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Section 1: General Topics
Tab le 1
are congenital limb deformities, tumors,
trauma, and infections. In children and
adults, causes of amputations vary by
region and can differ among the socioeconomic conditions of each region.
remodeling have a substantial effect on
the final outcome of either a pediatric
amputation or a limb salvage procedure,
particularly in a younger child. A 5-yearold child who undergoes a transfemoral amputation will have an extremely
short residual limb at skeletal maturity
because of the loss of the distal femoral
physis, resulting in a loss of approximately 1.2 cm per year until the end of
the growth period. Similarly, a 10-yearold child treated with a successful total
femoral endoprosthesis procedure will
have a substantial limb-length discrepancy at skeletal maturity because of the
loss of both proximal and distal femoral
physes of the affected leg and the continuing growth of the contralateral limb.
Because children generally have higher functional demands compared with
adults, who are often more sedentary
and overweight, remaining growth must
be accounted for when either limb salvage surgery or amputations are planned
to provide the best aesthetic and functional outcomes.
Etiology and Frequencya of Amputations
Etiology Adults Children Sex Ratio Limb Involved
Peripheral vascular disease ++++ − M = F LL
Trauma +++ + M > F LL > UL
8:2 in children
2:1 in adults
Tumors ++ ++ M = F LL > UL
Infections ++ ++ M = F LL > UL
Burns
Electrical injuries + +/− M > F in adults
Chemical burns ++ +/−
Thermal burns ++ +++
Cold injuries ++ +/−
LL = lower limb, UL = upper limb, M = male, F = female.
a
The greater the number of pluses (+) in a column, the greater the frequency. The minus sign (−) indicates an infrequent or rare event.
Children may have stunted growth,
painful overgrowth, and growth distur
bances such as limb shortening and/or
limb deviation.
1-15
can be lengthy, with substantial psy-
Skeletal growth and the potential for
chologic consequences.
instances, treatment can last several
years, thus resulting in years of potential pain, psychologic consequences,
and difficulties in accomplishing daily
activities such as eating, playing, and
schoolwork.
13-1 5
the cause of amputations, the emotional
aspect is particularly important because
of the evolution of disease and the expectations of surgery.
M = F in children
1-4
Moreover, treatment
1,5 -16
In some
When neoplasms are
15
nonviable, standard amputations are
-
usually performed.
In children, vascular amputation can
be secondary to congenital arterial malformation, vasculopathy, or constriction
band syndrome. Surgical treatment of
congenital birth defects (such as clubfoot or fibular or tibial hemimelia) can
be complicated by postoperative necrosis leading to vascular amputation;
however, this complication occurs infrequently. The area of necrosis coincides with the anatomic distribution of
the derivatives of the congenitally reduced or absent vessels, and the poor
tissue perfusion to this area can con-
LL = UL
tribute to the necrosis.19 Vasculopathy
Peripheral Vascular Disease
Vascular amputations are performed
almost exclusively in adult patients;
the major causes are diabetes and/or
peripheral arterial disease resulting in
a painful limb, poor limb perfusion,
untreatable ulcers, or gangrene (with
or without infection). The prevalence
of peripheral arterial disease in the
general population ranges between
12% and 14%, affecting up to 20% of
adults older than 70 years.
17,1 8
In this situation, the primary emphasis is on the
prevention of ischemia by medical and
surgical means. After the limb becomes
and arteriopathy in children are rare,
although they can be seen with higher
frequency in young patients with HIV.20
Deep constriction band syndrome can
result in neurovascular damage of variable intensities. Vessels and nerves are
compressed in the constricted regions,
but caliber and microscopic anatomy
are preserved proximally and distally to
the constricted area of the limb. Surgical treatment includes Z-plasty, W-plasty, or excision of the band with flap
rotation of subcutaneous fat and closure of skin. Amputation is performed
when limb salvage or reconstruction
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
62
Chapter 5: General Principles of Limb Salvage Versus Amputation in Children
procedures are not possible. When they
are required, amputations are mostly
transosseous.
21
Traumatic Amputations
Traumatic amputations are more common in adults than children. In children, amputations secondary to trauma
represent approximately 5% of all injuries. However, every year, approximately
one-third of traumatic amputation injuries occur in children younger than 18
1,2
years.
Approximately 80% of all amputations affect the lower limb, and the
remaining 20% affect the upper limb.
3,4
Most major amputations after trauma in
children involve the lower limbs, particularly the tibia. More than 95% of other amputations secondary to trauma in
children equally affect the foot or toes
and the hand or fingers.5 Hostetler et al1
reported that most traumatic amputa
tion injuries occur in boys younger than
2 years, involve fingers, and involve a
door as the mechanism of injury. However, such amputations are often minor
and, in most cases, do not substantively
compromise upper limb function. Older children, preadolescents, and ado
lescents experience a higher proportion
of more serious amputation injuries,
mostly related to high-energy trauma
(lawn mower, bicycle, motorbike, and
motor vehicle injuries). In a study in the
United Kingdom, Roche and Selvarajah3
reported that automobile-related injuries are responsible for approximately two-thirds of amputations in older
children.
3-5
Those percentages are substantially higher in adults. Skeletal immaturity predisposes children to higher
rates of complications compared with
adults; terminal overgrowth is often a
problem and can lead to residual limb
or phantom limb pain.
6,7
However, some
complications, such as secondary infections, slow wound healing, pulmonary
embolism, and venous thrombosis, are
often less severe and less frequent in the
pediatric population compared with
adult patients.
Malignant Tumors
Amputation has long been a mainstay of
treatment of severe soft-tissue and bone
tumors. During the past two to three
decades, limb salvage surgery has become increasingly common. Currently,
limb salvage procedures are the first-line
treatment (when technically feasible) of
bone and soft-tissue sarcomas, whereas
amputations are performed only in select cases.
16,22,23
Limb salvage techniques
provide slightly better functional outcomes compared with amputations in
most patients. Aksnes et al16 reported
that patients undergoing amputation
for Ewing sarcoma or osteosarcoma
had poorer outcomes compared with patients undergoing limb salvage surgery,
including increased pain, decreased
function, less satisfactory aesthetic
appearance, and poorer gait. Patients
-
who underwent amputations for bone
and soft-tissue sarcomas experienced
fewer complications than those who
underwent limb salvage procedures.
However, complications from limb salvage techniques are usually manageable.
Overall, the rate of local recurrence af-
-
ter amputation is similar to that of limb
salvage procedures, ranging from 5% to
10%. Similarly, long-term survival is the
same, ranging from 70% to 80% in both
patient populations.
Burn Injuries
Burn injuries are more common in
adults than children. These injuries
can be classified as electrical, chemical,
and thermal (for example, from fire or
frostbite).
10-15
Electrical Burns
High-tension electrical burns that potentially result in amputations usually
involve adult workers or electrical installation vandals
9,10
and are less common in children. Because the human
body effectively conducts electricity,
the passage of electric current through
the body can produce diverse, serious
injuries to the brain, heart, muscles,
and skin. High-voltage electrical injuries often cause a combination of burns
and blunt trauma. Direct contact with
electrical current can be lethal, and the
extent of lesions is related to the current
voltage. Typically, burns secondary to
electricity are often much worse than
they initially appear. Electrical burns
tend to affect a relatively small area of
the body surface compared with burns
resulting from hot liquids or fire; however, electric burns cause a deep, localized injur y.
9-12
Injuries result from
both the luminous bridging that occurs
when current is shorted and the direct
conduction of the current through the
patient. Fractures resulting from severe
muscle contractions or falls (also known
as indirect injuries) characterize patients
who have sustained electrical burns.
The mortality rate ranges from 3% to
15% and is related to the duration of
electrical contact.
9,10,12,13
Chemical Burns
Amputations caused by chemical burns
are uncommon. Overall, amputations
secondary to chemical burns are more
frequent in adults than children. Chemical burns can result from exposure to
acid, alkaline, or petroleum solutions.
Typically, alkali burns tend to be deeper
and more serious than burns secondary
to acidic products.
ermal Injuries
Cooking-related burns are a common
problem worldwide, resulting in the
most pediatric burns of any cause. Thermal burn injuries resulting in amputations are relatively uncommon; however,
the proportion of thermal injuries that
do result in amputation is particularly
high in countries where fire is located
at floor level, thus endangering children
who crawl or play inside or around the
home. Also, the habit of leaving young,
inexperienced children to prepare meals
for themselves and siblings is responsible for burn injuries in a high proportion
of cases. In many patients, burn injuries
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
63
Section 1: General Topics
can be complicated by infection, resulting in amputation to reduce associated
mortality.
11,13 -15
Frostbite and nonfreezing cold injuries frequently affect fit, active adults
such as climbers, expedition members,
skiers, mountaineers, and agriculture
workers. These injuries are rare in
children, except in high-latitude countries. Frostbite and nonfreezing cold
injuries can result in amputation, but
the need for amputation is correlated
more directly to the duration of cold
exposure rather than the temperature.
In particular, frostbite injuries can have
substantial repercussions on the distal
ends of the limbs (such as toes and fingers). The spectrum of injuries is heterogeneous, varying from minimal tissue
loss with mild long-term sequelae to
major necrosis of the distal limbs with
subsequent major amputations and resultant phantom limb pain. In children
living in high northern latitudes, cold
injury to the growth plates of phalanges
is common.
15
Purpura Fulminans
Purpura fulminans is an infrequent but
potentially catastrophic condition that
follows meningococcal infection. In recent years, most children with fulminant meningococcemia have survived,
likely because of prompt diagnosis and
effective aggressive resuscitation. Development of an effective vaccine has had
a major effect on the incidence of this
condition. New cases of purpura fulminans are becoming rarer and are almost
solely confined to very young children.
Survivors of purpura fulminans are at
increased risk for complications such as
soft-tissue loss, autoamputations, and
surgical amputations because of poor
tissue perfusion.24 If limb amputation is
required, residual limb complications
often persist after soft-tissue healing. Osseous overgrowth, growth disturbances,
and scar contractures are common. Specialized, custom prosthetic fitting is often required for this patient population.
24
Limb Salvage Techniques
and Amputation Options
Many types of limb salvage techniques
and several types of limb amputations
can be used in the treatment of traumatic injuries, malignant tumors, infections,
purpura fulminans, and burn injuries,
depending on the nature of the disorder.
Skeletal immaturity predisposes children to a higher rate of complications
as the limb continues to grow, resulting
in stunted growth, painful overgrowth,
and growth disturbances such as limb
shortening and/or limb deviation. Transosseous amputations in children are
characterized by substantial appositional bone growth not usually seen in
adults. In addition, children have higher functional demands compared with
many adults who are more sedentary
and have a lower incidence of phantom
limb symptoms, ostensibly because of
greater neuroplasticity.
Trauma
Severe traumatic injuries of the limbs
in children can be managed with amputations or limb salvage techniques.
The choice of procedure is influenced
primarily by the severity and location of
the injury, the time of ischemia, and the
presence of neurologic compromise.
In the acute trauma setting, the main
principles of optimizing the functional
outcome of the affected limbs should be
applied, particularly in children, whose
limbs need to remain functional for decades. Preserving limb length, major
growth plates, and proximal joints as
well as minimizing transosseous amputations, when practicable, are of major importance. Vascular repairs, nerve
repairs, the use of “discarded” parts for
fashioning end-bearing residual limbs
(for example, using distal tibiofibular
bone in the Ertl technique or placing
the proximal fibula upside down into
the tibia in a transtibial amputation),
and shortening osteotomies (to provide
soft-tissue coverage for the articular end
of the bone, which preserves the distal
1,5,8
25-27
28,29
growth plate and prevents overgrowth)
are all options for an experienced treatment team.
An amputation can be performed either as part of primary treatment (primary amputation) or during the initial
hospital stay (secondary amputation)
when the nature of the trauma and associated complications contraindicate
limb salvage. In severe limb injuries,
primary amputation is usually necessary as part of lifesaving treatment. Primary amputation should be performed
as a damage-control procedure when
hemorrhage is uncontrollable or when
critical ischemia has lasted more than
6 hours. The main objective is to stabilize and resuscitate the patient. Primary amputation is also indicated in an
incomplete traumatic amputation with
a substantially injured distal remnant
(for example, crush injuries and partial
avulsions). Ischemia exceeding 4 hours,
segmental muscle loss exceeding two
compartments, and bone loss greater
than one-third the bone length are not
absolute indications for primary amputation, and limb salvage techniques
can be considered. Absent or reduced
plantar sensation is not an indication
for primary amputation.
In skeletally mature patients (adolescents and adults) undergoing primary or
secondary amputation, functional joint
levels and as much residual limb length
as possible should be preserved. When
necessary, transtibial and transfemoral
amputations are preferred to transarticular amputations at the more proximal joint. In every case, the functional
proximal joint should be salvaged whenever possible. Energy expenditure after a
transtibial amputation is approximately
50% of that after a transfemoral amputation. Patients with bilateral transtibial
amputations incur an additional energy
cost greater than 40%, whereas those
with a bilateral amputation in which
one level is transfemoral may require
twice the energy expenditure for ambu-
26 ,27, 30
lation.
Soft-tissue coverage is often
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
64
Chapter 5: General Principles of Limb Salvage Versus Amputation in Children
an issue in severely injured patients.
Appropriate techniques, including skin
grafts and local or free-tissue transfer,
should be used for both limb salvage
procedures and amputations.
31,32
Malignant Tumors
The choice between limb salvage and
amputation is likely most important in
patients with malignant tumors. The
surgical decision has major implications
for the patient’s survival and potential
future function. Overall, when malignant bone and soft-tissue tumors can be
properly excised and adequate resection
margins obtained, limb salvage surgery
is the standard treatment as opposed
to amputation in patients with sarcomas of the limbs. The procedure must
allow wide resection with clean tumor
margins unless a palliative procedure
is deliberately chosen. Residual, even
microscopic, tumors will almost certainly result in local recurrence and have
an adverse effect on patient survival.
The survival, longevity, and long-term
complications of the selected procedure
should be carefully weighed, particularly in young children with substantial
skeletal growth remaining.
Current protocols for neoadjuvant
chemotherapy, with the surgical procedure usually planned several weeks
to months after the diagnosis and initial staging, allows time for gathering
relevant information about the lesion
using imaging, accurate diagnostic techniques, accurate staging, and an evaluation of the response to chemotherapy.
There also is time to assemble a team
of subspecialists and procure the surgical equipment and implants needed
(such as an endoprosthesis or allograft
bone). If amputation is considered,
adequate time exists for family and/or
multidisciplinary discussions and better acceptance of the surgical plan and
procedural goals. The procedure chosen
must ensure a viable, sensate, and functional limb. The location of the tumor,
resection margins, risk of recurrence,
potential complications, and limb function must be considered when planning
limb salvage surgeries and amputations.
Limb salvage surgery is preferred to
amputation if the tumor is located in
the appendicular skeleton and adequate
wide resection margins can be achieved;
the tumor recurrence risk is no greater
and survival is no worse than with amputation; potential complications do not
exceed potential benefits; the proposed
limb salvage technique is long-lasting
and not associated with a high rate of
complications (resulting in numerous
secondary procedures and frequent rehospitalizations); and the predicted limb
function is equal to or better than that
potentially obtained with amputation.
If the patient’s life expectancy is
reduced and palliation is the primary
goal of treatment, the procedure selected should produce the least morbidity,
ensure the fastest recovery, and allow
for the best pain control and functional
outcome. Usually, either endoprosthetic
replacement or amputation is selected.
Relative contraindications to limb
salvage techniques are pathologic fractures (fracture hematoma extending
beyond compartment limits), an inappropriately performed biopsy, surgical
site infection, predicted limb-length
discrepancy greater than 8 to 10 cm,
extensive soft-tissue involvement, poor
response to preoperative chemotherapy,
and vascular bypass that is unfeasible
because of tumor invasion of major neurovascular structures.
27,30,33,34
Outcomes for various limb salvage
surgical procedures are often comparable. The procedure must be chosen
based on a discussion with the patient
and his or her family and an assessment
of the tumor characteristics to ensure
that treatment is individually tailored
to each patient.
Purpura Fulminans
Planning amputation in patients with
purpura fulminans involves identification of viable tissues, use of adequate
imaging techniques, and determination
of limb function and potential complications.
24,31
Before surgical amputation,
it is mandatory to wait for clear demarcation between viable and nonviable
tissues. Obtaining appropriate imaging
studies before amputation, particularly technetium-Tc99m bone scanning,
helps determine clear demarcation of
the necrotic tissue. Amputation should
be delayed until dry gangrene (necrosis)
is clearly established and demarcated,
especially with respect to deep tissues,
because this facilitates selecting the correct level of amputation. Early amputation is not needed if no life-threatening
wet gangrene is present in the limbs.
To maintain limb function, the surgeon should preserve joints when possible (in particular, knee, elbow, and ankle
joints) and as much length as possible
to avoid short, poorly functioning residual limbs. Transosseous amputations
should be avoided whenever possible
(metaphyseal-diaphyseal segment resection with shortening), but preservation
of the distal epiphysis and joint surface
are advocated when necessary (such as
a Syme ankle disarticulation versus a
transtibial amputation).
32,35,36
Complications are relatively frequent,
even after amputations for this indication. Preserved growth plates beneath
areas of skin necrosis in both residual
and salvaged limbs are at risk for arrested growth.24 The treating surgeon
must be prepared to use innovative and
sometimes unorthodox techniques to
address the bone and soft-tissue issues
(both early and late) in patients with
purpura fulminans to achieve optimal
functional results.
31
Burn Injuries
Amputation is sometimes required as
part of lifesaving burn care. Conversely,
early amputation is required for unsalvageable limbs.
8-15
Amputations are also
performed in burn injuries complicated
by infection. In the presence of extensive
tissue necrosis or injuries complicated
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
65
Section 1: General Topics
Tab le 2
Tab le 3
by infection, amputation can reduce
the mortality rate. The role of limb salvage is relatively limited in this group
of patients and consists almost solely
of securing soft-tissue coverage over
the exposed deep tissues. Skin grafts,
fasciocutaneous flaps, and occasionally,
Options for Limb Salvage Surgeries
Local tissue aps,
transfers, and
excisions
Autologous transfers Vascular grafts
Allograft transplants Soft tissue (fascia, tendons)
Endoprostheses Custom-made prosthesis
Composite systems Composite allograft
Intercalary resections van Nes rotationplasty and its modications
Bone transfers Ilizarov frame
Local muscle ap
Local bular transfer (vascular and nonvascular)
Upside-down tibia
One-bone forearm
Nerve grafts
Nonvascularized or vascularized bone grafts
Composite vascularized grafts (muscle, skin, bone)
Vascularized muscle grafts
Bone (intercalary or osteochondral)
Modular prosthesis
Autograft, endoprosthetic implants
Multiplanar xator
Uniplanar xators
Magnetic intramedullary rods
Amputation Types
Transosseous
amputation
Transarticular
amputation
Intercalary Rotationplasty
Transfemoral
Transtibial
Transhumeral
Transradial
Syme ankle disarticulation (with removal of malleoli)
Boyd amputation (amputation through the ankle with
preservation of the posterior part of the calcaneus that is
fused to the distal tibia)
Lisfranc disarticulation (through the tarsometatarsal joints)
Chopart disarticulation (through the midtarsal joints)
Knee disarticulation
Upside-down tibia technique
bone-shortening osteotomies can be of
benefit. Flaps, skin grafts, and vacuum
suction dressings may need to be used
for the remaining wounds.
Overall, bone overgrowth occurs in
less than 10% of pediatric burn-related
amputations. The type of burn does not
11-15
influence overgrowth; lower limb amputations are more likely to result in overgrowth than upper limb amputations.8
Moreover, burn-related amputations are
often combined with other associated
injures (polytrauma) that can make care
more challenging.
Surgical Techniques
Developments in multiple areas have
improved surgical techniques for limb
salvage and amputations. Although the
treatment of malignant tumors of the
limbs have likely resulted in advances
in limb salvage surgery, the techniques
are now widely used for any situation in
which the limb is at risk, including trauma, infection, vascular abnormalities,
and in children with congenital limb
deficiencies. Even when amputation
is required, various limb salvage techniques can be used to achieve a more
functional residual limb.
35-46
Categories of limb salvage procedures
include local tissue flaps, transfers, and
excisions; autologous transfers; allograft
transplants; endoprostheses; composite
reconstructions (combined reconstructive modalities); intercalary resections;
and bone transfers (Table 2). Substantial
bone and soft-tissue losses can be reconstructed using various techniques;
the main goals are to provide biologic
reconstruction, restore bone stock, and
preserve joint kinematics to the extent
possible. In particular, the recent use of
“growing” devices in children help not
only to bridge the surgical defect but
also correct any eventual limb-length
discrepancy.
Amputations can be divided into
three main types: transarticular, transosseous, and intercalary (Table 3).
Even with technical progress made in
limb salvage procedures, amputation is
still the best choice in many instances.
Summary
There are many indications for pediatric
limb salvage surgery and amputation,
including trauma, vascular disease,
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
66
Chapter 5: General Principles of Limb Salvage Versus Amputation in Children
tumors, infections, and congenital
limb deficiency. The principles and
techniques of limb amputation in children differ from those in adults. Continuing skeletal growth and potential
overgrowth must be considered, as well
as the often greater functional demands
in children. The most common cause of
amputation in children continues to be
congenital limb deficiencies, followed by
tumors, infections, purpura fulminans,
and trauma. In most instances, limb salvage surgery is an option that should
be considered before an amputation is
performed. Transosseous amputations
should be avoided whenever possible.
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Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
68
Chapter 6
Amputee Gait: Normal and Abnormal
Robin M. Queen, PhD, FACSM Michael Orendur, PhD
Abstract
ree-dimensional gait analysis is valuable for guiding clinical decisions and in assessing
treatment outcomes for users of lower limb prostheses. Gait deviations in prosthesis users are complex and dynamic and inuenced by the level of limb loss and the prosthetic
components chosen by the clinician. A detailed understanding of the kinematic (motion)
and kinetic (force) patterns of the hip, knee, and ankle during walking in individuals who
are not amputees will aid the clinician in restoring a competent, ecient, and adaptable
gait pattern in prosthesis users that can improve functional performance in real-world
locomotive tasks.
Keywords: amputee gait; biomechanics; gait; locomotion;
pathological gait; walking
Introduction
Walking is a complex task that requires coordination of the entire low
er extremity. The coordination of the
neuromuscular system allows individuals to walk at various speeds, climb
stairs, run, jump, and complete many
complex tasks without thinking about
each movement required for these tasks.
However, if disease or injury alters this
delicate balance, the consequences
can drastically change an individual’s
quality of life. This chapter explores the
use of advanced gait mechanics techniques to quantify walking mechanics
in healthy individuals, as well as the
changes that occur in walking when
using a prosthesis after amputation. Although gait mechanics are complicated,
they can provide valuable information
to aid in determining the appropriate
clinical care for various orthopaedic
populations.
Dr. Queen ser ves as a paid consultant to or is an employee of Quest Diagnostic s; has received research
or institutional support from DJ Orthopaedics and Stryker; and serves as a board member, owner,
ocer, or committee member of the American College of Sports Medicine and the Orthopaedic
Research Society. Dr. Orendur is an employee of Orthocare Innovations and has stock or stock
options held in Orthocare Innovations.
Phases of Human Gait
The walking (or gait) cycle (Figure 1)
-
begins at foot contact and continues
until subsequent foot contact on the
same side. The gait cycle is divided into
two basic phases: stance and swing. The
stance phase comprises approximately
60% of the gait cycle, and the swing
phase comprises approximately 40%.
The stance phase begins when the foot
first contacts the ground and is completed when the foot leaves the ground
and begins the swing phase. During the
stance phase, there are two periods of
double-limb support (both feet on the
ground) and one period of single-limb
support (one foot on the ground).
During the initial contact phase of gait,
one foot contacts the ground at heel
strike and moves toward foot flat, while
the other foot begins toe-off and moves
into the swing phase. The swinging limb
then moves toward heel strike while the
stance limb moves through midsupport
and through terminal stance toward toeoff. The amount of time an individual
spends in each phase of the gait cycle
depends on walking speed; the stance
phase increases and the swing phase
decreases at slower walking speeds. In
addition, the presence of lower limb pathology can alter the timing and coordination of the gait cycle. For individuals
with limb loss, this often manifests as a
shorter stance phase on the prosthetic
limb, and shorter step length onto the
sound limb.
Amputee Gait
Individuals with lower limb loss have
specific challenges for ambulation that
depend greatly on the level of limb loss.
In general, more proximal limb loss has
a more substantial effect on joint motions (kinematics) and forces (kinetics),
as well as the energy cost of ambulation.
Over the past 20 years, prosthetic design has improved dramatically; however, the current designs still cannot
adequately replicate the motions and
forces of the missing native joints.
Microprocessor-controlled (MPC) prosthetic knees and ankles have created
small improvements in walking kinematics compared with standard pros-
7-23
theses,
but the walking patterns do
not replicate the functional motions of
the missing native joints.
16,24
Waters et
al25 and Jeans et al26 demonstrated in
adults and children, respectively, that
the metabolic cost of walking increases
with limb loss that is more proximal.
The gait efficiency of an individual
with limb loss can be improved with
an effective surgical approach combined
with appropriate prosthetic prescription
1-7
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
69
Section 1: General Topics
Figure 1
Illustration of the gait cycle, with the events, periods, tasks, and temporal characteristics used to describe human walking.
and care. However, not every ambulation deficit can be eliminated. Given the
existing surgical techniques, prosthetic
components (hips, knees, and ankles),
and limb-attachment technology (sockets), the goal for an individual with limb
loss is a functional, competent, and flexible gait pattern that maximizes both
stability and maneuverability.
Computerized Gait Analysis
The kinematic and inverse dynamics
calculations obtained from a computerized gait analysis laboratory can precisely quantify the motion, moments,
and powers of both the prosthetic components and the intact biologic joints
of a prosthetic user during walking.
These patterns are best interpreted by an
examiner experienced in gait mechanics
and analysis and with expertise in amputee gait deviations.
To accurately quantify gait, reflective markers are placed on specific anatomic landmarks to correctly define the
27, 28
three-dimensional coordinate axes for
each body segment (Figure 2). Analog
or digital cameras record the movement
of these markers in three-dimensional
space to track segment motion. Pelvic
segment movement is usually plotted
relative to the laboratory coordinate
system. Thigh segment motion is then
calculated relative to the pelvis in the
sagittal, coronal, and transverse planes
to describe hip flexion-extension,
abduction-adduction, and internal and
external rotation, respectively. Shank
segment motion is calculated relative
to the thigh (knee flexion-extension,
varus-valgus, and internal–external
rotation), and foot segment motion is
calculated relative to the shank (plantar
flexion–dorsiflexion [other movement
planes are usually neglected unless a
multisegment foot model
29,30
is included in the marker set]). The patterns of
these joint motions are plotted across
the gait cycle, time-normalized to foot
contact events. The biomechanical
model chosen can affect the results of
the computerized gait analysis, and a
careful assessment of the rotation axis
of prosthetic feet is essential.
18,19,31-33
Prosthetic knees often have an obvious
mechanical hinge and are somewhat less
susceptible to joint center calculation
errors. In general, much of the scientific evaluation and literature on applied
clinical efficacy examining prosthetic
components uses computerized gait
analysis to determine the differences
in component performance. Computerized three-dimensional gait analysis is the standard to which all other
methods of ambulation assessment are
compared. Observational gait analysis
may be clinically necessary, but it has
demonstrated only moderate reliability
and accuracy.
34-36
Moments are Effort;
Powers are Success
Inverse dynamic calculations are used to
quantify the effect of external forces on
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
70
Chapter 6: Amputee Gait: Normal and Abnormal
Figure 2
with a transtibial prosthesis with typical marker
placement used in computerized gait analysis.
The individual is walking over a force platform
and contacting it with the prosthetic foot.
Photograph of an individual
joint motion. These calculations use the
forces and moments obtained from force
platforms embedded in the laboratory
walkway to quantify the contribution of
each joint to support the body and move
the body forward during gait. Joint moments represent the forces that rotate a
joint and are inverted by convention to
represent the muscular effort needed to
counteract the moments applied at each
joint from the ground reaction forces
(GRFs). Therefore, the convention is to
present “internal” or “muscle” moments
to the reader. The moments are generally
normalized to the individual’s body
weight (Newton meters per kilogram)
and are identified by the muscle group
responsible for the movement, for example, the ankle plantar flexion (+) and
dorsiflexion (−); knee extension (+) and
flexion (+); hip extension (+) and flexion
(−) moments in the sagittal plane. Sagittal plane moments are often the focus
in walking studies because the moment
is greatest in this plane, and most of the
motion and force for forward propulsion
are generated there. Joint powers are
calculated by multiplying the angular
velocity by the moment for each instant
in time at each joint and are generally
normalized to body weight (work per
kilogram). Joint moments are equivalent to joint effort, and joint powers are
equivalent to successful task completion
(Figure 3).
Theoretic Models
of Human Gait
For many decades, the hypotheses of
Inman and Saunders37 (the six determinants of gait) dominated the literature
and the clinical approach to understanding locomotion in those with limb loss.
Although the original study lacks data
and testable hypotheses, the argument
was so compelling that these theories
about gait went unchallenged for more
than 50 years. The six determinants of
gait are pelvic rotation, pelvic tilt, knee
flexion in stance phase, foot mechanisms, knee mechanisms, and lateral
displacement of the pelvis.37 Most determinants have not been supported in
more recent publications,
celeration provided to the center of mass
by the trailing limb during active ankle
plantar flexion (push-off) is one determinant that has not been disproved by
detailed investigation.44 This concept is
central to the dynamic walking theory,
which makes a convincing mechanical
argument that acceleration of the center
of mass by the push-off power of the
trailing limb balances the deceleration
from the collision of the lead limb at
38-44
but the ac-
initial contact.
43,45 -47
This balance is hypothesized to create a center of mass
motion without abrupt trajectory alterations and will likely save mechanical
and, therefore, metabolic energy. Neither the six determinants nor the dynamic walking model fully explains all
aspects of human gait. All models are
flawed; however, some models help explain the consequences of specific treatment and prescription choices for lower
limb prosthetic users.
Ankle
The sagittal kinematics of the intact biologic ankle begin with the ankle in a
neutral to slightly plantarflexed position
at initial contact and continue as the ankle plantarflexes to approximately 10°
at about 10% of the gait cycle to achieve
foot flat (Figure 3, C). The ankle begins
to dorsiflex as the body moves over the
stance limb and reaches a maximum
dorsiflexion angle of approximately 10°
during the later stance phase. The ankle
begins to plantarflex again during preswing and reaches approximately 20° of
plantar flexion by foot-off. After foot-off,
the ankle returns to a neutral position,
where it remains during the swing phase
to facilitate clearance of the swing-phase
foot. The absent biologic ankle presents
some challenges to the treating physician
and the individual with limb loss. Nearly all prosthetic feet act as dual passive
springs. A heel portion is designed to
absorb, realign, and dampen the initial
contact force transiently, and a forefoot
keel flexes and recoils to varying degrees as stance progresses.
The passive properties mean that some
aspects of the angular pattern of the biologic ankle joint can be imitated with
moderate success (Figure 3, C), but
most prosthetic feet absorb as much
joint power as they generate (Figure 3,
I). (A passive spring is defined as a spring
in which power absorption and power generation are equal.) Therefore, all
currently available prosthetic feet have
push-off power that is lower than the
7,15,18, 21,22,48,49
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
71
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