Changes in Tissue Composition and Load Response After Transtibial Amputation Indicate Biomechanical Adaptation

Bramley, Jennifer Louise; Worsley, Peter; Bader, Dan L.; Everitt, Chris; Darekar, Angela; King, Leonard; Dickinson, Alexander

doi:10.1007/s10439-021-02858-0

Cited by 17 publications

(11 citation statements)

References 58 publications

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“…Elevated blood sugar levels, as seen in type 2 diabetes, may be associated with muscle atrophy 25 , which may explain why diabetic IWAs had the most thigh muscle atrophy. No significant differences in fat mass were found in any group, in contrast with previous work 23 , 26 – 28 , potentially due to our small sample sizes.…”

Section: Discussioncontrasting

confidence: 99%

Indications of musculoskeletal health in deceased male individuals with lower-limb amputations: comparison to non-amputee and diabetic controls

Finco

Finnerty

Ngo

et al. 2023

Sci Rep

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Individuals with lower-limb amputations, many of whom have type 2 diabetes, experience impaired musculoskeletal health. This study: (1) compared residual and intact limbs of diabetic and non-diabetic post-mortem individuals with amputation to identify structures vulnerable to injury, and (2) compared findings to diabetic and healthy control groups to differentiate influences of amputation and diabetes on musculoskeletal health. Postmortem CT scans of three groups, ten individuals each, were included: (1) individuals with transtibial or transfemoral amputations, half with diabetes (2) diabetic controls, and (3) healthy controls. Hip and knee joint spaces, cross-sectional thigh muscle and fat areas, and cross-sectional bone properties (e.g. area, thickness, geometry) were measured. Wilcoxon Signed-Rank and Kruskal–Wallis tests assessed statistical significance. Asymmetry percentages between limbs assessed clinical significance. Residual limbs of individuals with amputation, particularly those with diabetes, had significantly less thigh muscle area and thinner distal femoral cortical bone compared to intact limbs. Compared to control groups, individuals with amputation had significantly narrower joint spaces, less thigh muscle area bilaterally, and thinner proximal femoral cortical bone in the residual limb. Diabetic individuals with amputation had the most clinically significant asymmetry. Findings tended to align with those of living individuals. However, lack of available medical information and small sample sizes reduced the anticipated clinical utility. Larger sample sizes of living individuals are needed to assess generalizability of findings. Quantifying musculoskeletal properties and differentiating influences of amputation and diabetes could eventually help direct rehabilitation techniques.

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Section: Discussioncontrasting

confidence: 99%

Indications of musculoskeletal health in deceased male individuals with lower-limb amputations: comparison to non-amputee and diabetic controls

Finco

Finnerty

Ngo

et al. 2023

Sci Rep

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“…It may be that activity itself is related to residuum volume, as sweat, hydration, and musclular blood flow affect daily fluctuations and long-term changes in volume [ 27 ]. Short term, gross residuum volume reduction is seen due to recovery of oedema followed by more gradual muscle atrophy [ 28 – 30 ] alongside changes in tissue composition under mechanical loading with a prosthesis [ 31 ]. These studies report volume loss in the order of 10–35% in the first 18 months after amputation.…”

Section: Discussionmentioning

confidence: 99%

Activity, socket fit, comfort and community participation in lower limb prosthesis users: a Cambodian cohort study

Diment

Nguon²,

Seng³

et al. 2022

J NeuroEngineering Rehabil

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Background After amputation, many people become less active, feel lonely and lose independence. Understanding the factors associated with low physical activity levels and participation could contribute to defining key interventions which can support prosthesis users so they can live a more active and socially included lifestyle. This longitudinal observational study aims to assess relationships between physical activity, community participation, prosthetic fit, comfort and user satisfaction using actimetry, 3D scans and questionnaires in a Cambodian cohort of established lower limb prosthesis users. Methods Twenty participants (5F:15M, nine transfemoral, eleven transtibial, 24–60 years old and 3–43 years since amputation) were recruited. They completed a questionnaire which included their demographics, community participation, prosthesis satisfaction and comfort at the start of the study, and between three and six months later. Their prosthetic sockets and residual limbs were 3D scanned at the start and end of the study. Accelerometers were embedded under the cosmesis on the shank of the prosthesis, to collect ten weeks of activity data. Results Participants averaged 4470 steps/day (743–7315 steps/day), and wore their prosthesis for most waking hours, averaging 13.4 h/day (4.5–17.6 h/day). Self-reported measures of activity and hours of wear correlated with these accelerometer data (Spearman’s rho rs = 0.59, and rs = 0.71, respectively). Participants who were more active wore their prosthesis for more hours/day (Pearson r = 0.73) and were more satisfied with socket fit (rs = 0.49). A longer residual limb correlated with better community participation (rs = 0.56) and comfort (rs = 0.56). Self-reported community participation did not correlate with a person’s activity level (rs = 0.13), or their prosthesis comfort (rs = 0.19), and there was only weak correlation between how important the activity was to an individual, and how often they participated in it (rs = 0.37). A simple 0–10 scale of overall comfort did not provide enough detail to understand the types and severity of discomfort experienced. Conclusion Associations between perceived and measured activity levels correlated with socket satisfaction in this cohort of people with established lower limb amputations. The small sample size means these correlations should be interpreted with caution, but they indicate variables worthy of further study to understand barriers to community engagement and physical activity for prosthesis users in Cambodia, and potentially in other settings.

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“…The tendons of the tibialis anterior, peroneus longus, tibialis posterior, and lateral gastrocnemius should be transected as distal as possible to allow adequate length for creation of the AMI constructs.Approximately 2 × 3-cm free muscle grafts are harvested from the amputated extremity for RPNI 3 .Smooth tendon-gliding through the synovial tunnels should be confirmed before closure. If necessary, muscle debulking can improve gliding and decrease the size of the residual limb.Harvesting the extensor retinaculum for synovial tunnels has been our preferred method, although we acknowledge that other grafts options such as the tarsal tunnel are available 1 .…”

Section: Important Tipsmentioning

confidence: 99%

“…Colin J. Harrington, MD 1 Marissa Dearden, MD 1 John Richards, MD 1 Matthew Carty, MD 2 Jason Souza, MD 3 Benjamin K. Potter, MD 1…”

mentioning

confidence: 99%

The Agonist-Antagonist Myoneural Interface in a Transtibial Amputation

Harrington,

Dearden,

Richards

et al. 2023

JBJS Essential Surgical Techniques

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Background: The agonist-antagonist myoneural interface (AMI) technique at the time of transtibial amputation involves the use of agonist-antagonist muscle pairs to restore natural contraction-stretch relationships and to improve proprioceptive feedback when utilizing a prosthetic limb 1 . Description: Utilizing the standard incision for a long posterior myofasciocutaneous flap, the lateral and medial aspects of the limb are dissected, identifying and preserving the superficial peroneal and saphenous nerve, respectively. The tendons of the tibialis anterior and peroneus longus are transected distally to allow adequate length for the AMI constructs. After ligation of the anterior tibial vessels, the deep peroneal nerve is identified and tagged to create a regenerative peripheral nerve interface (RPNI). The tibia and fibula are cut approximately 15 cm from the medial joint line, facilitating dissection of the deep posterior compartment and ligation of the peroneal and posterior tibial vessels. The tendons of the lateral gastrocnemius and tibialis posterior are transected distally, and the amputation is completed. The extensor retinaculum is harvested from the residual limb along with multiple 2 × 3-cm free muscle grafts, which will be used for the RPNI constructs. The retinaculum is secured to the tibia with suture anchors, and AMI pairs of the lateral gastrocnemius and tibialis anterior as well as the tibialis posterior and peroneus longus are constructed. Separate RPNIs of the major lower-extremity nerves are performed, and the wound is closed in a standard layered fashion. Alternatives: An isometric myodesis of the gastrocnemius without coaptation of agonist-antagonist muscle pairs can be performed at the time of transtibial amputation. Rationale: The AMI technique restores natural agonist-antagonist relationships at the time of transtibial amputation to increase proprioceptive feedback and improve prosthetic control. These outcomes contrast with those of a traditional isometric myodesis, which prevents proprioceptive communication from the residual limb musculature to the central nervous system. Additionally, the AMI technique allows for concentric and eccentric muscular contractions, which may contribute to the maintenance of limb volume and aid with prosthetic fitting, as opposed to the typical limb atrophy observed following standard transtibial amputation 1,2 . With the development and availability of more advanced prostheses, the AMI technique offers more precise control and increases the functionality of these innovative devices. Expected Outcomes: Early clinical outcomes of the AMI technique at the time of transtibial amputation have been promising. In a case series of the first 3 patients who underwent the procedure, complications were minor and consisted of 2 episodes of cellulitis and 1 case of delayed wound healing 1 . Muscle activation measured through electromyography demonstrated an improved ability to limit unintended muscular co-contraction with attempted movement of the phantom limb, as compared with patients who underwent a standard transtibial amputation 1 . Additionally, residual limb volume was maintained postoperatively without the need for substantial prosthetic modifications. Important Tips: The tendons of the tibialis anterior, peroneus longus, tibialis posterior, and lateral gastrocnemius should be transected as distal as possible to allow adequate length for creation of the AMI constructs.Approximately 2 × 3-cm free muscle grafts are harvested from the amputated extremity for RPNI 3 .Smooth tendon-gliding through the synovial tunnels should be confirmed before closure. If necessary, muscle debulking can improve gliding and decrease the size of the residual limb.Harvesting the extensor retinaculum for synovial tunnels has been our preferred method, although we acknowledge that other grafts options such as the tarsal tunnel are available 1 . Acronyms & Abbreviations: RPNI = regenerative peripheral nerve interfaceAMI = agonist-antagonist myoneural interfaceEMG = electromyographic

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Changes in Tissue Composition and Load Response After Transtibial Amputation Indicate Biomechanical Adaptation

Cited by 17 publications

References 58 publications

Indications of musculoskeletal health in deceased male individuals with lower-limb amputations: comparison to non-amputee and diabetic controls

Indications of musculoskeletal health in deceased male individuals with lower-limb amputations: comparison to non-amputee and diabetic controls

Activity, socket fit, comfort and community participation in lower limb prosthesis users: a Cambodian cohort study

The Agonist-Antagonist Myoneural Interface in a Transtibial Amputation

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