Physiological responses to multiple speed treadmill walking for Syme vs. transtibial amputation--a case report.

PURPOSE: To date, there have been no longitudinal studies comparing walking at different levels of amputation. The objective of this study was to compare the self-selected walking velocity (SSWV) and selected physiologic variables during walking between a Syme and a later transtibial level of amputation for a single subject. Additional comparison was made between the SACH foot prosthesis and a dynamic response foot prosthesis. METHOD: A 35-year-old male with a traumatic Syme amputation later underwent elective transtibial amputation. SSWV and multiple speed treadmill walking tests (53.64, 67.05, 80.46, 93.87 and 107.28 m/min) were evaluated under three conditions (Syme prosthesis with SACH foot, transtibial prosthesis with SACH foot, and transtibial prosthesis with Flex-Foot). RESULTS: Walking with transtibial prosthesis showed minimal differences in oxygen consumption (0 - 5% reduction), heart rate response (0 - 1% reduction), or gait efficiency (0 - 5% improvement) across all speeds when compared with Syme prosthesis (both with SACH foot). However, the SSWV was 6 - 8% faster for the transtibial SACH foot. Walking with transtibial Flex-Foot required less cardiovascular demand than with transtibial SACH foot at higher speeds. CONCLUSIONS: In this case report, it seemed that transtibial amputation did not have adverse effects on selected physiological responses at a variety of walking speeds when compared to Syme amputation, and that the use of a dynamic response foot enhanced his gait performance. Further experimental studies involving more subjects with traumatic Syme and transtibial amputations are required to better understand the effect of these two levels of amputation on energy cost of walking.

Physiological measurements of walking and running in people with transtibial amputations with 3 different prostheses.

STUDY DESIGN: A 3-factor (foot type, speed, and mode of ambulation) repeated-measures experimental design was used. OBJECTIVES: To compare the differences in energy expenditure, gait efficiency, and relative exercise intensity in persons with transtibial amputations with various prostheses. BACKGROUND: There is a need for improved prosthetic designs to accommodate physically active persons with lower-extremity amputations. METHODS AND MEASURES: We used progressive speeds of treadmill walking (53.64, 67.05, 80.46, 93.87, and 107.28 m/min) and running (120.69, 134.1, and 147.51 m/min) with 3 different types of prostheses: the Solid Ankle Cushion Heel (SACH) foot, the Flex-Foot (FF), and the Re-Flex Vertical Shock Pylon (VSP) prosthesis. Five physically active men with unilateral transtibial amputations served as subjects (aged 31.6 +/- 4.28 years). RESULTS: The following statistically significant differences (improvements) between the Re-Flex VSP versus the FF and the SACH foot were found. Energy cost: walking (5%), running (11%); gait efficiency: walking (6%), running (9%); relative exercise intensity: walking (4%), running (5%). However, we found no significant differences between the FF and the SACH. CONCLUSIONS: The Re-Flex VSP appears to have a positive effect on energy cost, efficiency, and relative exercise intensity compared with the other prosthetic foot types during walking and running.

Schultz metacarpophalangeal arthroplasty: a long-term follow-up study.

We describe a prospective, long-term evaluation of the Schultz metacarpophalangeal joint implant. The prosthesis is a semiconstrained, cemented implant with a ball-in-socket articulation. Thirty-six implants were followed for an average of 10.9 years. There was a progressive decrease in range of motion and strength and a recurrence of ulnar deviation. The neck of the proximal phalangeal component fractured in 39% of the joints. Periarticular heterotopic bone formed in all joints, but was extensive in only 22%. Although some lucency of the bone-cement interface was seen in 80% of the joints, no prosthetic loosening occurred in this series. Our results indicate that long-term, intramedullary cement fixation of relatively long-stemmed components can be satisfactory. However, the articulated portion of this implant does not consistently withstand the stresses transmitted across the joint and does not provide long-term joint stability.

Electromyographic changes after carpal tunnel release.

This prospective clinical study was designed to quantitate post-carpal tunnel release electromyographic (EMG) changes in the median nerve, and changes in static two-point discrimination, pinch strength, and grip strength. Carpal tunnel release was performed in 54 hands of 36 patients (average age of patients was 44.6 years). The EMG and clinical studies were completed just before surgery, at 2 weeks, and then at postoperative periods of 3, 6, 9, 12, 18, and 24 months. The sensory latencies and motor latencies were significantly (p less than 0.05) improved at the 3- and 6-month postoperative periods, respectively. The motor and sensory conduction velocities were significantly (p less than 0.05) improved as early as 2 weeks postoperatively. Two-point discrimination values were significantly (p less than 0.05) improved at 2 weeks postoperatively. For the pinch and grip strengths, significant (p less than 0.05) improvement did not occur until the 6- and 9-month postoperative periods, respectively. These results should be of considerable value, especially in the evaluation of the post-carpal tunnel release patient with persistent or recurrent symptoms.

Proximal interphalangeal joint arthroplasty.

Prosthetic implant arthroplasty of the proximal interphalangeal (PIP) joint has a limited role in the reconstruction of the rheumatoid hand. Ninety-three PIP joint arthroplasties, including 56 Flatt, 30 Swanson, and seven Niebauer implants, were reviewed with postoperative follow-up periods averaging 6.2 years. The average maximum extension/flexion for the prostheses were Flatt, 28 degrees/45 degrees; Swanson, 1 degree/40 degrees; and Niebauer, 3 degrees/26 degrees. The average active ranges of motion for the prosthetic groups were Flatt, 15 degrees; Swanson, 37 degrees; and Niebauer, 19.5 degrees. Analysis of active motion at intervals of up to ten years indicated gradually decreasing active motion for each prosthesis. Comparison of preoperative motion with motion three years after operation indicated a decrease in the Flatt prosthesis group, from 35 degrees to 20 degrees. Radiographically, cortical perforation by the prosthesis was common with the Flatt prosthesis (80%), and recurrent swan-neck deformity was frequent with the Swanson spacer (27%). Despite suboptimal clinical results, patient satisfaction was high, and the ability of patients to perform activities of daily living was acceptable.

Metacarpophalangeal joint arthroplasty with a metallic hinged prosthesis.

A long-term clinical study of 41 Flatt metallic hinged prostheses inserted in the metacarpophalangeal joints of ten rheumatoid patients was completed to provide a historic and clinical perspective of the ongoing clinical performance of this prosthesis. Postsurgical analysis performed an average of 138 months after operation demonstrated an average active range of metacarpophalangeal joint motion of 24 degrees, with average maximum active extension of 16 degrees and flexion of 40 degrees. Motion through this device in the metacarpophalangeal joint was relatively well preserved with time and was within a functional range. Recurrent digital ulnar deviation was observed in 58% of patients, digital malrotation in 50%, and extensor tendon redislocation in 45%. The prosthesis failed by screw or prong failure (47%). Periprosthetic radiolucency was common (87%), indicating poor host bone tolerance. With net bone resorption the prosthesis migrated, often perforating the cortex of the metacarpal (44%) or proximal phalanx (59%). Patient satisfaction, despite suboptimal clinical results, was high. All patients considered the appearance of the operated hand and pain relief improved. These advantages must be considered relative to the disadvantages of recurrent digital deformity, poor host tolerance, and unpredictability of clinical results.

Metacarpophalangeal joint implant arthroplasty with a Silastic spacer.

We evaluated Silastic implant arthroplasty in the metacarpophalangeal joints of rheumatoid patients by a prospective analysis of the cases of twenty-eight patients. One hundred and fifteen such implants were followed for an average of fifty-four months (range, twenty-four to 125 months). The postoperative active motion of the metacarpophalangeal joint averaged 43 degrees, from 13 degrees of extension to 56 degrees of flexion. The average range of active motion of the metacarpophalangeal joint increased 17 degrees over preoperative values. Ulnar drift recurred in forty-nine fingers (43 per cent), and fracture of the spacer occurred in twenty-four joints (21 per cent). The sites of three spacers became infected, and treatment required the amputation of one finger. Preoperative and postoperative key pinch and grip strengths were unchanged. Patient satisfaction was high; twenty patients (71 per cent) experienced significant pain relief, nineteen patients (68 per cent) felt that they had much better hand function, and twenty-three patients (82 per cent) thought that the cosmetic appearance of the hand was improved.

Functional status in ulnar deficiency.

Function is the most important consideration in the evaluation of patients with congenital ulnar deficiency. The upper extremity function of 8 patients with ulnar deficiency was evaluated. None of these patients had been treated with surgical procedures directed to the elbow, forearm, or wrist. The functional criteria included: (a) active ranges of elbow, forearm, and wrist motion, (b) power grip, (c) prehension, (d) dexterity, and (e) a patient's activities questionnaire. The averaged total active range of joint motion was 229 degrees or 46% of predicted normal active motion. Power grip averaged 27% of the contralateral extremity, and prehension tests were generally well performed. Timed tests were completed an average of 11.6 s slower than the contralateral control hand. Our patients did not report any deficiencies in bimanual activities. Patients performed most poorly when their congenital anomaly included radiohumeral synostosis or congenital absence, deformity, or contracture of the ipsilateral digits. The radiographic appearances or classification of the ulnar deficiency, in the absence of radiohumeral synostosis, did not correlate well with patient function.

The absent fifth metacarpal.

Although many patterns of metacarpal abnormalities have been described, the congenital anomaly of complete or partial absence of the fifth metacarpal has not been well defined. This article reports on seven patients with longitudinal partial or complete absence of the fifth metacarpal with the ulna and the three phalanges of the little finger present.

The healing of below-knee amputations: a comparison of soft and plaster dressing.

To evaluate the effect of wound dressing upon wound healing, fifty-one patients undergoing below-knee amputation using a long posterior myocutaneous flap technic were randomly allocated into a soft or plaster dressing group. Neither wound dressing technic proved superior, as wounds healed in 85.2 per cent of the plaster dressing group and 83.3 per cent of the soft dressing group.