Lower Limb Amputation & Prostheses Goals and Objectives · 2020-06-15 · Innovative Educational Services Lower Limb Amputation & Prostheses Goals and Objectives Course Description

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

[email protected]

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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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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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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Course Outline and Schedule

3-hour live interactive webinar

Consider This


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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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


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


23 Levels of Amputation

Minor Amputation

Toe

Transmetatarsal

Lisfranc

Chopart

Major Amputation

Syme’s

Transtibial

Knee disarticulation

Transfemoral


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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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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.


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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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.


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.


38

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.


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.


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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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.


57 Determining MFCL• Errors in classification may limit functional mobility,

patient satisfaction, and quality of life.• There is no “gold standard” instrument.


58

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.


59

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


60

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11

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


61 Transfemoral Socket Design• Increased adduction angle of the femur improves

prosthetic control and balance.


62

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.


63

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


64

Transfemoral Suspension• Suspension systems hold the prosthesis in place

providing a connection that promotes stability with activity while minimizing skin breakdown.


65

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.


66

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12

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.


67

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 ®)


68

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.


69 Transtibial Interface and Suspension

• 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


70

Locking Suspension• The current recommendation, assuming user ability, is

a viscoelastic interface.• Multiple locking mechanisms

are available.


71


Pistoning• Excessive motion causes force absorption in the soft

tissues instead of transmission to the foot for loading and energy return in gait propulsion.


72

Vacuum Assisted Suspension (VAS)

• Least pistoning

Suction Suspension

Pin and lock Suspension

Supracondylar Cuff or Sleeve

• Compromised suspension


Consider This

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13

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.


73 Socket and Suspension Outcomes

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.


74

Knee Component• Based on the individual’s activity level, the knee

provides varying amounts of stability or motion.


75

• 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.


76

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.


77

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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14

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


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.


80

Knee Component Outcomes• Controlling flexion without sacrificing stability, the

microprocessor knee appears to improve efficiency and contribute to safety.


81

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


82

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.


84

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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15

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.


85

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®


86

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.


87

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.


88

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


89

• 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


90

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/

85 86

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16

Self Selected Gate Velocity (SSGV)• When ambulating with a prosthesis, several kinematic

variables are associated with walking speed an individual uses.


91

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.


92

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.


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


94

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.


95

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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17

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.


97 Stochastic Resonance• Sub-threshold vibration sensors located in the

prosthetic socket may enhance peripheral sensation sufficiently to result in improved postural stability and locomotor function.


98

Distributed Sensing• Built in sensors on the prosthetic liner will monitor

moisture, temperature, pressure, and shear stress.


99 Dynamic Socket• Multidirectional sensors detect volume change and

shift fluid from the internal bladders to adjust pressure on the residual limb.


100

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.


101 Osseointegration• A titanium implant in the residual limb allows direct

skeletal attachment of the prosthesis eliminating the need for a socket.


102

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


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.


104

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.


105

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.


106

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


107

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


108

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107 108


19

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.


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.


110

Computer Assisted RehabilitationEnvironment (CAREN)

• Immersive virtual reality environments allow patients to experience challenging scenarios in a safe, controlled manner.


111 3D Printing• 3D printing technology is expanding to include lower

extremity prosthetics that are biomechanically functional, sockets, couplers, and artistic embellishment.


112

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.


113

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


114

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20

2. What TcPO2 level is associated with impaired wound healing?

A. > 70 mmHgB. > 50 mmHgC. < 40 mmHgD. < 30 mmHg


115

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


116

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


117

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


118

6. Which suspension mechanism is most effective at minimizing pistoning?

A. Vacuum Assisted SuspensionB. Suction SuspensionC. Supracondylar CuffD. Pin and Lock


119

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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119 120


21

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


121

9. Osseointegration eliminates the need for which component of the traditional prosthesis?

A. Ankle assemblyB. Knee mechanismC. Pylon D. Socket


122

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


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 .


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 .


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 .


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

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Lower Limb Amputation & Prostheses Goals and Objectives · 2020-06-15 · Innovative Educational Services Lower Limb Amputation & Prostheses Goals and Objectives Course Description