Improving outcomes for amputees: The health-related quality of life and cost utility analysis of osseointegration prosthetics in transfemoral amputees.

AIM: Some amputees are unable to adequately ambulate using conventional socket prosthetics, osseointegrated prosthetics have been described as an alternative strategy in this patient group. This paper aims to assess the effect of osseointegrated prosthetics, commonly simply referred to as osseointegration, in transfemoral amputees on health-related quality of life and cost analysis. METHODS: Two centre analysis of patients receiving transcutaneous femoral osseointegration using The Osseointegration Group of Australia Osseointegration Prosthetic Limb (OGAP-OPL) implant. Retrospective health utility and cost analysis of prospectively collected patient reported health outcome data. Osseointegration cost was compared with the yearly cost of a poorly fitting conventional prosthetic determining cost/Quality Adjusted Life Year. RESULTS: Eighty amputees received osseointegration. Mean age was 39 years (range 20-57) and 66% were male (n = 53). The majority of subjects underwent unilateral (n = 62, 77.5%) rather than bilateral surgery (n = 18, 22.5%). Trauma was the most common indication (n = 59, 74%). Maximum follow up was 10.5-years. Mean preoperative EQ5D HUV in pooled data was 0.64 (SEM 0.025) increasing to 0.73 (0.036) at 5-years and 0.78 (0.051) at 6 years with continued improvement up to 10.5-years. In subgroup analysis those with a starting EQ5D HUV <0.60 reached a cost/QALY of <£30,000 at 5-years postoperatively and show statistically significant improvement in EQ5D HUV. The UK military experience was wholly positive with a mean starting EQ5D HUV of 0.48 (0.017) with significant (p < 0.05) improvement in EQ5D HUV at each time point and a resultant reducing cost/QALY at each time point being £28,616.89 at 5 years. CONCLUSION: There is both a quality of life and financial argument in favour of osseointegration in select patients with above transfemoral amputations. In those unable to mobilise satisfactorily with traditional prostheses and a pre-intervention score of <0.60, a consistent cost effectiveness and quality of life benefit can be seen. Such patients should be considered for osseointegration as these patients reap the maximum benefit and cost effectiveness of the device. This evidence lends strongly to the debate advocating the use of osseointegration through centrally funded resources, including the NHS.

Dynamic pressure testing for chronic exertional compartment syndrome in the UK military population.

OBJECTIVES: Chronic exertional compartment syndrome is one of the main causes of exertional leg pain. Diagnosis is based on the history and intracompartmental muscle pressure testing during exercise prior to consideration of fasciotomy for treatment. We present the data gathered at Defence Medical Rehabilitation Centre Headley Court during the first year of a revised protocol on dynamic pressure testing from May 2007. METHODS: The exercise protocol involved exercising patients using a representative military task: the Combat Fitness Test with a 15 kg Bergen on a treadmill, set at 6.5 km/h with zero incline up to 15 min and if completed, a further 5 min at 7.5 km/h. Subjects informed us when the exertional leg pain was 7/10 on a visual analogue scale and were instructed to carry on till failure (pain 10/10) or till the test finished. Mean pressure during this time period (7/10 to 10/10) was calculated by computer. RESULTS: Over 1 year, we performed 151 intracompartmental pressure studies in 76 patients. 120 were successful in 68 patients, with 31 technical failures. All studies were performed in the anterior or deep posterior muscle compartments as these were the symptomatic compartments; no patients had symptoms in the lateral or superficial posterior compartments and these were not tested. There was only one complication with a posterior tibial artery puncture. In 119 compartment studies, the mean pressure was 97.8 mm Hg (SD 31.7). These data are normally distributed (Shapiro Wilk test, W=0.98 p=0.125). CONCLUSIONS: Our data based on this exercise protocol are comparable with the few studies that record dynamic pressure during running-based exercise. There is no accepted diagnostic pressure or exercise protocol. Due to the uncertainty of diagnostic criteria, it is necessary to perform a study measuring dynamic pressures in normal asymptomatic subjects.

Visual and somatosensory processing in the macaque temporal cortex: the role of 'expectation'.

The somatosensory and visual properties of cells in a polymodal region of temporal cortex were studied in 4 awake behaving macaque monkeys. When stimulated passively and out of sight, cells with tactile responses were found to have very large receptive fields covering most of the body surface and an apparent lack of selectivity for size, shape or texture of the tactile stimulus. These properties are equivalent to those described for the anaesthetized preparation (Bruce et al. 1981). Our study revealed that tactile responses were influenced by the degree to which stimuli could be 'expected'. Tactile stimulation arising from active exploration of novel surfaces produced vigourous neuronal responses but equivalent stimulation of the skin arising when the monkey contacted 'expected' surfaces such as itself or items with which it had become familiar produced no responses. The responses of cells to active or passive tactile stimulation were attenuated when the monkey could see the objects causing the stimulation. For cells responsive to more than one sensory modality, visual and somatosensory responses were associated in a compatible manner. Cells responsive to the onset of touch were selective for the sight of objects moving towards the monkey, whereas cells selective for the offset of touch were responsive to the sight of movements away from the monkey.

Frameworks of analysis for the neural representation of animate objects and actions.

A variety of cell types exist in the temporal cortex providing high-level visual descriptions of bodies and their movements. We have investigated the sensitivity of such cells to different viewing conditions to determine the frame(s) of reference utilized in processing. The responses of the majority of cells in the upper bank of the superior temporal sulcus (areas TPO and PGa) found to be sensitive to static and dynamic information about the body were selective for one perspective view (e.g. right profile, reaching right or walking left). These cells can be considered to provide viewer-centred descriptions because they depend on the observer's vantage point. Viewer-centred descriptions could be used in guiding behaviour. They could also be used as an intermediate step for establishing view-independent responses of other cell types which responded to many or all perspective views selectively of the same object (e.g. head) or movement. These cells have the properties of object-centred descriptions, where the object viewed provides the frame of reference for describing the disposition of object parts and movements (e.g. head on top of shoulders, reaching across the body, walking forward 'following the nose'). For some cells in the lower bank of the superior temporal sulcus (area TEa) the responses to body movements were related to the object or goal of the movements (e.g. reaching for or walking towards a specific place). This goal-centred sensitivity to interaction allowed the cells to be selectively activated in situations where human subjects would attribute causal and intentional relationships.

Specialized face processing and hemispheric asymmetry in man and monkey: evidence from single unit and reaction time studies.

Experimental and clinical studies have generally shown that the neural mechanisms for face processing in man are (1) designed to deal with the configuration of upright faces and (2) located predominantly in the right cerebral hemisphere. Monkeys would seem to process faces in a different manner to humans since they appear to show no hemispheric asymmetry and to treat upright and inverted faces equivalently. We re-examine these claims. Our reaction time studies reveal that monkeys do behave like human subjects since they process facial configuration faster when stimuli are presented upright as compared with horizontal or inverted. Single unit studies in the monkey reveal patches of neurones responsive to faces in the upper bank and fundus of the left superior temporal sulcus (STS). Recording from the right hemisphere also reveals cells responsive to faces but in this hemisphere such cells appear less numerous. These cells process upright faces faster than inverted faces. Face processing in monkeys and man appears to utilize qualitatively similar mechanisms, but the extent and/or direction of cerebral asymmetry in these mechanisms may not be similar.

Visual analysis of body movements by neurones in the temporal cortex of the macaque monkey: a preliminary report.

Movement provides biologically important information about the nature (and intent) of animate objects. We have studied cells in the superior temporal sulcus of the macaque monkey which seem to process such visual information. We found that the majority of cells in this brain region were selective for type of movement and for stimulus form, most cells responding only to particular movements of the body or some part of it. A variety of cell types emerged, including cells sensitive to: translation of bodies in view, movements into view (appearance) or out of view (disappearance) and the articulation and rotation of the body/head. Directional selectivity for cells sensitive to translation tended to lie along one of 3 orthogonal Cartesian axes centred on the monkey (towards/away, left/right and up/down). One type of rotation sensitive cell was tuned to rotation about one or more of these axes, a second type was sensitive to different head rotations which brought the face to confront the monkey or turned the face away. Reconstructions of cell positions indicated that cells of the same type were clumped anatomically both across the surface of the cortex and perpendicular to the surface.

Visual cells in the temporal cortex sensitive to face view and gaze direction.

The direction of eye gaze and orientation of the face towards or away from another are important social signals for man and for macaque monkey. We have studied the effects of these signals in a region of the macaque temporal cortex where cells have been found to be responsive to the sight of faces. Of cells selectively responsive to the sight of the face or head but not to other objects (182 cells) 63% were sensitive to the orientation of the head. Different views of the head (full face, profile, back or top of the head, face rotated by 45 degrees up to the ceiling or down to the floor) maximally activated different classes of cell. All classes of cell, however, remained active as the preferred view was rotated isomorphically or was changed in size or distance. Isomorphic rotation by 90-180 degrees increased cell response latencies by 10-60 ms. Sensitivity to gaze direction was found for 64% of the cells tested that were tuned to head orientation. Eighteen cells most responsive to the full face preferred eye contact, while 18 cells tuned to the profile face preferred averted gaze. Sensitivity to gaze was thus compatible with, but could be independent of, sensitivity to head orientation. Results suggest that the recognition of one type of object may proceed via the independent high level analysis of several restricted views of the object (viewer-centred descriptions).

Neurones responsive to faces in the temporal cortex: studies of functional organization, sensitivity to identity and relation to perception.

We have investigated the distribution of cells responsive to faces within the macaque temporal cortex and their sensitivity to different face attributes. We found a functional organization of cells responsive to the sight of different views of the head. Cells of a similar type were grouped together both vertically down through the cortex, and horizontally in patches extending 0.5-2.0 mm across the surface of the cortex. A substantial proportion of cells responsive to faces were found to be sensitive to biologically important characteristics such as identity or expression. Cells were found to be highly selective for particular individuals that were familiar to the monkey with selectivity persisting across a great variety of viewing conditions such as changing face expression, orientation, colour, distance and size. Data suggested that sensitivity to identity arises at the level of specific views of the individual (e.g. full face). Information about different views may then be pooled to allow recognition independent of view. Visual transformations that make it difficult for humans to perceive faces (e.g., contrast reversal, isoluminant colour, coarsely quantized images, rotation or inversion) reduced the magnitude or increased the latency of cells' responses to faces. In this way, cell responses were related to perception and not simply to visual qualities of the image.