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JMIR Research Protocols Apr 2024Relative motion between the residual limb and socket in individuals with transtibial limb loss can lead to substantial consequences that limit mobility. Although...
Quantifying Bone and Skin Movement in the Residual Limb-Socket Interface of Individuals With Transtibial Limb Loss Using Dynamic Stereo X-Ray: Protocol for a Lower Limb Loss Cadaver and Clinical Study.
BACKGROUND
Relative motion between the residual limb and socket in individuals with transtibial limb loss can lead to substantial consequences that limit mobility. Although assessments of the relative motion between the residual limb and socket have been performed, there remains a substantial gap in understanding the complex mechanics of the residual limb-socket interface during dynamic activities that limits the ability to improve socket design. However, dynamic stereo x-ray (DSX) is an advanced imaging technology that can quantify 3D bone movement and skin deformation inside a socket during dynamic activities.
OBJECTIVE
This study aims to develop analytical tools using DSX to quantify the dynamic, in vivo kinematics between the residual limb and socket and the mechanism of residual tissue deformation.
METHODS
A lower limb cadaver study will first be performed to optimize the placement of an array of radiopaque beads and markers on the socket, liner, and skin to simultaneously assess dynamic tibial movement and residual tissue and liner deformation. Five cadaver limbs will be used in an iterative process to develop an optimal marker setup. Stance phase gait will be simulated during each session to induce bone movement and skin and liner deformation. The number, shape, size, and placement of each marker will be evaluated after each session to refine the marker set. Once an optimal marker setup is identified, 21 participants with transtibial limb loss will be fitted with a socket capable of being suspended via both elevated vacuum and traditional suction. Participants will undergo a 4-week acclimation period and then be tested in the DSX system to track tibial, skin, and liner motion under both suspension techniques during 3 activities: treadmill walking at a self-selected speed, at a walking speed 10% faster, and during a step-down movement. The performance of the 2 suspension techniques will be evaluated by quantifying the 3D bone movement of the residual tibia with respect to the socket and quantifying liner and skin deformation at the socket-residuum interface.
RESULTS
This study was funded in October 2021. Cadaver testing began in January 2023. Enrollment began in February 2024. Data collection is expected to conclude in December 2025. The initial dissemination of results is expected in November 2026.
CONCLUSIONS
The successful completion of this study will help develop analytical methods for the accurate assessment of residual limb-socket motion. The results will significantly advance the understanding of the complex biomechanical interactions between the residual limb and the socket, which can aid in evidence-based clinical practice and socket prescription guidelines. This critical foundational information can aid in the development of future socket technology that has the potential to reduce secondary comorbidities that result from complications of poor prosthesis load transmission.
INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)
DERR1-10.2196/57329.
Topics: Humans; Amputation Stumps; Artificial Limbs; Biomechanical Phenomena; Cadaver; Lower Extremity; Movement; Skin; Tibia
PubMed: 38669065
DOI: 10.2196/57329 -
Journal of Neurosurgery. Case Lessons Apr 2024Phantom limb pain and traumatic neuromas are not commonly seen in neurosurgical practice. These conditions can present with similar symptoms; however, management of...
BACKGROUND
Phantom limb pain and traumatic neuromas are not commonly seen in neurosurgical practice. These conditions can present with similar symptoms; however, management of traumatic neuroma is often surgical, whereas phantom limb pain is treated with conservative measures.
OBSERVATIONS
A 77-year-old female patient with a long-standing history of an above-the-knee amputation experienced severe pain in her right posterior buttocks area for several years' duration, attributed to phantom limb pain, which radiated down the stump of her leg and was treated with a variety of conservative measures. A recent exacerbation of her pain led to a prolonged hospitalization with magnetic resonance imaging of her leg stump, revealing a mass in the sciatic notch, at a relative distance from the stump. The anatomical location of the mass on the sciatic nerve in the notch led to a presumed radiological diagnosis of nerve sheath tumor, for which she underwent excision. At surgery, a neuroma of the proximal portion of the transected sciatic nerve that had retracted from the amputated stump to the notch was diagnosed.
LESSONS
Traumatic neuromas of transected major nerves after limb amputation should be considered in the differential diagnosis of phantom limb pain.
PubMed: 38621303
DOI: 10.3171/CASE247 -
The Pan African Medical Journal 2024During the 1970s, scientists first used botulinum toxin to treat strabismus. While testing on monkeys, they noticed that the toxin could also reduce wrinkles in the... (Review)
Review
During the 1970s, scientists first used botulinum toxin to treat strabismus. While testing on monkeys, they noticed that the toxin could also reduce wrinkles in the glabella area. This led to its widespread use in both medical and cosmetic fields. The objective of the study was to evaluate the potential use of Botox in managing post-operative contracture after below-knee amputation. We conducted a systematic review In Pubmed, Cochrane Library, Embase, and Google Scholar using the MESH terms Botox, botulinum toxin, post-operative contracture, amputation, and below knee amputation. Our goal was to evaluate the potential use of Botox to manage post-operative contracture in patients who have undergone below-knee amputation. Our findings show evidence in the literature that Botox can effectively manage stump hyperhidrosis, phantom pain, and jumping stump, but no clinical trial has been found that discusses the use of Botox for post-operative contracture. Botox has been used in different ways to manage spasticity. Further studies and clinical trials are needed to support the use of Botox to manage this complication.
Topics: Humans; Botulinum Toxins, Type A; Amputation, Surgical; Contracture; Amputation Stumps; Muscle Spasticity; Joint Dislocations; Neuromuscular Agents
PubMed: 38558551
DOI: 10.11604/pamj.2024.47.26.42249 -
Fukushima Journal of Medical Science Apr 2024In foot amputation, Chopart amputation is considered to have a high risk of deformity, and can result in poor function. We experienced a case in which Chopart amputation...
BACKGROUND
In foot amputation, Chopart amputation is considered to have a high risk of deformity, and can result in poor function. We experienced a case in which Chopart amputation combined with tendon transfer and tendon lengthening was performed, and the patient was eventually able to walk independently with a foot prosthesis without experiencing deformity of the foot. We investigated walking speed and plantar pressure after Chopart amputation with and without a foot prosthesis.
CASE
A 78-year-old man underwent Chopart amputation with tendon transfer and tendon lengthening. As a result, he was able to stand up and walk, both while bearing weight on the heel of the affected foot, but he was unable to push off the ground using that foot. When a foot prosthesis was introduced, the patient's walking speed increased from 0.6 m/s without the prosthesis to 0.8 m/s with the prosthesis, which was an increase of 33%. The plantar pressure at the stump decreased from 129.3 N/cm on average without the prosthesis to 51.6 N/cm with the prosthesis, which was a 59% decrease. Wearing a foot prosthesis improved the patient's walking speed and decreased plantar pressure at the amputation stump.
Topics: Humans; Male; Aged; Pressure; Amputation, Surgical; Foot; Walking Speed; Artificial Limbs; Walking
PubMed: 38494732
DOI: 10.5387/fms.23-00003 -
Handchirurgie, Mikrochirurgie,... Feb 2024The upper extremity and particularly the hands are crucial for patients in interacting with their environment, therefore amputations or severe damage with loss of hand...
BACKGROUND
The upper extremity and particularly the hands are crucial for patients in interacting with their environment, therefore amputations or severe damage with loss of hand function significantly impact their quality of life. In cases where biological reconstruction is not feasible or does not lead to sufficient success, bionic reconstruction plays a key role in patient care. Classical myoelectric prostheses are controlled using two signals derived from surface electrodes in the area of the stump muscles. Prosthesis control, especially in high amputations, is then limited and cumbersome. The surgical technique of Targeted Muscle Reinnervation (TMR) offers an innovative solution: The major arm nerves that have lost their target organs due to amputation are rerouted to muscles in the stump area. This enables the establishment of cognitive control signals that allow significantly improved prosthesis control.
PATIENTS/MATERIALS AND METHODS
A selective literature review on TMR and bionic reconstruction was conducted, incorporating relevant articles and discussing them considering the clinical experience of our research group. Additionally, a clinical case is presented.
RESULTS
Bionic reconstruction combined with Targeted Muscle Reinnervation enables intuitive prosthetic control with simultaneous movement of various prosthetic degrees of freedom and the treatment of neuroma and phantom limb pain. Long-term success requires a high level of patient compliance and intensive signal training during the prosthetic rehabilitation phase. Despite technological advances, challenges persist, especially in enhancing signal transmission and integrating natural sensory feedback into bionic prostheses.
CONCLUSION
TMR surgery represents a significant advancement in the bionic care of amputees. Employing selective nerve transfers for signal multiplication and amplification, opens up possibilities for improving myoelectric prosthesis function and thus enhancing patient care. Advances in the area of external prosthetic components, improvements in the skeletal connection due to osseointegration and more fluid signal transmission using wireless, fully implanted electrode systems will lead to significant progress in bionic reconstruction, both in terms of precision of movement and embodiment.
Topics: Humans; Quality of Life; Amputation, Surgical; Upper Extremity; Amputation Stumps; Prosthesis Implantation; Artificial Limbs; Muscle, Skeletal
PubMed: 38417811
DOI: 10.1055/a-2260-9842 -
Journal of Personalized Medicine Jan 2024Lower limb trauma often results in mangled extremities, and in some cases, complete amputation may be necessary. However, limiting the extent of amputation and...
Lower limb trauma often results in mangled extremities, and in some cases, complete amputation may be necessary. However, limiting the extent of amputation and preserving the major knee joint are crucial to enhance mobility and overall functionality. By providing painless soft tissue coverage on the stump, early prosthesis use and the initiation of physiotherapy become more feasible. Soft tissue transfers hold the potential to benefit patients in two essential aspects: first, resolving soft tissue deficiencies without causing bone shortening, and second, preparing the stump to enhance overall functionality. A retrospective study conducted at Chang Gung Memorial Hospital (2009-2016) focused on lower limb amputation patients who underwent soft tissue transfers at different time periods compared to those without stump reconstruction. Out of the 2391 cases of lower limb injuries treated operatively, 117 amputations were performed in 110 patients (44 above the knee and 73 below the knee). Among them, 12 patients received soft tissue transfers for limb salvage and soft tissue deficiency after amputations. It was observed that patients in this group were typically younger, predominantly female, had longer hospital stays, and underwent a greater number of surgical procedures ( < 0.05). Through the use of soft tissue transfers, successfully preserved tibial bone length and functional knee joint in selected patients was achieved. This approach effectively resolved soft tissue deficiencies following lower limb amputations, optimizing physiotherapy and facilitating functional rehabilitation.
PubMed: 38392593
DOI: 10.3390/jpm14020160 -
Frontiers in Medicine 2024Low-grade fibromyxoid sarcoma (LGFMS) is a rare type of soft tissue sarcoma that often involves the deep soft tissue of the extremities and trunk in young and...
BACKGROUND
Low-grade fibromyxoid sarcoma (LGFMS) is a rare type of soft tissue sarcoma that often involves the deep soft tissue of the extremities and trunk in young and middle-aged adults. It is uncommon in the elderly. Here we discuss a case of LGFMS in an elderly patient who had recurrence and metastasis within 2 years of resection of the primary tumor.
CASE REPORT
A 71-year-old LGFMS patient was presented with a mass in the left forearm accompanied by pain and numbness from the left upper arm to fingers. The patient subsequently underwent 3 surgical resections, although she had 3 recurrences within 6 months after the initial diagnosis. Considering the malignant biological behavior of the tumor, an amputation at 5 cm above the elbow was eventually performed. However, recurrence in the extremity of the stump and chest wall metastasis were observed 2 years after amputation. Then resection of the metastases, radiotherapy and particle implantation therapy were performed. The patient is currently undergoing follow-up and has no evidence of recurrence.
CONCLUSION
In our case, multiple early postoperative recurrences may be associated with a positive margin at initial operation. The patient underwent a total of 5 operations including local resection of the primary tumor, twice wide resections, amputation and metastatic surgery with 4 early postoperative recurrences and metastases within 4 years, suggesting that LGFMS may have highly invasive biological behavior. Our case demonstrated that early aggressive surgical treatment is recommended for LGFMS patients with a positive margin at initial operation and patients who had recurrence even after wide resection rather than local resection. Further research is needed to develop more effective treatment options for rapidly progress and highly aggressive LGFMS.
PubMed: 38362535
DOI: 10.3389/fmed.2024.1172746 -
Medicinski Glasnik : Official... Feb 2024Aim To study the character of blood circulation in the bone stump at tight and loose closure of the medullary cavity. Methods Two series of experiments on 39 rabbits...
Aim To study the character of blood circulation in the bone stump at tight and loose closure of the medullary cavity. Methods Two series of experiments on 39 rabbits with mid-third femoral amputation and muscular plasty were carried out. In the 1st (experimental) series, the bone scapula was closed by thin cortical autograft taken from the epimetaphyseal area, and then the muscles were sutured, and in the 2nd - the scapula was closed by myoplasty only. Follow-up periods: 1st series - 7, 14, 21 days and 1, 3, 6 months, 2nd series - 1, 3, 6 months. Histological methods with infusion of vessels with ink-gelatin mixture and morphometry was used. Results In the 1st series there was a rapid restoration of the disturbed macro- and microcirculation due to the reserve sources of blood circulation and the development of extravascular ways of microcirculation. In the 2nd series, blood circulation recovery was significantly slower and occurred mainly due to the development of extravascular microcirculatory pathways. Conclusion The study established undeniable usefulness of tight closure of the bone marrow cavity during amputation.
PubMed: 38341643
DOI: 10.17392/1677-23 -
JNMA; Journal of the Nepal Medical... Sep 2023Crush injury with bone loss results in shortening the length of the thumb. Most of the immediate intervention is amputation and stump closure. Revision amputation with...
UNLABELLED
Crush injury with bone loss results in shortening the length of the thumb. Most of the immediate intervention is amputation and stump closure. Revision amputation with stump closure gives loss of functional length and the patient is unable to do daily activities as before. In most of all hand functions, the opposition of the thumb plays an important role. Reconstruction of the thumb with iliac crest bone graft with its functional length is one of the major achievements for the patient. As in our case, the patient is right-hand dominant he is more concerned about the functional length of the thumb, whatever the aesthetic appearance. Here we present a case of a 24-year-old male with thumb reconstruction in a severely injured thumb with loss of bone and soft tissue just distal to the base of the proximal phalanx. Nine months postoperatively, the patient showed a great outcome with restored thumb length, function, grip strength, and a good range of motion.
KEYWORDS
case reports; injury; thumb.
Topics: Male; Humans; Young Adult; Adult; Thumb; Ilium; Groin; Amputation, Traumatic; Plastic Surgery Procedures
PubMed: 38289797
DOI: 10.31729/jnma.8264 -
JBJS Essential Surgical Techniques 2024The biology of osseointegration of any intramedullary implant depends on the design, the press-fit anchoring, and the loading history of the endoprosthesis. In...
BACKGROUND
The biology of osseointegration of any intramedullary implant depends on the design, the press-fit anchoring, and the loading history of the endoprosthesis. In particular, the material and surface of the endoprosthetic stem are designed to stimulate on- and in-growth of bone as the prerequisite for stable and long-lasting integration. Relative movement between a metal stem and the bone wall may stimulate the formation of a connective-tissue interface, thereby increasing the risk of peri-implant infections and implant loss. The maximum achievable press-fit (i.e., the force closure between the implant and bone wall) depends on the diameter and length of the residual bone and thus on the amputation level. Beyond this, the skin-penetrating connector creates specific medical and biological challenges, especially the risk of ascending intramedullary infections. On the one hand, bacterial colonization of the skin-penetrating area (i.e., the stoma) with a gram-positive taxon is obligatory and almost impossible to avoid. On the other hand, a direct structural and functional connection between the osseous tissue and the implant, without intervening connective tissue, has been shown to be a key for infection-free osseointegration.
DESCRIPTION
We present a 2-step implantation process for the standard Endo-Fix Stem (ESKA Orthopaedic Handels) into the residual femur and describe the osseointegration of the prosthesis. In addition, we demonstrate the single-step implantation of a custom-made short femoral implant and a custom-made humeral BADAL X implant (OTN Implants) in a patient who experienced a high-voltage injury with the loss of both arms and the left thigh. Apart from the standard preparation procedures (e.g., marking the lines for skin incisions, preparation of the distal part of the residual bone), special attention must be paid when performing the operative steps that are crucial for successful osseointegration and utilization of the prosthesis. These include shortening of the residual bone to the desired length, preparation of the intramedullary cavity for hosting of the prosthetic stem, precise trimming of the soft tissue, and wound closure. Finally, we discuss the similarities and differences between the Endo-Fix Stem and the BADAL X implant in terms of their properties, intramedullary positioning, and the mechanisms leading to successful osseointegration.
ALTERNATIVES
Socket prostheses for transfemoral or transtibial amputees have been the gold standard for decades. However, such patients face many challenges to recover autonomous mobility, and an estimated 30% of all amputees report unsatisfactory rehabilitation and 10% cannot use a socket prosthesis at all.
RATIONALE
Transcutaneous osseointegrated prosthetic systems especially benefit patients who are unable to tolerate socket suspension systems, such as those with short residual limbs and/or bilateral limb loss. The use of a firmly integrated endoprosthetic stem allows patients and surgeons to avoid many of the limitations associated with conventional socket prostheses, such as the need to continually fit and refit the socket to match an ever-changing stump. Discussion between patients who are considering an osseointegrated prosthesis and those who have already received one ("peer patients") has proven to be a powerful tool to prevent unrealistic expectations. Patients with a transhumeral amputation especially benefit from the stable connection between the residual limb and exoprosthesis. Motion of the affected and even the contralateral shoulder is no longer impaired, as straps and belts are dispensable. Furthermore, transmission of myoelectric signals from surrounding muscles to the prosthesis is fundamentally improved. However, comorbidities such as diabetes mellitus or peripheral arterial disease require careful counseling, even if these conditions were not responsible for the loss of the limb. Transcutaneous osseointegrated prosthetic systems for replacement of an upper or lower limb might not be an option in patients who are unable, for any reason, to take adequate care of the stoma.
EXPECTED OUTCOMES
Despite subtle differences between the systems utilized for the intramedullary anchoring of the prosthetic stem, all data indicate that mobility and quality of life significantly increase while the frequency of stoma infections is remarkably low as long as the patient is able to follow simple postoperative care protocols.
IMPORTANT TIPS
The impaction pressure of the implant depends on the diameter of the implant and the quality of the residual bone (i.e., the time interval between the amputation and the implantation of the prosthetic stem). The extent of reaming of the inner cortex of the residual bone must be adapted to these conditions. The standard Endo-Fix Stem and BADAL X implant are both slightly curved to adapt to the physiological shape of the femur. Thus, the surgeon must be sure to insert the implant in the right position and at the correct rotational alignment. When preparing a short femoral stump, carefully identify the exact transection level in order to obtain enough bone stock to anchor the implant in the correct intramedullary position for an additional locking screw into the femoral neck and head. Depending on the residual length of the humerus and the press-fit stability of the implant, the utilization of locking screws is optional, as a notch at the distal end of the implant guarantees primary rotational stability.
ACRONYMS AND ABBREVIATIONS
TOPS = transcutaneous osseointegrated prosthesis systemsEEP = endo-exo prosthesisMRSA = methicillin-resistant a.p. = anteroposteriorK-wire = Kirschner wireCT = computed tomographyDCA = double conus adapterOFP = osseointegrated femur prosthesis.
PubMed: 38268768
DOI: 10.2106/JBJS.ST.23.00010