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Innovative Educational Services
Lower Limb Amputation & Prostheses Goals and Objectives
Course Description “Lower Limb Amputation & Prostheses” is a live (real-time) interactive webinar for athletic trainers that examines common amputations of the lower extremity. This course includes a review of current literature relating to pathophysiology of conditions leading to amputation, diagnostic techniques, surgical procedures, and lower limb prosthetic components.
Course Rationale The purpose of this course is to present contemporary knowledge about lower extremity amputations and prosthetics to athletic trainers so that they may use this information to maximize functional outcomes. Areas of focus include causative conditions, assessment, surgical interventions, and post-operative prosthetic options.
Course Goals and Objectives Upon completion of this course, participants will be able to:
1. Detail the pathophysiology of conditions leading to amputations of the lower limb. 2. Define the levels of lower limb amputation. 3. Identify diagnostic procedures utilized to determine tissue viability. 4. Detail lower limb amputation surgical procedures. 5. Define functional classification levels for expected mobility. 6. Outline the primary components of the lower limb prostheses. 7. Compare and contrast the mechanisms of lower limb prosthetic suspension. 8. Identify the primary characteristics of prosthetic knee units. 9. Detail the benefits of foot and ankle prosthetic designs. 10. List examples of specialty lower limb prostheses.
Course Provider – Innovative Educational Services
Provider Conflict of Interest - None
Course Instructor - Jodi Gootkin, PT, Med
Instructor Conflict of Interest - None
Target Audience – Athletic Trainers
Athletic Training Practice Domains - Treatment and Rehabilitation (0401, 0403, 0404, 0405, 0406)
Level of Difficulty – Essential
Course Prerequisites – None
Method of Instruction/Availability – Live Interactive Webinar available on scheduled dates/times.
Criteria for Issuance of CE Credits – Verified attendance and at least 70% correct on the course post-test.
Continuing Education Credits – Three (3) hours of continuing education credit.
Fees - $39.95
Refund Policy - Unrestricted 100% refund upon request. The request for a refund by the learner shall be honored in full without penalty or other consideration of any kind. The request for a refund may be made by the learner at any time without limitations before, during, or after course participation.
Approval -
Innovative Educational Services is approved by the Board of Certification, Inc. to offer continuing education for Certified Athletic Trainers.
Lower Extremity Amputation & ProsthesesCopyright Jodi Gootkin 2019
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L o w e r L i m b A m p u t a t i o n &
P r o s t h e s e s
Live Interact ive Webinar Presented ByJodi Gootkin, PT, MED, CEAS
Course Overview• “Lower Limb Amputation & Prostheses” is a live (real-
time) interactive webinar for rehabilitation professionals that examines common amputations of the lower extremity. This course includes a review of current literature relating to pathophysiology of conditions leading to amputation, diagnostic techniques, surgical procedures, and lower limb prosthetic components.
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Copyright Jodi Gootkin 2019
Course Rationale
• The purpose of this course is to present contemporary knowledge about lower extremity amputations and prosthetics to rehabilitation professionals so that they may use this information to maximize functional outcomes. Areas of focus include causative conditions, assessment, surgical interventions, and post-operative prosthetic options.
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Copyright Jodi Gootkin 2019
Goals and Objectives1. Detail the pathophysiology of conditions leading to amputations of the lower limb.
2. Define the levels of lower limb amputation.
3. Identify diagnostic procedures utilized to determine tissue viability.
4. Detail lower limb amputation surgical procedures.
5. Define functional classification levels for expected mobility.
6. Outline the primary components of the lower limb prostheses.
7. Compare and contrast the mechanisms of lower limb prosthetic suspension.
8. Identify the primary characteristics of prosthetic knee units.
9. Detail the benefits of foot and ankle prosthetic designs.
10. List examples of specialty lower limb prostheses.
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Copyright Jodi Gootkin 2019
Disclaimer• Application of concepts presented in this webinar is at
the discretion of the individual participant in accordance with federal, state, and professional regulations.
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Copyright Jodi Gootkin 2019
Course Outline and Schedule
3-hour live interactive webinar
Consider This
Copyright Jodi Gootkin 2019
6Topic TimeEpidemiology of Lower Limb Amputations 0:00-0:05Causes of Amputation 0:06-0:10
Diabetes 0:11-0:15Critical Limb Ischemia 0:16-0:25
Determining Level of Amputation 0:26-0:30Surgical Procedures 0:31-0:35
Partial Foot Amputation 0:36-0:40Syme Amputation 0:41-0:45Transtibial Amputation 0:46-0:50
Interactive Discussion of Clinical Applications 0:51-1:00Knee Disarticulation 1:01-1:05Transfemoral Amputation 1:06-1:10
General Surgical Considerations 1:11-1:15Complications and Phantom Limb Pain 1:16:1:25Medicare Functional Classification Levels 1:26-1:35Sockets and Suspension 1:36-1:40
Transfemoral and Transtibial 1:41-1:50Interactive Discussion of Clinical Applications 1:51-2:00Microprocessor Knee 2:01-2:05Prosthetic Feet 2:06-2:15Rehabilitation Outcome Measures 2:16-2:20Specialty Prostheses 2:21-2:25Emerging Techniques and Components 2:26-2:30
Socket Sensors 2:31-2:35Osseointegration 2:36-2:40Agonist Antagonist Myoneural Interface 2:41-2:45Gait Analysis Innovations 2:46-2:50
Interactive Discussion of Clinical Applications 2:51-3:00
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Lower Extremity Amputation & ProsthesesCopyright Jodi Gootkin 2019
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How To Obtain CEUs For This Course
• After the live interactive webinar and prior to 11:59 pm TONIGHT go to www.cheapceus.com
• Complete the post test with score of at least 70%–May be retaken multiple times
• Submit online payment for course• Print certificate• Course review and summary for post test at the
end of the webinar.
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Consider This
Copyright Jodi Gootkin 2019
Historical Perspective• Technology advances have contributed to
developments in prosthetic design to enhance quality of life.
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Causes of Lower Limb Loss• Amputation is a difficult decision made to improve
health, function, and quality of life.
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Etiology
Non-healing ulcers
Critical Limb
Ischemia
Infection
Tumors
Congenital anomalies
Trauma
Non-traumatic Lower Limb Amputation• Incidence trends suggest opportunities for public
education on healthy life-style.
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0 20 40 60 80100
120
2000
2009
2015
Cases per 1,000
Toe Foot Knee/Below Knee Above Knee
Clinical decision making
MortalityDisease prevention
Geiss, L. S., Li, Y., Hora, I., Albright, A., Rolka, D., & Gregg, E. W. (2019). Resurgence of diabetes-related nontraumatic lower-extremity amputation in the young and middle-aged adult US population. Diabetes care, 42(1), 50-54.
Diabetes Mellitus• Poor healing associated with diabetes contributes to
ulcer failure to heal with infections common and increased amputation risk.
• Nutritional support should be a component of management to ensure food consumption is adequate for metabolic needs during healing.
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Xie, Y., Zhang, H., Ye, T., Ge, S., Zhuo, R., & Zhu, H. (2017). The geriatric nutritional risk index independently predicts mortality in diabetic foot ulcers patients undergoing amputations. Journal of diabetes research, 2017.
Ulcer Assessment• Probe-to-bone test, procalcitonin (PCT) levels and
MRI guide diagnosis of soft tissue versus osteomyelitis to aid clinical decision making for appropriate management.
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Lam, K., van Asten, S. A., Nguyen, T., La Fontaine, J., & Lavery, L. A. (2016). Diagnostic accuracy of probe to bone to detect osteomyelitis in the diabetic foot: a systematic review. Clinical Infectious Diseases, 63(7), 944-948.
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Critical Limb Ischemia (CLI)• Peripheral arterial disease (PAD) involves progressive
atherosclerosis of the arteries in the limb leading to claudication, and skin lesions.
• CLI presents as nocturnal and at rest pain, ulcers, and gangrene.
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Fontaine classification • Stage III-IV
Rutherford classification • Grade 4-6
PAD Assessment• Ankle-Brachial Index (ABI) is a diagnostic sensitive
index for assessing perfusion.
• Walking Impairment Questionnaire (WIQ) measures self-reported walking distance, speed, and stair climbing.
• 6-Minute Walk Test documentation should include total walking and claudication onset time or distance.
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Ankle systolic blood
pressure
Brachial systolic blood
pressure
≤ 0.9 PAD presence0.69 – 0.41 Moderate PAD< 0.4 Significant PAD
Jain, A., Liu, K., Ferrucci, L., Criqui, M. H., Tian, L., Guralnik, J. M., … McDermott, M. M. (2012). The Walking Impairment Questionnaire stair-climbing score predicts mortality in men and women with peripheral arterial disease. Journal of vascular surgery, 55(6), 1662–73.e2.
PAD Management• Surgical or catheter based endovascular
revascularization restores arterial blood flow to the lower extremity.
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Therapeutic Angiogenesis
Endovascular Intervention Open Bypass Minor
AmputationMajor
Amputation
Therapeutic Angiogenesis• Facilitating the formation of new capillaries and
collateralization of existing vessels can replace occluded arteries ensuring adequate oxygen supply to ischemic tissues.
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Medications
Benedek, T., Kovács, I., & Benedek, I. (2017). Therapeutic Angiogenesis for Severely Ischemic Limbs—from Bench to Bedside in Acute Vascular Care. Journal of Cardiovascular Emergencies, 3(4), 160-171.Sheu, J. J., Lin, P. Y., Sung, P. H., Chen, Y. C., Leu, S., Chen, Y. L., … Yip, H. K. (2014). Levels and values of lipoprotein-associated phospholipase A2, galectin-3, RhoA/ROCK, and endothelial progenitor cells in critical limb ischemia: pharmaco-therapeutic role of cilostazol and clopidogrel combination therapy. Journal of translational medicine, 12, 101.
Stem Cell Angiogenesis • Safe harvesting, delivery and efficacy are being
established for this promising therapy to reduce amputation risk and improve wound healing.
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Trial Cells OutcomeTACT Intramuscular bone
marrow cellsImproved leg pain, reduced ulcer size, increased pain-free walking distance.
PROVASA Intra-arterial bone marrow cells
Improved ulcer healing, pain, but not significant change in ABI
Benedek, T., Kovács, I., & Benedek, I. (2017). Therapeutic Angiogenesis for Severely Ischemic Limbs—from Bench to Bedside in Acute Vascular Care. Journal of Cardiovascular Emergencies, 3(4), 160-171.
PAD Surgical Failure Risk Factors• Compared to
timing of revascularization surgery, comorbidities are more influential on wound healing and limb loss.
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Diabetes
End stage renal disease
Hyperlipidemia
Congestive heart failureBMI ≥ 30
Smoking
Shi, E., Jex, M., Patel, S., & Garg, J. (2019). Outcomes of Wound Healing and Limb Loss After TransmetatarsalAmputation in the Presence of Peripheral Vascular Disease. The Journal of Foot and Ankle Surgery, 58(1), 47-51.11
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Determining Lower Extremity Amputation Level
• Physicians consider multiple factors when making the decision to amputate a limb.
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Tissue viability
Prosthesis suitability
Mobility and
FunctionCosmesis
Wound, Ischemia, foot Infection Classification (WIfI)
• To predict 1-year amputation risk in individuals with PAD, a classification system has been developed based on the major risk factors leading to lower limb amputation.
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Wound
Ulcer size and depthRegion of footGangrene of extent
Ischemia
Transcutaneous oximetryABIToe pressure
foot Infection
Tissue depthSizeSystemic inflammation
Mills Sr, J. L., Conte, M. S., Armstrong, D. G., Pomposelli, F. B., Schanzer, A., Sidawy, A. N., ... & Society for Vascular Surgery Lower Extremity Guidelines Committee. (2014). The society for vascular surgery lower extremity threatened limb classification system: risk stratification based on wound, ischemia, and foot infection (WIfI). Journal of vascular surgery, 59(1), 220-234.
Consider This
Transcutaneous Oxygen (TcPO2) • Hemodynamic indicators of oxygenation released
from the tissues in the lower extremity can support physician decision making.
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Arsenault, K. A., Al-Otaibi, A., Devereaux, P. J., Thorlund, K., Tittley, J. G., & Whitlock, R. P. (2012). The use of transcutaneous oximetry to predict healing complications of lower limb amputations: a systematic review and meta-analysis. European Journal of vascular andEndovascular surgery, 43(3), 329-336.Zingg M, Lacraz A, Robert-Ebadi H, Kressmann B, Glauser F, Waibel F, et al. (2019). Transcutaneous Oxygen Pressure Values Often Fail to Predict Stump Failures after Foot or Limb Amputation in Chronically Ischemic Patients. Clin Surg. 4: 2366.
>50 mmHg • Normal
<40 mmHg• Impaired healing
<30 mmHg • Critical limb ischemia
Consider This
Limb Salvage• Reconstructive techniques attempt to avoid
amputation and preserve an individual’s limb that has experienced severe trauma.
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MESS• Mangled Extremity Severity Score• Amputation Threshold: >7
LSI • Limb Salvage Index• Amputation Threshold: >6
PSI• Predictive Salvage Index• Amputation Threshold: >8
NISSSA• Nerve Injury, Ischemia, Soft Tissue, Skeletal, Shock,
Age score• Amputation Threshold: >11
Schirò, G. R., Sessa, S., Piccioli, A., & Maccauro, G. (2015). Primary amputation vs limb salvage in mangled extremity: a systematic review of the current scoring system. BMC musculoskeletal disorders, 16(1), 372.
Mangled Extremity Severity Score (MESS)• Most commonly utilized tool to predict success of
limb salvage surgery.
Skeletal/soft tissue injury
Limb ischemia
Shock
Age
Copyright Jodi Gootkin 2019
23 Levels of Amputation
Minor Amputation
Toe
Transmetatarsal
Lisfranc
Chopart
Major Amputation
Syme’s
Transtibial
Knee disarticulation
Transfemoral
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Lower Extremity Amputation & ProsthesesCopyright Jodi Gootkin 2019
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Surgical Technique for Muscles• When determining closure, the surgeon considers
proper muscle balance and creating a stable soft tissue envelope.
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MyodesisMuscle to periosteum
MyoplastyAntagonists sewn together
Tenodesis Tendon to periosteum
Partial Foot Amputation
Transmetatarsal• Midsection of
metatarsals
Lisfranc• Tarsometatarsal
joint
Chopart• Talonavicular and
calcaneocuboid joints
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Partial Foot Muscle Relocation• Elimination of foot musculature attachments can
contribute to the development of equinovarus deformity.
• Altering tendon mechanical advantage can reduce the risk of contracture development.
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Sukur, E., Akar, A., Uyar, A. Ç., Cicekli, O., Kochai, A., Turker, M., & Topcu, H. N. (2018). Vacuum-assisted closure versus moist dressings in the treatment of diabetic wound ulcers after partial foot amputation: A retrospective analysis in 65 patients. Journal of Orthopaedic Surgery, 26(3), 2309499018799769.
Achilles lengtheningAllow dorsiflexion
Preservation of peroneus brevisRetain eversion
Tibialis anterior orExtensor digitorum longustendon transfer
Promote dorsiflexion in sagittal plane
Transmetatarsal Amputation Gait • Maximizing foot length can minimize altered weight
bearing on the residual limb that leads to increased re-amputation risk.
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Increased plantar surface pressures
Loss of rigid lever
Achilles loss of elasticity
Shorter plantarflexion moment
Syme Amputation• Ankle disarticulation is performed with tenodesis of
achilles to posterior tibia and anchoring of heel pad to anterior tibia.
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Benefits
Tibia epiphysis intact
Proprioception End weight bearing
Syme Outcomes• Adults present with more complications and require
re-amputation more frequently than children.
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Pediatric
Calcaneus reformation
Heel pad migration
Skin problems
Adult
Residual limb pain
Ulceration and Infection
Skin problems
Morrison, S. G., Thomson, P., Lenze, U., & Donnan, L. T. (2019). Syme Amputation: Function, Satisfaction, and Prostheses. Journal of pediatric orthopedics.Braaksma, R., Dijkstra, P. U., & Geertzen, J. H. (2018). Syme Amputation: A Systematic Review. Foot & ankle international, 39(3), 284-291.
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Lower Extremity Amputation & ProsthesesCopyright Jodi Gootkin 2019
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Transtibial Surgical Procedure• The optimal length of the residual limb can be
calculated based on height for adults.• At minimum, the tibia shaft should be equal to the
tibial plateau width.• The fibula should be 1-2 cm shorter than the tibia.• The Burgess procedure utilizes a long posterior
muscle flap for closure.
cm30 cm 2.5 cm
cm
Pasquina, P. F., Bryant, P. R., Huang, M. E., Roberts, T. L., Nelson, V. S., & Flood, K. M. (2006). Advances in amputee care. Archives of Physical Medicine and Rehabilitation, 87(3), 34-43. Copyright Jodi Gootkin 2019
31 Transtibial Osteomyoplasty(Ertl Procedure)
• An osteoperiosteal or fibular graft is placed between the distal ends of the amputated tibia and fibula.
• With healing, a bony strut is created allowing end-bearing onthe residual limb.
www.ertlreconstruction.com/about/procedure/
Bone bridge
Closed marrow cavity
Myoplasty
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Ertl vs. Burgess Procedure• The Transtibial Amputation Outcomes Study (TAOS)
is currently in progress to evaluate surgical technique functional outcomes and complication rate.
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Bosse, M. J., Morshed, S., Reider, L., Ertl, W., Toledano, J., Firoozabadi, R., ... & MacKenzie, E. J. (2017). Transtibial amputation outcomes study (TAOS): comparing transtibial amputation with and without a tibiofibular synostosis (Ertl) procedure. Journal of orthopaedic trauma, 31, S63-S69.
Burgess Ertl
Longer surgical time
Better prosthetic fit
Wounds from “bottom out”
Lower complication
rate
Transtibial Surgical Technique Outcomes
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Population Outcome18 – 65 y.o.Very active prosthetic ambulators
Curb: Ertl limb work similar to intact limbSit-to-stand: Ertl quicker performance
Retrospective Young Active duty military
Similar functional outcomes onlong-term follow-up
Ferris, A. E. (2016). Biomechanical Assessment of Ertl and Burgess Transtibial Amputation Techniques. University of North Colorado. Dissertation.Shawen, L. P. S. B., Forsberg, C. J. A., Kirk, L. K. L., Hsu, L. J. R., Gwinn, C. D. E., & Potter, M. P. B. K. (2013). Comparison of functional outcomes following bridge synostosis with non-bone-bridging transtibial combat-related amputations. JBJS, 95(10), 888-893.
Knee Disarticulation• This level amputation may be beneficial for
non-ambulatory patients by providing increased sitting comfort and eliminating the risk of knee flexion contracture.
• Sectioning through the knee joint requires an intact gastrocnemius for a posterior flap.
• The patellar tendon is sutured into the cruciate ligaments.
Copyright Jodi Gootkin 2019
35 Knee Disarticulation Outcomes• Retaining femur length provides a longer lever arm,
permits end-bearing, and improved suspension but leads to an off-set prosthetic knee component.
Etiology OutcomeInfection, thrombosis, trauma
Diabetes and infection reduced ambulation.Greater ambulation in trauma cohort.
Albino, F., Seidel, R., Brown, B. J., Crone, C., & Attinger, C.(2014). Through knee amputation: technique modifications and surgical outcomes. Archives of plastic surgery, 41(5), 562. Copyright Jodi Gootkin 2019
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Lower Extremity Amputation & ProsthesesCopyright Jodi Gootkin 2019
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Transfemoral Surgical Procedure
• The Ertl osteomyopathic technique places bone grafting as an end-cap on amputated femur.
• The Gritti-Stokes procedure involves femur transection at the level of the adductor tubercle with patella arthrodesis.
Copyright Jodi Gootkin 2019
37 Transfemoral Muscle Relocation Adduction
• To minimize lateralization of the femur with prosthetic gait, the adductor myodesis is secured over the distal end of the femur with the hip in slight adduction.
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Transfemoral Muscle Relocation Extension
• Through myodesis to the femur or myoplasty to each other, the quadriceps and hamstrings are secured with appropriate balancing to allow hip ROM.
• Failure to attach the iliotibial band to the femur may contribute to hip flexion contracture.
Copyright Jodi Gootkin 2019
39 Surgery General Considerations• Several general considerations are required for all
patients regardless of the level of amputation and specific surgical technique employed.
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Complications
Anesthesia
Post-op dressing
Anesthesia Outcomes• Type of anesthesia does not appear to influence
outcomes for patients with advanced age and impaired functional status.
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Population Outcomes≥ 75 y.o. and pre-op partial/total functional dependence
No difference in wound or pulmonary complications, CVA, UTI or MI
≥65 y.o. No difference in pulmonary or cardiac complications, or mortality
Moreira, C. C., Farber, A., Kalish, J. A., Eslami, M. H., Didato, S., Rybin, D., ... & Siracuse, J. J. (2016). The effect of anesthesia type on major Lower Limb amputation in functionally impaired elderly patients. Journal of vascular surgery, 63(3), 696-701.Bilgili, B., Haliloglu, M., Edipoglu, E., Cetingok, H., Pektas, Y., & Bilgili, M. G. (2017). The type of anesthesia technique does not have an impact on 30-day mortality in geriatric patients undergoing Lower Limb amputation. International Surgery, 102(3-4), 178-183.
Post-operative Dressing• Several types of dressing are available to provide
wound protection and edema control.
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Unclear which is superior following transtibial
amputation
Soft dressing
Rigid dressing
Removeable rigid dressing (RRD)
Kwah, L. K., Webb, M. T., Goh, L., & Harvey, L. A. (2019). Rigid dressings versus soft dressings for transtibial amputations. Cochrane Database of Systematic Reviews, (6).
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Negative Pressure Wound Therapy (NPWT)• The goal is to promote healing and
reduce post operative wound complications.
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• Serial debridement• Promotes granulation• Reduced infections
Open Surgical SiteNPWT
• Reduce incision tension• Reduce edema• Reduce seroma formation• Increase blood flow
Closed IncisioniNPWT
Zayan, N. E., West, J. M., Schulz, S. A., Jordan, S. W., & Valerio, I. L. (2019). Incisional Negative Pressure Wound Therapy: An Effective Tool for Major Limb Amputation and Amputation Revision Site Closure. Advances in wound care, 8(8), 368–373. Stenqvist, C. P., Nielsen, C. T., Napolitano, G. M., Larsen, B. M., Flies, M. J., Brander, D. C., ... & Pallesen, P. (2019). Does closed incision negative wound pressure therapy in non‐traumatic major lower‐extremity amputations improve survival rates?. International wound journal.
Consider This
Surgical Drain• Some physicians elect to utilize a drain in the initial
days following surgery.
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Coulston, J. E., Tuff, V., Twine, C. P., Chester, J. F., Eyers, P. S., & Stewart, A. H. R. (2012). Surgical factors in the prevention of infection following major Lower Limb amputation. European Journal of Vascular and Endovascular Surgery, 43(5), 556-560.
Minimize dead spaceReduce hematoma formation
Increased infection risk
Revision Surgery• Residual limb pain during prosthetic use can result
from unequal bone length, scarring, neuroma, or excessive soft tissue that may require surgical revision.
Copyright Jodi Gootkin 2019
45 Neuroma• Multiple surgical techniques have been proposed to
inhibit or treat neuromas that create pain and limit prosthetic use.
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Targeted muscle
reinnervation(TMR)
Embed in bone or soft
tissue
Nerve coaption
Collagen wrap
Targeted Muscle Reinnervation• To minimize neuroma formation, nerves that are
resected from the amputated portion of the limb are relocated to nearby muscles.
• Surgical planning utilizes anatomical “road maps” to determine locations of motor nerve targets.
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Superficial peroneal to EDL or Peroneus longus
Deep peroneal to Tibialis anterior
Tibial to Soleus or FDL
Phantom Limb Pain• There are multiple theories to explain pain associated
with the portion of the limb that is no longer present.
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His
tori
cal Psychogenic
theory
Peri
pher
al
mec
hani
sm Neuroma hyperactivity
Cen
tral
neu
rona
l m
echa
nism Neurosignature
Spinal cord sensitizationCortical reorganization
Subedi, B., & Grossberg, G. T. (2011). Phantom limb pain: mechanisms and treatment approaches. Pain research and treatment, 2011, 864605.
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Lower Extremity Amputation & ProsthesesCopyright Jodi Gootkin 2019
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Phantom Exercise• Active movements of the sound limb are performed
while mental imagery replicates movement of the phantom limb to modulate pain.
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Külünkoğlu, B., Erbahceci, F., & Alkan, A. (2019). A comparison of the effects of mirror therapy and phantom exercises on phantom limb pain. Turkish journal of medical sciences, 49(1), 101-109.Collins, K. L., Russell, H. G., Schumacher, P. J., Robinson-Freeman, K. E., O’Conor, E. C., Gibney, K. D., ... & Tsao, J. W. (2018). A review of current theories and treatments for phantom limb pain. The Journal of clinical investigation, 128(6), 2168-2176.
Positive feedback to
motor cortex
Reversal of neural
reorganization
Diminish visual responsiveness
of sensorimotor
cortex
Mirror Therapy• Use of a reflected image of the intact limb moving
provides visual feedback replacing the amputated limb has been successful in diminishing phantom limb pain.
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Chan, A. W. Y., Bilger, E., Griffin, S., Elkis, V., Weeks, S., Hussey-Anderson, L., ... & Baker, C. I. (2019). Visual responsiveness in sensorimotor cortex is increased following amputation and reduced after mirror therapy. NeuroImage: Clinical, 101882.Chan, B. L., Witt, R., Charrow, A. P., Magee, A., Howard, R., Pasquina, P. F., ... & Tsao, J. W. (2007). Mirror therapy for phantom limb pain. New England Journal of Medicine, 357(21), 2206-2207.
Virtual Reality• Participants view virtual images of two intact limbs
and at the same time perform motions with their sound and residual limbs.
• Visualizing the phantom limb in motion on the avatar is an enhancement of mirror therapy.
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Ambron, E., Miller, A., Kuchenbecker, K. J., Buxbaum, L. J., & Coslett, H. (2018). Immersive low-cost virtual reality treatment for phantom limb pain: Evidence from two cases. Frontiers in neurology, 9, 67.Rutledge, T., Velez, D., Depp, C., McQuaid, J. R., Wong, G., Jones, R. C. W., ... & Giap, H. (2019). A Virtual Reality Intervention for the Treatment of Phantom Limb Pain: Development and Feasibility Results. Pain Medicine.
Post-operative Mobility
• Higher level of independence with activities of daily living (ADLs) is associated with higher survival rates, prosthetic use, and good walking ability.
Influences
Age
Strength and
balance
Comorbidity
Cognition
Emotional distress
Pain
Madsen, U. R., Bååth, C., Berthelsen, C. B., & Hommel, A. (2018). A prospective study of short-term functional outcome after dysvascularmajor lower limb amputation. International journal of orthopaedic and trauma nursing, 28, 22-29.
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Psychological Considerations• Cognitively and emotionally individuals experience
and array of complicated thoughts and feelings.
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Regaining ControlManaging consequences and
building hope and self-motivation
Support independence
Digesting the Shock
Detecting the amputate body and life-changing decision Demonstrate empathy
Losing Control
Overwhelmed and facing dependency
Allow patient to express themselves
Madsen, U. R., Hommel, A., Bååth, C., & Berthelsen, C. B. (2016). Pendulating—A grounded theory explaining patients’ behavior shortly after having a leg amputated due to vascular disease. International journal of qualitative studies on health and well-being, 11(1), 32739.
Self-efficacy• An individual’s confidence in their ability to perform
specific life activities can positively contribute to successful rehabilitation.
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Minimize medical set-backs
Teach adaptive skills
Encourage return to activity
Gradual forward progress
Positive self-efficacy
Wise, J., White, A., Stinner, D. J., & Fergason, J. R. (2017). A unique application of negative pressure wound therapy used to facilitate patient engagement in the amputation recovery process.
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Prosthetic Components• For insurance to cover prosthetic components,
medical necessity is demonstrated based on the individual’s current status, expected functional potential, and desire to ambulate.
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Socket Suspension
Knee
Ankle Foot
Medicare Functional Classification Levels (MFCL)
K0
• Does not have the ability or potential to ambulate or transfer safely with or without assistance and prosthesis does not enhance their quality of life or mobility.
K1
• Has the ability or potential to use prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator.
K2
• Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator.
K3
• Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.
K4
• Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete.
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Consider This
https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/LLP_Consensus_Document.pdf
Not Medically Necessary• Trends from third party insurance providers appear
aligned in what is not covered by insurance.–Prosthesis for K-0 functional level–Consumable supplies for device care–Components not required for participation in
normal activities of daily living.
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patient satisfaction, and quality of life.• There is no “gold standard” instrument.
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Specialized MeasuresAmputee Mobility Predictor (AMP)
General Measures6-minute walk (6MWT)Timed Up and Go (TUG)Climbing Stairs QuestionnaireShort Form Health Survey 12 (SF-12)
SubjectiveClinician experience
Personal Opinion
Balk EM, Gazula A, Markozannes G, et al. Lower Limb Prostheses: Measurement Instruments, Comparison of Component Effects by Subgroups, and Long-Term Outcomes [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2018 Sep. (Comparative Effectiveness Review, No. 213.)
Amputee Mobility Predictor (AMP)• Developed to measure the individual’s functional
performance and predict their potential ability to utilize a prosthesis.
• Scored tasks with and without the prosthesis are designed to correlate with K-levels.
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AMPnoPRO• 0-38 AMPPRO
• 0-42
Gailey RS, Roach KE, Applegate EB, et al. The amputee mobility predictor: aninstrum ent to assess determinants of the lower-limb amputee's ability to ambulate. Arch Phys Med Rehabil. 2002;83(5):613-627. Raya, M. A., Gailey, R. S., Gaunaurd, I. A., Ganyard, H., Knapp-Wood, J., McDonough, K., & Palmisano, T. (2013). Amputee mobility predictor-bilateral: a performance-based measure of mobility for people with bilateral lower-limb loss. Journal of Rehabilitation Research & Development, 50(7)
Socket and Suspension
Socket Design
Residual Limb Interface
Suspension
• Shape creating load bearing pressures on residual limb
• Materials between residual limb and socket
• Mechanism to maintain prosthesis on residual limb
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Socket and Suspension Considerations• Pressure distribution
in the socket facilitates load transfer under static and dynamic conditions with minimal movement at the limb-prosthesis interface.
Pressure Distribution
Comfort
Skin Integrity
Limb healthPerformance
Convenience
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prosthetic control and balance.
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Quadrilateral and Ischial
Containment
Selective loading
pressure tolerant
HiFi
Sub-ischial compression
and relief zones
High-Fidelity (HiFi) System• Indirect skeletal anchoring occurs through tissue
compression and release method.• Gait vibrations are transmitted into the
skeletal system allowing increased proprioceptor activity.
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HiFi
Brimless
Alternate pressure and relief
Osseoperception
Proprioception• Prosthetic components increasing awareness of limb
position contribute to accuracy of interpreting the relationship between the prosthetic foot and the ground.
Increased
Walking velocity,balance, and confidence
ReducedCompensatory steppage
Circumduction Energy expenditure
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Transfemoral Suspension• Suspension systems hold the prosthesis in place
providing a connection that promotes stability with activity while minimizing skin breakdown.
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Belt, strap, or sleeve
Mechanical Pin and LockPassive negative pressureActive vacuum assisted
Suction
Vacuum Assisted Suspension (VAS) Devices
• Sleeve applied to the residual limb creates a seal around the edge of the socket.
• A mechanical or electrical pump removes excess air to create a secure fit.
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VAS Benefits• When other socket systems are not successful in
ensuring fit or skin breakdown is a concern the vacuum suction may be an alternative.
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Controls volume fluctuationReduces forces on residual limbImproved proprioceptionSuspension without vascular restrictionImproved tissue oxygenation
Increased socket weightRequire maintenance
Transfemoral VAS Models• Manufacturers incorporate mechanical or electrical
systems to generate the suspension.– eVAC® – LimbLogic ® – Vacuum-Assisted Socket System (VASS ®)
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Transtibial Socket Design• The current recommendation to maximize comfort
and function is total surface bearing.
Patellar Tendon Bearing (PTB)• Pressure
tolerant and intolerant regions
Total Surface Bearing (TSB)• Equal surface
loading on tissues
Stevens, P. M., DePalma, R. R., & Wurdeman, S. R. (2019). Transtibial Socket Design, Interface, and Suspension: A Clinical Practice Guideline. JPO: Journal of Prosthetics and Orthotics, 31(3), 172-178.
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• Socket contours to femoral condyles • Socks accommodate limb volume changes
Anatomic
• Elastic liner with distal locking mechanismLocking Liner
• External sleeve and valve create suctionSuction
• Pump creates suction sealVacuum Assisted Suspension
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Locking Suspension• The current recommendation, assuming user ability, is
a viscoelastic interface.• Multiple locking mechanisms
are available.
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Stevens, P. M., DePalma, R. R., & Wurdeman, S. R. (2019). Transtibial Socket Design, Interface, and Suspension: A Clinical Practice Guideline. JPO: Journal of Prosthetics and Orthotics, 31(3), 172-178.
Pistoning• Excessive motion causes force absorption in the soft
tissues instead of transmission to the foot for loading and energy return in gait propulsion.
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Vacuum Assisted Suspension (VAS)
• Least pistoning
Suction Suspension
Pin and lock Suspension
Supracondylar Cuff or Sleeve
• Compromised suspension
Stevens, P. M., DePalma, R. R., & Wurdeman, S. R. (2019). Transtibial Socket Design, Interface, and Suspension: A Clinical Practice Guideline. JPO: Journal of Prosthetics and Orthotics, 31(3), 172-178.
Consider This
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Infinite Socket ®• For the transfemoral socket, carbon fiber struts
attached to a flexible pressure management strap allow the individual control comfort and stability.
• The transtibial socket includes adjustable air bladders and adjustable closure system.
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Socket OutcomeIschial containment vs. HiFi
HiFi improved gait velocity, prosthetic motion, center of mass deviation, and perceived disability.
All types of transtibial sockets and suspension
• Suction decreased gait asymmetry and distal pain but more difficult donning.
• Pin-lock preferred for comfort and function• PTB with Pelite high durability and low cost
Klenow, T. D., Kahle, J. T., Fedel, F. J., Ropp, J., & Highsmith, M. J. (2017). Comparative Efficacy of Transfemoral Prosthetic Interfaces: Analysis of Gait and Perceived Disability. JPO: Journal of Prosthetics and Orthotics, 29(3), 130-136.Gholizadeh, H., Osman, N. A., Eshraghi, A., Ali, S., & Razak, N. A. (2014). Transtibial prosthesis suspension systems: systematic review of literature. Clinical biomechanics, 29(1), 87-97.
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Knee Component• Based on the individual’s activity level, the knee
provides varying amounts of stability or motion.
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• Exoskeletal single axis manual lock or friction control
• Endoskeletal friction swing and stance control
• Single axis, constant friction knee
• Fluid or pneumatic • Microprocessor controlled• Endoskeletal knee-shin system
• High activity knee control
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33787&ContrId=140&ver=17&ContrVer=2&CntrctrSelected=140*2&Cntrctr=140&s=12&DocType=2&bc=AAgAAAQAAAAA&
Microprocessor Knee• Dynamic variation to step cadence is achieved though
variable resistance swing and stance phase control that simulates natural knee adaptations.
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Battery drain safe mode
Stumble recovery with stance control
Microprocessor varies resistance based on feedback from sensors.
Consider This
Microprocessor Knee Benefits• Insurance may require additional justification for
medical necessity including cardiovascular, functional, and cognitive requirements for coverage.
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Improved/Increased
Gait on uneven surfacesStair negotiationGait cadence
Reduced
Energy Expenditure
Cognitive demands of ambulation
Microprocessor Knee Models• Manufacturers include a variety of control options to
maximize function.– Endolite Orion®– Endolite Intelligent Prosthesis®– Endolite SmartIP®– Genium and X2®– Otto-Bock C-Leg®– Ossur RheoKnee®
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Endoskeletal Knee-Shin System • In addition to the microprocessor controlled knee,
the prosthesis includes a powered and programmable knee flexion and extension assist control motor.
–Ossur Power Knee
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79 Endoskeletal Knee-Shin System Coverage• According to criteria outlined in the Centers for Medicare
and Medicaid Services Local Coverage Determination, the following individuals may benefit from the use of a power knee-ankle device:
– the individual has a microprocessor (swing and stance phase type (L5856) controlled (electronic) knee
– is K3 functional level only– has a weight greater than 110 lbs and less than 275 lbs– has a documented comorbidity of the spine and/or
sound limb affecting hip extension and/or quadriceps function that impairs K-3 level function with the use of a microprocessor-controlled knee alone
– is able to make use of a product that requires daily charging
– is able to understand and respond to error alerts and alarms indicating problems with the function of the unit.
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Knee Component Outcomes• Controlling flexion without sacrificing stability, the
microprocessor knee appears to improve efficiency and contribute to safety.
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Stevens, P. M., & Wurdeman, S. R. (2019). Prosthetic Knee Selection for Individuals with Unilateral Transfemoral Amputation: A Clinical Practice Guideline. JPO: Journal of Prosthetics and Orthotics, 31(1), 2-8.Lura, D. J., Wernke, M. W., Carey, S. L., Kahle, J. T., Miro, R. M., & Highsmith, M. J. (2017). Crossover study of amputee stair ascent and descent biomechanics using Genium and C-Leg prostheses with comparison to non-amputee control. Gait & posture, 58, 103–107.Squella, S. A. F., Kannenberg, A., & Benetti, Â. B. (2018). Enhancement of a prosthetic knee with a microprocessor-controlled gait phase switch reduces fallsand improves balance confidence and gait speed in community ambulators with unilateral transfemoral amputation. Prosthetics and Orthotics International, 42(2), 228.
OutcomeCompared to fluid knee for active walkers: Microprocessor increased speed, comfort, and symmetry
Compared to fluid for young high-functioning: Microprocessor decreased falls, increased uneven surface walking speed.
Microprocessor for limited community ambulators: increased balance and reduced falls
Genium vs. C-leg: Genium step-over-step ascent, increased prosthetic peak knee flexion, increase swing duration
Powered Lower Limb Prosthesis• Combined microprocessor motor powered knee and
ankle systems fabricated into one prosthesis support higher level mobility.
– LiNX®
– Symbionic® Leg 3
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Prosthetic Foot
Solid Ankle Cushioned Heel (SACH)Single Axis Foot
Flexible-keel footMultiaxial ankle/foot
Microprocessor controlled ankle foot systemEnergy Storing And Return (ESAR)Dynamic Response Foot (DRF)Flex foot systemFlex-walk systemShank foot system with vertical loading pylon
Microprocessor foot or ankle with power assist
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33787&ContrId=140&ver=17&ContrVer=2&CntrctrSelected=140*2&Cntrctr=140&s=12&DocType=2&bc=AAgAAAQAAAAA& Copyright Jodi Gootkin 2019
83 Energy Storage and Return Foot (ESAR) and Dynamic Response Foot (DRF)
• Engineering of the prosthetic foot allows mechanical energy to be stored during late stance which is released to assist propulsion during push-off.
• Decreased ground reaction force in the sound limb during stance reduces stress and risk of overuse injury to the sound limb and low back.
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Stevens, P. M., Rheinstein, J., & Wurdeman, S. R. (2018). Prosthetic Foot Selection for Individuals with Lower-Limb Amputation: A Clinical Practice Guideline. Journal of Prosthetics and Orthotics, 30(4), 175.
Consider This
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Microprocessor Controlled Ankle and Foot
• Through sensor technology, the microprocessor identifies sloping gradients.
• The ankle angle is adjusted to the terrain to promote gait symmetry.
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Adjusts ankle angle during swing
Alters power for cadence
Identifies sloping gradients
Microprocessor Ankle and Foot Models• Some models additionally contain a motor to allow
powered push-off with gait.– BiOM® Foot– EmPOWER ® Ankle– Elan Foot®– Kinnex®– Meridium Foot®– Proprio Foot®– Raize®– Triton Smart Ankle®
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Weighted Walking• When carrying heavy loads, the prosthetic ankle-foot
system must provide support while in addition to good function for mobility during unweighted activities.
• For K4 level activity, a compliant forefoot keel appears to enhance late-stance energy return contributing to reduced physiologic metabolic cost.
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Koehler-McNicholas, S. R., Nickel, E. A., Barrons, K., Blaharski, K. E., Dellamano, C. A., Ray, S. F., ... & Hansen, A. H. (2018). Mechanical and dynamic characterization of prosthetic feet for high activity users during weighted and unweighted walking. PloS one, 13(9), e0202884.
Foot Outcomes• Single-axis foot is recommended for single speed
ambulators requiring stability due to weakness and poor balance.
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ImStevens, P. M., Rheinstein, J., & Wurdeman, S. R. (2018). Prosthetic Foot Selection for Individuals with Lower-Limb Amputation: A Clinical Practice Guideline. Journal of Prosthetics and Orthotics, 30(4), 175.Highsmith, M. J., Kahle, J. T., Miro, R. M., Orendurff, M. S., Lewandowski, A. L., Orriola, J. J., ... & Ertl, J. P. (2016). Prosthetic interventions for people with transtibial amputation: Systematic review and meta-analysis of high-quality prospective literature and systematic reviews. Journal of Rehabilitation Research & Development, 53(2).Geertzen, J., van der Linde, H., Rosenbrand, K., Conradi, M., Deckers, J., Koning, J., ... & Schrier, E. (2015). Dutch evidence-based guidelines for amputation and prosthetics of the lower extremity: amputation surgery and postoperative management. Part 1. Prosthetics and orthotics international, 39(5), 351-360.
OutcomeESAR greater prosthetic stability and propulsion than flex keelBetter stair negotiation and gait efficiency than SACHESAR less fatigue than single and multi axis
ESAR longer sound side step length than SACHESAR higher walking speed
Amputee Rehabilitation Outcome Measures
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• Amputee Activity Survey• Prosthesis Evaluation Questionnaire (PEQ)• Prosthetic Profile of the Amputee (PPA)• Locomotor Capabilities Index (LCI)• Orthotic Prosthetic User’s Survey (OPUS)• Trinity Amputation and Prosthesis Experience Scale (TAPES)
Patient Reported
• Timed Up and Go (TUG)• Six Minute Walk Test (6MWT)• Amputee Mobility Predictor (AMPPRO and AMPnoPRO)• Comprehensive High-Activity Mobility Predictor (CHAMP)
Performance
• Symmetry in External Work Measure (SEW)Biomechanical
Agrawal, V. (2016). Clinical Outcome Measures for Rehabilitation of Amputees – A review. Physical Medicine and Rehabilitation International. 3(2): 1080.
Patient Reported Outcome Measures (PROM)
Amputee Activity Survey (AAS)
• Prosthesis/assistive device use, employment, gait habits, social activity
Locomotor Capabilities Index (LCI)
• Skill with prosthesis on different surfaces, level of independence
Orthotic Prosthetic User’s Survey (OPUS)
• Lower limb function, quality of life, satisfaction with prosthesis
Prosthesis Evaluation Questionnaire (PEQ)
• Prosthesis function, mobility, psychosocial experience, well-being
Prosthetic Profile of the Amputee (PPA)
• Prosthetic use, prosthetic capabilities, environment, leisure
Trinity Amputation and Prosthesis Experience Scale (TAPES)
• Physical and psychological aspect of adjustment to prosthetic limb
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Balk EM, Gazula A, Markozannes G, et al. Lower Limb Prostheses: Measurement Instruments, Comparison of Component Effects by Subgroups, and Long-Term Outcomes [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2018 Sep. (Comparative Effectiveness Review, No. 213.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK531523/
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Self Selected Gate Velocity (SSGV)• When ambulating with a prosthesis, several kinematic
variables are associated with walking speed an individual uses.
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Increased Increased
Efficiency Stability
Step length
Step width
Lateral center of motion deviation
SSGV
Symmetry
Specialty Prostheses• To allow high level of work and sport participation
manufacturers have developed prosthesis with specific components to address the individual’s needs.
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Heel Height• The user adjusted heel height allows the wearer to
accommodate to different types of shoes.• Training considerations for control over center of
gravity and shifted biomechanics.
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93 Waterproof Limbs• Submergible devices are available for showering,
swimming, and recreational purposes.– Amphibian Water Leg®– Endolite Aqualimb®– Genium® X3– Kinnex Foot®– Ottoock Aqualine® System– Plie® 3
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Running Specific Feet• The absence of a heel sacrifices stability in low to
moderate impact activities for enhanced running. • Biomechanical analysis demonstrates equivalent
mediolateral foot displacement in non-amputee and Paralympic sprinters.
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Arellano, C. J., McDermott, W. J., Kram, R., & Grabowski, A. M. (2015). Effect of running speed and leg prostheses on mediolateral foot placement and its variability. PloS one, 10(1), e0115637.Image: https://www.af.mil/News/Article-Display/Article/1290904/rescue-airman-amputee-wins-battle-to-serve-in-afrc/
Rock Climbing Prosthesis• The front toe region of the traditional prosthesis is
too flexible for stability with climbing.
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Emerging Techniques and Components• Government, private, and individual researchers
continue to innovate to enhance the lives of individuals with lower limb loss.
• Beyond prevention of limb loss, minimizing complications, and prosthetic components, well-being and general health are explored to enhance quality of life.
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prosthetic socket may enhance peripheral sensation sufficiently to result in improved postural stability and locomotor function.
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Distributed Sensing• Built in sensors on the prosthetic liner will monitor
moisture, temperature, pressure, and shear stress.
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shift fluid from the internal bladders to adjust pressure on the residual limb.
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Evaporative Cooling System• Activity can cause a dramatic increase in skin
temperature within the prosthesis causing discomfort and perspiration accumulation.
• Embedded skin temperature sensors and an evaporative cooling system may ameliorate these problems.
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skeletal attachment of the prosthesis eliminating the need for a socket.
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Frolke, J. P. M., Leijendekkers, R. A., & Meent, H. (2017). Osseointegrated prosthesis for patients with an amputation: Multidisciplinary team approach in the Netherlands.
Consider This
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Osseointegration Benefits
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103Improved comfortElimination of poor socket fitOsseoperceptionImproved energy transferEnhanced prosthetic controlAccommodates short limbs
Infection riskSkin irritation
Osseointegration Training Prosthesis• The short training prosthesis is made in knee-length
to reduce the length of the lever arm and allow early controlled axial weight bearing.
• Combined with a general exercise program bone mineralization is stimulated by loading the bone-implant unit in additional directions other than axial.
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Variable Stiffness Prosthetic Ankle• A powered device that can vary sagittal plane stiffness
using a pneumatic actuator to simulate anterior compartment muscles.
• A linear spring simulates contraction of the posterior muscles.
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Shepherd, M. K., Azocar, A. F., Major, M. J., & Rouse, E. J. (2018). Amputee perception of prosthetic ankle stiffness during locomotion. Journal of neuroengineering and rehabilitation, 15(1), 99.
Prosthetic Foot Emulator• The robotic prosthetic foot can be adjusted to
simulate a variety of commercially available foot options to allow the individual to “try on” different options prior to prescription.
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Ewing Amputation• During the below knee amputation, muscles previously
inserting distal to the ankle are mechanically connected to each other in pairs.
• Dynamic muscle relationships are preserved between.
–Tibialis anterior to lateral gastroc–Peroneus longus to tibialis posterior
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Neural activation of agonist
Antagonist stretched
Afferent feedbackProprioception
Clites, T. R., Herr, H. M., Srinivasan, S. S., Zorzos, A. N., & Carty, M. J. (2018). The Ewing Amputation: The First Human Implementation of the Agonist-Antagonist Myoneural Interface. Plastic and Reconstructive Surgery–Global Open, 6(11), e1997.
Consider This
Agonist Antagonist Myoneural Interface (AMI)
• AMI is the name of the process that allows patients with the Ewing amputation to receive proprioceptive feedback from a robotic ankle.
Active contraction
Electrode activation
Motorized prosthetic ankle
joint motion
Muscle proprioceptors
stimulated
Prosthetic motion perceived
by brain
Natural motion with movement
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Mobile Gait Analysis System• Combined communication from a shoe attachment
with force sensors and inertial measurement units (IMU) on the trunk and lower extremities collect data on gait to provide information to promote gait symmetry during rehabilitation.
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109 Smartphone Apps• ReLoad plays music during gait. When the sensors
detect gait deviations, the music becomes out of tune providing instant feedback for correction.
• GaitRite uses the smarphone’s built in accelerometer to record gait movements during dual-task activities outside the clinical assessment environment.
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Computer Assisted RehabilitationEnvironment (CAREN)
• Immersive virtual reality environments allow patients to experience challenging scenarios in a safe, controlled manner.
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extremity prosthetics that are biomechanically functional, sockets, couplers, and artistic embellishment.
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Conclusion• Innovations in surgical procedures, prosthetic
component design, and socket-limb interface are focused on restoration of tissue structure, functional mobility, and maximum quality of life.
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1. The WIfI scale (assessing wound size, infection, and foot ischemia) is utilized to predict amputation risk by in patients with which diagnosis?
A. Crush InjuryB. Congenital Limb DeformityC. MalignancyD. Peripheral Arterial Disease
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2. What TcPO2 level is associated with impaired wound healing?
A. > 70 mmHgB. > 50 mmHgC. < 40 mmHgD. < 30 mmHg
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3. Transfer of which tendons during a partial foot amputation reduces the risk of developing equinovarus?
A. Gastrocnemius and SoleusB. Peroneus Longus and BrevisC. Flexor Hallucis Longus and Tibialis PosteriorD. Tibialis Anterior and Extensor Digitorum Longus
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4. Which of the following is NOT a benefit of Negative Pressure Wound Therapy to facilitate healing of the residual limb?
A. Increased incision tensionB. Enhanced granulationC. Increased blood flowD. Reduced seroma
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5. What Medicare Functional Classification Level (MFCL) would be assigned to a patient anticipated to achieve household ambulation with a prosthesis on level surfaces at a fixed cadence?
A. K0B. K1C. K2D. K3
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6. Which suspension mechanism is most effective at minimizing pistoning?
A. Vacuum Assisted SuspensionB. Suction SuspensionC. Supracondylar CuffD. Pin and Lock
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7. Which type of knee component incorporates a stumble recovery mechanism that senses instability and stiffens the knee allowing the individual to regain their balance?
A. Single axis constant frictionB. Non-microprocessor controlledC. Microprocessor controlledD. Fluid controlled
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8. An energy storage and return prosthetic foot enhances prosthetic limb propulsion at what phase of the gait cycle?
A. Heel StrikeB. Push-OffC. Mid-SwingD. Terminal Swing
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9. Osseointegration eliminates the need for which component of the traditional prosthesis?
A. Ankle assemblyB. Knee mechanismC. Pylon D. Socket
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10. What is unique about the Ewing amputation surgical technique?
A. A longer residual limb is createdB. The dynamic muscle relationship is preservedC. General anesthesia is not requiredD. Skin grafting is minimal
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123 ReferencesA d a m s C T , L a k r a A . B e l ow K n ee A m p u t a t i on ( B K A) [ Up d a t ed 2 0 1 8 N ov 2 8 ] . I n : S t a t P e a r l s [ I n t e r n e t ] . T r e a s u re I s l a n d ( F L ) : S t a t P e a r l s P u b l i s h i n g ; 2 0 1 8 J a n - . A va i l a b l e f r om : h t t p s : / / w w w .n cb i . n lm . n i h . g o v / b ook s / NB K5 3 47 7 3/A g r a w a l , M . , K a l r a , A . S . , & J o s h i , M . ( 2 0 1 7 ) . C or re l a t i on o f a m b u l a t i on p o t e n t i a l w i t h q u a l i t y o f l i f e i n L ow er L i m b a m p u t e e s . I n t e r n a t i o n a l J o u r n a l O f C o m m u n i t y M e d i c i n e A n d P u b l i c H e a l t h , 4 ( 1 1 ) , 4 2 5 9 - 4 2 6 5 .A l b i n o , F . , S e i d e l , R . , B r ow n , B . J . , C r on e , C . , & A t t i n g e r , C . ( 2 0 1 4 ) . T h r o u g h kn ee a m p u t a t i on : t e c h n i q u e m o d i f i c a t i on s a n d s u r g i c a l ou t c om es . A r ch i v e s o f p l a s t i c s u r g e r y , 4 1 ( 5 ) , 5 6 2 .A m b r o n , E . , M i l l e r , A . , K u c h e n b e c ke r , K . J . , B u x b a u m , L . J . , & C os l e t t , H . ( 2 0 1 8 ) . I m m e r s i v e l ow - c o s t v i r t u a l r e a l i t y t r e a t m en t f o r p h a n t om l i m b p a i n : E v i d en c e f r om t w o c a s e s . F r on t i e r s i n n e u r o l o g y , 9 , 6 7 .A m m e n d o l a , M . , S a c co , R . , B u t r i co , L . , S a m m a r c o , G . , d e F r a n c i s c i s , S . , & S e r r a , R . ( 2 0 1 7 ) . T h e c a r e o f t r a n s m e t a t a r s a l a m p u t a t i on i n d i a b e t i c f oo t g a n g r e n e . I n t e r n a t i o n a l w o u n d j o u r n a l , 1 4 ( 1 ) , 9 - 1 5 .A n d re w s , K . L . , Na n o s a n d , K . N . , & H os k i n , T . L . ( 2 0 1 7 ) . D e t e r m i n i n g K - l e v e l s f o l l o w i n g t r a n s t i b i a l a m p u t a t i on . I n t . J . P h y s . M e d . R e h a b i l , 5 ( 2 ) .A r e l l a n o , C . J . , M c D er m o t t , W . J . , K r a m , R . , & G ra b o w s k i , A . M . ( 2 0 1 5 ) . E f f e c t o f r u n n i n g s p e ed a n d l e g p r o s t h e s e s on m e d i o l a t e r a l f oo t p l a c em en t a n d i t s v a r i a b i l i t y . P l o S on e , 1 0 ( 1 ) , e 0 1 1 5 6 3 7 .A r s e n a u l t , K . A . , A l -O t a i b i , A . , D ev e r ea u x , P . J . , T h o r l u n d , K . , T i t t l e y , J . G . , & W h i t l o c k , R . P . ( 2 0 1 2 ) . T h e u s e o f t r a n s cu t a n eo u s ox i m e t r y t o p r ed i c t h e a l i n g c om p l i c a t i on s o f l ow er l i m b a m p u t a t i on s : a s y s t e m a t i c r e v i ew a n d m e t a - a n a l y s i s . E u r op e a n J ou r n a l o f v a s c u l a r a n d E n d ov a s cu l a r s u r g e r y , 4 3 ( 3 ) , 3 2 9 - 3 3 6 .B a b i ć , S . , T a n a s ko v i ć , S . , L o z u k , B . , S a m a rd ž i ć , D . , P op o v , P . , G a j i n , P . , . . . & R a d a k , D . ( 2 0 1 6 ) . T r ea t m e n t o f s t u m p com p l i c a t i on s a f t e r a b ov e - kn ee a m p u t a t i on u s i n g n eg a t i v e - p r e s s u re w ou n d t h e r a p y . S r p A r h Ce l o k L ek , 1 4 4 ( 9 - 1 0 ) , 5 0 3 - 5 0 6 .B a l k E M , G a z u l a A , Ma rk oz a n n e s G , e t a l . L ow er L i m b P r o s t h e s e s : M ea s u r e m en t I n s t r u m e n t s , C om p a r i s on o f C om p on e n t E f f e c t s b y S u b g r ou p s , a n d L on g -T e r m Ou t c om e s [ I n t e r n e t ] . R o ck v i l l e (MD ) : A g e n c y f o r H e a l t h c a r e R e s e a r c h a n d Qu a l i t y (U S ) ; 2 0 1 8 S e p . (C om p a r a t i v e E f f e c t i v e n e s s R e v i ew , No . 2 1 3 . ) Av a i l a b l e f r om : h t t p s : / / w w w. n c b i . n l m .n i h . g o v / bo oks / NBK 5 31 5 23 /B e a u l i eu , R . J . , G r i m m , J . C . , L y u , H . , A b u l a r r a g e , C . J . , & P e r l e r , B . A . ( 2 0 1 5 ) . R a t e s a n d p r ed i c t o r s o f r e a d m i s s i o n a f t e r m i n o r L ow e r L i m b a m p u t a t i on s . J o u r n a l o f v a s c u l a r s u r g e r y , 6 2 ( 1 ) , 1 0 1 - 1 0 5 .B e n e d ek , T . , K ov á c s , I . , & B e n e d e k , I . ( 2 0 1 7 ) . T h e r a p e u t i c A n g i o g e n e s i s f o r S ev e r e l y I s c h em i c L i m b s — f r om B e n c h t o B ed s i d e i n Ac u t e V a s c u l a r Ca r e . J o u r n a l o f C a r d i o v a s c u l a r E m er g en c i e s , 3 ( 4 ) , 1 6 0 - 1 7 1 .B i l g i l i , B . , H a l i l o g l u , M . , E d i p o g l u , E . , C e t i n g ok , H . , P e k t a s , Y . , & B i l g i l i , M . G . ( 2 0 1 7 ) . T h e t y p e o f a n e s t h e s i a t e ch n i q u e d oe s n o t h a v e a n i m p a c t on 3 0 - d a y m o r t a l i t y i n g e r i a t r i c p a t i e n t s u n d er g o i n g L o w e r L i m b a m p u t a t i on . I n t e r n a t i on a l S u r g e r y , 1 0 2 ( 3 - 4 ) , 1 7 8 - 1 8 3 .B l a k e , D . F . , Y o u n g , D . A . , & B r ow n , L . H . ( 2 0 1 8 ) . T r a n s c u t a n e ou s ox i m e t r y : v a r i a b i l i t y i n n o r m a l v a l u e s f o r t h e u p p e r a n d l ow er l i m b . D i v i n g a n d h y p e r b a r i c m e d i c i n e , 4 8 ( 1 ) , 2 – 9 . d o i : 1 0 . 2 8 9 2 0 / d h m 48 . 1 .2 - 9B or r e n p o h l , D . , K a l u f , B . , & Ma j o r , M . J . ( 2 0 1 6 ) . S u r v e y o f US p r a c t i t i o n e r s on t h e v a l i d i t y o f t h e Me d i c a r e F u n c t i o n a l C l a s s i f i c a t i on L e v e l s y s t e m a n d u t i l i t y o f c l i n i c a l o u t c om e m ea s u r e s f o r a i d i n g K - l e v e l a s s i g n m e n t . A r c h i v e s o f p h y s i c a l m e d i c i n e a n d r e h a b i l i t a t i o n , 9 7 ( 7 ) , 1 0 5 3 - 1 0 6 3 .B o s s e , M . J . , Mor s h e d , S . , R e i d e r , L . , E r t l , W . , T o l e d a n o , J . , F i r o o z a b a d i , R . , . . . & Ma cK e n z i e , E . J . ( 2 0 1 7 ) . T r a n s t i b i a l a m p u t a t i on ou t c om e s s t u d y (T A OS ) : c om p a r i n g t r a n s t i b i a l a m p u t a t i on w i t h a n d w i t h ou t a t i b i o f i b u l a r s y n o s t o s i s ( E r t l ) p r o c ed u r e . J o u r n a l o f o r t h o p a e d i c t r a u m a , 3 1 , S 6 3 - S 6 9 . I s c h e m i c P a t i e n t s .
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B os s e , M . J . , T e a g u e , D . , R e i d e r , L . , G a r y , J . L . , M or s h ed , S . , S e ym ou r , R . B . , . . . & L u l y , J . ( 2 0 1 7 ) . Ou t c om e s a f t e r s e v e re d i s t a l t i b i a , a n k l e , a n d /o r f oo t t r a u m a : c om p a r i s o n o f l i m b s a l v a g e v e r s u s t r a n s t i b i a l a m p u t a t i on (OU T L E T ) . J o u r n a l o f o r t h o p a e d i c t r a u m a , 3 1 , S 4 8 - S 5 5 .B ow ke r H K , M i c h a e l J W ( ed s ) : A t l a s o f L i m b P r o s t h e t i c s : S u r g i c a l , P r o s t h e t i c , a n d R eh a b i l i t a t i o n P r i n c i p l e s . R o s e m on t , I L , A m er i c a n A ca d e m y o f Or t h op e d i c S u r g e on s , e d i t i o n 2 , 1 9 9 2 , r e p r i n t ed 2 0 0 2 .B r a a k s m a , R . , D i j k s t r a , P . U . , & G e e r t z e n , J . H . ( 2 0 1 8 ) . S y m e A m p u t a t i on : A S y s t em a t i c R e v i ew . F o o t & a n k l e i n t e r n a t i on a l , 3 9 ( 3 ) , 2 8 4 - 2 9 1 .B r ow n r i g g , J . R . W . , H i n c h l i f f e , R . J . , A p e l q v i s t , J . , B o y ko , E . J . , F i t r i d g e , R . , M i l l s , J . L . , . . . & O n b eh a l f I n t e r n a t i on a l W or k i n g G ro u p on t h e D i a b e t i c F oo t ( I W G D F ) . ( 2 0 1 6 ) . P e r f o r m a n c e o f p r o g n o s t i c m a r k e r s i n t h e p r e d i c t i on o f w o u n d h ea l i n g o r a m p u t a t i on a m on g p a t i e n t s w i t h f oo t u l c e r s i n d i a b e t e s : a s y s t em a t i c r e v i ew . D i a b e t e s / m e t a b o l i s m r e s e a r c h a n d r e v i e w s , 3 2 , 1 2 8 - 1 3 5 .C en t e r s f o r Me d i c a r e a n d Med i c a i d S e r v i c e s . ( 2 0 1 7 ) . L o w e r L i m b P ro s t h e t i c W o r kg r ou p C on s e n s u s D oc u m en t . h t t p s : / / w w w. cm s . g o v / Me d i c a r e /C ov er a g e / D e t e r m i na t ion P r oc e s s / d own l o ad s / L LP _ Co n s ens u s _D oc u me n t . p d fC h a n , A . W . Y . , B i l g e r , E . , G r i f f i n , S . , E l k i s , V . , W ee ks , S . , H u s s ey -A n d er s on , L . , . . . & B a k e r , C . I . ( 2 0 1 9 ) . V i s u a l r e s p on s i v e n e s s i n s e n s o r i m o t o r co r t e x i s i n c r e a s ed f o l l ow i n g a m p u t a t i on a n d r ed u c ed a f t e r m i r r o r t h e r a p y . N e u r o I m a g e : C l i n i c a l , 1 0 1 8 8 2 .C h a n , B . L . , W i t t , R . , C h a r ro w , A . P . , M a g e e , A . , H ow a r d , R . , P a s q u i n a , P . F . , . . . & T s a o , J . W . ( 2 0 0 7 ) . M i r r o r t h e r a p y f o r p h a n t om l i m b p a i n . N ew E n g l a n d J o u r n a l o f M e d i c i n e , 3 5 7 ( 2 1 ) , 2 2 0 6 - 2 2 0 7 .C h a n , B r en d a n & W S h i e l d s , D a v i d & F i n d l a y , H e l en & M a h en d r a , A s h i s h & G u p t a , S a n j a y . ( 2 0 1 8 ) . N eg a t i v e P r e s s u r e W ou n d T h e r a p y f o r L ow er L i m b A m p u t a t i o n P a t i e n t s -A Ca s e Co n t r o l T r i a l . J u n i p e r On l i n e J o u r n a l o f Or t h o p l a s t i c & M i c ro s u r g i c a l R e c on s t r u c t i o n . 1 ( 4 ) .C h e n , C . , H a n s on , M . , C h a t u r v e d i , R . , Ma t t k e , S . , H i l l e s t a d , R . , & L i u , H . H . ( 2 0 1 8 ) . E c on om i c b e n e f i t s o f m i c r o p r oc e s s o r c on t r o l l ed p ro s t h e t i c k n e e s : a m od e l i n g s t u d y . J o u r n a l o f n eu r o en g i n e e r i n g a n d r e h a b i l i t a t i o n , 1 5 ( 1 ) , 6 2 .C l i t e s , T . R . , H er r , H . M . , S r i n i v a s a n , S . S . , Z o r z o s , A . N . , & C a r t y , M . J . ( 2 0 1 8 ) . T h e E w i n g A m p u t a t i on : T h e F i r s t H u m a n I m p l e m e n t a t i on o f t h e A g o n i s t - An t a g on i s t M y on eu r a l I n t e r f a c e . P l a s t i c a n d R e c o n s t r u c t i v e S u r g e r y – G l o b a l O p e n , 6 ( 1 1 ) , e 1 9 9 7 .C MS . ( 2 0 1 6 ) . Me a s u r e # 4 3 7 P a t e o f s u r g i c a l c on v e r s i on f r om l o w e r ex t r em i t y e n d ova s c u l a r i z a t i o n p r oc e d u r e . h t t p s : / / q p p . c m s . g o v / d oc s /QP P _q u a l i t y _m e a s u r e_ s pec i f i c a t i o n s / C l a i ms -R e g i s t r y -M e a s u r e s / 2 0 1 7 _Me a s u r e_4 3 7_Re g i s t r y . p d fC n o t l i w y , M . , S z u m i ł ow i c z , J . , S a f r a n ow , K . , P e t r i c z ko , W . , W i e r n i c k i , I . , & G u t ow s k i , P . ( 2 0 0 7 ) . T h e R o l e o f I s o l a t ed P r o f u n d a p l a s t y i n A t t em p t s t o L ow er t h e L ev e l o f A m p u t a t i on i n C r i t i c a l L i m b I s c h e m i a , P o l i s h J o u r n a l o f S u r g e r y , 7 9 ( 1 2 ) , 7 7 3 - 7 7 8 . d o i : h t t p s : / / d o i . o r g / 10 . 24 7 8/ v 1 0 0 35 - 0 0 7- 0 1 1 9- 2C o l l i n s , K . L . , R u s s e l l , H . G . , S c h u m a c h e r , P . J . , R ob i n s on - F r ee m a n , K . E . , O ’ C on or , E . C . , G i b n ey , K . D . , . . . & T s a o , J . W . ( 2 0 1 8 ) . A r e v i ew o f c u r r en t t h e o r i e s a n d t r e a t m en t s f o r p h a n t om l i m b p a i n . T h e J o u r n a l o f c l i n i c a l i n v e s t i g a t i o n , 1 2 8 ( 6 ) , 2 1 6 8 - 2 1 7 6 .C ou l s t on , J . E . , T u f f , V . , T w i n e , C . P . , Ch e s t e r , J . F . , E y e r s , P . S . , & S t ew a r t , A . H . R . ( 2 0 1 2 ) . S u r g i c a l f a c t o r s i n t h e p r ev en t i on o f i n f e c t i on f o l l ow i n g m a j o r L ow er L i m b a m p u t a t i on . E u r o p e a n J o u r n a l o f V a s c u l a r a n d E n d o v a s c u l a r S u r g e r y , 4 3 ( 5 ) , 5 5 6 - 5 6 0 .C r i s t e a , Ş . Ş t . , P op e s cu , R . , Cu c u l i c i , Ş . Ş t . , S a v a , M . , P r u n d ea n u , A . , G r o s e a n u , F . , G eo r g e a n u , V . , & V i ș a n , R . ( 2 0 1 8 ) . R e s e c t i on R ec on s t r u c t i on V e r s u s A m p u t a t i on i n t h e T r e a t m en t o f Ma l i g n a n t T u m or s o f t h e L i m b s , R o m a n i a n J o u r n a l o f O r t h o p a e d i c S u r g e r y a n d T r a u m a t o l o g y , 1 ( S u p p l e m e n t ) , 6 0 - 6 0 . d o i : h t t p s : / / d o i . o r g / 1 0 . 2 47 8 / r o jo s t - 2 01 8 - 0 07 1 Copyright Jodi Gootkin 2019 125
C u t t i , A . G . , L e t t i e r i , E . , & V e r n i , G . ( 2 0 1 9 , J a n u a r y ) . H e a l t h T ec h n o l o g y As s e s s m en t a s T h eo r e t i c a l F r a m e w or k t o As s e s s L ow er - L i m b P r o s t h e t i c s — I s s u e s a n d Op p or t u n i t i e s f r om a n I n t e r n a t i on a l P e r s p e c t i v e . I n J P O : J o u r n a l o f P r o s t h e t i c s a n d O r t h o t i c s (V o l . 3 1 , N o . 1 S , p p . P 5 5 - P 7 3 ) . L W W .D a r l i n g , J . D . , M c C a l l u m , J . C . , S od e n , P . A . , G u z m a n , R . J . , W y e r s , M . C . , H a m d a n , A . D . , V e r h a g e n , H . J . , … S ch e r m e r h o r n , M . L . ( 2 0 1 7 ) . P r e d i c t i v e a b i l i t y o f t h e S o c i e t y f o r V a s c u l a r S u r g e r y W ou n d , I s ch em i a , a n d f oo t I n f e c t i on (W I f I ) c l a s s i f i c a t i on s y s t em a f t e r f i r s t - t i m e l ow er e x t r e m i t y r e v a s c u l a r i z a t i on s . J o u r n a l o f v a s c u l a r s u r g e r y , 6 5 ( 3 ) , 6 9 5 - 7 0 4 .D a v i e s , A . , L a z z a r i n i , P . , S h a r m a , B . , & R e ed , L . ( 2 0 1 5 ) . I s t h e r e a r e l a t i o n s h i p b e t w ee n s c r e en i n g f o r d i a b e t e s r e l a t ed f oo t c om p l i c a t i on s a n d l i m b a m p u t a t i on ? . J o u r n a l o f f o o t a n d a n k l e r e s e a r c h , 8 ( 2 ) , O1 1 .D a v i e - S m i t h , F . ( 2 0 1 7 ) . F a c t o r s i n f l u e n c i n g q u a l i t y o f l i f e a f t e r L o w e r L i m b a m p u t a t i o n f o r p e r i p h e r a l a r t e r i a l o c c l u s i v e d i s e a s e (D o c t o r a l d i s s e r t a t i o n , U n i v e r s i t y o f G l a s g o w ) .D e l Co re , M . A . , A h n , J . , L ew i s I I I , R . B . , R a s p ov i c , K . M . , L a l l i , T . A . , & W u k i c h , D . K . ( 2 0 1 8 ) . T h e E v a l u a t i on a n d T r ea t m e n t o f D i a b e t i c F oo t U l ce r s a n d D i a b e t i c F o o t I n f e c t i on s . F o o t & A n k l e O r t h o p a e d i c s , 3 ( 3 ) , 2 4 7 3 0 1 1 4 1 8 7 88 8 6 4 .D e p a r t m e n t o f V e t e r a n s A f f a i r s a n d D e p a r t m en t o f D e f en s e . ( 2 0 1 9 ) . T h e n ex t s t ep : T h e r eh a b i l i t a t i o n j o u r n e y a f t e r L ow er L i m b a m p u t a t i on . D i l l o n , M . P . , F a t on e , S . , & Qu i g l e y , M . ( 2 0 1 5 ) . D es c r i b i n g t h e ou t com es o f d y s v a s cu l a r p a r t i a l f oo t a m p u t a t i on a n d h o w t h e s e c om p a r e t o t r a n s t i b i a l a m p u t a t i on : a s y s t e m a t i c r e v i ew p r o t o c o l f o r t h e d ev e l op m en t o f s h a r ed d e c i s i o n m a k i n g r e s ou r ce s . S y s t em a t i c r e v i e w s , 4 ( 1 ) , 1 7 3 .D i l l o n , M . P . , M a j o r , M . J . , K a l u f , B . , B a l a s a n ov , Y . , & F a t on e , S . ( 2 0 1 8 ) . P r ed i c t t h e M ed i c a r e F u n c t i on a l C l a s s i f i c a t i on L e v e l (K - l e v e l ) u s i n g t h e A m p u t ee Mob i l i t y P r e d i c t o r i n p eop l e w i t h u n i l a t e r a l t r a n s f em or a l a n d t r a n s t i b i a l a m p u t a t i on : A p i l o t s t u d y . P r o s t h e t i c s a n d o r t h o t i c s i n t e r n a t i o n a l , 4 2 ( 2 ) , 1 9 1 - 1 9 7 .D o b s on , A . , M u r r a y , K . , M a n o l o v , N . , & D a V a n z o , J . E . ( 2 0 1 8 ) . E c on om i c v a l u e o f o r t h o t i c a n d p ro s t h e t i c s e r v i c e s a m on g m e d i c a r e b e n e f i c i a r i e s : a c l a i m s - b a s ed r e t ro s p ec t i v e c oh o r t s t u d y , 2 0 1 1 – 2 0 1 4 . J o u r n a l o f n eu r o en g i n e e r i n ga n d r e h a b i l i t a t i o n , 1 5 ( 1 ) , 5 5 .D u a , A . , P a t e l , B . , D es a i , S . S . , H o l co m b , J . B . , W a d e , C . E . , C oog a n , S . , & F ox , C . J . ( 2 0 1 4 ) . Com p a r i s on o f m i l i t a r y a n d c i v i l i a n p op l i t e a l a r t e r y t r a u m a ou t co m es . J o u r n a l o f v a s c u l a r s u r g e r y , 5 9 ( 6 ) , 1 6 2 8 - 1 6 3 2 .E c on om i d e s , J . M . , D eF a z i o , M . V . , A t t i n g e r , C . E . , & B a rb ou r , J . R . ( 2 0 1 6 ) . P r ev en t i on o f p a i n f u l n e u r om a a n d p h a n t om l i m b p a i n a f t e r t r a n s f em o ra l a m p u t a t i on s t h r ou g h c on c om i t a n t n e r v e c o a p t a t i on a n d c o l l a g e n n e r ve w r a p p i n g . N eu r o s u r g e r y , 7 9 ( 3 ) , 5 0 8 - 5 1 3 .E l l e y , C . , & Ne l s on , C . A . ( 2 0 1 8 , A p r i l ) . A P a s s i v e T w o -D e g re e - o f - F r ee d om A n k l e - F oo t P r o s t h e s i s . I n 2 0 1 8 D e s i g n o f M e d i c a l D e v i c e s C o n f e r e n c e ( p p . V 0 0 1 T 0 3 A0 0 4-V 00 1 T0 3 A0 0 4 ) . Am er i c a n S oc i e t y o f M ec h a n i c a l E n g i n e e r s .E r t l , C . W . ( 2 0 1 8 ) . L o w e r e x t r em i t y t r a u m a t i c a m p u t a t i on s — b r i e f r e v i ew o f r e co n s t r u c t i on , w o u n d a n d s o f t t i s s u e m a n a g e m e n t , a l t e r n a t i v e s t o co n v en t i on a l p r a c t i c e . J o u r n a l o f E m e r g e n c y a n d C r i t i c a l C a r e M e d i c i n e , 2 ( 4 ) .F e r r i s , A . E . ( 2 0 1 6 ) . B i om ec h a n i c a l A s s e s s m e n t o f E r t l a n d B u r g e s s T r a n s t i b i a l Am p u t a t i on T e ch n i q u e s . Un i v e r s i t y o f No r t h C o l o r a d o . D i s s e r t a t i on .F e r r i s , D . P . , & S ch l i n k , B . R . ( 2 0 1 7 ) . R o b o t i c d e v i c e s t o e n h a n c e h u m a n m ov e m en t p e r f o r m a n c e . K i n e s i o l o g y R e v i e w , 6 ( 1 ) , 7 0 - 7 7 .F r a c o l , M . E . , J a n e s , L . E . , K o , J . H . , & D u m a n i a n , G . A . ( 2 0 1 8 ) . T a r g e t ed m u s c l e r e i n n e r v a t i on i n t h e l ow er l e g : a n a n a t om i c a l s t u d y . P l a s t i c a n d r e c o n s t r u c t i v e s u r g e r y , 1 4 2 ( 4 ) , 5 4 1 e - 5 5 0 e .F rö l k e , J . P . , L e i j en d e kk er s , R . A . , & v a n d e M e en t , H . ( 2 0 1 7 ) . Os s eo i n t e g r a t ed p r o s t h e s i s f o r p a t i en t s w i t h a n a m p u t a t i on : M u l t i d i s c i p l i n ar y t e a m a p p r oa ch i n t h e N e t h e r l a n d s . Os s e o i n t e g r i e r t e P r o t h e s e f ü r P a t i en t en n a c hA m p u t a t i on : Mu l t i d i s z i p l i n ä r e r B e h a n d l u n g s a n s at z i n d e n N i ed e r l a n d en . D e r U n f a l l c h i r u r g , 1 2 0 ( 4 ) , 2 9 3 – 2 9 9 . Copyright Jodi Gootkin 2019 126
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G a i l e y R S , R oa c h K E , A p p l e g a t e E B , e t a l . T h e a m p u t e e m ob i l i t y p r ed i c t o r : a n i n s t r u m en t t o a s s e s s d e t e r m i n a n t s o f t h e l ow er - l i m b a m p u t ee ' s a b i l i t y t o a m b u l a t e . A r c h P h y s M e d R e h a b i l . 2 0 0 2 ; 8 3 ( 5 ) : 6 1 3 - 6 2 7 . G a i l e y R S , R oa c h K E , A p p l e g a t e E B , e t a l . T h e a m p u t e e m ob i l i t y p r ed i c t o r : a n i n s t r u m en t t o a s s e s s d e t e r m i n a n t s o f t h e l ow er - l i m b a m p u t ee ' s a b i l i t y t o a m b u l a t e . A r c h P h y s M e d R e h a b i l . 2 0 0 2 ; 8 3 ( 5 ) : 6 1 3 - 6 2 7 . G a m b a rd e l l a , G . a n d B l u m e , P . ( 2 0 1 3 ) . U n d e r s t a n d i n g t h e b i om e ch a n i c s o f t h e t r a n s m e t a t a r s a l a m p u t a t i o n . P o d i a t r y T od a y , 2 6 ( 3 ) , 4 6 - 5 6 .G e e r t z e n , J . , v a n d e r L i n d e , H . , R o s e n b r a n d , K . , C on r a d i , M . , D ec ke r s , J . , K on i n g , J . , . . . & S ch r i e r , E . ( 2 0 1 5 ) . D u t ch e v i d e n c e - b a s ed g u i d e l i n e s f o r a m p u t a t i o n a n d p r o s t h e t i c s o f t h e l o w e r ex t r em i t y : a m p u t a t i on s u r g e r y a n d p o s t o p e r a t i v e m a n a g e m e n t . P a r t 1 . P r o s t h e t i c s a n d o r t h o t i c s i n t e r n a t i o n a l , 3 9 ( 5 ) , 3 5 1 - 3 6 0 .G e i s s , L . S . , L i , Y . , H or a , I . , A l b r i g h t , A . , R o l k a , D . , & G r e g g , E . W . ( 2 0 1 9 ) . R e s u r g e n c e o f d i a b e t e s - r e l a t ed n o n t r a u m a t i c l o w e r - ex t r e m i t y a m p u t a t i on i n t h e yo u n g a n d m i d d l e - a g ed a d u l t U S p op u l a t i on . D i a b e t e s c a r e , 4 2 ( 1 ) , 5 0 - 5 4 .
G h o l i z a d eh , H . , A b u Os m a n , N . A . , E s h r a g h i , A . , A l i , S . , A r i f i n , N . , & W a n A b a s , W . A . ( 2 0 1 4 ) . E v a l u a t i on o f n ew s u s p e n s i on s y s t e m f o r l i m b p r o s t h e t i c s . B i o m e d i c a l e n g i n e e r i n g o n l i n e , 1 3 , 1 . d o i : 1 0 . 1 1 8 6 / 14 7 5 - 92 5 X -1 3 - 1G h o l i z a d eh , H . , Os m a n , N . A . , E s h r a g h i , A . , A l i , S . , & R a z a k , N . A . ( 2 0 1 4 ) . T r a n s t i b i a l p r o s t h e s i s s u s p e n s i on s y s t e m s : s y s t em a t i c r e v i e w o f l i t e r a t u r e . C l i n i c a l b i o m e c h a n i c s , 2 9 ( 1 ) , 8 7 - 9 7 .G i u m m a r r a , M . J . , & M os e l e y , G . L . ( 2 0 1 1 ) . P h a n t om l i m b p a i n a n d b od i l y a w a re n e s s : c u r r e n t co n c ep t s a n d f u t u r e d i r e c t i o n s . Cu r r e n t O p i n i o n i n A n e s t h e s i o l o g y , 2 4 ( 5 ) , 5 2 4 - 5 3 1 .H a f n e r , B . J . , & S m i t h , D . G . ( 2 0 0 9 ) . D i f f e r e n c e s i n f u n c t i on a n d s a f e t y b e t w ee n M e d i c a r e F u n c t i on a l C l a s s i f i c a t i on L e v e l - 2 a n d - 3 t r a n s f e m or a l a m p u t ee s a n d i n f l u e n c e o f p r o s t h e t i c kn ee j o i n t c on t ro l . J o u r n a l o f R e h a b i l i t a t i o n R e s ea r c h & D e v e l o p m e n t , 4 6 ( 3 ) .
H a h n , H . M . , J e on g , K . S . , P a r k , M . C . , P a r k , D . H . , & L e e , I . J . ( 2 0 1 7 ) . F r e e - F l a p T r a n s f e r f o r Cov e r a g e o f T r a n s m e t a t a r s a l Am p u t a t i on S t u m p t o P r e s e r v e R e s i d u a l F oo t L e n g t h . T h e i n t e r n a t i o n a l j o u r n a l o f l o w e r e x t r em i t y w o u n d s , 1 6 ( 1 ) , 6 0 - 6 5 .H a s a n a d k a , R . , Mc L a f f e r t y , R . B . , M oor e , C . J . , H ood , D . B . , R a m s e y , D . E . , & H o d g s on , K . J . ( 2 0 1 1 ) . P r e d i c t o r s o f w o u n d c om p l i c a t i on s f o l l o w i n g m a j o r a m p u t a t i o n f o r c r i t i c a l l i m b i s ch em i a . J o u r n a l o f v a s c u l a r s u r g e r y , 5 4 ( 5 ) , 1 3 7 4 - 1 3 8 2 .H a w k i n s , E . J . , & R i d d i c k , W . ( 2 0 1 8 ) . R e l i a b i l i t y , V a l i d i t y , a n d R e s p on s i v e n e s s o f C l i n i c a l P e r f o r m a n ce – B a s ed Ou t com e Me a s u re s o f W a l k i n g f o r I n d i v i d u a l s W i t h L o w e r L i m b A m p u t a t i on s : A S y s t e m a t i c R e v i e w . P h y s i c a l t h e r a p y , 9 8 ( 1 2 ) , 1 0 3 7 - 1 0 4 5 .H e r a rd , P . , & B o i l l o t , F . ( 2 0 1 2 ) . A m p u t a t i on i n em e r g en c y s i t u a t i on s : i n d i c a t i on s , t e c h n i q u e s a n d Mé d e c i n s S a n s F ro n t i è r e s F r a n c e ' s e x p e r i e n c e i n H a i t i . I n t e r n a t i o n a l o r t h o p a e d i c s , 3 6 ( 1 0 ) , 1 9 7 9 - 8 1 . H i g g i n s , T . F . , K l a t t , J . B . , & B e a l s , T . C . ( 2 0 1 0 ) . L ow er E x t r e m i t y A s s e s s m en t P r o j e c t ( L E A P )– t h e b e s t a v a i l a b l e e v i d e n c e on l i m b - t h r ea t en i n g l ow e r e x t r em i t y t r a u m a . O r t h o p ed i c C l i n i c s , 4 1 ( 2 ) , 2 3 3 - 2 3 9 .H i g h s m i t h , M . J . , K a h l e , J . T . , M i ro , R . M . , Or e n d u r f f , M . S . , L ew a n d o w s k i , A . L . , Or r i o l a , J . J . , . . . & E r t l , J . P . ( 2 0 1 6 ) . P r o s t h e t i c i n t e r v en t i on s f o r p e op l e w i t h t r a n s t i b i a l a m p u t a t i on : S y s t em a t i c r e v i ew a n d m e t a - a n a l y s i s o f h i g h - q u a l i t y p r o s p ec t i v e l i t e r a t u r e a n d s y s t em a t i c r e v i ew s . J o u r n a l o f R e h a b i l i t a t i o n R e s ea r ch & D ev e l op m en t , 5 3 ( 2 ) .H i g h s m i t h , M . J . , K a h l e , J . T . , W e rn ke , M . M . , Ca r ey , S . L . , M i r o , R . M . , L u r a , D . J . , & S u t t on , B . S . ( 2 0 1 6 ) . E f f e c t s o f t h e g e n i u m kn ee s y s t e m on f u n c t i on a l l e v e l , s t a i r a m b u l a t i on , p e r c e p t i v e a n d e co n om i c ou t com es i n t r a n s f e m or a l a m p u t ee s . T e c h n o l o g y a n d i n n o v a t i o n , 1 8 ( 2 - 3 ) , 1 3 9 . Copyright Jodi Gootkin 2019 127
H i m m e l b e r g , N . , & B u n s , M . T h e i n f l u e n c e o f p r o s t h e t i c f o o t s t i f f n e s s on en e r g y ex p e n d i t u r e i n u n i l a t e r a l b e l o w -k n ee a m p u t e e s .H s u , E . , & Co h e n , S . P . ( 2 0 1 3 ) . P o s t a m p u t a t i on p a i n : e p i d em i o l o g y , m ec h a n i s m s , a n d t r e a t m e n t . J o u r n a l o f p a i n r e s e a r c h , 6 , 1 2 1 - 3 6 . H u n s t a d , J . P . , M i c h a e l s , J . , B u r n s , A . J . , S l e z a k , S . , S t e v en s , W . G . , C l ow e r , D . M . , & R u b i n , J . P . ( 2 0 1 5 ) . A p r o s p ec t i v e , r a n d om i z ed , m u l t i c e n t e r t r i a l a s s e s s i n g a n ov e l l y s i n e - d e r i v ed u re t h a n e a d h e s i v e i n a l a r g e f l a p s u r g i c a l p r o c ed u r e w i t h ou t d r a i n s . A e s t h e t i c p l a s t i c s u r g e r y , 3 9 ( 4 ) , 6 1 6 - 6 2 4 .I n g r a h a m , K . A . , F e y , N . P . , S i m on , A . M . , & H a r g r ov e , L . J . ( 2 0 1 6 ) . A s s e s s i n g t h e r e l a t i v e con t r i b u t i o n s o f a c t i v e a n k l e a n d kn ee a s s i s t a n c e t o t h e w a l k i n g m e c h a n i c s o f t r a n s f em or a l a m p u t e e s u s i n g a p o w e r ed p r o s t h e s i s . P l o S o n e , 1 1 ( 1 ) , e0 1 4 7 6 6 1 .I o s u e , H . a n d R o s en b l u m , B . ( 2 0 1 7 ) . T r a n s m e t a t a r s a l a m p u t a t i on : P r ed i c t o r s o f s u c c e s s a n d f a i l u r e . P o d i a t r y T od a y , 3 0 ( 8 ) , 4 2 - 4 7 .J a i n , A . , L i u , K . , F e r r u cc i , L . , C r i q u i , M . H . , T i a n , L . , G u r a l n i k , J . M . , … M c D e r m ot t , M . M . ( 2 0 1 2 ) . T h e W a l k i n g I m p a i r m e n t Qu es t i o n n a i r e s t a i r - c l i m b i n g s c o r e p r ed i c t s m or t a l i t y i n m e n a n d w om e n w i t h p e r i p h e r a l a r t e r i a l d i s e a s e . J o u r n a l o f v a s c u l a r s u r g e r y , 5 5 ( 6 ) , 1 6 6 2 – 7 3 . e2J h a v e r i , D . , & S h a h , A . ( 2 0 1 7 ) . L ow er L i m b P r o s t h e s i s A S i m p l i . P A R I P E X - I ND I AN J O U R N A L O F R E S E A R C H , 6 ( 1 ) .J u p i t e r , D . C . , T h o r u d , J . C . , B u c k l e y , C . J . , & S h i b u y a , N . ( 2 0 1 6 ) . T h e i m p a c t o f f oo t u l c e r a t i on a n d a m p u t a t i on on m o r t a l i t y i n d i a b e t i c p a t i e n t s . I : f r om u l c e r a t i on t o d e a t h , a s y s t em a t i c r e v i ew . I n t e r n a t i o n a l w o u n d j o u r n a l , 1 3 ( 5 ) , 8 9 2 - 9 0 3 .K a c z y ń s k i , J . , D i l l o n , M . , & H i l t on , J . ( 2 0 1 2 ) . L ow e r L i m b T r a u m a : L i m b S a l v a g e o r a n E a r l y A m p u t a t i on ? , P o l i s h J o u r n a l o f S u r g e r y , 8 4 ( 8 ) , 4 2 0 - 4 2 5 . d o i : h t t p s : / / d o i . o r g / 1 0 . 2 4 78 / v 1 00 3 5- 0 1 2 - 0 07 1 - 7K a l u f , B . ( 2 0 1 9 , J a n u a r y ) . P r o v i d e r P e r s p e c t i v e i n t h e H ea l t h C a r e E c on om i c s o f L ow e r - L i m b P r o s t h e t i c R eh a b i l i t a t i o n . I n J P O : J o u r n a l o f P r o s t h e t i c s a n d O r t h o t i c s (V o l . 3 1 , N o . 1 S , p p . P 4 3 - P 4 8 ) . L W W .K a u f f m a n , R . ( 2 0 1 7 ) . U t i l i z i n g t h e A m p u t e e M ob i l i t y P r e d i c t o r f o r D e t e r m i n a t i o n o f F u n c t i o n a l L e ve l F o l l o w i n g a U n i l a t e r a l T r a n s t i b i a l A m p u t a t i on : A Ca s e S t u d y .K a u r , A . , & G u a n , Y . X . ( 2 0 1 8 ) . P h a n t om l i m b p a i n : A l i t e r a t u re r e v i e w . Ch i n e s e J o u r n a l o f T r a u m a t o l o g y .K ee l i n g , S h a w e n , L . P . S . B . , F o r s b e r g , C . J . A . , K i r k , L . K . L . , H s u , L . J . R . , G w i n n , C . D . E . , & P o t t e r , M . P . B . K . ( 2 0 1 3 ) . Co m p a r i s on o f f u n c t i o n a l ou t co m e s f o l l o w i n g b r i d g e s yn o s t o s i s w i t h n on - b o n e - b r i d g i n g t r a n s t i b i a l co m b a t -r e l a t ed a m p u t a t i on s . J B J S , 9 5 ( 1 0 ) , 8 8 8 - 8 9 3 .K h a n , M . A . , J a v e d , A . A . , R a o , D . J . , Co rn er , J . A . , & R o s en f i e l d , P . ( 2 0 1 6 ) . P e d i a t r i c T r a u m a t i c L i m b A m p u t a t i on : T h e P r i n c i p l e s o f M a n a g e m e n t a n d Op t i m a l R e s i d u a l L i m b L e n g t h s . W o r l d j o u r n a l o f p l a s t i c s u r g e r y , 5 ( 1 ) , 7 - 1 4 .K l e n ow , T . D . , K a h l e , J . T . , F ed e l , F . J . , R op p , J . , & H i g h s m i t h , M . J . ( 2 0 1 7 ) . C om p a r a t i v e E f f i c a c y o f T r a n s f em or a l P r o s t h e t i c I n t e r f a c e s : A n a l y s i s o f G a i t a n d P e r ce i v e d D i s a b i l i t y . J P O : J o u r n a l o f P r o s t h e t i c s a n d O r t h o t i c s , 2 9 ( 3 ) , 1 3 0 -1 3 6 .K l e n ow , T . D . , M en g e l koc h , L . J . , S t e ve n s , P . M . , R à b a g o , C . A . , H i l l , O . T . , L a t l i e f , G . A . , . . . & H i g h s m i t h , M . J . ( 2 0 1 8 ) . T h e r o l e o f e x e r c i s e t e s t i n g i n p r ed i c t i n g s u c c e s s f u l a m b u l a t i on w i t h a L ow e r L i m b p r o s t h e s i s : a s y s t e m a t i c l i t e r a t u r e r e v i ew a n d c l i n i c a l p r a c t i c e g u i d e l i n e . J o u r n a l o f n eu r o en g i n e e r i n g a n d r e h a b i l i t a t i o n , 1 5 ( 1 ) , 6 4 .K oe h l e r -M c N i ch o l a s S R , N i c ke l E A , B a r r on s K , B l a h a r s k i K E , D e l l a m a n o C A , R a y S F , e t a l . ( 2 0 1 8 ) M ec h a n i c a l a n d d y n a m i c c h a r a c t e r i z a t i on o f p ro s t h e t i c f e e t f o r h i g h a c t i v i t y u s e r s d u r i n g w e i g h t e d a n d u n w e i g h t e d w a l k i n g . P L o SON E 1 3 ( 9 ) : e0 2 0 2 8 8 4 . h t t p s : / / d o i . o r g / 1 0 . 1 37 1 / jo u r n a l . p o ne . 0 20 2 88 4K oe h l e r -M c N i ch o l a s S R , N i c ke l E A , M e d v ec J , B a r r on s K , M i on S , H a n s e n AH ( 2 0 1 7 ) T h e i n f l u en ce o f a h y d r a u l i c p r o s t h e t i c a n k l e on r e s i d u a l l i m b l o a d i n g d u r i n g s l op ed w a l k i n g . P L oS ONE 1 2 ( 3 ) : e 0 1 7 3 4 2 3 . h t t p s : / / d o i . o r g / 1 0 . 1 37 1 / jo u r n a l . p on e . 0 17 3 42 3 Copyright Jodi Gootkin 2019 128
K oe h l e r -Mc N i ch o l a s S R , S a v v a s S l a t e r B C , K oes t e r K , N i ck e l E A , F e r g u s on J E , H a n s e n AH ( 2 0 1 8 ) B i m od a l a n k l e -f o o t p ro s t h e s i s f o r e n h a n c e d s t a n d i n g s t a b i l i t y . P L oS ON E 1 3 ( 9 ) : e0 2 0 4 5 1 2 . h t t p s : / / d o i . o r g / 1 0 . 1 37 1 / jo u r n a l . p on e . 0 20 4 51 2K oe h l e r -Mc N i ch o l a s , S . R . , N i ck e l , E . A . , B a r r on s , K . , B l a h a r s k i , K . E . , D e l l a m a n o , C . A . , R a y , S . F . , . . . & H a n s e n , A . H . ( 2 0 1 8 ) . Me ch a n i c a l a n d d y n a m i c ch a r a c t e r i z a t i o n o f p r o s t h e t i c f e e t f o r h i g h a c t i v i t y u s e r s d u r i n g w e i g h t e d a n d u n w e i g h t e d w a l k i n g . P l o S o n e , 1 3 ( 9 ) , e0 2 0 2 8 8 4 .K r i s t en s en , M . T . , N i e l s e n , A . Ø . , T op p , U . M . , H o l m eh a v e ‐ B r a n d t , J . , P e t t e r s on , C . F . , & G e b u h r , P . ( 2 0 1 8 ) . D e v e l op m e n t a n d p s y c h om e t r i c p r op e r t i e s o f t h e B a s i c A m p u t ee Mo b i l i t y S c o r e f o r u s e i n p a t i en t s w i t h a m a j o r L o w e r L i m b a m p u t a t i on . G e r i a t r i c s & g e r o n t o l o g y i n t e r n a t i o n a l , 1 8 ( 1 ) , 1 3 8 - 1 4 5 .K ü l ü n k o ğ l u , B . , E r b a h c ec i , F . , & A l k a n , A . ( 2 0 1 9 ) . A c om p a r i s on o f t h e e f f e c t s o f m i r ro r t h e r a p y a n d p h a n t om e x er c i s e s on p h a n t om l i m b p a i n . T u r k i s h j o u r n a l o f m e d i c a l s c i e n c e s , 4 9 ( 1 ) , 1 0 1 - 1 0 9 .K w a h , L . K . , W e b b , M . T . , G o h , L . , & H a r v ey , L . A . ( 2 0 1 9 ) . R i g i d d r e s s i n g s v e r s u s s o f t d r e s s i n g s f o r t r a n s t i b i a l a m p u t a t i on s . Co c h r a n e D a t a b a s e o f S y s t em a t i c R e v i e w s , ( 6 ) .L a i n g , S . , L e e , P . V . , & G o h , J . C . ( 2 0 1 1 ) . E n g i n ee r i n g a t r a n s - t i b i a l p r o s t h e t i c s o c ke t f o r t h e l ow e r l i m b a m p u t ee . A n n a l s o f t h e A c a d e m y o f M e d i c i n e - S i n g a p o r e , 4 0 ( 5 ) , 2 5 2 .L a m , K . , v a n As t e n , S . A . , Ng u y en , T . , L a F on t a i n e , J . , & L a v e r y , L . A . ( 2 0 1 6 ) . D i a g n o s t i c a c cu r a c y o f p r ob e t o b o n e t o d e t e c t o s t e om y e l i t i s i n t h e d i a b e t i c f oo t : a s y s t em a t i c r e v i e w . C l i n i c a l I n f e c t i o u s D i s e a s e s , 6 3 ( 7 ) , 9 4 4 - 9 4 8 .L a n s a d e , C . , V i c a u t , E . , P a y s a n t , J . , M én a g e r , D . , C r i s t i n a , M . C . , B r a a t z , F . , . . . & C h i e s a , G . ( 2 0 1 8 ) . M ob i l i t y a n d s a t i s f a c t i on w i t h a m i c r op r oc e s s o r - co n t r o l l ed k n e e i n m od er a t e l y a c t i v e a m p u t e e s : A m u l t i - c en t r i c r a n d om i z ed c r o s s o ve r t r i a l . A n n a l s o f p h y s i c a l a n d r e h a b i l i t a t i o n m e d i c i n e .L i u H H , Ch en C , H a n s on MA , e t a l . E c on om i c v a l u e o f a d v a n ce d t r a n s f em or a l p r o s t h e t i c s . 2 0 1 7 . Av a i l a b l e a t : h t t p s : / / w w w. r a nd . o r g / c on t en t / d a m / r a n d / p u bs / r e s e a r c h _ r e p o r t s / R R20 0 0 /R R2 09 6 / R A N D _R R2 0 96 . pd f .L i u , K . , T a n g , T . , W a n g , A . , & C u i , S . ( 2 0 1 5 ) . S u r g i c a l r e v i s i o n f o r s t u m p p ro b l e m s a f t e r t r a u m a t i c a b o ve - a n k l e a m p u t a t i on s o f t h e l ow er ex t r e m i t y . B M C m u s c u l o s k e l e t a l d i s o r d e r s , 1 6 ( 1 ) , 4 8 .L u p u , A . , E n e , R . , C u r s a r u , A . , A n g h e l e s cu , D . , P op e s c u , E . , & C î r s t o i u , C . ( 2 0 1 8 ) . I n d i c a t i on o f A m p u t a t i on a f t e r T u m or a l A r t h r o p l a s t y , R o m a n i a n J o u r n a l o f O r t h o p a e d i c S u r g e r y a n d T r a u m a t o l o g y , 1 ( S u p p l e m e n t ) , 9 - 9 . d o i : h t t p s : / / d o i . o r g / 1 0 . 2 47 8 / r o jo s t - 2 01 8 - 0 02 0L u r a , D . J . , W er n k e , M . M . , C a re y , S . L . , K a h l e , J . T . , M i r o , R . M . , & H i g h s m i t h , M . J . ( 2 0 1 5 ) . D i f f e r e n c e s i n k n e e f l e x i on b e t w ee n t h e G en i u m a n d C -L e g m i c r op r oc e s s o r k n e e s w h i l e w a l k i n g on l e ve l g r o u n d a n d r a m p s . C l i n i c a l B i o m e c h a n i c s , 3 0 ( 2 ) , 1 7 5 - 1 8 1 .L u r a , D . J . , W er n k e , M . W . , C a r e y , S . L . , K a h l e , J . T . , M i r o , R . M . , & H i g h s m i t h , M . J . ( 2 0 1 7 ) . C r o s s ov e r s t u d y o f a m p u t ee s t a i r a s c e n t a n d d e s c en t b i om e c h a n i c s u s i n g G en i u m a n d C -L e g p r o s t h e s e s w i t h com p a r i s on t o n o n -a m p u t ee c on t ro l . G a i t & p o s t u r e , 5 8 , 1 0 3 – 1 0 7 .L y , T . V . , T r a v i s on , T . G . , C a s t i l l o , R . C . , B o s s e , M . J . , M a c K en z i e , E . J . , & L E AP S t u d y G r ou p . ( 2 0 0 8 ) . A b i l i t y o f l o w e r - ex t r e m i t y i n j u r y s e v e r i t y s co re s t o p r e d i c t f u n c t i on a l o u t c om e a f t e r l i m b s a l v a g e . T h e J o u r n a l o f B o n e a n d J o i n t S u r g e r y . A m e r i c a n v o l u m e . , 9 0 ( 8 ) , 1 7 3 8 .M a d s e n , U . R . , B å å t h , C . , B e r t h e l s en , C . B . , & H o m m e l , A . ( 2 0 1 8 ) . A p r o s p e c t i v e s t u d y o f s h o r t - t e rm f u n c t i on a l ou t co m e a f t e r d y s v a s c u l a r m a j o r l ow er l i m b a m p u t a t i o n . I n t e r n a t i o n a l j o u r n a l o f o r t h o p a e d i c a n d t r a u m a n u r s i n g , 2 8 , 2 2 - 2 9 .M a d s e n , U . R . , H o m m e l , A . , B å å t h , C . , & B e r t h e l s e n , C . B . ( 2 0 1 6 ) . P e n d u l a t i n g — A g r ou n d e d t h e o r y ex p l a i n i n g p a t i en t s ’ b eh a v i o r s h o r t l y a f t e r h a v i n g a l e g a m p u t a t ed d u e t o v a s cu l a r d i s e a s e . I n t e r n a t i o n a l j o u r n a l o f q u a l i t a t i v e s t u d i e s o n h e a l t h a n d w e l l - b e i n g , 1 1 ( 1 ) , 3 2 7 3 9 .
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Mi l l s S r , J . L . , C on t e , M . S . , A r m s t r on g , D . G . , P om p os e l l i , F . B . , S c h a n z e r , A . , S i d a w y , A . N . , . . . & S o c i e t y f o r V a s c u l a r S u r g e r y L o w e r E x t r em i t y G u i d e l i n e s Co m m i t t ee . ( 2 0 1 4 ) . T h e s o c i e t y f o r v a s c u l a r s u r g e r y l ow er ex t r e m i t y t h r e a t e n e d l i m b c l a s s i f i c a t i on s y s t em : r i s k s t r a t i f i c a t i on b a s e d on w ou n d , i s ch em i a , a n d f oo t i n f e c t i on (W I f I ) . J o u r n a l o f v a s c u l a r s u r g e r y , 5 9 ( 1 ) , 2 2 0 - 2 3 4 .Mo h i e l d i n , A . , Ch i d a m b a r a m , A . , S a b a p a t h i v i na y a g a m, R . , & A l B u s a i r i , W . ( 2 0 1 0 ) . Qu a n t i t a t i v e A s s e s s m e n t o f P o s t u r a l S t a b i l i t y a n d B a l a n c e B e t w ee n P e r s o n s w i t h L ow e r L i m b Am p u t a t i on a n d N or m a l S u b j e c t s b y u s i n g D y n a m i c P o s t u r o g r a p h y , M a c ed o n i a n J o u r n a l o f M e d i c a l S c i e n c e s , 3 ( 2 ) , 1 3 8 - 1 4 3 . d o i : h t t p s : / / d o i . o r g / 1 0 . 3 88 9 / MJ MS . 18 5 7 - 5 77 3 . 2 0 10 . 00 9 5Mo re i r a , C . C . , F a r b e r , A . , K a l i s h , J . A . , E s l a m i , M . H . , D i d a t o , S . , R yb i n , D . , . . . & S i r a c u s e , J . J . ( 2 0 1 6 ) . T h e e f f e c t o f a n e s t h e s i a t y p e on m a j o r L o w e r L i m b a m p u t a t i on i n f u n c t i on a l l y i m p a i r ed e l d e r l y p a t i en t s . J o u r n a l o f v a s c u l a r s u r g e r y , 6 3 ( 3 ) , 6 9 6 - 7 0 1 .Mo rg a n S J , M cD on a l d C L , H a l s n e E G , C h e ev e r S M , S a l e m R , K r a m er P A , e t a l . ( 2 0 1 8 ) L a b o r a t o r y - a n d c om m u n i t y -b a s ed h ea l t h ou t c om e s i n p eop l e w i t h t r a n s t i b i a l a m p u t a t i on u s i n g c ro s s o ve r a n d en e r g y - s t o r i n g p r o s t h e t i c f e e t : A r a n d o m i z e d c r o s s o v e r t r i a l . P L oS ON E 1 3 ( 2 ) : e0 1 8 9 6 5 2 . h t t p s : / / d o i . o r g / 10 . 13 7 1 / j o u r n a l . po n e . 01 8 9 65 2Mo r r i s on , S . G . , T h om s on , P . , L en z e , U . , & D on n a n , L . T . ( 2 0 1 9 ) . S y m e A m p u t a t i o n : F u n c t i on , S a t i s f a c t i on , a n d P r o s t h e s e s . J o u r n a l o f p e d i a t r i c o r t h o p ed i c s .Mu n d e l l , B . F . , K r em e r s , H . M . , V i s s ch e r , S . , H op p e , K . M . , & K a u f m a n , K . R . ( 2 0 1 6 ) . P r e d i c t o r s o f r e c e i v i n g a p r o s t h e s i s f o r a d u l t s w i t h a b ov e - kn ee a m p u t a t i on s i n a w e l l - d e f i n ed p op u l a t i o n . P M & R , 8 ( 8 ) , 7 3 0 - 7 3 7 .My e r s M , Ch a u v i n B J . A b o ve t h e K n ee A m p u t a t i o n s (AK A ) [ U p d a t ed 2 0 1 9 J u l 1 3 ] . I n : S t a t P ea r l s [ I n t e r n e t ] . T r ea s u r e I s l a n d ( F L ) : S t a t P e a r l s P u b l i s h i n g ; 2 0 1 9 J a n - . A va i l a b l e f r om : h t t p s : / / w w w .n cb i . n lm . n i h . g o v / b ook s / NB K5 4 43 5 0/Na r r e s , M . , K v i t k i n a , T . , C l a e s s e n , H . , D r o s t e , S . , S c h u s t e r , B . , Mor b a c h , S . , . . . & I c k s , A . ( 2 0 1 7 ) . I n c i d e n c e o f L o w e r L i m b a m p u t a t i on s i n t h e d i a b e t i c c om p a r e d w i t h t h e n on -d i a b e t i c p o p u l a t i on : a s y s t e m a t i c r e v i e w . P l o S o n e , 1 2 ( 8 ) , e0 1 8 2 0 8 1 .Ne l s on , V . S . , F l ood , K . M . , B r y a n t , P . R . , H u a n g , M . E . , P a s q u i n a , P . F . , & R o b e r t s , T . L . ( 2 0 0 6 ) . L i m b d e f i c i e n c y a n d p r o s t h e t i c m a n a g em en t . 1 . D e c i s i on m a k i n g i n p r o s t h e t i c p r e s c r i p t i on a n d m a n a g em en t . A r c h i v e s o f p h y s i c a l m e d i c i n e a n d r e h a b i l i t a t i o n , 8 7 ( 3 ) , 3 - 9 .O ’ D on e l l , E . ( 2 0 1 7 ) . A b e t t e r w a y t o a m p u t a t e . H a r v a rd Ma g a z i n e . h t t p s : / / h a r v a r d m a g a z i ne . c om / 20 1 7 /0 9 / p r o st h e t i c -l i m b s - a d v a n c e m e n t sOn g , E . T . , N g , S . Y . , Y a n g , Y . , & T h on g , S . Y . ( 2 0 1 7 ) . F a c t o r s a f f e c t i n g p o s t - o p e r a t i v e m or - t a l i t y r a t e a f t e r m a j o r L o w e r L i m b a m p u t a t i on s i n a t e r t i a r y i n s t i t u t i on i n S i n g a p o r e . A n e s t h e s i o l O p en J , 2 ( 1 ) , 1 - 8 .Ör n e h o l m , H . ( 2 0 1 7 ) . T h e D i a b e t i c F o o t : P l a n t a r f o r e f o o t u l c e r , h e e l u l c e r a n d m i n o r a m p u t a t i o n . L u n d U n i ve r s i t y .P a s q u i n a , P . F . , B r y a n t , P . R . , H u a n g , M . E . , R o b e r t s , T . L . , Ne l s on , V . S . , & F l ood , K . M . ( 2 0 0 6 ) . A d v a n c e s i n a m p u t ee c a r e . A r c h i v e s o f P h y s i c a l M e d i c i n e a n d R e h a b i l i t a t i o n , 8 7 ( 3 ) , 3 4 - 4 3P a t e rn ò , L . , I b r a h i m i , M . , G r u p p i on i , E . , M en c i a s s i , A . , & R i co t t i , L . ( 2 0 1 8 ) . S o c ke t s f o r l i m b p r o s t h e s e s : a r e v i e w o f e x i s t i n g t e c h n o l o g i e s a n d o p e n c h a l l e n g e s . I E E E T r a n s a c t i o n s o n B i o m e d i c a l E n g i n e e r i n g . P i e r r e - L ou i s , W . S . , B a t h , J . , M i kk i l i n en i , S . , S c o t t , M . C . , H a r l a n d e r - L oc ke , M . , R a s o r , Z . , & S m e d s , M . ( 2 0 1 9 ) . Ne u t r op h i l t o L ym p h o cy t e R a t i o a s a P r e d i c t o r o f Ou t c om e s a f t e r A m p u t a t i o n . A n n a l s o f v a s c u l a r s u r g e r y , 5 4 , 8 4 - 9 1 .P l u c kn e t t e , B . F . , K r u eg e r , C . A . , R i v e r a , J . C . , & W en ke , J . C . ( 2 0 1 6 ) . C om b a t - r e l a t e d b r i d g e s y n o s t o s i s v e r s u s t r a d i t i o n a l t r a n s t i b i a l a m p u t a t i o n : c om p a r i s on o f m i l i t a r y - s p e c i f i c ou t co m es . S t r a t e g i e s i n T r a u m a a n d L i m b R e c o n s t r u c t i o n , 1 1 ( 1 ) , 5 - 1 1 .Qa d u r a M , T e r e n z i D C , V e r m a S , A l -Om ra n M , H es s D A . C e l l T h e r a p y f o r Cr i t i c a l L i m b I s ch em i a : A n I n t e g r a t ed R ev i ew o f P r e - c l i n i c a l a n d C l i n i c a l S t u d i e s . S t e m Ce l l s . 2 0 1 7R a n d o n , C . , D e r oo s e , J . , & V er m a s s en , F . ( 2 0 0 3 ) . H ow t o p e r f o r m a b e l o w -k n e e a m p u t a t i on . A c t a C h i r u r g i c a B e l g i c a , 1 0 3 ( 2 ) , 2 3 8 - 2 4 0 .
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R a ya , M . A . , G a i l e y , R . S . , G a u n a u r d , I . A . , G a n ya r d , H . , K n a p p -W oo d , J . , Mc D on ou g h , K . , & P a l m i s a n o , T . ( 2 0 1 3 ) . A m p u t ee m ob i l i t y p r e d i c t o r - b i l a t e r a l : a p e r f o r m a n c e - b a s e d m e a s u re o f m ob i l i t y f o r p e op l e w i t h b i l a t e r a l l o w e r -l i m b l o s s . J o u r n a l o f R e h a b i l i t a t i o n R e s e a r c h & D e v e l o p m e n t , 5 0 ( 7R eh m a n , S . , A s g h a r , I . , A k i n b a m i j o , A . , & On w u d i ke , M . ( 2 0 1 6 ) . D r a i n A n c h o r i n g a n d R e m ov a l T ec h n i q u e W i t h ou t C h a n g e o f D r e s s i n g i n T r a n s t i b i a l Am p u t a t i on . E J V E S s h o r t r e p o r t s , 3 0 , 2 1 .R i c h m on d , J . ( 2 0 1 9 , J a n u a r y ) . E c on om i c S c i en ce i n L ow e r - L i m b P r o s t h e t i c R e h a b i l i t a t i o n : T h e C on s u m er ’ s P e r s p e c t i v e . I n J P O : J o u r n a l o f P r o s t h e t i c s a n d O r t h o t i c s (V o l . 3 1 , N o . 1 S , p p . P 3 7 - P 4 2 ) . L W W .R i c h t e r , K . , & K n u d s on , B . ( 2 0 1 3 ) . V a c u u m - a s s i s t ed c l o s u r e t h e r a p y f o r a c om p l i c a t ed , op e n , a b o ve - t h e - k n e e a m p u t a t i on w ou n d . T h e J o u r n a l o f t h e A m e r i c a n O s t e o p a t h i c A s s o c i a t i o n , 1 1 3 ( 2 ) , 1 7 4 - 1 7 6 .R ob er t s on , L . , & R och e , A . ( 2 0 1 3 ) . P r i m a r y p r op h y l a x i s f o r v e n ou s t h r o m b oe m b o l i s m i n p e op l e u n d e r g o i n g m a j o r a m p u t a t i on o f t h e l ow er ex t r e m i t y . Co c h r a n e D a t a b a s e o f S y s t em a t i c R e v i e w s , ( 1 2 ) .R oc k CG , W u r d em a n S R , S t e r g i ou N , T a k a h a s h i K Z ( 2 0 1 8 ) S t r i d e - t o - s t r i d e f l u c t u a t i on s i n t r a n s t i b i a l a m p u t e e s a r e n o t a f f e c t ed b y ch a n g e s i n p u s h -o f f m e c h a n i c s f r om u s i n g d i f f e r e n t p r o s t h e s e s . P L oS ON E 1 3 ( 1 0 ) : e 0 2 0 5 0 9 8 . h t t p s : / / d o i . o r g / 1 0 . 1 37 1 / jo u r n a l . p on e . 0 20 5 09 8R od r i g u ez , E . D . , B l u e b on d - L a n g n e r , R . , C op e l a n d , C . , G r i m , T . N . , S i n g h , N . K . , & S c a l e a , T . ( 2 0 0 9 ) . F u n c t i on a l ou t co m es o f p o s t t r a u m a t i c L o w e r L i m b s a l v a g e : a p i l o t s t u d y o f a n t e r o l a t e r a l t h i g h p e r f o r a t o r f l a p s v e r s u s m u s c l e f l a p s . J o u r n a l o f T r a u m a a n d A c u t e C a r e S u r g e r y , 6 6 ( 5 ) , 1 3 1 1 - 1 3 1 4 .R u t l ed g e , T . , V e l e z , D . , D ep p , C . , Mc Qu a i d , J . R . , W on g , G . , J o n e s , R . C . W . , . . . & G i a p , H . ( 2 0 1 9 ) . A V i r t u a l R ea l i t y I n t e r v e n t i on f o r t h e T r ea t m e n t o f P h a n t om L i m b P a i n : D e ve l o p m e n t a n d F e a s i b i l i t y R e s u l t s . P a i n M e d i c i n e .S a g l a m , Y . , G u l e n c , B . , B i r i s i k , F . , E r s e n , A . , Y a l c i n k a y a , E . Y . , & Y a z i c i o g l u , O . ( 2 0 1 7 ) . T h e q u a l i t y o f l i f e a n a l y s i s o f k n ee p r o s t h e s i s w i t h c om p l e t e m i c r op r oc e s s o r c on t ro l i n t r a n s - f e m or a l a m p u t ee s . A c t a o r t h o p a e d i c a e t t r a u m a t o l o g i c a t u r c i c a , 5 1 ( 6 ) , 4 6 6 - 4 6 9 .S a h , R . P . ( 2 0 1 8 ) . S t u m p h e a l i n g i n b e l o w kn ee a m p u t a t i on s u s i n g s o f t v e r s u s r i g i d d r e s s i n g . J o u r n a l o f P a t a nA c a d e m y o f H ea l t h S c i e n c e s , 5 ( 2 ) , 2 3 - 2 6 .S ch i r ò , G . R . , S e s s a , S . , P i c c i o l i , A . , & M a c c a u r o , G . ( 2 0 1 5 ) . P r i m a r y a m p u t a t i on v s l i m b s a l v a g e i n m a n g l ed e x t r em i t y : a s y s t e m a t i c r e v i e w o f t h e cu r r en t s co r i n g s y s t em . B MC m u s cu l o s k e l e t a l d i s o r d e r s , 1 6 ( 1 ) , 3 7 2 .S ch m i e g e l ow , M . T . , S od e , N . , R i i s , T . , L a u r i t z en , J . B . , D u u s , B . R . , & L i n d b er g - L a r s en , M . ( 2 0 1 8 ) . R e - a m p u t a t i o n s a n d m or t a l i t y a f t e r b e l o w -k n e e , t h ro u g h - k n e e a n d a b ov e - k n e e a m p u t a t i on s . D a n i s h m e d i c a l j o u r n a l , 6 5 ( 1 2 ) .S co t t , H . , C on d i e , M . E . , T r ew ee k , S . P . , & S o c k a l i n g a m , S . ( 2 0 0 0 ) . An e v a l u a t i on o f t h e Am p u t ee M ob i l i t y A i d (A MA ) e a r l y w a l k i n g a i d . P r o s t h e t i c s a n d o r t h o t i c s i n t e r n a t i o n a l , 2 4 ( 1 ) , 3 9 - 4 6 .S co t t , S . W . M . , B ow r e y , S . , C l a r k e , D . , Ch ok e , E . , B ow n , M . J . , & T h om p s o n , J . P . ( 2 0 1 4 ) . F a c t o r s i n f l u en c i n g s h o r t ‐ a n d l on g ‐ t e rm m or t a l i t y a f t e r L ow er L i m b a m p u t a t i on . A n a e s t h e s i a , 6 9 ( 3 ) , 2 4 9 - 2 5 8 .S e a m a n J P . ( 2 0 1 1 ) W h a t yo u m i g h t ex p e c t d u r i n g t h e f i r s t 1 2 m o n t h s a s a l ow er - l i m b a m p u t e e . A m p u t e e C oa l i t i o n . S e g a l , A . D . , Z e l i k , K . E . , K l u t e , G . K . , M or g e n r o t h , D . C . , H a h n , M . E . , Or en d u r f f , M . S . , A d a m c z y k , P . G . , C o l l i n s , S . H . , K u o , A . D . , … Cz e r n i e c k i , J . M . ( 2 0 1 1 ) . T h e e f f e c t s o f a c on t r o l l e d en e r g y s t o r a g e a n d r e t u r n p r o t o t y p e p r o s t h e t i c f o o t on t r a n s t i b i a l a m p u t e e a m b u l a t i on . H u m a n m o v e m e n t s c i e n c e , 3 1 ( 4 ) , 9 1 8 - 3 1 .S en g e h , D . M . , & H er r , H . ( 2 0 1 3 ) . A v a r i a b l e - i m p e d a n c e p r o s t h e t i c s o c ke t f o r a t r a n s t i b i a l a m p u t e e d e s i g n ed f ro m m a g n e t i c r e s on a n c e i m a g i n g d a t a . J P O : J o u r n a l o f P r o s t h e t i c s a n d O r t h o t i c s , 2 5 ( 3 ) , 1 2 9 - 1 3 7 .S ey ed a l i , M . , C z e r n i e c k i , J . M . , Mor g en r o t h , D . C . , & H a h n , M . E . ( 2 0 1 2 ) . Co - c on t r a c t i on p a t t e r n s o f t r a n s - t i b i a l a m p u t ee a n k l e a n d k n e e m u s c u l a t u r e d u r i n g g a i t . J o u r n a l o f n eu r o en g i n e e r i n g a n d r e h a b i l i t a t i o n , 9 , 2 9 .S h a w e n , L . P . S . B . , F o r s b e r g , C . J . A . , K i r k , L . K . L . , H s u , L . J . R . , G w i n n , C . D . E . , & P o t t e r , M . P . B . K . ( 2 0 1 3 ) . C om p a r i s o n o f f u n c t i on a l ou t c om e s f o l l o w i n g b r i d g e s y n o s t o s i s w i t h n o n - b on e - b r i d g i n g t r a n s t i b i a l c om b a t - r e l a t ed a m p u t a t i on s . J B J S , 9 5 ( 1 0 ) , 8 8 8 - 8 9 3 . Copyright Jodi Gootkin 2019 131
S h e l l , C . E . , K l u t e , G . K . , & N ep t u n e , R . R . ( 2 0 1 8 ) . I d en t i f y i n g c l a s s i f i e r i n p u t s i g n a l s t o p r e d i c t a c r o s s - s l op e d u r i n g t r a n s t i b i a l a m p u t e e w a l k i n g . P l o S o n e , 1 3 ( 2 ) , e0 1 9 2 9 5 0 .S h ep h e r d , M . K . , A z oc a r , A . F . , M a j o r , M . J . , & R o u s e , E . J . ( 2 0 1 8 ) . Am p u t ee p e r c ep t i on o f p ro s t h e t i c a n k l e s t i f f n e s s d u r i n g l o co m ot i on . J o u r n a l o f n eu r o en g i n e e r i n g a n d r e h a b i l i t a t i o n , 1 5 ( 1 ) , 9 9 .S h eu , J . J . , L i n , P . Y . , S u n g , P . H . , Ch en , Y . C . , L eu , S . , Ch en , Y . L . , … Y i p , H . K . ( 2 0 1 4 ) . L e ve l s a n d v a l u e s o f l i p o p r o t e i n - a s s o c i a t e d p h o s p h o l i p a s e A 2 , g a l e c t i n - 3 , R h oA / R OC K , a n d en d o t h e l i a l p r o g en i t o r c e l l s i n c r i t i c a l l i m b i s c h e m i a : p h a r m a co - t h e r a p eu t i c ro l e o f c i l o s t a z o l a n d c l o p i d o g r e l c om b i n a t i on t h e r a p y . J o u rn a l o f t r a n s l a t i o n a l m e d i c i n e , 1 2 , 1 0 1 .S h i , E . , J e x , M . , P a t e l , S . , & G a r g , J . ( 2 0 1 9 ) . Ou t com es o f W ou n d H e a l i n g a n d L i m b L o s s A f t e r T r a n s m e t a t a r s a lA m p u t a t i on i n t h e P r e s en c e o f P e r i p h e r a l V a s cu l a r D i s e a s e . T h e J ou r n a l o f F oo t a n d A n k l e S u r g e r y , 5 8 ( 1 ) , 4 7 -5 1 . 1 1S h i s h eh b o r , M . H . , W h i t e , C . J . , G r a y , B . H . , M en a r d , M . T . , L ook s t e i n , R . , R o s e n f i e l d , K . , & J a f f , M . R . ( 2 0 1 6 ) . C r i t i c a l l i m b i s c h e m i a : a n ex p e r t s t a t e m e n t . J o u r n a l o f t h e A m e r i c a n C o l l e g e o f C a r d i o l o g y , 6 8 ( 1 8 ) , 2 0 0 2 - 2 0 1 5 .S i m o n A M , I n g r a h a m K A , F e y N P , F i n u c a n e S B , L i p s ch u t z R D , Y ou n g A J , e t a l . ( 2 0 1 4 ) C on f i g u r i n g a P ow er e d K n ee a n d A n k l e P r o s t h e s i s f o r T r a n s f em or a l A m p u t e e s w i t h i n F i v e S p e c i f i c A m b u l a t i o n M od es . P L oS ON E 9 ( 6 ) : e 9 9 3 8 7 . h t t p s : / / d o i . o r g / 1 0 . 1 37 1 / jo u r n a l . p on e . 0 09 9 38 7S m i t h , D . G . ( 2 0 0 4 ) . G en er a l p r i n c i p l e s o f a m p u t a t i on s u r g e r y . A t l a s o f a m p u t a t i o n s a n d l i m b d e f i c i e n c i e s : s u r g i c a l , p r o s t h e t i c , a n d r e h a b i l i t a t i o n p r i n c i p l e s . 3 r d e d . R o s em o n t , I L : A m e r i c a n A c a d e m y o f O r t h o p a ed i c S u r g e o n s , 2 1 - 3 0 .S ou z a , J . M . , Ch ee s b o r ou g h , J . E . , K o , J . H . , Ch o , M . S . , K u i ke n , T . A . , & D u m a n i a n , G . A . ( 2 0 1 4 ) . T a r g e t ed m u s c l e r e i n n e r v a t i on : a n o v e l a p p r o a ch t o p o s t a m p u t a t io n n e u r om a p a i n . C l i n i c a l O r t h o p a e d i c s a n d R e l a t e d R e s ea r c h ® , 4 7 2 ( 1 0 ) , 2 9 8 4 - 2 9 9 0 .S q u e l l a , S . A . F . , K a n n en b e r g , A . , & B en e t t i , Â . B . ( 2 0 1 8 ) . E n h a n c e m e n t o f a p r o s t h e t i c kn e e w i t h a m i c r o p r oc e s s o r - c on t r o l l e d g a i t p h a s e s w i t c h r ed u c e s f a l l s a n d i m p r ov e s b a l a n c e c on f i d e n c e a n d g a i t s p ee d i n c om m u n i t y a m b u l a t o r s w i t h u n i l a t e r a l t r a n s f e m or a l a m p u t a t i on . P r o s t h e t i c s a n d O r t h o t i c s I n t e r n a t i o n a l , 4 2 ( 2 ) , 2 2 8 .S t en q v i s t , C . P . , N i e l s en , C . T . , N a p o l i t a n o , G . M . , L a r s e n , B . M . , F l i e s , M . J . , B r a n d e r , D . C . , . . . & P a l l e s e n , P . ( 2 0 1 9 ) . D oe s c l o s e d i n c i s i o n n eg a t i v e w ou n d p r e s s u r e t h e r a p y i n n o n ‐ t r a u m a t i c m a j o r l o w e r ‐ e x t r em i t y a m p u t a t i on s i m p r ov e s u r v i v a l r a t e s ? . I n t e r n a t i o n a l w o u n d j o u r n a l .S t e v en s , P . M . , & W u r d em a n , S . R . ( 2 0 1 9 ) . P r o s t h e t i c K n ee S e l e c t i o n f o r I n d i v i d u a l s w i t h U n i l a t e r a l T r a n s f e m or a l A m p u t a t i on : A C l i n i c a l P r a c t i c e G u i d e l i n e . J P O : J o u r n a l o f P r o s t h e t i c s a n d O r t h o t i c s , 3 1 ( 1 ) , 2 - 8 .S t e v en s , P . M . , D eP a l m a , R . R . , & W u r d e m a n , S . R . ( 2 0 1 9 ) . T r a n s t i b i a l S o c ke t D es i g n , I n t e r f a ce , a n d S u s p e n s i o n : A C l i n i c a l P r a c t i c e G u i d e l i n e . J P O : J o u r n a l o f P r o s t h e t i c s a n d O r t h o t i c s , 3 1 ( 3 ) , 1 7 2 - 1 7 8 .S t e v en s , P . M . , H i g h s m i t h , M . J . , & S u t t on , B . ( 2 0 1 9 , J a n u a r y ) . M ea s u r i n g V a l u e i n t h e P r ov i s i o n o f L ow e r - L i m b P r o s t h e s e s . I n J P O : J o u r n a l o f P r o s t h e t i c s a n d O r t h o t i c s (V o l . 3 1 , N o . 1 S , p p . P 2 3 - P 3 1 ) . L W W .S t ev en s , P . M . , R h e i n s t e i n , J . , & W u r d em a n , S . R . ( 2 0 1 8 ) . P r o s t h e t i c F oo t S e l e c t i on f o r I n d i v i d u a l s w i t h L ow e r -L i m b A m p u t a t i on : A C l i n i c a l P r a c t i c e G u i d e l i n e . J ou r n a l o f P r o s t h e t i c s a n d O r t h o t i c s , 3 0 ( 4 ) , 1 7 5 . S u b e d i , B . , & G r o s s b e r g , G . T . ( 2 0 1 1 ) . P h a n t om l i m b p a i n : m e c h a n i s m s a n d t r e a t m en t a p p ro a c h e s . P a i n r e s e a r c h a n d t r e a t m e n t , 2 0 1 1 , 8 6 4 6 0 5 . S u ku r , E . , A k a r , A . , U y a r , A . Ç . , C i c e k l i , O . , K o ch a i , A . , T u r k e r , M . , & T op cu , H . N . ( 2 0 1 8 ) . V a cu u m - a s s i s t e d c l o s u re v e r s u s m o i s t d r e s s i n g s i n t h e t r e a t m en t o f d i a b e t i c w ou n d u l c e r s a f t e r p a r t i a l f oo t a m p u t a t i on : A r e t r o s p ec t i v e a n a l y s i s i n 6 5 p a t i en t s . J o u rn a l o f Or t h op a e d i c S u r g e r y , 2 6 ( 3 ) , 2 3 0 9 4 9 9 0 1 8 7 99 7 69 .S u m p i o , B . , S h i n e , S . R . , M a h l e r , D . , & S u m p i o , B . E . ( 2 0 1 3 ) . A c om p a r i s o n o f i m m ed i a t e p o s t op er a t i v e r i g i d a n d s o f t d r e s s i n g s f o r b e l o w -k n e e a m p u t a t i on s . A n n a l s o f v a s c u l a r s u r g e r y , 2 7 ( 6 ) , 7 7 4 - 7 8 0 .
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T a n , M . N . A . , L o , Z . J . , L ee , S . H . , T e o , R . M . , T a n , W . L . G . , & C h a n d r a s ek a r , S . ( 2 0 1 8 ) . R ev i e w o f T r a n s m e t a t a r s a l Am p u t a t i on s i n t h e M a n a g e m e n t o f P e r i p h e r a l A r t e r i a l D i s e a s e i n a n A s i a n P o p u l a t i on . A n n a l s o f v a s c u l a r d i s e a s e s , o a - 1 7 .T h e R e h a b i l i t a t i o n o f I n d i v i d u a l s w i t h L ow er L i m b A m p u t a t i on W o rk G r ou p ( 2 0 1 7 ) . V A /D o D C l i n i c a l p r a c t i c e g u i d e l i n e f o r r e h a b i l i t a t i o n o f i n d i v i d u a l s w i t h l o w e r l i m b a m p u t a t i o n . D e p a r t m e n t o f V e t e r a n s A f f a i r s , p p . 1 - 1 2 3 .T h i e l e , J . , S ch ö l l i g , C . , B e l l m a n n , M . , & K r a f t , M . ( 2 0 1 8 ) . D es i g n s a n d p e r f o r m a n c e o f t h r e e n e w m i c r op ro ce s s o r -c on t r o l l e d kn ee j o i n t s . B i o m e d i c a l E n g i n e e r i n g / B i o m ed i z i n i s c h e T e c h n i k .T h o ru d , J . ( 2 0 1 6 ) . A r e t r a n s m e t a t a r s a l a m p u t a t i on s r e a l l y b e t t e r ? . P o d i a t r y T od a y , 2 9 ( 7 ) , 1 6 - 2 2 .T h o ru d , J . a n d S e i d e l , J . ( 2 0 1 8 ) . A c l o s e r l ook a t m or t a l i t y a f t e r l ow er l i m b a m p u t a t i o n . . P o d i a t r y T od a y . 3 1 ( 4 ) , 1 2 - 1 6 .T i l l a n d e r , J . , H a g b e r g , K . , H a g b e r g , L . , & B r å n e m a rk , R . ( 2 0 1 0 ) . Os s eo i n t e g r a t e d t i t a n i u m i m p l a n t s f o r l i m b p r o s t h e s e s a t t a c h m en t s : i n f e c t i ou s co m p l i c a t i on s . C l i n i c a l O r t h o p a e d i c s a n d R e l a t e d R e s ea r c h ® , 4 6 8 ( 1 0 ) , 2 7 8 1 -2 7 8 8 .T ov ey , G . , & T h o m p s on , J . P . ( 2 0 0 5 ) . A n a e s t h e s i a f o r L ow er L i m b r e v a s cu l a r i z a t i on . Co n t i n u i n g E d u c a t i o n i n A n a e s t h e s i a , C r i t i c a l C a r e & P a i n , 5 ( 3 ) , 8 9 - 9 2 .Ü l g e r , Ö . , T o p u z , S . , B a y r a m l a r , K . , Ş e n e r , G . , & E r b a h ç e c i , F . ( 2 0 0 9 ) . E f f e c t i v e n e s s o f p h a n t om e x e r c i s e s f o r p h a n t om l i m b p a i n : a p i l o t s t u d y . J o u r n a l o f r e h a b i l i t a t i o n m e d i c i n e , 4 1 ( 7 ) , 5 8 2 - 5 8 4 .Ü l g e r , Ö . , Y ı l d ı r ı m Ş a h a n , T . , & Çe l i k , S . E . ( 2 0 1 8 ) . A s y s t e m a t i c l i t e r a t u r e r e v i ew o f p h y s i o t h e r a p y a n d r eh a b i l i t a t i o n a p p r oa c h e s t o l ow er - l i m b a m p u t a t i o n . P h y s i o t h e r a p y t h e o r y a n d p r a c t i c e , 3 4 ( 1 1 ) , 8 2 1 - 8 3 4 .V a n N e t t e n , J . J . , F o r t i n g t on , L . V . , H i n c h l i f f e , R . J . , & H i j m a n s , J . M . ( 2 0 1 6 ) . E a r l y p o s t - op e r a t i v e m or t a l i t y a f t e r m a j o r L o w e r L i m b a m p u t a t i on : a s y s t em a t i c r e v i e w o f p op u l a t i on a n d r e g i on a l b a s ed s t u d i e s . E u r o p e a n J o u r n a l o f V a s c u l a r a n d E n d o v a s c u l a r S u r g e r y , 5 1 ( 2 ) , 2 4 8 - 2 5 7 .V e l i s s a r i s , D . , P a n t z a r i s , N . , P l a t a n a k i , C . , A n t o n op ou l ou , N . , & G og o s , C . ( 2 0 1 8 ) . P r o ca l c i t on i n a s a d i a g n o s t i c a n d p r o g n o s t i c m a r k e r i n d i a b e t i c f oo t i n f e c t i on . A cu r r en t l i t e r a t u r e r e v i ew , R o m a n i a n J o u r n a l o f I n t e r n a l M e d i c i n e , 5 6 ( 1 ) , 3 - 8 . d o i : h t t p s : / / d o i . o r g / 1 0 .1 5 15 / r j im -2 0 1 7- 0 0 3 9V en er m o , M . , V i k a t m a a , P . , T e r a s a k i , H . , & S u g a n o , N . ( 2 0 1 2 ) . V a s c u l a r l a b o r a t o r y f o r c r i t i c a l l i m b i s c h a e m i a . S c a n d i n a v i a n J o u r n a l o f S u r g e r y , 1 0 1 ( 2 ) , 8 6 - 9 3 .W e z e n b er g , D . , Cu t t i , A . G . , B r u n o , A . , & H ou d i j k , H . ( 2 0 1 4 ) . D i f f e r e n t i a t i o n b e t w ee n s o l i d - a n k l e c u s h i on ed h e e l a n d en e r g y s t o r a g e a n d r e t u r n p r o s t h e t i c f oo t b a s ed on s t ep - t o - s t e p t r a n s i t i o n co s t . J o u r n a l o f r e h a b i l i t a t i o n r e s e a r c h a n d d e v e l o p m en t , 5 1 ( 1 0 ) , 1 5 7 9 .W i s e , E . S . , M cM a s t e r J r , W . G . , W i l l i a m s on , K . , W e r g i n , J . E . , H oc k i n g , K . M . , & B ro p h y , C . M . ( 2 0 1 6 ) . P r e op e r a t i v e p r ed i c t o r s o f 3 0 - d a y m or t a l i t y a n d p r o l o n g ed l en g t h o f s t a y a f t e r a b ov e - k n e e a m p u t a t i on . A n n a l s o f v a s c u l a r s u r g e r y , 3 1 , 1 2 4 - 1 3 3 .W i s e , J . , W h i t e , A . , S t i n n e r , D . J . , & F e r g a s o n , J . R . ( 2 0 1 7 ) . A U n i q u e A p p l i c a t i on o f Ne g a t i v e P r e s s u r e W ou n d T h e r a p y U s e d t o F a c i l i t a t e P a t i e n t E n g a g e m e n t i n t h e A m p u t a t i o n R ec ov e r y P r oce s s . A d v a n c e s i n w o u n d c a r e , 6 ( 8 ) , 2 5 3 - 2 6 0 .W oo s t e r , M . E . , & I I , O . ( 2 0 1 2 ) . E s c a p e f r om a G r e a t e r A f f l i c t i o n : T h e H i s t o r i c a l E v o l u t i o n o f Am p u t a t i on .W u , J . T . , W o n g , M . , L o , Z . J . , W on g , W . E . , Na r a y a n a n , S . , T a n , G . W . L . , & Ch a n d r a s ek a r , S . ( 2 0 1 7 ) . A s e r i e s o f 2 1 0 p e r i p h e r a l a r t e r i a l d i s e a s e b e l ow -kn ee a m p u t a t i on s a n d p r ed i c t o r s f o r s u b s e q u e n t a b ov e - kn ee a m p u t a t i on s . A n n a l s o f v a s c u l a r d i s e a s e s , 1 0 ( 3 ) , 2 1 7 - 2 2 2 .
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Wu r dem a n , S . R . , S t ev en s , P . M . , & C a m p b e l l , J . H . ( 2 0 1 8 ) . Mob i l i t y a n a l y s i s o f a m p u t ees ( MA A T 3 ) : M a t c h i n g i n d i v i du a l s b a s ed on com orb i d h ea l t h r e vea l s i m p roved f u n c t i on f o r a b ove - kn ee p r os t h e s i s u s e r s w i t h m i c rop r oce s s or kn ee t e ch n o l og y . A s s i s t i v e T e c h no l o g y , 1 - 7 .X i e , Y . , Z h a n g , H . , Y e , T . , G e , S . , Zh u o , R . , & Zh u , H . ( 2 0 1 7 ) . T h e g er i a t r i c n u t r i t i on a l r i s k i n dex i n dep en d en t l y p r ed i c t s m or t a l i t y i n d i a b e t i c f oo t u l c e r s p a t i en t s u n der g o i n g a m p u t a t i on s . J o u r n a l o f d i a b e t e s r e s e a r c h , 2 0 1 7 .Z a n f i r , A . , G eor g es cu , D . , T u r t u r i c a , S . , E c z ed i , M . , & M i r on i u c , A . ( 2 0 1 7 ) . I m m er s i v e V R i n Ph a n tom L i m b Pa i n T h er a p y o f A m p u tee Pa t i en t s D u e t o C r i t i c a l L i m b I s ch em i a , A c t a M ed i c a M a r i s i e n s i s , 6 3 ( 3 ) , 1 1 5 - 1 2 0 . do i : h t t p s : / / do i . o r g / 1 0 . 1 5 1 5 / a m m a - 2 0 1 7 - 0 0 3 1Z a t i , A . , C a v a z z u t i , L . , Ok i t a , Y . , M a r i a n i , E . , & B en ed et t i , M . G . ( 2 0 1 7 ) . A n O r i g i n a l S u p p or t i n g F r a m e f o r E a r l y M ob i l i z a t i on a f t e r L ow er - L im b A m p u t a t i on f o r M u s c u l os ke l e t a l T u m or . J P O : J o u r na l o f P r o s t h e t i c s a n d O r t h o t i c s , 2 9 ( 1 ) , 3 5 - 3 8 .Z a y a n , N . E . , Wes t , J . M . , S ch u l z , S . A . , J or da n , S . W. , & V a l e r i o , I . L . ( 2 0 1 9 ) . I n c i s i on a l N eg a t i v e P r es s u re Wou n d T h er a p y : A n E f f e c t i v e T oo l f o r M a j o r L i m b A m p u ta t i on a n d A m p u ta t i on R ev i s i on S i t e C lo s u r e . A dv a n ce s i n w ou n d c a r e , 8 ( 8 ) , 3 6 8 – 3 7 3 . Z i n g g M , L a c r a z A , R ob er t - E b a d i H , Kr e s s m a n n B , G l a u s er F , Wa i b e l F , e t a l . ( 2 0 1 9 ) . T r a n s cu t a n eou s Ox yg en P r es s u re V a l u es O f ten F a i l t o P r ed i c t S tu m p F a i l u r e s a f t e r F oo t or L i m b A m p u ta t i on i n C h r on i c a l l y I s ch em i c P a t i en t s . C l i n S u r g . 4 : 2 3 6 6 .
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Lower Limb Amputation & Prostheses Resources Geriatric Nutritional Risk Index https://www.mdcalc.com/nutritional-risk-index-nri Walking Impairment Questionnaire https://www.sciencedirect.com/science/article/pii/S0741521403003124 Wound, Ischemia, foot Infection Classification (WIfI) App https://apps.apple.com/us/app/svs-ipg/id1014644425 Mangled Extremity Severity Score (MESS) https://www.mdcalc.com/mangled-extremity-severity-score-mess-score#targetText=The%20Mangled%20Extremity%20Severity%20Score,setting%20of%20lower%20extremity%20trauma. Medicare Functional Classification Levels (MFCL) https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/LLP_Consensus_Document.pdf Agency for Healthcare Research and Quality: Lower Limb Prostheses: Measurement Instruments, Comparison of Component Effects by Subgroups, and Long Term Outcomes https://www.ncbi.nlm.nih.gov/books/NBK531523/pdf/Bookshelf_NBK531523.pdf Amputee Mobility Predictor (AMP) https://www.sralab.org/rehabilitation-measures/amputee-mobility-predictor-0 Agrawal, V. (2016). Clinical Outcome Measures for Rehabilitation of Amputees – A review. Physical Medicine and Rehabilitation International. 3(2): 1080. https://austinpublishinggroup.com/physical-medicine/fulltext/pmr-v3-id1080.php VA Center for Limb Loss and MoBility (CLiMB) https://www.amputation.research.va.gov/index.asp National Institutes of Health 3D Print Exchange https://3dprint.nih.gov/ Copyright Jodi Gootkin 2019