatively investigate the barriers and facilitators to PA participation in the TOA population. Design This study is an observational, qualitative research using thematic analysis. Methods Semistructured interviews were utilized to collect information-rich data from nine men with TOA. Results The participants reported minimal body structure impairments but still experience impairment to body functions. Participants reported that they were limited during running and resistance exercises during before and after the actual amputation surgery. The majority of participants value PA benefits as they relate to prevention of chronic disease but fail to recognize potential benefits on function. An individuals motivation to participate can serve as both a facilitator and barrier to PA. Having the opportunity to socialize during PA is important to these participants. The quality of postoperative care program has a direct influence on the long-term PA participation for these participants. Conclusions People with TOA continue to experience body function impairment, activity limitations, and participation restrictions. The health care team can play a significant role in the adoption of a physically active lifestyle for people with TOA.

Cross-sectional study of residuum measures during gait and work-related activities in men with transtibial amputation resulting from a traumatic event

ABSTRACT Most adults with transtibial amputation due to trauma (TTAT) are work-eligible yet are disproportionately unemployed. Inappropriate residuum muscle activity and load at the distal residuum-prosthetic socket interface (RSI) during prosthetic use are suggested contributors to employment-ending injury. The purposes of this study were to examine residuum muscle activity and RSI loads during self-paced gait, brisk gait, and carrying and to determine lift/carry capacities in 10 men with TTAT and 31 controls. A cross-sectional study design was used. Descriptive and bone health biomarker data were collected. During self-paced and brisk 2-minute walk tests, distances, step-length difference, and muscle activity (rectus femoris, tibialis anterior, gastrocnemius) were recorded. In participants with TTAT, RSI loads were simultaneously determined. Floor-to-knuckle lift and 25-ft carry capacity tests were conducted. Participants were similar in personal characteristics, biomarker values, self-paced/brisk walking step length differences, and distances walked. One participant with conventional TTAT and nine with osteomyoplastic TTAT demonstrated lower carrying (25.0 kg, p < 0.01) and lifting (28.0 kg, p < 0.05) capacities than controls did. In participants with TTAT, (1) all muscles tested were active during initial and terminal stance, (2) gastrocnemius activation was inverse to respective activation in intact/control limbs during self-paced and brisk walking, and (3) RSI loads were greater throughout self-paced and brisk gait. Authors caution that generalizations cannot be made because of sample size. Men with TTAT walked similarly in step length and distance but demonstrated lower lift and carry capacities than controls did. Future study may be warranted concerning rehabilitation strategies as well as muscle activation and RSI loading during gait based on surgical approach in men with TTAT.

Changes in Residual Limb Anthropometrics and Lift, Carry, and Timed Walking Performance in Men with Transtibial Amputation due to Trauma

Introduction Despite advances in prosthetic management and rehabilitation, otherwise healthy men with transtibial amputation (TTA) risk residuum injury during work-related activity (WRA) performance. Little is known about WRAs, perceived exertion, or residuum anthropometric changes over time in this cohort. This information may help direct longer-term considerations for those with TTA within the workforce. Materials and Methods In this preliminary study, investigators prospectively examined and compared WRA performance (floor-to-knuckle lift, 25-ft carry, self-paced, and brisk 2-minute walk tests [2MWT]), gait asymmetry (differences in step length, stride length, and cadence), report of perceived exertion (RPE), and residuum anthropometrics (length, girths) in otherwise healthy men with TTA at least 6 months after rehabilitation, during two visits, 12 months apart. Results Twenty-one participants showed little difference between visits in residuum anthropometrics or in distances walked (self-paced, brisk 2MWT; p > 0.05). All had received rehabilitation varying from time of surgery and beyond initial receipt of prosthesis (n = 8; 38%) to only upon receipt of the initial prosthesis (n = 13; 62%). However, participants reported greater exertion at visit 2 during the brisk 2MWT (0.9 RPE difference; p = 0.034) but lifted 40.4 lb more at visit 2 than at the initial visit (p = 0.034). There was a progressively larger cadence difference from visit 1 to visit 2 (increased asymmetry) during the timed self-paced walk test (p = 0.026). Conclusions Regardless of improved lift capacity or residuum anthropometric stability, this healthy male cohort with TTA demonstrated progressively worsened cadence asymmetry during self-paced 2MWT and reported increased exertion during brisk-paced 2MWT. Otherwise healthy working-age men with TTA may require continual intervention to minimize cadence asymmetry and perceived exertion, potentially reducing residuum injury risk.

Non-invasive methods to maintain cervical spine position after pediatric tracheal resections

OBJECTIVES To present our experience with two methods of neck stabilization after pediatric tracheal resection with primary anastomosis as possible alternatives to the traditional chest-chin suture. METHODS Children undergoing tracheal resection and/or cricotracheal resection with anastomosis under tension were placed in cervical spine flexion postoperatively with either a chest-chin (Grillo) suture, an Aspen cervical collar or Trulife Johnson cervical-thoracic orthosis (CTO). A retrospective chart review of tracheal resections performed between 2005 and 2016 was completed to evaluate the positive and negative factors associated with each neck flexion technique. RESULTS Of the 20 patients, there were 13 patients with the Grillo suture, 4 with the Aspen collar and 3 patients with the Johnson CTO. There were 13 tracheal resection procedures and 7 cricotracheal resections, all of which had anastomosis under tension. One major anastomosis dehiscence was noted with the Grillo suture technique which required reoperation. Two patients with the Grillo suture experienced skin breakdown at the suture site. The Aspen cervical collar, which fixed the cervical spine and prevented lateral and rotational motion, was limited in several cases in that it placed the spine in slight hyperextension. The Johnson CTO provided the most support in a flexed position and prevented cervical spine motion in all directions. No anastomosis complications were noted with the Aspen collar or the Johnson CTO, however, several patients sustained minor cutaneous wounds. CONCLUSION In this series the Aspen cervical collar and Johnson CTO were used successfully as non-Grillo alternatives to postoperative neck stabilization in pediatric tracheal resections. Modifications to both devices are proposed to minimize cutaneous injuries and increase immobilization of the cervical spine in the desired flexed position. Although these devices appear to be safe and may be better tolerated, further innovation is needed to improve the design and fit of these devices.

Effectiveness of a Modified Icex® Casting Technique Based on Circumferential Change in Residual Limb Volume

ABSTRACTThis article outlines a modified Icex® (Ossur Americas, Foothill Ranch, CA) casting technique and documents statistically significant (p ⩽ 0.05) volume changes in circumferential measurements of the residuum after the application of this casting technique. The investigator-proposed hypothesis for this study was that the modified Icex casting technique would achieve sufficient volume reduction to validate the efficacy of using the technique. The investigator retrospectively collected demographic and measurement data of patients with transtibial amputation, from the University of Oklahoma Health Sciences Center in the Orthotic and Prosthetic Section, whose residua were cast using the modified Icex casting technique. The patients were initially identified through a billing code search of all patients treated from January 2001 through December 2008. Seventy-eight patients who underwent a total of 82 transtibial amputations who met the inclusion criteria with sufficient measurement information documented in the chart were included. One patient’s data were excluded because of the extreme brevity of the residuum resulting in insufficient normalized data. All of the patients’ residual limbs (n = 81) were cast for their initial preparatory prosthetic socket. Twenty-four of the original 78 patients were also cast for their first definitive socket during the same period. The subjects included 56 male and 22 female patients with a mean age of 50.6 (20–72) years. The studied population included 44 right and 38 left transtibial residual limbs, with the breakdown of the type of surgical amputation being 33 traditional and 49 osteomyoplastic amputations. Circumferential measurement data were collected for all casting procedures to analyze volume reduction achieved through the application of the casting bladder pressurized to 120 mm Hg. Residual limb circumferential measurement data were normalized to three levels: proximal, middle, and distal for statistical analysis in the Statistical Package for the Social Sciences (SPSS) version 18 (SPSS Inc, 2010).1 Statistical analysis, using a two-way repeated analysis of variance (ANOVA), yielded significant (p < 0.001) volume reduction at all three levels of the residual limb. The reduction in volume is not only scientifically significant but also clinically relevant.