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Clinical Evidence Finder – Lower Limb Prosthetics

This page gathers together the clinical evidence supporting Blatchford’s lower limb prosthetic products. Use the filter options on the left to find the information you are looking for. There is a downloadable PDF for every product, and most references include a one-page PDF summary.

  • AvalonK2

    Improvements in Clinical Outcomes using Avalon compared to non-hydraulic feet

    • Improved gait performance
      • Faster self-selected walking speed1
      • Smoother centre-of-pressure progression1
    • Keel and ankle designed for Activities of Daily Living
      • Easier sit-to-stand2
    • Mean 34% reduction in stance phase timing asymmetry3
    • Maximum 86% reduction in stance phase timing asymmetry3
    • More symmetrical inter-limb loading1
    • Patient reported outcome measures indicate improvements
      • Mean improvement across all Prosthesis Evaluation Questionnaire domains4

    Clinical Outcomes using the Avalon/Navigator keel design

    • Shorter keel allows for more consistent rollover radius of curvature, regardless of changing footwear5
    • The most energy efficient radius of curvature for a rollover shape has been identified as 30% of the walker’s leg length. For a person of a typical adult height between 1.5m and 1.8m, this equates to approximately 245-290mm. The Avalon keel design has a rollover shape of ~250mm5.

    References

    1. Barnett CT, Brown OH, Bisele M, et al. Individuals with Unilateral Transtibial Amputation and Lower Activity Levels Walk More Quickly when Using a Hydraulically Articulating Versus Rigidly Attached Prosthetic Ankle-Foot Device. JPO J Prosthet Orthot 2018; 30: 158–64.
    2. McGrath M, Moser D, Baier A. Anforderungen an eine geeignete Prosthesentechnologie für ältere, dysvaskuläre Amputierte - Requirements of a suitable prosthesis technology for elderly, dysvascular amputees. Orthop-Tech; 11. Download
    Overview
    3. Moore R. Effect on Stance Phase Timing Asymmetry in Individuals with Amputation Using Hydraulic Ankle Units. JPO J Prosthet Orthot 2016; 28: 44–48. Download
    Overview
    4. Moore R. Patient Evaluation of a Novel Prosthetic Foot with Hydraulic Ankle Aimed at Persons with Amputation with Lower Activity Levels. JPO J Prosthet Orthot 2017; 29: 44–47. Download
    Overview
    5. Curtze C, Hof AL, van Keeken HG, et al. Comparative roll-over analysis of prosthetic feet. J Biomech 2009; 42: 1746–1753.
  • AvalonK2VAC

    Improvements in Clinical Outcomes using Avalon compared to non-hydraulic feet

    • Improved gait performance
      • Faster self-selected walking speed1
      • Smoother centre-of-pressure progression1
    • Keel and ankle designed for Activities of Daily Living
      • Easier sit-to-stand2
    • Mean 34% reduction in stance phase timing asymmetry3
    • Maximum 86% reduction in stance phase timing asymmetry3
    • More symmetrical inter-limb loading1
    • Patient reported outcome measures indicate improvements
      • Mean improvement across all Prosthesis Evaluation Questionnaire domains4

    Improvements in Clinical Outcomes using EVS compared to other suspension types

    • Fewer falls and less chance of multiple falls
      • No trans-tibial EVS users reported multiple falls, while 75% of the non-EVS users did5
    • Better balance in functional clinical tests
      • Significant improvements in the Berg Balance Scale (BBS), the Four Square Step Test (FSST) and the Timed-Up-and-Go (TUG) test6
    • Better balance reported in patient-reported outcome measures
      • Improvements in the Activity Balance Confidence (ABC) scale questionnaire7
    • Fewer gait compensations8-10
    • Knee contact forces not significantly different to those of able-bodied controls11
    • Decreased pistoning
      • Reductions of over 69% and 83%, compared to suction10,12 and pin-lock13 suspensions, respectively, with other researchers and practitioners reporting similar observations7,8,14,15
    • Maintain residual limb volume
      • Suction suspension = mean 6.5% loss in volume; EVS = mean 3.7% increase in volume (N.B. it is possible that the increase may have been due to the fact that these individuals attended the clinic wearing their regular prostheses before using the EVS system).10
      • Other studies have since confirmed the observation that residuum volume loss is prevented by EVS8,16-19
    • Healthier residual limb tissue and skin
      • Higher trans-cutaneous oxygen measurement after activity20
      • Decreased trans-epidermal water loss after activity20
      • Decreased attenuated reactive hyperemia20
    • Reduced interface pressures
      • Pressures reduced by a mean of 4% compared to suction suspension21
      • Pressure impulses reduced by a mean of 7.5% compared to suction suspension21
    • Improved wound management
      • Continued prosthesis use while the wounds healed22-24
      • Wounds heal more quickly with EVS than other suspension methods25
    • Less painful than other suspension methods
      • Expert opinion8 and clinical case studies26 agree that EVS is less painful and more comfortable than other suspension methods.
      • Improved Socket Comfort Score compared to other suspension methods5
    • Patients are more satisfied wearing their prosthesis5,7,8,15,23,26-28

    Clinical Outcomes using the Avalon/Navigator keel design

    • Shorter keel allows for more consistent rollover radius of curvature, regardless of changing footwear29
    • The most energy efficient radius of curvature for a rollover shape has been identified as 30% of the walker’s leg length. For a person of a typical adult height between 1.5m and 1.8m, this equates to approximately 245-290mm. The Avalon keel design has a rollover shape of ~250mm29.

    Other Evidence

    Vacuum levels generated:

    When sensory control of the lower limb joints is lost, it is essential that the replacement behaves predictably. Consistency of performance is vital in providing prosthetic confidence. In terms of socket suspension method, this means providing the same good connection throughout a gait cycle, from one step to the next, and day-to-day, over the lifetime of the socket.

    The difference between the vacuum levels generated by suction suspension, and that generated when using EVS, can be demonstrated by using a negative pressure gauge30. Figure 1 illustrates these measurements. Commonly, when the user bears weight on their prosthesis during stance phase, with suction suspension, the magnitude of the vacuum is low. When the leg is lifted into swing phase, the vacuum increases in magnitude, holding the socket to the residual limb. Comparatively, EVS retains a high level during stance phase – higher, in fact, than the peak swing phase vacuum with suction. Additionally, the difference between stance and swing phase is less pronounced, so that the vacuum level is more consistent throughout the gait cycle. For the amputee illustrated in the graph30, EVS gave an approximate 85% increase in peak vacuum magnitude and an approximate 67% reduction in the ‘amplitude’ of the vacuum measurement signal.

    Figure 1: Negative pressure within the socket when walking using a one-way valve suction suspension (grey) and an elevated vacuum (EV) suspension. N.B. Data recorded with Echelon Vac system.

    The difference in vacuum generated by the AvalonVAC, compared to that generated by the Echelon Vac, is shown in Figure 2. Despite differences in the method used (keel vs springs, different socket, different pressure gauge), when the same patient was asked to walk at ‘K2 walking speed’ (~2km/h, short steps), the trend of vacuum level to number of steps taken was comparable to when measured at ‘K3 walking speed’ (4-5km/h) with Echelon Vac.

    Figure 2: Comparison of the EchelonVAC and AvalonVAC vacuum generation by number of steps (regardless of walking speed).

    References

    1. Barnett CT, Brown OH, Bisele M, et al. Individuals with Unilateral Transtibial Amputation and Lower Activity Levels Walk More Quickly when Using a Hydraulically Articulating Versus Rigidly Attached Prosthetic Ankle-Foot Device. JPO J Prosthet Orthot 2018; 30: 158–64.
    2. McGrath M, Moser D, Baier A. Anforderungen an eine geeignete Prosthesentechnologie für ältere, dysvaskuläre Amputierte - Requirements of a suitable prosthesis technology for elderly, dysvascular amputees. Orthop-Tech; 11. Download
    Overview
    3. Moore R. Effect on Stance Phase Timing Asymmetry in Individuals with Amputation Using Hydraulic Ankle Units. JPO J Prosthet Orthot 2016; 28: 44–48. Download
    Overview
    4. Moore R. Patient Evaluation of a Novel Prosthetic Foot with Hydraulic Ankle Aimed at Persons with Amputation with Lower Activity Levels. JPO J Prosthet Orthot 2017; 29: 44–47. Download
    Overview
    5. Rosenblatt NJ, Ehrhardt T, Fergus R, et al. Effects of Vacuum-Assisted Socket Suspension on Energetic Costs of Walking, Functional Mobility, and Prosthesis-Related Quality of Life. JPO J Prosthet Orthot 2017; 29: 65–72.
    6. Samitier CB, Guirao L, Costea M, et al. The benefits of using a vacuum-assisted socket system to improve balance and gait in elderly transtibial amputees. Prosthet Orthot Int 2016; 40: 83–88.
    7. Ferraro C. Outcomes study of transtibial amputees using elevated vacuum suspension in comparison with pin suspension. JPO J Prosthet Orthot 2011; 23: 78–81.
    8. Gholizadeh H, Lemaire ED, Eshraghi A. The evidence-base for elevated vacuum in lower limb prosthetics: Literature review and professional feedback. Clin Biomech 2016; 37: 108–116.
    9. Xu H, Greenland K, Bloswick D, et al. Vacuum level effects on gait characteristics for unilateral transtibial amputees with elevated vacuum suspension. Clin Biomech Bristol Avon 2017; 43: 95–101.
    10. Board WJ, Street GM, Caspers C. A comparison of trans-tibial amputee suction and vacuum socket conditions. Prosthet Orthot Int 2001; 25: 202–209.
    11. Xu H, Greenland K, Bloswick D, et al. Vacuum level effects on knee contact force for unilateral transtibial amputees with elevated vacuum suspension. J Biomech 2017; 57: 110–116.
    12. Gerschutz MJ, Hayne ML, Colvin JM, et al. Dynamic Effectiveness Evaluation of Elevated Vacuum Suspension. JPO J Prosthet Orthot 2015; 27: 161–165.
    13. Klute GK, Berge JS, Biggs W, et al. Vacuum-assisted socket suspension compared with pin suspension for lower extremity amputees: effect on fit, activity, and limb volume. Arch Phys Med Rehabil 2011; 92: 1570–1575.
    14. Darter BJ, Sinitski K, Wilken JM. Axial bone-socket displacement for persons with a traumatic transtibial amputation: The effect of elevated vacuum suspension at progressive body-weight loads. Prosthet Orthot Int 2016; 40: 552–557.
    15. Scott H, Hughes J. Investigating The Use Of Elevated Vacuum Suspension On The Adult PFFD Patient: A Case Study. ACPOC 2013; 19: 7–12.
    16. Youngblood RT, Brzostowski JT, Hafner BJ, et al. Effectiveness of elevated vacuum and suction prosthetic suspension systems in managing daily residual limb fluid volume change in people with transtibial amputation. Prosthet Orthot Int 2020; Online first.
    17. Sanders JE, Harrison DS, Myers TR, et al. Effects of elevated vacuum on in-socket residual limb fluid volume: Case study results using bioimpedance analysis. J Rehabil Res Dev 2011; 48: 1231.
    18. Street G. Vacuum suspension and its effects on the limb. Orthopadie Tech 2006; 4: 1–7.
    19. Goswami J, Lynn R, Street G, et al. Walking in a vacuum-assisted socket shifts the stump fluid balance. Prosthet Orthot Int 2003; 27: 107–113.
    20. Rink C, Wernke MM, Powell HM, et al. Elevated vacuum suspension preserves residual-limb skin health in people with lower-limb amputation: Randomized clinical trial. J Rehabil Res Dev 2016; 53: 1121–1132.
    21. Beil TL, Street GM, Covey SJ. Interface pressures during ambulation using suction and vacuum-assisted prosthetic sockets. J Rehabil Res Dev 2002; 39: 693.
    22. Hoskins RD, Sutton EE, Kinor D, et al. Using vacuum-assisted suspension to manage residual limb wounds in persons with transtibial amputation: a case series. Prosthet Orthot Int 2014; 38: 68–74.
    23. Traballesi M, Delussu AS, Fusco A, et al. Residual limb wounds or ulcers heal in transtibial amputees using an active suction socket system. A randomized controlled study. Eur J Phys Rehabil Med 2012; 48: 613–23.
    24. Traballesi M, Averna T, Delussu AS, et al. Trans-tibial prosthesization in large area of residual limb wound: Is it possible? A case report. Disabil Rehabil Assist Technol 2009; 4: 373–375.
    25. Brunelli S, Averna T, Delusso M, et al. Vacuum assisted socket system in transtibial amputees: Clinical report. Orthop-Tech Q Engl Ed; 2.
    26. Arndt B, Caldwell R, Fatone S. Use of a partial foot prosthesis with vacuum-assisted suspension: A case study. JPO J Prosthet Orthot 2011; 23: 82–88.
    27. Carvalho JA, Mongon MD, Belangero WD, et al. A case series featuring extremely short below-knee stumps. Prosthet Orthot Int 2012; 36: 236–238.
    28. Sutton E, Hoskins R, Fosnight T. Using elevated vacuum to improve functional outcomes: A case report. JPO J Prosthet Orthot 2011; 23: 184–189.
    29. Curtze C, Hof AL, van Keeken HG, et al. Comparative roll-over analysis of prosthetic feet. J Biomech 2009; 42: 1746–1753.
    30. McGrath M, Laszczak P, McCarthy J, et al. The biomechanical effects on gait of elevated vacuum suspension compared to suction suspension. Cape Town, South Africa, 2017.
  • BladeXT

    Clinical Outcomes using e-carbon feet

    • High mean radius of curvature for Esprit-style e-carbon feet2: “The larger the radius of curvature, the more stable is the foot”
    • Allow variable running speeds3
    • Increased self-selected walking speed4
    • Elite-style e-carbon feet (L code VL5987) or VT units demonstrate the second highest mobility levels, behind only microprocessor feet5
    • Users demonstrate confidence in prosthetic loading during high activity6
    • Improved prosthetic push-off work compared to SACH feet7
    • Increased prosthetic positive work done4
    • High degree of user satisfaction, particularly with high activity users8

    Much research confirms the substantial equivalency of all energy-storing and return feet, including Blatchford e-carbon feet1.

    References

    1. Crimin A, McGarry A, Harris EJ, et al. The effect that energy storage and return feet have on the propulsion of the body: A pilot study. Proc Inst Mech Eng [H] 2014; 228: 908–915.
    2. Curtze C, Hof AL, van Keeken HG, et al. Comparative roll-over analysis of prosthetic feet. J Biomech 2009; 42: 1746–1753.
    3. Strike SC, Arcone D, Orendurff M. Running at submaximal speeds, the role of the intact and prosthetic limbs for trans-tibial amputees. Gait Posture 2018; 62: 327–332.
    4. Ray SF, Wurdeman SR, Takahashi KZ. Prosthetic energy return during walking increases after 3 weeks of adaptation to a new device. J Neuroengineering Rehabil 2018; 15: 6.
    5. Wurdeman SR, Stevens PM, Campbell JH. Mobility analysis of AmpuTees (MAAT 5): Impact of five common prosthetic ankle-foot categories for individuals with diabetic/dysvascular amputation. J Rehabil Assist Technol Eng 2019; 6: 2055668318820784.
    6. Haber CK, Ritchie LJ, Strike SC. Dynamic elastic response prostheses alter approach angles and ground reaction forces but not leg stiffness during a start-stop task. Hum Mov Sci 2018; 58: 337–346.
    7. Rock CG, Wurdeman SR, Stergiou N, Takahashi KZ. Stride-to-stride fluctuations in transtibial amputees are not affected by changes in push-off mechanics from using different prostheses. PloS one. 2018;13(10).
    8. Highsmith MJ, Kahle JT, Miro RM, et al. Differences in Military Obstacle Course Performance Between Three Energy-Storing and Shock-Adapting Prosthetic Feet in High-Functioning Transtibial Amputees: A Double-Blind, Randomized Control Trial. Mil Med 2016; 181: 45–54.
  • Child’s 4-bar knee

    Improvements in Clinical Outcomes using four-bar, polycentric knees compared to monoaxial knees

    • Increased mean prosthetic minimum toe clearance2,4, reducing the likelihood of tripping.
    • Fully satisfies stance phase stability3
    • Acceptable cosmetics for knee disarticulation amputees and trans-femoral amputees with long residua1
    • Meets all the design requirements for paediatric patients3

    References

    1. de Laat FA, van Kuijk AA, Geertzen JH, et al. Cosmetic effect of knee joint in a knee disarticulation prosthesis. J Rehabil Res Dev 2014; 51: 1545.
    2. Sensinger JW, Intawachirarat N, Gard SA. Contribution of prosthetic knee and ankle mechanisms to swing-phase foot clearance. IEEE Trans Neural Syst Rehabil Eng 2012; 21: 74–80.
    3. Andrysek J, Naumann S, Cleghorn WL. Design characteristics of pediatric prosthetic knees. IEEE Trans Neural Syst Rehabil Eng 2004; 12: 369–378.
    4. Gard SA, Childress DS, Uellendahl JE. The influence of four-bar linkage knees on prosthetic swing-phase floor clearance. JPO J Prosthet Orthot 1996; 8: 34–40.
  • Comfort Liner

    There are two published literature reviews that discuss different aspects of lower limb prosthetic liner technology1,2.

    • The main purpose of prosthetic liners is to cushion the transfer of loads from the prosthetic socket to the residual limb1.
    • Based on load-displacement data from the compressive stiffness tests, silicone was one of three materials that were recommended for situations where it is desirable for the liner to maintain thickness and volume since these materials had the least non-recovered strain1,3.
    • Under cyclic compressive loading, silicone was one of two materials that had the greatest cycles to failure under compressive loading, while the Pedilin and polyurethane samples lasted orders of magnitude less1,4.
    • Prosthetic liners and sockets are highly resistive to heat conduction and could be a major contributor to elevated skin temperatures1,5.
    • There are reduced residual limb pressures with the silicone liner compared to other conditions (no liner; soft inserts) suggesting that silicone has an ability to distribute pressure evenly to the residual limb1,6.
    • In terms of patient outcomes, there was no clear preference between silicone and Pelite liners1,7.

    References

    1. Klute GK, Glaister BC, Berge JS. Prosthetic liners for lower limb amputees: a review of the literature. Prosthet Orthot Int 2010; 34: 146–153.
    2. Richardson A, Dillon MP. User experience of transtibial prosthetic liners: a systematic review. Prosthet Orthot Int 2017; 41: 6–18.
    3. Sanders JE, Greve JM, Mitchell SB, et al. Material properties of commonly-used interface materials and their static coefficients of friction with skin and socks. J Rehabil Res Dev 1998; 35: 161–176.
    4. Emrich R, Slater K. Comparative analysis of below-knee prosthetic socket liner materials. J Med Eng Technol 1998; 22: 94–98.
    5. Klute GK, Rowe GI, Mamishev AV, et al. The thermal conductivity of prosthetic sockets and liners. Prosthet Orthot Int 2007; 31: 292–299.
    6. Sonck WA, Cockrell JL, Koepke GH. Effect of liner materials on interface pressures in below-knee prostheses. Arch Phys Med Rehabil 1970; 51: 666.
    7. Lee WC, Zhang M, Mak AF. Regional differences in pain threshold and tolerance of the transtibial residual limb: including the effects of age and interface material. Arch Phys Med Rehabil 2005; 86: 641–649.
  • Echelon

    Improvements in Clinical Outcomes using Echelon compared to ESR feet

    • Reduced risk of tripping and falls
      • Increased minimum toe clearance during swing phase1,2
    • Improving standing balance on a slope
      • 24-25% reduction in mean inter-limb centre-of-pressure root mean square (COP RMS)3
    • Reduced energy expenditure during walking
      • Mean 11.8% reduction in energy use on level ground, across all walking speeds4
      • Mean 20.2% reduction in energy use on slopes, across all gradients4
      • Mean 8.3% faster walking speed for the same amount of effort4
    • Improved gait performance
      • Faster self-selected walking speed2,5-7
      • Higher PLUS-M scores than FlexFoot and FlexWalk style feet8
    • Improved ground compliance when walking on slopes
      • Increased plantarflexion peak during level walking, fast level walking and cambered walking9
      • Increased dorsiflexion peak during level walking, fast level walking and cambered walking9
    • Less of a prosthetic “dead spot” during gait
      • Reduced aggregate negative COP displacement5
      • Centre-of-pressure passes anterior to the shank statistically significantly earlier in stance5
      • Increased minimum instantaneous COM velocity during prosthetic-limb single support phase5
      • Reduced peak negative COP velocity7
      • Reduced COP posterior travel distance7
    • Improved ground compliance when walking on slopes
      • Increased plantarflexion range during slope descent10
      • Increased dorsiflexion range during slope ascent10
    • Helps protect vulnerable residual limb tissue, reducing likelihood of damage
      • Reduced peak stresses on residual limb11
      • Reduced stress RMS on residual limb11
      • Reduced loading rates on residual limb11
    • Greater contribution of prosthetic limb to support during walking
      • Increased residual knee negative work6
    • Reduced reliance on sound limb for support during walking
      • Reduced intact limb peak hip flexion moment6
      • Reduced intact limb peak dorsiflexion moment6
      • Reduced intact ankle negative work and total work6
      • Reduced intact limb total joint work6
    • Better symmetry of loading between prosthetic and sound limbs during standing on a slope
      • Degree of asymmetry closer to zero for 5/5 amputees3
    • Reduced residual and sound joint moments during standing of a slope
      • Significant reductions in both prosthetic and sound support moments12
    • Less pressure on the sole of the contralateral foot
      • Peak plantar-pressure13
    • Improved gait symmetry
      • Reduced stance phase timing asymmetry14
    • Patient reported outcome measures indicate improvements
      • Mean improvement across all Prosthesis Evaluation Questionnaire domains15
      • Bilateral patients showed highest mean improvement in satisfaction15
    • Subjective user preference for hydraulic ankle
      • 13/13 participants preferred hydraulic ankle13

    References

    1. Riveras M, Ravera E, Ewins D, Shaheen AF, Catalfamo-Formento P. Minimum toe clearance and tripping probability in people with unilateral transtibial amputation walking on ramps with different prosthetic designs. Gait & Posture. 2020 Sep 1;81:41-8.
    2. Johnson L, De Asha AR, Munjal R, et al. Toe clearance when walking in people with unilateral transtibial amputation: effects of passive hydraulic ankle. J Rehabil Res Dev 2014; 51: 429. Download
    Overview
    3. McGrath M, Laszczak P, Zahedi S, et al. Microprocessor knees with “standing support” and articulating, hydraulic ankles improve balance control and inter-limb loading during quiet standing. J Rehabil Assist Technol Eng 2018; 5: 2055668318795396. Download
    Overview
    4. Askew GN, McFarlane LA, Minetti AE, et al. Energy cost of ambulation in trans-tibial amputees using a dynamic-response foot with hydraulic versus rigid ‘ankle’: insights from body centre of mass dynamics. J NeuroEngineering Rehabil 2019; 16: 39. Download
    Overview
    5. De Asha AR, Munjal R, Kulkarni J, et al. Impact on the biomechanics of overground gait of using an ‘Echelon’hydraulic ankle–foot device in unilateral trans-tibial and trans-femoral amputees. Clin Biomech 2014; 29: 728–734. Download
    Overview
    6. De Asha AR, Munjal R, Kulkarni J, et al. Walking speed related joint kinetic alterations in trans-tibial amputees: impact of hydraulic’ankle’damping. J Neuroengineering Rehabil 2013; 10: 1. Download
    Overview
    7. De Asha AR, Johnson L, Munjal R, et al. Attenuation of centre-of-pressure trajectory fluctuations under the prosthetic foot when using an articulating hydraulic ankle attachment compared to fixed attachment. Clin Biomech 2013; 28: 218–224. Download
    Overview
    8. Wurdeman SR, Stevens PM, Campbell JH. Mobility analysis of AmpuTees (MAAT 5): Impact of five common prosthetic ankle-foot categories for individuals with diabetic/dysvascular amputation. J Rehabil Assist Technol Eng 2019; 6: 2055668318820784. Download
    Overview
    9. Bai X, Ewins D, Crocombe AD, et al. Kinematic and biomimetic assessment of a hydraulic ankle/foot in level ground and camber walking. PLOS ONE 2017; 12: e0180836. Download
    Overview
    10. Bai X, Ewins D, Crocombe AD, et al. A biomechanical assessment of hydraulic ankle-foot devices with and without micro-processor control during slope ambulation in trans-femoral amputees. PLOS ONE 2018; 13: e0205093. Download
    Overview
    11. Portnoy S, Kristal A, Gefen A, et al. Outdoor dynamic subject-specific evaluation of internal stresses in the residual limb: hydraulic energy-stored prosthetic foot compared to conventional energy-stored prosthetic feet. Gait Posture 2012; 35: 121–125. Download
    Overview
    12. McGrath M, Davies KC, Laszczak P, et al. The influence of hydraulic ankles and microprocessor-control on the biomechanics of trans-tibial amputees during quiet standing on a 5° slope. Can Prosthet Orthot J; 2.
    13. Moore R. Effect of a Prosthetic Foot with a Hydraulic Ankle Unit on the Contralateral Foot Peak Plantar Pressures in Individuals with Unilateral Amputation. JPO J Prosthet Orthot 2018; 30: 165–70. Download
    Overview
    14. Moore R. Effect on Stance Phase Timing Asymmetry in Individuals with Amputation Using Hydraulic Ankle Units. JPO J Prosthet Orthot 2016; 28: 44–48. Download
    Overview
    15. Sedki I, Moore R. Patient evaluation of the Echelon foot using the Seattle Prosthesis Evaluation Questionnaire. Prosthet Orthot Int 2013; 37: 250–254. Download
    Overview
  • EchelonVAC

    Improvements in Clinical Outcomes using Echelon compared to ESR feet

    • Reduced risk of tripping and falls
      • Increased minimum toe clearance during swing phase1,2
    • Improving standing balance on a slope
      • 24-25% reduction in mean inter-limb centre-of-pressure root mean square (COP RMS)3
    • Reduced energy expenditure during walking
      • Mean 11.8% reduction in energy use on level ground, across all walking speeds4
      • Mean 20.2% reduction in energy use on slopes, across all gradients4
      • Mean 8.3% faster walking speed for the same amount of effort4
    • Improved gait performance
      • Faster self-selected walking speed2,5-7
      • Higher PLUS-M scores than FlexFoot and FlexWalk style feet8
    • Improved ground compliance when walking on slopes
      • Increased plantarflexion peak during level walking, fast level walking and cambered walking9
      • Increased dorsiflexion peak during level walking, fast level walking and cambered walking9
    • Less of a prosthetic “dead spot” during gait
      • Reduced aggregate negative COP displacement5
      • Centre-of-pressure passes anterior to the shank statistically significantly earlier in stance5
      • Increased minimum instantaneous COM velocity during prosthetic-limb single support phase5
      • Reduced peak negative COP velocity7
      • Reduced COP posterior travel distance7
    • Improved ground compliance when walking on slopes
      • Increased plantarflexion range during slope descent10
      • Increased dorsiflexion range during slope ascent10
    • Helps protect vulnerable residual limb tissue, reducing likelihood of damage
      • Reduced peak stresses on residual limb11
      • Reduced stress RMS on residual limb11
      • Reduced loading rates on residual limb11
    • Greater contribution of prosthetic limb to support during walking
      • Increased residual knee negative work6
    • Reduced reliance on sound limb for support during walking
      • Reduced intact limb peak hip flexion moment6
      • Reduced intact limb peak dorsiflexion moment6
      • Reduced intact ankle negative work and total work6
      • Reduced intact limb total joint work6
    • Better symmetry of loading between prosthetic and sound limbs during standing on a slope
      • Degree of asymmetry closer to zero for 5/5 amputees3
    • Reduced residual and sound joint moments during standing of a slope
      • Significant reductions in both prosthetic and sound support moments12
    • Less pressure on the sole of the contralateral foot
      • Peak plantar-pressure13
    • Improved gait symmetry
      • Reduced stance phase timing asymmetry14
    • Patient reported outcome measures indicate improvements
      • Mean improvement across all Prosthesis Evaluation Questionnaire domains15
      • Bilateral patients showed highest mean improvement in satisfaction15
    • Subjective user preference for hydraulic ankle
      • 13/13 participants preferred hydraulic ankle13

    Improvements in Clinical Outcomes using EVS compared to other suspension types

    • Fewer falls and less chance of multiple falls
      • No trans-tibial EVS users reported multiple falls, while 75% of the non-EV users did16
    • Better balance in functional clinical tests
      • Significant improvements in the Berg Balance Scale (BBS), the Four Square Step Test (FSST) and the Timed-Up-and-Go (TUG) test17
    • Better balance reported in patient-reported outcome measures
      • Improvements in the Activity Balance Confidence (ABC) scale questionnaire18
    • Fewer gait compensations19-21
    • Knee contact forces not significantly different to those of able-bodied controls22
    • Decreased pistoning
      • Reductions of over 69% and 83%, compared to suction21,23 and pin-lock24 suspensions, respectively, with other researchers and practitioners reporting similar observations18,19,25,26
    • Maintain residual limb volume
      • Suction suspension = mean 6.5% loss in volume; EVS = mean 3.7% increase in volume (N.B. it is possible that the increase may have been due to the fact that these individuals attended the clinic wearing their regular prostheses before using the EVS system)21
      • Other studies have since confirmed the observation that residuum volume loss is prevented by EVS19,27-30
    • Healthier residual limb tissue and skin
      • Higher trans-cutaneous oxygen measurement after activity31
      • Decreased trans-epidermal water loss after activity31
      • Decreased attenuated reactive hyperemia31
    • Reduced interface pressures
      • Pressures reduced by a mean of 4% compared to suction suspension32
      • Pressure impulses reduced by a mean of 7.5% compared to suction suspension32
    • Improved wound management
      • Continued prosthesis use while the wounds healed33-35
      • Wounds heal more quickly with EVS than other suspension methods36
    • Less painful than other suspension methods
      • Expert opinion19 and clinical case studies37 agree that EVS is less painful and more comfortable than other suspension methods.
      • Improved Socket Comfort Score compared to other suspension methods38
    • Patients are more satisfied wearing their prosthesis18,19,26,34,37-38.

    Other Evidence

    Vacuum levels generated:

    When sensory control of the lower limb joints is lost, it is essential that the replacement behaves predictably. Consistency of performance is vital in providing prosthetic confidence. In terms of socket suspension method, this means providing the same good connection throughout a gait cycle, from one step to the next, and day-to-day, over the lifetime of the socket.

    The difference between the vacuum levels generated by suction suspension, and that generated when using EVS, can be demonstrated by using a negative pressure gauge30. Figure 1 illustrates these measurements. Commonly, when the user bears weight on their prosthesis during stance phase, with suction suspension, the magnitude of the vacuum is low. When the leg is lifted into swing phase, the vacuum increases in magnitude, holding the socket to the residual limb. Comparatively, EVS retains a high level during stance phase – higher, in fact, than the peak swing phase vacuum with suction. Additionally, the difference between stance and swing phase is less pronounced, so that the vacuum level is more consistent throughout the gait cycle. For the amputee illustrated in the graph30, EVS gave an approximate 85% increase in peak vacuum magnitude and an approximate 67% reduction in the ‘amplitude’ of the vacuum measurement signal.

    Figure 1: Negative pressure within the socket when walking using a one-way valve suction suspension (grey) and an elevated vacuum (EV) suspension. N.B. Data recorded with Echelon Vac system.

    The difference in vacuum generated by the AvalonVAC, compared to that generated by the Echelon Vac, is shown in Figure 2. Despite differences in the method used (keel vs springs, different socket, different pressure gauge), when the same patient was asked to walk at ‘K2 walking speed’ (~2km/h, short steps), the trend of vacuum level to number of steps taken was comparable to when measured at ‘K3 walking speed’ (4-5km/h) with Echelon Vac.

    Figure 2: Comparison of the EchelonVAC and AvalonVAC vacuum generation by number of steps (regardless of walking speed).

    References

    1. Riveras M, Ravera E, Ewins D, Shaheen AF, Catalfamo-Formento P. Minimum toe clearance and tripping probability in people with unilateral transtibial amputation walking on ramps with different prosthetic designs. Gait & Posture. 2020 Sep 1;81:41-8.
    2. Johnson L, De Asha AR, Munjal R, et al. Toe clearance when walking in people with unilateral transtibial amputation: effects of passive hydraulic ankle. J Rehabil Res Dev 2014; 51: 429. Download
    Overview
    3. McGrath M, Laszczak P, Zahedi S, et al. Microprocessor knees with “standing support” and articulating, hydraulic ankles improve balance control and inter-limb loading during quiet standing. J Rehabil Assist Technol Eng 2018; 5: 2055668318795396. Download
    Overview
    4. Askew GN, McFarlane LA, Minetti AE, et al. Energy cost of ambulation in trans-tibial amputees using a dynamic-response foot with hydraulic versus rigid ‘ankle’: insights from body centre of mass dynamics. J NeuroEngineering Rehabil 2019; 16: 39. Download
    Overview
    5. De Asha AR, Munjal R, Kulkarni J, et al. Impact on the biomechanics of overground gait of using an ‘Echelon’ hydraulic ankle–foot device in unilateral trans-tibial and trans-femoral amputees. Clin Biomech 2014; 29: 728–734. Download
    Overview
    6. De Asha AR, Munjal R, Kulkarni J, et al. Walking speed related joint kinetic alterations in trans-tibial amputees: impact of hydraulic ’ankle’ damping. J Neuroengineering Rehabil 2013; 10: 1. Download
    Overview
    7. De Asha AR, Johnson L, Munjal R, et al. Attenuation of centre-of-pressure trajectory fluctuations under the prosthetic foot when using an articulating hydraulic ankle attachment compared to fixed attachment. Clin Biomech 2013; 28: 218–224. Download
    Overview
    8. Wurdeman SR, Stevens PM, Campbell JH. Mobility analysis of AmpuTees (MAAT 5): Impact of five common prosthetic ankle-foot categories for individuals with diabetic/dysvascular amputation. J Rehabil Assist Technol Eng 2019; 6: 2055668318820784. Download
    Overview
    9. Bai X, Ewins D, Crocombe AD, et al. Kinematic and biomimetic assessment of a hydraulic ankle/foot in level ground and camber walking. PLOS ONE 2017; 12: e0180836. Download
    Overview
    10. Bai X, Ewins D, Crocombe AD, et al. A biomechanical assessment of hydraulic ankle-foot devices with and without micro-processor control during slope ambulation in trans-femoral amputees. PLOS ONE 2018; 13: e0205093. Download
    Overview
    11. Portnoy S, Kristal A, Gefen A, et al. Outdoor dynamic subject-specific evaluation of internal stresses in the residual limb: hydraulic energy-stored prosthetic foot compared to conventional energy-stored prosthetic feet. Gait Posture 2012; 35: 121–125. Download
    Overview
    12. McGrath M, Davies KC, Laszczak P, et al. The influence of hydraulic ankles and microprocessor-control on the biomechanics of trans-tibial amputees during quiet standing on a 5° slope. Can Prosthet Orthot J; 2.
    13. Moore R. Effect of a Prosthetic Foot with a Hydraulic Ankle Unit on the Contralateral Foot Peak Plantar Pressures in Individuals with Unilateral Amputation. JPO J Prosthet Orthot 2018; 30: 165–70. Download
    Overview
    14. Moore R. Effect on Stance Phase Timing Asymmetry in Individuals with Amputation Using Hydraulic Ankle Units. JPO J Prosthet Orthot 2016; 28: 44–48. Download
    Overview
    15. Sedki I, Moore R. Patient evaluation of the Echelon foot using the Seattle Prosthesis Evaluation Questionnaire. Prosthet Orthot Int 2013; 37: 250–254. Download
    Overview
    16. Rosenblatt NJ, Ehrhardt T. The effect of vacuum assisted socket suspension on prospective, community-based falls by users of lower limb prostheses. Gait Posture, http://www.sciencedirect.com/science/article/pii/S096663621730111X (2017, accessed 2 May 2017).
    17. Samitier CB, Guirao L, Costea M, et al. The benefits of using a vacuum-assisted socket system to improve balance and gait in elderly transtibial amputees. Prosthet Orthot Int 2016; 40: 83–88.
    18. Ferraro C. Outcomes study of transtibial amputees using elevated vacuum suspension in comparison with pin suspension. JPO J Prosthet Orthot 2011; 23: 78–81.
    19. Gholizadeh H, Lemaire ED, Eshraghi A. The evidence-base for elevated vacuum in lower limb prosthetics: Literature review and professional feedback. Clin Biomech 2016; 37: 108–116.
    20. Xu H, Greenland K, Bloswick D, et al. Vacuum level effects on gait characteristics for unilateral transtibial amputees with elevated vacuum suspension. Clin Biomech Bristol Avon 2017; 43: 95–101.
    21. Board WJ, Street GM, Caspers C. A comparison of trans-tibial amputee suction and vacuum socket conditions. Prosthet Orthot Int 2001; 25: 202–209.
    22. Xu H, Greenland K, Bloswick D, et al. Vacuum level effects on knee contact force for unilateral transtibial amputees with elevated vacuum suspension. J Biomech 2017; 57: 110–116.
    23. Gerschutz MJ, Hayne ML, Colvin JM, et al. Dynamic Effectiveness Evaluation of Elevated Vacuum Suspension. JPO J Prosthet Orthot 2015; 27: 161–165.
    24. Klute GK, Berge JS, Biggs W, et al. Vacuum-assisted socket suspension compared with pin suspension for lower extremity amputees: effect on fit, activity, and limb volume. Arch Phys Med Rehabil 2011; 92: 1570–1575.
    25. Darter BJ, Sinitski K, Wilken JM. Axial bone-socket displacement for persons with a traumatic transtibial amputation: The effect of elevated vacuum suspension at progressive body-weight loads. Prosthet Orthot Int 2016; 40: 552–557.
    26. Scott H, Hughes J. Investigating The Use Of Elevated Vacuum Suspension On The Adult PFFD Patient: A Case Study. ACPOC 2013; 19: 7–12.
    27. Youngblood RT, Brzostowski JT, Hafner BJ, et al. Effectiveness of elevated vacuum and suction prosthetic suspension systems in managing daily residual limb fluid volume change in people with transtibial amputation. Prosthet Orthot Int 2020; 0309364620909044.
    28. Sanders JE, Harrison DS, Myers TR, et al. Effects of elevated vacuum on in-socket residual limb fluid volume: Case study results using bioimpedance analysis. J Rehabil Res Dev 2011; 48: 1231.
    29. Street G. Vacuum and its effects on the limb. Orthopadie Tech 2006; 4: 1–7. Goswami J, Lynn R, Street G, et al. Walking in a vacuum-assisted socket shifts the stump fluid balance. Prosthet Orthot Int 2003; 27: 107–113.
    30. 30. Goswami J, Lynn R, Street G, et al. Walking in a vacuum-assisted socket shifts the stump fluid balance. Prosthet Orthot Int 2003; 27: 107–113.
    31. Rink C, Wernke MM, Powell HM, et al. Elevated vacuum suspension preserves residual-limb skin health in people with lower-limb amputation: Randomized clinical trial. J Rehabil Res Dev 2016; 53: 1121–1132.
    32. Beil TL, Street GM, Covey SJ. Interface pressures during ambulation using suction and vacuum-assisted prosthetic sockets. J Rehabil Res Dev 2002; 39: 693.
    33. Hoskins RD, Sutton EE, Kinor D, et al. Using vacuum-assisted suspension to manage residual limb wounds in persons with transtibial amputation: a case series. Prosthet Orthot Int 2014; 38: 68–74.
    34. Traballesi M, Delussu AS, Fusco A, et al. Residual limb wounds or ulcers heal in transtibial amputees using an active suction socket system. A randomized controlled study. Eur J Phys Rehabil Med 2012; 48: 613–23.
    35. Traballesi M, Averna T, Delussu AS, et al. Trans-tibial prosthesization in large area of residual limb wound: Is it possible? A case report. Disabil Rehabil Assist Technol 2009; 4: 373–375.
    36. Brunelli S, Averna T, Delusso M, et al. Vacuum assisted socket system in transtibial amputees: Clinical report. Orthop-Tech Q Engl Ed; 2.
    37. Arndt B, Caldwell R, Fatone S. Use of a partial foot prosthesis with vacuum-assisted suspension: A case study. JPO J Prosthet Orthot 2011; 23: 82–88.
    38. Rosenblatt NJ, Ehrhardt T, Fergus R, et al. Effects of Vacuum-Assisted Socket Suspension on Energetic Costs of Walking, Functional Mobility, and Prosthesis-Related Quality of Life. JPO J Prosthet Orthot 2017; 29: 65–72.
    39. Carvalho JA, Mongon MD, Belangero WD, et al. A case series featuring extremely short below-knee stumps. Prosthet Orthot Int 2012; 36: 236–238.
    40. Sutton E, Hoskins R, Fosnight T. Using elevated vacuum to improve functional outcomes: A case report. JPO J Prosthet Orthot 2011; 23: 184–189.
    41. McGrath M, Laszczak P, McCarthy J, et al. The biomechanical effects on gait of elevated vacuum suspension compared to suction suspension. Cape Town, South Africa, 2017.
  • EchelonVT

    Improvements in Clinical Outcomes using Echelon compared to ESR feet

    • Reduced risk of tripping and falls
      • Increased minimum toe clearance during swing phase1,2
    • Improving standing balance on a slope
      • 24-25% reduction in mean inter-limb centre-of-pressure root mean square (COP RMS)3
    • Reduced energy expenditure during walking
      • Mean 11.8% reduction in energy use on level ground, across all walking speeds4
      • Mean 20.2% reduction in energy use on slopes, across all gradients4
      • Mean 8.3% faster walking speed for the same amount of effort4
    • Improved gait performance
      • Faster self-selected walking speed2,5-7
      • Higher PLUS-M scores than FlexFoot and FlexWalk style feet8
    • Improved ground compliance when walking on slopes
      • Increased plantarflexion peak during level walking, fast level walking and cambered walking9
      • Increased dorsiflexion peak during level walking, fast level walking and cambered walking9
    • Less of a prosthetic “dead spot” during gait
      • Reduced aggregate negative COP displacement5
      • Centre-of-pressure passes anterior to the shank statistically significantly earlier in stance5
      • Increased minimum instantaneous COM velocity during prosthetic-limb single support phase5
      • Reduced peak negative COP velocity7
      • Reduced COP posterior travel distance7
    • Improved ground compliance when walking on slopes
      • Increased plantarflexion range during slope descent10
      • Increased dorsiflexion range during slope ascent10
    • Helps protect vulnerable residual limb tissue, reducing likelihood of damage
      • Reduced peak stresses on residual limb11
      • Reduced stress RMS on residual limb11
      • Reduced loading rates on residual limb11
    • Greater contribution of prosthetic limb to support during walking
      • Increased residual knee negative work6
    • Reduced reliance on sound limb for support during walking
      • Reduced intact limb peak hip flexion moment6
      • Reduced intact limb peak dorsiflexion moment6
      • Reduced intact ankle negative work and total work6
      • Reduced intact limb total joint work6
    • Better symmetry of loading between prosthetic and sound limbs during standing on a slope
      • Degree of asymmetry closer to zero for 5/5 amputees3
    • Reduced residual and sound joint moments during standing of a slope
      • Significant reductions in both prosthetic and sound support moments12
    • Less pressure on the sole of the contralateral foot
      • Peak plantar-pressure13
    • Improved gait symmetry
      • Reduced stance phase timing asymmetry14
    • Patient reported outcome measures indicate improvements
      • Mean improvement across all Prosthesis Evaluation Questionnaire domains15
      • Bilateral patients showed highest mean improvement in satisfaction15
    • Subjective user preference for hydraulic ankle
      • 13/13 participants preferred hydraulic ankle13

    Improvements in Clinical Outcomes using shock-absorbing pylon/torque absorber compared to rigid pylon

    Reduced back pain during twisting movements e.g. golf swings16

    • Reduced compensatory knee flexion at loading response17
    • No reduction in step activity18
    • Blatchford torsion adaptors match the able-bodied rotational range19
    • Reduced loading rate on prosthetic limb20, particularly at fast walking speeds21
    • Users feel less pressure on their residual limb22
    • Patient preference, citing improved comfort, smoothness of gait and easier stairs descent20

    References

    1. Riveras M, Ravera E, Ewins D, Shaheen AF, Catalfamo-Formento P. Minimum toe clearance and tripping probability in people with unilateral transtibial amputation walking on ramps with different prosthetic designs. Gait & Posture. 2020 Sep 1;81:41-8.
    2. Johnson L, De Asha AR, Munjal R, et al. Toe clearance when walking in people with unilateral transtibial amputation: effects of passive hydraulic ankle. J Rehabil Res Dev 2014; 51: 429. Download
    Overview
    3. McGrath M, Laszczak P, Zahedi S, et al. Microprocessor knees with “standing support” and articulating, hydraulic ankles improve balance control and inter-limb loading during quiet standing. J Rehabil Assist Technol Eng 2018; 5: 2055668318795396. Download
    Overview
    4. Askew GN, McFarlane LA, Minetti AE, et al. Energy cost of ambulation in trans-tibial amputees using a dynamic-response foot with hydraulic versus rigid ‘ankle’: insights from body centre of mass dynamics. J NeuroEngineering Rehabil 2019; 16: 39. Download
    Overview
    5. De Asha AR, Munjal R, Kulkarni J, et al. Impact on the biomechanics of overground gait of using an ‘Echelon’hydraulic ankle–foot device in unilateral trans-tibial and trans-femoral amputees. Clin Biomech 2014; 29: 728–734. Download
    Overview
    6. De Asha AR, Munjal R, Kulkarni J, et al. Walking speed related joint kinetic alterations in trans-tibial amputees: impact of hydraulic’ankle’damping. J Neuroengineering Rehabil 2013; 10: 1. Download
    Overview
    7. De Asha AR, Johnson L, Munjal R, et al. Attenuation of centre-of-pressure trajectory fluctuations under the prosthetic foot when using an articulating hydraulic ankle attachment compared to fixed attachment. Clin Biomech 2013; 28: 218–224. Download
    Overview
    8. Wurdeman SR, Stevens PM, Campbell JH. Mobility analysis of AmpuTees (MAAT 5): Impact of five common prosthetic ankle-foot categories for individuals with diabetic/dysvascular amputation. J Rehabil Assist Technol Eng 2019; 6: 2055668318820784. Download
    Overview
    9. Bai X, Ewins D, Crocombe AD, et al. Kinematic and biomimetic assessment of a hydraulic ankle/foot in level ground and camber walking. PLOS ONE 2017; 12: e0180836. Download
    Overview
    10. Bai X, Ewins D, Crocombe AD, et al. A biomechanical assessment of hydraulic ankle-foot devices with and without micro-processor control during slope ambulation in trans-femoral amputees. PLOS ONE 2018; 13: e0205093. Download
    Overview
    11. Portnoy S, Kristal A, Gefen A, et al. Outdoor dynamic subject-specific evaluation of internal stresses in the residual limb: hydraulic energy-stored prosthetic foot compared to conventional energy-stored prosthetic feet. Gait Posture 2012; 35: 121–125. Download
    Overview
    12. McGrath M, Davies KC, Laszczak P, et al. The influence of hydraulic ankles and microprocessor-control on the biomechanics of trans-tibial amputees during quiet standing on a 5° slope. Can Prosthet Orthot J; 2.
    13. Moore R. Effect of a Prosthetic Foot with a Hydraulic Ankle Unit on the Contralateral Foot Peak Plantar Pressures in Individuals with Unilateral Amputation. JPO J Prosthet Orthot 2018; 30: 165–70. Download
    Overview
    14. Moore R. Effect on Stance Phase Timing Asymmetry in Individuals with Amputation Using Hydraulic Ankle Units. JPO J Prosthet Orthot 2016; 28: 44–48. Download
    Overview
    15. Sedki I, Moore R. Patient evaluation of the Echelon foot using the Seattle Prosthesis Evaluation Questionnaire. Prosthet Orthot Int 2013; 37: 250–254. Download
    Overview
    16. Rogers JP, Strike SC, Wallace ES. The effect of prosthetic torsional stiffness on the golf swing kinematics of a left and a right-sided trans-tibial amputee. Prosthet Orthot Int 2004; 28: 121–131.
    17. Berge JS, Czerniecki JM, Klute GK. Efficacy of shock-absorbing versus rigid pylons for impact reduction in transtibial amputees based on laboratory, field, and outcome metrics. J Rehabil Res Dev 2005; 42: 795.
    18. Klute GK, Berge JS, Orendurff MS, et al. Prosthetic intervention effects on activity of lower-extremity amputees. Arch Phys Med Rehabil 2006; 87: 717–722.
    19. Flick KC, Orendurff MS, Berge JS, et al. Comparison of human turning gait with the mechanical performance of lower limb prosthetic transverse rotation adapters. Prosthet Orthot Int 2005; 29: 73–81.
    20. Gard SA, Konz RJ. The effect of a shock-absorbing pylon on the gait of persons with unilateral transtibial amputation. J Rehabil Res Dev 2003; 40: 109–124.
    21. Boutwell E, Stine R, Gard S. Shock absorption during transtibial amputee gait: Does longitudinal prosthetic stiffness play a role? Prosthet Orthot Int 2017; 41: 178–185.
    22. Adderson JA, Parker KE, Macleod DA, et al. Effect of a shock-absorbing pylon on transmission of heel strike forces during the gait of people with unilateral trans-tibial amputations: a pilot study. Prosthet Orthot Int 2007; 31: 384–393.
  • Elan

    Improvements in Clinical Outcomes using Elan compared to ESR feet

    • Reduced risk of tripping and falls
      • Increased minimum toe clearance during swing phase1,2
    • Improved knee stability on the prosthetic side during slope descent
      • Increased mid-stance external prosthetic knee extensor moment3
    • Improving standing balance on a slope
      • 24-25% reduction in mean inter-limb centre-of-pressure root mean square (COP RMS)4
    • Reduced energy expenditure during walking
      • Mean 11.8% reduction in energy use on level ground, across all walking speeds5
      • Mean 20.2% reduction in energy use on slopes, across all gradients5
      • Mean 8.3% faster walking speed for the same amount of effort5
    • Improved gait performance
      • Faster self-selected walking speed2,6-9
    • Improved ground compliance when walking on slopes
      • Increased plantarflexion peak during level walking, fast level walking and cambered walking10
      • Increased dorsiflexion peak during level walking, fast level walking and cambered walking10
    • Less of a prosthetic “dead spot” during gait
      • Reduced aggregate negative COP displacement7
      • Centre-of-pressure passes anterior to the shank statistically significantly earlier in stance7
      • Increased minimum instantaneous COM velocity during prosthetic-limb single support phase7
      • Reduced peak negative COP velocity9
      • Reduced COP posterior travel distance9
    • Improved ground compliance when walking on slopes
      • Increased plantarflexion range during slope descent3
      • Increased dorsiflexion range during slope ascent3
    • Less effort on residual hip for trans-femoral amputees on varied terrains
      • Reduced the mean hip extension and flexion moments11
    • Effects consistent over time
      • Same gait variable changes in two gait lab sessions one year apart6
      • Magnitude of changes comparable between sessions6
    • Brake mode during slope descent to control momentum build up
      • Reduced mean prosthetic shank angular velocity in single support12
      • Increased Unified Deformable Segment (prosthetic ‘ankle’) negative work12
    • Less gait compensation movements during slope descent
      • Reduced residual knee flexion at loading response12
    • Helps protect vulnerable residual limb tissue, reducing likelihood of damage
      • Reduced peak stresses on residual limb13
      • Reduced stress RMS on residual limb13
      • Reduced loading rates on residual limb13
    • Greater contribution of prosthetic limb to support during walking
      • Increased residual knee peak extension moment6
      • Decreased residual knee peak flexion moment6
      • Increased residual knee negative work8
    • Reduced reliance on sound limb for support during walking
      • Reduced intact limb peak hip flexion moment8
      • Reduced intact limb peak dorsiflexion moment8
      • Reduced intact ankle negative work and total work8
      • Reduced intact limb total joint work8
    • Better symmetry of loading between prosthetic and sound limbs during standing on a slope
      • Degree of asymmetry closer to zero for 5/5 amputees4
    • Reduced residual and sound joint moments during standing of a slope
      • Significant reductions in both prosthetic and sound support moments14
    • Reduced residual joint moments during standing of a slope for bilateral amputees
      • Significant reductions in prosthetic support moment14
      • Permitted ‘natural’ ground reaction vector sagittal plane position, relative to knee joint centres14
    • Less pressure on the sole of the contralateral foot
      • Peak plantar-pressure15
    • Improved gait symmetry
      • Reduced stance phase timing asymmetry16
    • Patient reported outcome measures indicate improvements
      • Mean improvement across all Prosthesis Evaluation Questionnaire domains17
      • Bilateral patients showed highest mean improvement in satisfaction17
    • Subjective user preference for hydraulic ankle
      • 13/13 participants preferred hydraulic ankle15

    Improvements in Clinical Outcomes using Elan compared to non-microprocessor-control hydraulic ankle-feet

    • Improved knee stability on the prosthetic side during slope descent
      • Increased mid-stance external prosthetic knee extensor moment3
    • Improved ground compliance when walking down slopes
      • Reduced time to foot flat12
    • Brake mode during slope descent increases resistance to dorsiflexion to control momentum build up
      • Reduced dorsiflexion range during slope descent3
      • Reduced mean prosthetic shank angular velocity in single support12
      • Increased Unified Deformable Segment (prosthetic ‘ankle’) negative work12
      • Transition from dorsiflexion to plantarflexion moment occurs earlier in stance phase18
      • Increase in mean prosthetic ‘ankle’ plantarflexion moment integral18
    • Assist mode during slope ascent decreases resistance to dorsiflexion to allow easier progression
      • Transition from dorsiflexion to plantarflexion moment occurs later in stance phase18
      • Decrease in mean prosthetic ‘ankle’ plantarflexion moment integral18
    • Less gait compensation movements during slope descent
      • Reduced residual knee flexion at loading response12
    • Greater reliance on prosthetic side for bodyweight support during slope descent
      • Increased support moment integral18
    • Less reliance on sound side for bodyweight support during slope descent
      • Decreased support moment integral18
    • Less reliance on sound side for bodyweight support during slope ascent
      • Decreased support moment integral18
    • Reduced sound joint moments during standing of a slope
      • Significant reductions in sound support moment14
    • Reduced residual joint moments during standing of a slope for bilateral amputees
      • Significant reductions in prosthetic support moment14
      • Permitted ‘natural’ ground reaction vector sagittal plane position, relative to knee joint centres14

    References

    1. Riveras M, Ravera E, Ewins D, Shaheen AF, Catalfamo-Formento P. Minimum toe clearance and tripping probability in people with unilateral transtibial amputation walking on ramps with different prosthetic designs. Gait & Posture. 2020 Sep 1;81:41-8.
    2. Johnson L, De Asha AR, Munjal R, et al. Toe clearance when walking in people with unilateral transtibial amputation: effects of passive hydraulic ankle. J Rehabil Res Dev 2014; 51: 429. Download
    Overview
    3. Bai X, Ewins D, Crocombe AD, et al. A biomechanical assessment of hydraulic ankle-foot devices with and without micro-processor control during slope ambulation in trans-femoral amputees. PLOS ONE 2018; 13: e0205093. Download
    Overview
    4. McGrath M, Laszczak P, Zahedi S, et al. Microprocessor knees with “standing support” and articulating, hydraulic ankles improve balance control and inter-limb loading during quiet standing. J Rehabil Assist Technol Eng 2018; 5: 2055668318795396. Download
    Overview
    5. Askew GN, McFarlane LA, Minetti AE, et al. Energy cost of ambulation in trans-tibial amputees using a dynamic-response foot with hydraulic versus rigid ‘ankle’: insights from body centre of mass dynamics. J NeuroEngineering Rehabil 2019; 16: 39. Download
    Overview
    6. De Asha AR, Barnett CT, Struchkov V, et al. Which Prosthetic Foot to Prescribe?: Biomechanical Differences Found during a Single-Session Comparison of Different Foot Types Hold True 1 Year Later. JPO J Prosthet Orthot 2017; 29: 39–43. Download
    Overview
    7. De Asha AR, Munjal R, Kulkarni J, et al. Impact on the biomechanics of overground gait of using an ‘Echelon’hydraulic ankle–foot device in unilateral trans-tibial and trans-femoral amputees. Clin Biomech 2014; 29: 728–734.
    8. De Asha AR, Munjal R, Kulkarni J, et al. Walking speed related joint kinetic alterations in trans-tibial amputees: impact of hydraulic’ankle’damping. J Neuroengineering Rehabil 2013; 10: 1. Download
    Overview
    9. De Asha AR, Johnson L, Munjal R, et al. Attenuation of centre-of-pressure trajectory fluctuations under the prosthetic foot when using an articulating hydraulic ankle attachment compared to fixed attachment. Clin Biomech 2013; 28: 218–224. Download
    Overview
    10. Bai X, Ewins D, Crocombe AD, et al. Kinematic and biomimetic assessment of a hydraulic ankle/foot in level ground and camber walking. PLOS ONE 2017; 12: e0180836. Download
    Overview
    11. Alexander N, Strutzenberger G, Kroell J, et al. Joint Moments During Downhill and Uphill Walking of a Person with Transfemoral Amputation with a Hydraulic Articulating and a Rigid Prosthetic Ankle—A Case Study. JPO J Prosthet Orthot 2018; 30: 46–54. Download
    Overview
    12. Struchkov V, Buckley JG. Biomechanics of ramp descent in unilateral trans-tibial amputees: Comparison of a microprocessor controlled foot with conventional ankle–foot mechanisms. Clin Biomech 2016; 32: 164–170. Download
    Overview
    13. Portnoy S, Kristal A, Gefen A, et al. Outdoor dynamic subject-specific evaluation of internal stresses in the residual limb: hydraulic energy-stored prosthetic foot compared to conventional energy-stored prosthetic feet. Gait Posture 2012; 35: 121–125. Download
    Overview
    14. McGrath M, Davies KC, Laszczak P, et al. The influence of hydraulic ankles and microprocessor-control on the biomechanics of trans-tibial amputees during quiet standing on a 5° slope. Can Prosthet Orthot J; 2. Download
    Overview
    15. Moore R. Effect of a Prosthetic Foot with a Hydraulic Ankle Unit on the Contralateral Foot Peak Plantar Pressures in Individuals with Unilateral Amputation. JPO J Prosthet Orthot 2018; 30: 165–70. Download
    Overview
    16. Moore R. Effect on Stance Phase Timing Asymmetry in Individuals with Amputation Using Hydraulic Ankle Units. JPO J Prosthet Orthot 2016; 28: 44–48. Download
    Overview
    17. Sedki I, Moore R. Patient evaluation of the Echelon foot using the Seattle Prosthesis Evaluation Questionnaire. Prosthet Orthot Int 2013; 37: 250–254. Download
    Overview
    18. McGrath M, Laszczak P, Zahedi S, et al. The influence of a microprocessor-controlled hydraulic ankle on the kinetic symmetry of trans-tibial amputees during ramp walking: a case series. J Rehabil Assist Technol Eng 2018; 5: 2055668318790650. Download
    Overview
  • ElanIC

    Improvements in Clinical Outcomes using Elan compared to ESR feet

    • Reduced risk of tripping and falls
      • Increased minimum toe clearance during swing phase1,2
    • Improved knee stability on the prosthetic side during slope descent
      • Increased mid-stance external prosthetic knee extensor moment3
    • Improving standing balance on a slope
      • 24-25% reduction in mean inter-limb centre-of-pressure root mean square (COP RMS)4
    • Reduced energy expenditure during walking
      • Mean 11.8% reduction in energy use on level ground, across all walking speeds5
      • Mean 20.2% reduction in energy use on slopes, across all gradients5
      • Mean 8.3% faster walking speed for the same amount of effort5
    • Improved gait performance
      • Faster self-selected walking speed2,6-9
    • Improved ground compliance when walking on slopes
      • Increased plantarflexion peak during level walking, fast level walking and cambered walking10
      • Increased dorsiflexion peak during level walking, fast level walking and cambered walking10
    • Less of a prosthetic “dead spot” during gait
      • Reduced aggregate negative COP displacement7
      • Centre-of-pressure passes anterior to the shank statistically significantly earlier in stance7
      • Increased minimum instantaneous COM velocity during prosthetic-limb single support phase7
      • Reduced peak negative COP velocity9
      • Reduced COP posterior travel distance9
    • Improved ground compliance when walking on slopes
      • Increased plantarflexion range during slope descent3
      • Increased dorsiflexion range during slope ascent3
    • Less effort on residual hip for trans-femoral amputees on varied terrains
      • Reduced the mean hip extension and flexion moments11
    • Effects consistent over time
      • Same gait variable changes in two gait lab sessions one year apart6
      • Magnitude of changes comparable between sessions6
    • Brake mode during slope descent to control momentum build up
      • Reduced mean prosthetic shank angular velocity in single support12
      • Increased Unified Deformable Segment (prosthetic ‘ankle’) negative work12
    • Less gait compensation movements during slope descent
      • Reduced residual knee flexion at loading response12
    • Helps protect vulnerable residual limb tissue, reducing likelihood of damage
      • Reduced peak stresses on residual limb13
      • Reduced stress RMS on residual limb13
      • Reduced loading rates on residual limb13
    • Greater contribution of prosthetic limb to support during walking
      • Increased residual knee peak extension moment6
      • Decreased residual knee peak flexion moment6
      • Increased residual knee negative work8
    • Reduced reliance on sound limb for support during walking
      • Reduced intact limb peak hip flexion moment8
      • Reduced intact limb peak dorsiflexion moment8
      • Reduced intact ankle negative work and total work8
      • Reduced intact limb total joint work8
    • Better symmetry of loading between prosthetic and sound limbs during standing on a slope
      • Degree of asymmetry closer to zero for 5/5 amputees4
    • Reduced residual and sound joint moments during standing of a slope
      • Significant reductions in both prosthetic and sound support moments14
    • Reduced residual joint moments during standing of a slope for bilateral amputees
      • Significant reductions in prosthetic support moment14
      • Permitted ‘natural’ ground reaction vector sagittal plane position, relative to knee joint centres14
    • Less pressure on the sole of the contralateral foot
      • Peak plantar-pressure15
    • Improved gait symmetry
      • Reduced stance phase timing asymmetry16
    • Patient reported outcome measures indicate improvements
      • Mean improvement across all Prosthesis Evaluation Questionnaire domains17
      • Bilateral patients showed highest mean improvement in satisfaction17
    • Subjective user preference for hydraulic ankle
      • 13/13 participants preferred hydraulic ankle15

    Improvements in Clinical Outcomes using Elan compared to non-microprocessor-control hydraulic ankle-feet

    • Improved knee stability on the prosthetic side during slope descent
      • Increased mid-stance external prosthetic knee extensor moment3
    • Improved ground compliance when walking down slopes
      • Reduced time to foot flat12
    • Brake mode during slope descent increases resistance to dorsiflexion to control momentum build up
      • Reduced dorsiflexion range during slope descent3
      • Reduced mean prosthetic shank angular velocity in single support12
      • Increased Unified Deformable Segment (prosthetic ‘ankle’) negative work12
      • Transition from dorsiflexion to plantarflexion moment occurs earlier in stance phase18
      • Increase in mean prosthetic ‘ankle’ plantarflexion moment integral18
    • Assist mode during slope ascent decreases resistance to dorsiflexion to allow easier progression
      • Transition from dorsiflexion to plantarflexion moment occurs later in stance phase18
      • Decrease in mean prosthetic ‘ankle’ plantarflexion moment integral18
    • Less gait compensation movements during slope descent

    Reduced residual knee flexion at loading response12

    • Greater reliance on prosthetic side for bodyweight support during slope descent
      • Increased support moment integral18
    • Less reliance on sound side for bodyweight support during slope descent
      • Decreased support moment integral18
    • Less reliance on sound side for bodyweight support during slope ascent
      • Decreased support moment integral18
    • Reduced sound joint moments during standing of a slope
      • Significant reductions in sound support moment14
    • Reduced residual joint moments during standing of a slope for bilateral amputees
      • Significant reductions in prosthetic support moment14
      • Permitted ‘natural’ ground reaction vector sagittal plane position, relative to knee joint centres14

    References

    1. Riveras M, Ravera E, Ewins D, Shaheen AF, Catalfamo-Formento P. Minimum toe clearance and tripping probability in people with unilateral transtibial amputation walking on ramps with different prosthetic designs. Gait & Posture. 2020 Sep 1;81:41-8.
    2. Johnson L, De Asha AR, Munjal R, et al. Toe clearance when walking in people with unilateral transtibial amputation: effects of passive hydraulic ankle. J Rehabil Res Dev 2014; 51: 429. Download
    Overview
    3. Bai X, Ewins D, Crocombe AD, et al. A biomechanical assessment of hydraulic ankle-foot devices with and without micro-processor control during slope ambulation in trans-femoral amputees. PLOS ONE 2018; 13: e0205093. Download
    Overview
    4. McGrath M, Laszczak P, Zahedi S, et al. Microprocessor knees with “standing support” and articulating, hydraulic ankles improve balance control and inter-limb loading during quiet standing. J Rehabil Assist Technol Eng 2018; 5: 2055668318795396. Download
    Overview
    5. Askew GN, McFarlane LA, Minetti AE, et al. Energy cost of ambulation in trans-tibial amputees using a dynamic-response foot with hydraulic versus rigid ‘ankle’: insights from body centre of mass dynamics. J NeuroEngineering Rehabil 2019; 16: 39. Download
    Overview
    6. De Asha AR, Barnett CT, Struchkov V, et al. Which Prosthetic Foot to Prescribe?: Biomechanical Differences Found during a Single-Session Comparison of Different Foot Types Hold True 1 Year Later. JPO J Prosthet Orthot 2017; 29: 39–43. Download
    Overview
    7. De Asha AR, Munjal R, Kulkarni J, et al. Impact on the biomechanics of overground gait of using an ‘Echelon’hydraulic ankle–foot device in unilateral trans-tibial and trans-femoral amputees. Clin Biomech 2014; 29: 728–734.
    8. De Asha AR, Munjal R, Kulkarni J, et al. Walking speed related joint kinetic alterations in trans-tibial amputees: impact of hydraulic’ankle’damping. J Neuroengineering Rehabil 2013; 10: 1. Download
    Overview
    9. De Asha AR, Johnson L, Munjal R, et al. Attenuation of centre-of-pressure trajectory fluctuations under the prosthetic foot when using an articulating hydraulic ankle attachment compared to fixed attachment. Clin Biomech 2013; 28: 218–224. Download
    Overview
    10. Bai X, Ewins D, Crocombe AD, et al. Kinematic and biomimetic assessment of a hydraulic ankle/foot in level ground and camber walking. PLOS ONE 2017; 12: e0180836. Download
    Overview
    11. Alexander N, Strutzenberger G, Kroell J, et al. Joint Moments During Downhill and Uphill Walking of a Person with Transfemoral Amputation with a Hydraulic Articulating and a Rigid Prosthetic Ankle—A Case Study. JPO J Prosthet Orthot 2018; 30: 46–54. Download
    Overview
    12. Struchkov V, Buckley JG. Biomechanics of ramp descent in unilateral trans-tibial amputees: Comparison of a microprocessor controlled foot with conventional ankle–foot mechanisms. Clin Biomech 2016; 32: 164–170. Download
    Overview
    13. Portnoy S, Kristal A, Gefen A, et al. Outdoor dynamic subject-specific evaluation of internal stresses in the residual limb: hydraulic energy-stored prosthetic foot compared to conventional energy-stored prosthetic feet. Gait Posture 2012; 35: 121–125. Download
    Overview
    14. McGrath M, Davies KC, Laszczak P, et al. The influence of hydraulic ankles and microprocessor-control on the biomechanics of trans-tibial amputees during quiet standing on a 5° slope. Can Prosthet Orthot J; 2. Download
    Overview
    15. Moore R. Effect of a Prosthetic Foot with a Hydraulic Ankle Unit on the Contralateral Foot Peak Plantar Pressures in Individuals with Unilateral Amputation. JPO J Prosthet Orthot 2018; 30: 165–70. Download
    Overview
    16. Moore R. Effect on Stance Phase Timing Asymmetry in Individuals with Amputation Using Hydraulic Ankle Units. JPO J Prosthet Orthot 2016; 28: 44–48. Download
    Overview
    17. Sedki I, Moore R. Patient evaluation of the Echelon foot using the Seattle Prosthesis Evaluation Questionnaire. Prosthet Orthot Int 2013; 37: 250–254. Download
    Overview
    18. McGrath M, Laszczak P, Zahedi S, et al. The influence of a microprocessor-controlled hydraulic ankle on the kinetic symmetry of trans-tibial amputees during ramp walking: a case series. J Rehabil Assist Technol Eng 2018; 5: 2055668318790650. Download
    Overview
  • Elite Blade

    Clinical Outcomes using e-carbon feet

    • High mean radius of curvature for Esprit-style e-carbon feet2: “The larger the radius of curvature, the more stable is the foot”
    • Allow variable running speeds3
    • Increased self-selected walking speed4
    • Elite-style e-carbon feet (L code VL5987) or VT units demonstrate the second highest mobility levels, behind only microprocessor feet5
    • Users demonstrate confidence in prosthetic loading during high activity6
    • Improved prosthetic push-off work compared to SACH feet7
    • Increased prosthetic positive work done4
    • High degree of user satisfaction, particularly with high activity users8

    Much research confirms the substantial equivalency of all energy-storing and return feet, including Blatchford e-carbon feet1.

    References

    1. Crimin A, McGarry A, Harris EJ, et al. The effect that energy storage and return feet have on the propulsion of the body: A pilot study. Proc Inst Mech Eng [H] 2014; 228: 908–915.
    2. Curtze C, Hof AL, van Keeken HG, et al. Comparative roll-over analysis of prosthetic feet. J Biomech 2009; 42: 1746–1753.
    3. Strike SC, Arcone D, Orendurff M. Running at submaximal speeds, the role of the intact and prosthetic limbs for trans-tibial amputees. Gait Posture 2018; 62: 327–332.
    4. Ray SF, Wurdeman SR, Takahashi KZ. Prosthetic energy return during walking increases after 3 weeks of adaptation to a new device. J Neuroengineering Rehabil 2018; 15: 6.
    5. Wurdeman SR, Stevens PM, Campbell JH. Mobility analysis of AmpuTees (MAAT 5): Impact of five common prosthetic ankle-foot categories for individuals with diabetic/dysvascular amputation. J Rehabil Assist Technol Eng 2019; 6: 2055668318820784. Download
    Overview
    6. Haber CK, Ritchie LJ, Strike SC. Dynamic elastic response prostheses alter approach angles and ground reaction forces but not leg stiffness during a start-stop task. Hum Mov Sci 2018; 58: 337–346.
    7. Rock CG, Wurdeman SR, Stergiou N, Takahashi KZ. Stride-to-stride fluctuations in transtibial amputees are not affected by changes in push-off mechanics from using different prostheses. PloS one. 2018;13(10).
    8. Highsmith MJ, Kahle JT, Miro RM, et al. Differences in Military Obstacle Course Performance Between Three Energy-Storing and Shock-Adapting Prosthetic Feet in High-Functioning Transtibial Amputees: A Double-Blind, Randomized Control Trial. Mil Med 2016; 181: 45–54.
  • Elite BladeVT

    Clinical Outcomes using e-carbon feet

    • High mean radius of curvature for Esprit-style e-carbon feet2: “The larger the radius of curvature, the more stable is the foot”
    • Allow variable running speeds3
    • Increased self-selected walking speed4
    • Elite-style e-carbon feet (L code VL5987) or VT units demonstrate the second highest mobility levels, behind only microprocessor feet5
    • Users demonstrate confidence in prosthetic loading during high activity6
    • Improved prosthetic push-off work compared to SACH feet7
    • Increased prosthetic positive work done4
    • High degree of user satisfaction, particularly with high activity users8

    Improvements in Clinical Outcomes using shock-absorbing pylon/torque absorber compared to rigid pylon

    • Reduced back pain during twisting movements e.g. golf swings9
    • Reduced compensatory knee flexion at loading response10
    • No reduction in step activity11
    • Blatchford torsion adaptors match the able-bodied rotational range12
    • Reduced loading rate on prosthetic limb13, particularly at fast walking speeds14
    • Users feel less pressure on their residual limb15
    • Patient preference, citing improved comfort, smoothness of gait and easier stairs descent13

    Much research confirms the substantial equivalency of all energy-storing and return feet, including Blatchford e-carbon feet1.

    References

    1. Crimin A, McGarry A, Harris EJ, et al. The effect that energy storage and return feet have on the propulsion of the body: A pilot study. Proc Inst Mech Eng [H] 2014; 228: 908–915.
    2. Curtze C, Hof AL, van Keeken HG, et al. Comparative roll-over analysis of prosthetic feet. J Biomech 2009; 42: 1746–1753.
    3. Strike SC, Arcone D, Orendurff M. Running at submaximal speeds, the role of the intact and prosthetic limbs for trans-tibial amputees. Gait Posture 2018; 62: 327–332.
    4. Ray SF, Wurdeman SR, Takahashi KZ. Prosthetic energy return during walking increases after 3 weeks of adaptation to a new device. J Neuroengineering Rehabil 2018; 15: 6.
    5. Wurdeman SR, Stevens PM, Campbell JH. Mobility analysis of AmpuTees (MAAT 5): Impact of five common prosthetic ankle-foot categories for individuals with diabetic/dysvascular amputation. J Rehabil Assist Technol Eng 2019; 6: 2055668318820784. Download
    Overview
    6. Haber CK, Ritchie LJ, Strike SC. Dynamic elastic response prostheses alter approach angles and ground reaction forces but not leg stiffness during a start-stop task. Hum Mov Sci 2018; 58: 337–346.
    7. Rock CG, Wurdeman SR, Stergiou N, Takahashi KZ. Stride-to-stride fluctuations in transtibial amputees are not affected by changes in push-off mechanics from using different prostheses. PloS one. 2018;13(10).
    8. Highsmith MJ, Kahle JT, Miro RM, et al. Differences in Military Obstacle Course Performance Between Three Energy-Storing and Shock-Adapting Prosthetic Feet in High-Functioning Transtibial Amputees: A Double-Blind, Randomized Control Trial. Mil Med 2016; 181: 45–54.
    9. Rogers JP, Strike SC, Wallace ES. The effect of prosthetic torsional stiffness on the golf swing kinematics of a left and a right-sided trans-tibial amputee. Prosthet Orthot Int 2004; 28: 121–131.
    10. Berge JS, Czerniecki JM, Klute GK. Efficacy of shock-absorbing versus rigid pylons for impact reduction in transtibial amputees based on laboratory, field, and outcome metrics. J Rehabil Res Dev 2005; 42: 795.
    11. Klute GK, Berge JS, Orendurff MS, et al. Prosthetic intervention effects on activity of lower-extremity amputees. Arch Phys Med Rehabil 2006; 87: 717–722.
    12. Flick KC, Orendurff MS, Berge JS, et al. Comparison of human turning gait with the mechanical performance of lower limb prosthetic transverse rotation adapters. Prosthet Orthot Int 2005; 29: 73–81.
    13. Gard SA, Konz RJ. The effect of a shock-absorbing pylon on the gait of persons with unilateral transtibial amputation. J Rehabil Res Dev 2003; 40: 109–124.
    14. Boutwell E, Stine R, Gard S. Shock absorption during transtibial amputee gait: Does longitudinal prosthetic stiffness play a role? Prosthet Orthot Int 2017; 41: 178–185.
    15. Adderson JA, Parker KE, Macleod DA, et al. Effect of a shock-absorbing pylon on transmission of heel strike forces during the gait of people with unilateral trans-tibial amputations: a pilot study. Prosthet Orthot Int 2007; 31: 384–393.
  • Elite2

    Clinical Outcomes using e-carbon feet

    • High mean radius of curvature for Esprit-style e-carbon feet2: “The larger the radius of curvature, the more stable is the foot”
    • Allow variable running speeds3
    • Increased self-selected walking speed4
    • Elite-style e-carbon feet (L code VL5987) or VT units demonstrate the second highest mobility levels, behind only microprocessor feet5
    • Users demonstrate confidence in prosthetic loading during high activity6
    • Improved prosthetic push-off work compared to SACH feet7
    • Increased prosthetic positive work done4
    • High degree of user satisfaction, particularly with high activity users8

    Much research confirms the substantial equivalency of all energy-storing and return feet, including Blatchford e-carbon feet1.

    References

    1. Crimin A, McGarry A, Harris EJ, et al. The effect that energy storage and return feet have on the propulsion of the body: A pilot study. Proc Inst Mech Eng [H] 2014; 228: 908–915.
    2. Curtze C, Hof AL, van Keeken HG, et al. Comparative roll-over analysis of prosthetic feet. J Biomech 2009; 42: 1746–1753.
    3. Strike SC, Arcone D, Orendurff M. Running at submaximal speeds, the role of the intact and prosthetic limbs for trans-tibial amputees. Gait Posture 2018; 62: 327–332.
    4. Ray SF, Wurdeman SR, Takahashi KZ. Prosthetic energy return during walking increases after 3 weeks of adaptation to a new device. J Neuroengineering Rehabil 2018; 15: 6.
    5. Wurdeman SR, Stevens PM, Campbell JH. Mobility analysis of AmpuTees (MAAT 5): Impact of five common prosthetic ankle-foot categories for individuals with diabetic/dysvascular amputation. J Rehabil Assist Technol Eng 2019; 6: 2055668318820784. Download
    Overview
    6. Haber CK, Ritchie LJ, Strike SC. Dynamic elastic response prostheses alter approach angles and ground reaction forces but not leg stiffness during a start-stop task. Hum Mov Sci 2018; 58: 337–346.
    7. Rock CG, Wurdeman SR, Stergiou N, Takahashi KZ. Stride-to-stride fluctuations in transtibial amputees are not affected by changes in push-off mechanics from using different prostheses. PloS one. 2018;13(10).
    8. Highsmith MJ, Kahle JT, Miro RM, et al. Differences in Military Obstacle Course Performance Between Three Energy-Storing and Shock-Adapting Prosthetic Feet in High-Functioning Transtibial Amputees: A Double-Blind, Randomized Control Trial. Mil Med 2016; 181: 45–54.
  • EliteVT

    Clinical Outcomes using e-carbon feet

    • High mean radius of curvature for Esprit-style e-carbon feet2: “The larger the radius of curvature, the more stable is the foot”
    • Allow variable running speeds3
    • Increased self-selected walking speed4
    • Elite-style e-carbon feet (L code VL5987) or VT units demonstrate the second highest mobility levels, behind only microprocessor feet5
    • Users demonstrate confidence in prosthetic loading during high activity6
    • Improved prosthetic push-off work compared to SACH feet7
    • Increased prosthetic positive work done4
    • High degree of user satisfaction, particularly with high activity users8

    Improvements in Clinical Outcomes using shock-absorbing pylon/torque absorber compared to rigid pylon

    • Reduced back pain during twisting movements e.g. golf swings9
    • Reduced compensatory knee flexion at loading response10
    • No reduction in step activity11
    • Blatchford torsion adaptors match the able-bodied rotational range12
    • Reduced loading rate on prosthetic limb13, particularly at fast walking speeds14
    • Users feel less pressure on their residual limb15
    • Patient preference, citing improved comfort, smoothness of gait and easier stairs descent13

    Much research confirms the substantial equivalency of all energy-storing and return feet, including Blatchford e-carbon feet1.

    References

    1. Crimin A, McGarry A, Harris EJ, et al. The effect that energy storage and return feet have on the propulsion of the body: A pilot study. Proc Inst Mech Eng [H] 2014; 228: 908–915.
    2. Curtze C, Hof AL, van Keeken HG, et al. Comparative roll-over analysis of prosthetic feet. J Biomech 2009; 42: 1746–1753.
    3. Strike SC, Arcone D, Orendurff M. Running at submaximal speeds, the role of the intact and prosthetic limbs for trans-tibial amputees. Gait Posture 2018; 62: 327–332.
    4. Ray SF, Wurdeman SR, Takahashi KZ. Prosthetic energy return during walking increases after 3 weeks of adaptation to a new device. J Neuroengineering Rehabil 2018; 15: 6.
    5. Wurdeman SR, Stevens PM, Campbell JH. Mobility analysis of AmpuTees (MAAT 5): Impact of five common prosthetic ankle-foot categories for individuals with diabetic/dysvascular amputation. J Rehabil Assist Technol Eng 2019; 6: 2055668318820784. Download
    Overview
    6. Haber CK, Ritchie LJ, Strike SC. Dynamic elastic response prostheses alter approach angles and ground reaction forces but not leg stiffness during a start-stop task. Hum Mov Sci 2018; 58: 337–346.
    7. Rock CG, Wurdeman SR, Stergiou N, Takahashi KZ. Stride-to-stride fluctuations in transtibial amputees are not affected by changes in push-off mechanics from using different prostheses. PloS one. 2018;13(10).
    8. Highsmith MJ, Kahle JT, Miro RM, et al. Differences in Military Obstacle Course Performance Between Three Energy-Storing and Shock-Adapting Prosthetic Feet in High-Functioning Transtibial Amputees: A Double-Blind, Randomized Control Trial. Mil Med 2016; 181: 45–54.
    9. Rogers JP, Strike SC, Wallace ES. The effect of prosthetic torsional stiffness on the golf swing kinematics of a left and a right-sided trans-tibial amputee. Prosthet Orthot Int 2004; 28: 121–131.
    10. Berge JS, Czerniecki JM, Klute GK. Efficacy of shock-absorbing versus rigid pylons for impact reduction in transtibial amputees based on laboratory, field, and outcome metrics. J Rehabil Res Dev 2005; 42: 795.
    11. Klute GK, Berge JS, Orendurff MS, et al. Prosthetic intervention effects on activity of lower-extremity amputees. Arch Phys Med Rehabil 2006; 87: 717–722.
    12. Flick KC, Orendurff MS, Berge JS, et al. Comparison of human turning gait with the mechanical performance of lower limb prosthetic transverse rotation adapters. Prosthet Orthot Int 2005; 29: 73–81.
    13. Gard SA, Konz RJ. The effect of a shock-absorbing pylon on the gait of persons with unilateral transtibial amputation. J Rehabil Res Dev 2003; 40: 109–124.
    14. Boutwell E, Stine R, Gard S. Shock absorption during transtibial amputee gait: Does longitudinal prosthetic stiffness play a role? Prosthet Orthot Int 2017; 41: 178–185.
    15. Adderson JA, Parker KE, Macleod DA, et al. Effect of a shock-absorbing pylon on transmission of heel strike forces during the gait of people with unilateral trans-tibial amputations: a pilot study. Prosthet Orthot Int 2007; 31: 384–393.
  • Epirus

    Clinical Outcomes using e-carbon feet

    • High mean radius of curvature for Esprit-style e-carbon feet2: “The larger the radius of curvature, the more stable is the foot”
    • Allow variable running speeds3
    • Increased self-selected walking speed4
    • Elite-style e-carbon feet (L code VL5987) or VT units demonstrate the second highest mobility levels, behind only microprocessor feet5
    • Users demonstrate confidence in prosthetic loading during high activity6
    • Improved prosthetic push-off work compared to SACH feet7
    • Increased prosthetic positive work done4
    • High degree of user satisfaction, particularly with high activity users8

    Clinical Outcomes using Multiflex-style ankles

    • Low stiffness at weight acceptance leads to early foot-flat and greater stability for lower mobility patients22
    • No loss of stability during standing with Multiflex than fixed ankle/foot23
    • Easier to walk on uneven ground with Multiflex than fixed ankle/foot23,24
    • Easier to walk up a slope with Multiflex than fixed ankle/foot23
    • Little to no difference in gait mechanics compared to flexible, “energy storing” prosthetic feet25
    • Increased prosthetic ankle range-of-motion with Multiflex compared to fixed ankle/foot23,24,26-28
    • Increased prosthetic ankle power with Multiflex compared to fixed ankle/foot24
    • Prosthetic rollover shape closer to natural biomechanics than fixed ankle/foot26
    • Users can walk longer distances and report “smoother” gait with Multiflex compared to fixed ankle/foot24
    • Benefits in mobility for bilateral users23,24,26,27
    • Mixed objective results when user group was more active than is recommended for Multiflex29,30 so may benefit more from a similar but higher activity foot like Epirus.
    • Equivalent socket comfort to higher technology, energy-storing feet29
    • Improved stance phase timing symmetry with Multiflex compared to fixed ankle/foot28
    • Reduced sound limb loading with Multiflex compared to fixed ankle/foot28
    • Mixed subjective feedback around preferences when user group was more active than is recommended for Multiflex25 so may benefit more from a similar but higher activity foot like Epirus.
    • Majority of users rate Multiflex as either “good” or “acceptable”31 and prefer Multiflex to fixed ankle/foot24

    Much research confirms the substantial equivalency of all energy-storing and return feet, including Blatchford e-carbon feet1.

    Multiflex was the “habitual” foot for all or majority of participants in 13 different studies9-21

    References

    1. Crimin A, McGarry A, Harris EJ, et al. The effect that energy storage and return feet have on the propulsion of the body: A pilot study. Proc Inst Mech Eng [H] 2014; 228: 908–915.
    2. Curtze C, Hof AL, van Keeken HG, et al. Comparative roll-over analysis of prosthetic feet. J Biomech 2009; 42: 1746–1753.
    3. Strike SC, Arcone D, Orendurff M. Running at submaximal speeds, the role of the intact and prosthetic limbs for trans-tibial amputees. Gait Posture 2018; 62: 327–332.
    4. Ray SF, Wurdeman SR, Takahashi KZ. Prosthetic energy return during walking increases after 3 weeks of adaptation to a new device. J Neuroengineering Rehabil 2018; 15: 6.
    5. Wurdeman SR, Stevens PM, Campbell JH. Mobility analysis of AmpuTees (MAAT 5): Impact of five common prosthetic ankle-foot categories for individuals with diabetic/dysvascular amputation. J Rehabil Assist Technol Eng 2019; 6: 2055668318820784. Download
    Overview
    6. Haber CK, Ritchie LJ, Strike SC. Dynamic elastic response prostheses alter approach angles and ground reaction forces but not leg stiffness during a start-stop task. Hum Mov Sci 2018; 58: 337–346.
    7. Rock CG, Wurdeman SR, Stergiou N, Takahashi KZ. Stride-to-stride fluctuations in transtibial amputees are not affected by changes in push-off mechanics from using different prostheses. PloS one. 2018;13(10).
    8. Highsmith MJ, Kahle JT, Miro RM, et al. Differences in Military Obstacle Course Performance Between Three Energy-Storing and Shock-Adapting Prosthetic Feet in High-Functioning Transtibial Amputees: A Double-Blind, Randomized Control Trial. Mil Med 2016; 181: 45–54.
    9. Moore R. Patient Evaluation of a Novel Prosthetic Foot with Hydraulic Ankle Aimed at Persons with Amputation with Lower Activity Levels. JPO J Prosthet Orthot 2017; 29: 44–47.
    10. Moore R. Effect on Stance Phase Timing Asymmetry in Individuals with Amputation Using Hydraulic Ankle Units. JPO J Prosthet Orthot 2016; 28: 44–48.
    11. Buckley JG, De Asha AR, Johnson L, et al. Understanding adaptive gait in lower-limb amputees: insights from multivariate analyses. J Neuroengineering Rehabil 2013; 10: 98.
    12. Sedki I, Moore R. Patient evaluation of the Echelon foot using the Seattle Prosthesis Evaluation Questionnaire. Prosthet Orthot Int 2013; 37: 250–254.
    13. Rogers JP, Strike SC, Wallace ES. The effect of prosthetic torsional stiffness on the golf swing kinematics of a left and a right-sided trans-tibial amputee. Prosthet Orthot Int 2004; 28: 121–131.
    14. Kobayashi T, Orendurff MS, Boone DA. Dynamic alignment of transtibial prostheses through visualization of socket reaction moments. Prosthet Orthot Int 2015; 39: 512–516.
    15. Wright D, Marks L, Payne R. A comparative study of the physiological costs of walking in ten bilateral amputees. Prosthet Orthot Int 2008; 32: 57–67.
    16. Vanicek N, Strike SC, Polman R. Kinematic differences exist between transtibial amputee fallers and non-fallers during downwards step transitioning. Prosthet Orthot Int 2015; 39: 322–332.
    17. Barnett C, Vanicek N, Polman R, et al. Kinematic gait adaptations in unilateral transtibial amputees during rehabilitation. Prosthet Orthot Int 2009; 33: 135–147.
    18. Emmelot C, Spauwen P, Hol W, et al. Case study: Trans tibial amputation for reflex sympathetic dystrophy: Postoperative management. Prosthet Orthot Int 2000; 24: 79–82.
    19. Boonstra A, Fidler V, Eisma W. Walking speed of normal subjects and amputees: aspects of validity of gait analysis. Prosthet Orthot Int 1993; 17: 78–82.
    20. Datta D, Harris I, Heller B, et al. Gait, cost and time implications for changing from PTB to ICEX® sockets. Prosthet Orthot Int 2004; 28: 115–120.
    21. de Castro MP, Soares D, Mendes E, et al. Center of pressure analysis during gait of elderly adult transfemoral amputees. JPO J Prosthet Orthot 2013; 25: 68–75.
    22. Major MJ, Scham J, Orendurff M. The effects of common footwear on stance-phase mechanical properties of the prosthetic foot-shoe system. Prosthet Orthot Int 2018; 42: 198–207.
    23. McNealy LL, A. Gard S. Effect of prosthetic ankle units on the gait of persons with bilateral trans-femoral amputations. Prosthet Orthot Int 2008; 32: 111–126.
    24. Su P-F, Gard SA, Lipschutz RD, et al. Gait characteristics of persons with bilateral transtibial amputations. J Rehabil Res Dev 2007; 44: 491–502.
    25. Boonstra A, Fidler V, Spits G, et al. Comparison of gait using a Multiflex foot versus a Quantum foot in knee disarticulation amputees. Prosthet Orthot Int 1993; 17: 90–94.
    26. Gard SA, Su P-F, Lipschutz RD, et al. The Effect of Prosthetic Ankle Units on Roll-Over Shape Characteristics During Walking in Persons with Bilateral Transtibial Amputations. J Rehabil Res Dev 2011; 48: 1037.
    27. Major MJ, Stine RL, Gard SA. The effects of walking speed and prosthetic ankle adapters on upper extremity dynamics and stability-related parameters in bilateral transtibial amputee gait. Gait Posture 2013; 38: 858–863.
    28. Van der Linden M, Solomonidis S, Spence W, et al. A methodology for studying the effects of various types of prosthetic feet on the biomechanics of trans-femoral amputee gait. J Biomech 1999; 32: 877–889.
    29. Graham LE, Datta D, Heller B, et al. A comparative study of conventional and energy-storing prosthetic feet in high-functioning transfemoral amputees. Arch Phys Med Rehabil 2007; 88: 801–806.
    30. Graham LE, Datta D, Heller B, et al. A comparative study of oxygen consumption for conventional and energy-storing prosthetic feet in transfemoral amputees. Clin Rehabil 2008; 22: 896–901.
    31. Mizuno N, Aoyama T, Nakajima A, et al. Functional evaluation by gait analysis of various ankle-foot assemblies used by below-knee amputees. Prosthet Orthot Int 1992; 16: 174–182.
  • Esprit

    Clinical Outcomes using e-carbon feet

    • High mean radius of curvature for Esprit-style e-carbon feet2: “The larger the radius of curvature, the more stable is the foot”
    • Allow variable running speeds3
    • Increased self-selected walking speed4
    • Elite-style e-carbon feet (L code VL5987) or VT units demonstrate the second highest mobility levels, behind only microprocessor feet5
    • Users demonstrate confidence in prosthetic loading during high activity6
    • Improved prosthetic push-off work compared to SACH feet7
    • Increased prosthetic positive work done4
    • High degree of user satisfaction, particularly with high activity users8

    Much research confirms the substantial equivalency of all energy-storing and return feet, including Blatchford e-carbon feet1.

    References

    1. Crimin A, McGarry A, Harris EJ, et al. The effect that energy storage and return feet have on the propulsion of the body: A pilot study. Proc Inst Mech Eng [H] 2014; 228: 908–915.
    2. Curtze C, Hof AL, van Keeken HG, et al. Comparative roll-over analysis of prosthetic feet. J Biomech 2009; 42: 1746–1753.
    3. Strike SC, Arcone D, Orendurff M. Running at submaximal speeds, the role of the intact and prosthetic limbs for trans-tibial amputees. Gait Posture 2018; 62: 327–332.
    4. Ray SF, Wurdeman SR, Takahashi KZ. Prosthetic energy return during walking increases after 3 weeks of adaptation to a new device. J Neuroengineering Rehabil 2018; 15: 6.
    5. Wurdeman SR, Stevens PM, Campbell JH. Mobility analysis of AmpuTees (MAAT 5): Impact of five common prosthetic ankle-foot categories for individuals with diabetic/dysvascular amputation. J Rehabil Assist Technol Eng 2019; 6: 2055668318820784. Download
    Overview
    6. Haber CK, Ritchie LJ, Strike SC. Dynamic elastic response prostheses alter approach angles and ground reaction forces but not leg stiffness during a start-stop task. Hum Mov Sci 2018; 58: 337–346.
    7. Rock CG, Wurdeman SR, Stergiou N, Takahashi KZ. Stride-to-stride fluctuations in transtibial amputees are not affected by changes in push-off mechanics from using different prostheses. PloS one. 2018;13(10).
    8. Highsmith MJ, Kahle JT, Miro RM, et al. Differences in Military Obstacle Course Performance Between Three Energy-Storing and Shock-Adapting Prosthetic Feet in High-Functioning Transtibial Amputees: A Double-Blind, Randomized Control Trial. Mil Med 2016; 181: 45–54.
  • Javelin

    Clinical Outcomes using e-carbon feet

    • High mean radius of curvature for Esprit-style e-carbon feet2: “The larger the radius of curvature, the more stable is the foot”
    • Allow variable running speeds3
    • Increased self-selected walking speed4
    • Elite-style e-carbon feet (L code VL5987) or VT units demonstrate the second highest mobility levels, behind only microprocessor feet5
    • Users demonstrate confidence in prosthetic loading during high activity6
    • Improved prosthetic push-off work compared to SACH feet7
    • Increased prosthetic positive work done4
    • High degree of user satisfaction, particularly with high activity users8

    Much research confirms the substantial equivalency of all energy-storing and return feet, including Blatchford e-carbon feet1.

    References

    1. Crimin A, McGarry A, Harris EJ, et al. The effect that energy storage and return feet have on the propulsion of the body: A pilot study. Proc Inst Mech Eng [H] 2014; 228: 908–915.
    2. Curtze C, Hof AL, van Keeken HG, et al. Comparative roll-over analysis of prosthetic feet. J Biomech 2009; 42: 1746–1753.
    3. Strike SC, Arcone D, Orendurff M. Running at submaximal speeds, the role of the intact and prosthetic limbs for trans-tibial amputees. Gait Posture 2018; 62: 327–332.
    4. Ray SF, Wurdeman SR, Takahashi KZ. Prosthetic energy return during walking increases after 3 weeks of adaptation to a new device. J Neuroengineering Rehabil 2018; 15: 6.
    5. Wurdeman SR, Stevens PM, Campbell JH. Mobility analysis of AmpuTees (MAAT 5): Impact of five common prosthetic ankle-foot categories for individuals with diabetic/dysvascular amputation. J Rehabil Assist Technol Eng 2019; 6: 2055668318820784.
    6. Haber CK, Ritchie LJ, Strike SC. Dynamic elastic response prostheses alter approach angles and ground reaction forces but not leg stiffness during a start-stop task. Hum Mov Sci 2018; 58: 337–346.
    7. Rock CG, Wurdeman SR, Stergiou N, Takahashi KZ. Stride-to-stride fluctuations in transtibial amputees are not affected by changes in push-off mechanics from using different prostheses. PloS one. 2018;13(10).
    8. Highsmith MJ, Kahle JT, Miro RM, et al. Differences in Military Obstacle Course Performance Between Three Energy-Storing and Shock-Adapting Prosthetic Feet in High-Functioning Transtibial Amputees: A Double-Blind, Randomized Control Trial. Mil Med 2016; 181: 45–54.
  • KX06

    Improvements in Clinical Outcomes using four-bar, polycentric knees compared to monoaxial knees

    • Increased mean prosthetic minimum toe clearance2,4, reducing the likelihood of tripping.
    • Fully satisfies stance phase stability3
    • Acceptable cosmetics for knee disarticulation amputees and trans-femoral amputees with long residua1
    • Meets all the design requirements for paediatric patients3

    References

    1. de Laat FA, van Kuijk AA, Geertzen JH, et al. Cosmetic effect of knee joint in a knee disarticulation prosthesis. J Rehabil Res Dev 2014; 51: 1545.
    2. Sensinger JW, Intawachirarat N, Gard SA. Contribution of prosthetic knee and ankle mechanisms to swing-phase foot clearance. IEEE Trans Neural Syst Rehabil Eng 2012; 21: 74–80.
    3. Andrysek J, Naumann S, Cleghorn WL. Design characteristics of pediatric prosthetic knees. IEEE Trans Neural Syst Rehabil Eng 2004; 12: 369–378.
    4. Gard SA, Childress DS, Uellendahl JE. The influence of four-bar linkage knees on prosthetic swing-phase floor clearance. JPO J Prosthet Orthot 1996; 8: 34–40.
  • Linx

    Improvements in Clinical Outcomes using Linx compared to mechanical knees

    • Significantly reduced number of falls1,2
    • Reduced centre-of-pressure fluctuations by 9-11% with standing support active when standing on sloped ground3
    • Less cognitive demand during walking, leading to reduced postural sway4
    • Increased walking speed5
    • Easier to walk at different speeds6
    • Higher scores in mobility-related patient-reported outcome measures7
    • More natural gait6,8
    • Easier to walk on slopes6
    • Reduced energy expenditure compared to mechanical knees9-13
    • Equivalent energy expenditure to other MPKs14
    • Reduced self-perceived effort6,8
    • Energy expenditure closer to that of able-bodied control subjects15
    • Able to walk further before becoming tired6
    • Better step length symmetry5
    • Reduced loading asymmetry with standing support active when standing on sloped ground3
    • Reduced fear of falling1
    • Reduced limitations due to an emotional problem8
    • Preference over other prosthetic knees1,6
    • Greater prosthetic confidence in slope descent and gait termination16
    • Reductions in direct and indirect healthcare costs when using an MPK17

    Improvements in Clinical Outcomes using Linx compared to ESR feet

    • Reduced risk of tripping and falls
      • Increased minimum toe clearance during swing phase18,19
    • Improved knee stability on the prosthetic side during slope descent
      • Increased mid-stance external prosthetic knee extensor moment20
    • Improving standing balance on a slope
      • 24-25% reduction in mean inter-limb centre-of-pressure root mean square (COP RMS)3
    • Reduced energy expenditure during walking
      • Mean 11.8% reduction in energy use on level ground, across all walking speeds21
      • Mean 20.2% reduction in energy use on slopes, across all gradients21
      • Mean 8.3% faster walking speed for the same amount of effort21
    • Improved gait performance
      • Faster self-selected walking speed18,22-25
    • Improved ground compliance when walking on slopes
      • Increased plantarflexion peak during level walking, fast level walking and cambered walking26
      • Increased dorsiflexion peak during level walking, fast level walking and cambered walking26
    • Less of a prosthetic “dead spot” during gait
      • Reduced aggregate negative COP displacement23
      • Centre-of-pressure passes anterior to the shank statistically significantly earlier in stance23
      • Increased minimum instantaneous COM velocity during prosthetic-limb single support phase23
      • Reduced peak negative COP velocity25
      • Reduced COP posterior travel distance25
    • Improved ground compliance when walking on slopes
      • Increased plantarflexion range during slope descent19
      • Increased dorsiflexion range during slope ascent19
    • Less effort on residual hip for trans-femoral amputees on varied terrains
      • Reduced the mean hip extension and flexion moments27
    • Effects consistent over time
      • Same gait variable changes in two gait lab sessions one year apart22
      • Magnitude of changes comparable between sessions22
    • Brake mode during slope descent to control momentum build up
      • Reduced mean prosthetic shank angular velocity in single support28
      • Increased Unified Deformable Segment (prosthetic ‘ankle’) negative work28
    • Less gait compensation movements during slope descent
      • Reduced residual knee flexion at loading response28
    • Helps protect vulnerable residual limb tissue, reducing likelihood of damage
      • Reduced peak stresses on residual limb29
      • Reduced stress RMS on residual limb29
      • Reduced loading rates on residual limb29
    • Greater contribution of prosthetic limb to support during walking
      • Increased residual knee peak extension moment22
      • Decreased residual knee peak flexion moment22
      • Increased residual knee negative work24
    • Reduced reliance on sound limb for support during walking
      • Reduced intact limb peak hip flexion moment24
      • Reduced intact limb peak dorsiflexion moment24
      • Reduced intact ankle negative work and total work24
      • Reduced intact limb total joint work24
    • Better symmetry of loading between prosthetic and sound limbs during standing on a slope
      • Degree of asymmetry closer to zero for 5/5 amputees20
    • Reduced residual and sound joint moments during standing of a slope
      • Significant reductions in both prosthetic and sound support moments30
    • Reduced residual joint moments during standing of a slope for bilateral amputees
      • Significant reductions in prosthetic support moment30
      • Permitted ‘natural’ ground reaction vector sagittal plane position, relative to knee joint centres30
    • Less pressure on the sole of the contralateral foot
      • Peak plantar-pressure31
    • Improved gait symmetry
      • Reduced stance phase timing asymmetry32
    • Patient reported outcome measures indicate improvements
      • Mean improvement across all Prosthesis Evaluation Questionnaire domains33
      • Bilateral patients showed highest mean improvement in satisfaction33
    • Subjective user preference for hydraulic ankle
      • 13/13 participants preferred hydraulic ankle31

    Improvements in Clinical Outcomes using Linx compared to non-microprocessor-control hydraulic ankle-feet

    • Improved knee stability on the prosthetic side during slope descent
      • Increased mid-stance external prosthetic knee extensor moment19
    • Improved ground compliance when walking down slopes
      • Reduced time to foot flat28
    • Brake mode during slope descent increases resistance to dorsiflexion to control momentum build up
      • Reduced dorsiflexion range during slope descent19
      • Reduced mean prosthetic shank angular velocity in single support28
      • Increased Unified Deformable Segment (prosthetic ‘ankle’) negative work28
      • Transition from dorsiflexion to plantarflexion moment occurs earlier in stance phase34
      • Increase in mean prosthetic ‘ankle’ plantarflexion moment integral34
    • Assist mode during slope ascent decreases resistance to dorsiflexion to allow easier progression
      • Transition from dorsiflexion to plantarflexion moment occurs later in stance phase34
      • Decrease in mean prosthetic ‘ankle’ plantarflexion moment integral34
    • Less gait compensation movements during slope descent
      • Reduced residual knee flexion at loading response28
    • Greater reliance on prosthetic side for bodyweight support during slope descent
      • Increased support moment integral34
    • Less reliance on sound side for bodyweight support during slope descent
      • Decreased support moment integral34
    • Less reliance on sound side for bodyweight support during slope ascent
      • Decreased support moment integral34
    • Reduced sound joint moments during standing of a slope
      • Significant reductions in sound support moment30
    • Reduced residual joint moments during standing of a slope for bilateral amputees
      • Significant reductions in prosthetic support moment30
      • Permitted ‘natural’ ground reaction vector sagittal plane position, relative to knee joint centres30
    • Greater prosthetic confidence in slope descent and gait termination16

    References

    1. Kaufman KR, Bernhardt KA, Symms K. Functional assessment and satisfaction of transfemoral amputees with low mobility (FASTK2): A clinical trial of microprocessor-controlled vs. non-microprocessor-controlled knees. Clin Biomech 2018; 58: 116–122.
    2. Campbell JH, Stevens PM, Wurdeman SR. OASIS 1: Retrospective analysis of four different microprocessor knee types. Journal of Rehabilitation and Assistive Technologies Engineering. 2020 Nov;7:2055668320968476.
    3. McGrath M, Laszczak P, Zahedi S, et al. Microprocessor knees with ‘standing support’ and articulating, hydraulic ankles improve balance control and inter-limb loading during quiet standing. J Rehabil Assist Technol Eng 2018; 5: 2055668318795396.
    4. Heller BW, Datta D, Howitt J. A pilot study comparing the cognitive demand of walking for transfemoral amputees using the Intelligent Prosthesis with that using conventionally damped knees. Clin Rehabil 2000; 14: 518–522.
    5. Chin T, Maeda Y, Sawamura S, et al. Successful prosthetic fitting of elderly trans-femoral amputees with Intelligent Prosthesis (IP): a clinical pilot study. Prosthet Orthot Int 2007; 31: 271–276.
    6. Datta D, Howitt J. Conventional versus microchip controlled pneumatic swing phase control for trans-femoral amputees: user’s verdict. Prosthet Orthot Int 1998; 22: 129–135.
    7. Wurdeman SR, Stevens PM, Campbell JH. Mobility analysis of amputees (MAAT 3): Matching individuals based on comorbid health reveals improved function for above-knee prosthesis users with microprocessor knee technology. Assist Technol 2018; 1–7.
    8. Saglam Y, Gulenc B, Birisik F, et al. The quality of life analysis of knee prosthesis with complete microprocessor control in trans-femoral amputees. Acta Orthop Traumatol Turc 2017; 51: 466e469.
    9. Chin T, Sawamura S, Shiba R, et al. Energy expenditure during walking in amputees after disarticulation of the hip: a microprocessor-controlled swing-phase control knee versus a mechanical-controlled stance-phase control knee. J Bone Joint Surg Br 2005; 87: 117–119.
    10. Datta D, Heller B, Howitt J. A comparative evaluation of oxygen consumption and gait pattern in amputees using Intelligent Prostheses and conventionally damped knee swing-phase control. Clin Rehabil 2005; 19: 398–403.
    11. Buckley JG, Spence WD, Solomonidis SE. Energy cost of walking: comparison of “intelligent prosthesis” with conventional mechanism. Arch Phys Med Rehabil 1997; 78: 330–333.
    12. Taylor MB, Clark E, Offord EA, et al. A comparison of energy expenditure by a high level trans-femoral amputee using the Intelligent Prosthesis and conventionally damped prosthetic limbs. Prosthet Orthot Int 1996; 20: 116–121.
    13. Kirker S, Keymer S, Talbot J, et al. An assessment of the intelligent knee prosthesis. Clin Rehabil 1996; 10: 267–273.
    14. Chin T, Machida K, Sawamura S, et al. Comparison of different microprocessor controlled knee joints on the energy consumption during walking in trans-femoral amputees: intelligent knee prosthesis (IP) versus C-leg. Prosthet Orthot Int 2006; 30: 73–80.
    15. Chin T, Sawamura S, Shiba R, et al. Effect of an Intelligent Prosthesis (IP) on the walking ability of young transfemoral amputees: comparison of IP users with able-bodied people. Am J Phys Med Rehabil 2003; 82: 447–451.
    16. Abdulhasan ZM, Scally AJ, Buckley JG. Gait termination on a declined surface in trans-femoral amputees: Impact of using microprocessor-controlled limb system. Clin Biomech Bristol Avon 2018; 57: 35–41.
    17. Chen C, Hanson M, Chaturvedi R, et al. Economic benefits of microprocessor controlled prosthetic knees: a modeling study. J Neuroengineering Rehabil 2018; 15: 62.
    18. Riveras M, Ravera E, Ewins D, Shaheen AF, Catalfamo-Formento P. Minimum toe clearance and tripping probability in people with unilateral transtibial amputation walking on ramps with different prosthetic designs. Gait & Posture. 2020 Sep 1;81:41-8.
    19. Johnson L, De Asha AR, Munjal R, et al. Toe clearance when walking in people with unilateral transtibial amputation: effects of passive hydraulic ankle. J Rehabil Res Dev 2014; 51: 429.
    20. Bai X, Ewins D, Crocombe AD, et al. A biomechanical assessment of hydraulic ankle-foot devices with and without micro-processor control during slope ambulation in trans-femoral amputees. PLOS ONE 2018; 13: e0205093.
    21. Askew GN, McFarlane LA, Minetti AE, et al. Energy cost of ambulation in trans-tibial amputees using a dynamic-response foot with hydraulic versus rigid ‘ankle’: insights from body centre of mass dynamics. J NeuroEngineering Rehabil 2019; 16: 39.
    22. De Asha AR, Barnett CT, Struchkov V, et al. Which Prosthetic Foot to Prescribe?: Biomechanical Differences Found during a Single-Session Comparison of Different Foot Types Hold True 1 Year Later. JPO J Prosthet Orthot 2017; 29: 39–43.
    23. De Asha AR, Munjal R, Kulkarni J, et al. Impact on the biomechanics of overground gait of using an ‘Echelon’ hydraulic ankle–foot device in unilateral trans-tibial and trans-femoral amputees. Clin Biomech 2014; 29: 728–734.
    24. De Asha AR, Munjal R, Kulkarni J, et al. Walking speed related joint kinetic alterations in trans-tibial amputees: impact of hydraulic ’ankle’ damping. J Neuroengineering Rehabil 2013; 10: 1.
    25. De Asha AR, Johnson L, Munjal R, et al. Attenuation of centre-of-pressure trajectory fluctuations under the prosthetic foot when using an articulating hydraulic ankle attachment compared to fixed attachment. Clin Biomech 2013; 28: 218–224.
    26. Bai X, Ewins D, Crocombe AD, et al. Kinematic and biomimetic assessment of a hydraulic ankle/foot in level ground and camber walking. PLOS ONE 2017; 12: e0180836.
    27. Alexander N, Strutzenberger G, Kroell J, et al. Joint Moments During Downhill and Uphill Walking of a Person with Transfemoral Amputation with a Hydraulic Articulating and a Rigid Prosthetic Ankle—A Case Study. JPO J Prosthet Orthot 2018; 30: 46–54.
    28. Struchkov V, Buckley JG. Biomechanics of ramp descent in unilateral trans-tibial amputees: Comparison of a microprocessor controlled foot with conventional ankle–foot mechanisms. Clin Biomech 2016; 32: 164–170.
    29. Portnoy S, Kristal A, Gefen A, et al. Outdoor dynamic subject-specific evaluation of internal stresses in the residual limb: hydraulic energy-stored prosthetic foot compared to conventional energy-stored prosthetic feet. Gait Posture 2012; 35: 121–125.
    30. McGrath M, Davies KC, Laszczak P, et al. The influence of hydraulic ankles and microprocessor-control on the biomechanics of trans-tibial amputees during quiet standing on a 5° slope. Can Prosthet Orthot J; 2.
    31. Moore R. Effect of a Prosthetic Foot with a Hydraulic Ankle Unit on the Contralateral Foot Peak Plantar Pressures in Individuals with Unilateral Amputation. JPO J Prosthet Orthot 2018; 30: 165–70.
    32. Moore R. Effect on Stance Phase Timing Asymmetry in Individuals with Amputation Using Hydraulic Ankle Units. JPO J Prosthet Orthot 2016; 28: 44–48.
    33. Sedki I, Moore R. Patient evaluation of the Echelon foot using the Seattle Prosthesis Evaluation Questionnaire. Prosthet Orthot Int 2013; 37: 250–254.
    34. McGrath M, Laszczak P, Zahedi S, et al. The influence of a microprocessor-controlled hydraulic ankle on the kinetic symmetry of trans-tibial amputees during ramp walking: a case series. J Rehabil Assist Technol Eng 2018; 5: 2055668318790650.
  • Mini BladeXT

    Clinical Outcomes using e-carbon feet

    • High mean radius of curvature for Esprit-style e-carbon feet2: “The larger the radius of curvature, the more stable is the foot”
    • Allow variable running speeds3
    • Increased self-selected walking speed4
    • Elite-style e-carbon feet (L code VL5987) or VT units demonstrate the second highest mobility levels, behind only microprocessor feet5
    • Users demonstrate confidence in prosthetic loading during high activity6
    • Improved prosthetic push-off work compared to SACH feet7
    • Increased prosthetic positive work done4
    • High degree of user satisfaction, particularly with high activity users8

    Much research confirms the substantial equivalency of all energy-storing and return feet, including Blatchford e-carbon feet1.

    References

    1. Crimin A, McGarry A, Harris EJ, et al. The effect that energy storage and return feet have on the propulsion of the body: A pilot study. Proc Inst Mech Eng [H] 2014; 228: 908–915.
    2. Curtze C, Hof AL, van Keeken HG, et al. Comparative roll-over analysis of prosthetic feet. J Biomech 2009; 42: 1746–1753.
    3. Strike SC, Arcone D, Orendurff M. Running at submaximal speeds, the role of the intact and prosthetic limbs for trans-tibial amputees. Gait Posture 2018; 62: 327–332.
    4. Ray SF, Wurdeman SR, Takahashi KZ. Prosthetic energy return during walking increases after 3 weeks of adaptation to a new device. J Neuroengineering Rehabil 2018; 15: 6.
    5. Wurdeman SR, Stevens PM, Campbell JH. Mobility analysis of AmpuTees (MAAT 5): Impact of five common prosthetic ankle-foot categories for individuals with diabetic/dysvascular amputation. J Rehabil Assist Technol Eng 2019; 6: 2055668318820784.
    6. Haber CK, Ritchie LJ, Strike SC. Dynamic elastic response prostheses alter approach angles and ground reaction forces but not leg stiffness during a start-stop task. Hum Mov Sci 2018; 58: 337–346.
    7. Rock CG, Wurdeman SR, Stergiou N, Takahashi KZ. Stride-to-stride fluctuations in transtibial amputees are not affected by changes in push-off mechanics from using different prostheses. PloS one. 2018;13(10).
    8. Highsmith MJ, Kahle JT, Miro RM, et al. Differences in Military Obstacle Course Performance Between Three Energy-Storing and Shock-Adapting Prosthetic Feet in High-Functioning Transtibial Amputees: A Double-Blind, Randomized Control Trial. Mil Med 2016; 181: 45–54.
  • Multiflex

    Clinical Outcomes using Multiflex feet

    • Low stiffness at weight acceptance leads to early foot-flat and greater stability for lower mobility patients14
    • No loss of stability during standing with Multiflex than fixed ankle/foot15
    • Easier to walk on uneven ground with Multiflex than fixed ankle/foot15,16
    • Easier to walk up a slope with Multiflex than fixed ankle/foot15
    • Little to no difference in gait mechanics compared to flexible, “energy storing” prosthetic feet17
    • Increased prosthetic ankle range-of-motion with Multiflex compared to fixed ankle/foot15,16,18-20
    • Increased prosthetic ankle power with Multiflex compared to fixed ankle/foot for bilateral users16
    • Prosthetic rollover shape closer to natural biomechanics than fixed ankle/foot18
    • Bilateral users can walk longer distances and report “smoother” gait with Multiflex compared to fixed ankle/foot16
    • Benefits in mobility for bilateral users15,16,18,19
    • Equivalent socket comfort to higher technology, energy-storing feet21
    • Improved stance phase timing symmetry with Multiflex compared to fixed ankle/foot20
    • Reduced sound limb loading with Multiflex compared to fixed ankle/foot20
    • Majority of users rate Multiflex as either “good” or “acceptable”22 and bilateral users prefer Multiflex to fixed ankle/foot16

    Multiflex was the “habitual” foot for all or majority of participants in 13 different studies1-13.

    References

    1. Moore R. Patient Evaluation of a Novel Prosthetic Foot with Hydraulic Ankle Aimed at Persons with Amputation with Lower Activity Levels. JPO J Prosthet Orthot 2017; 29: 44–47.
    2. Moore R. Effect on Stance Phase Timing Asymmetry in Individuals with Amputation Using Hydraulic Ankle Units. JPO J Prosthet Orthot 2016; 28: 44–48.
    3. Buckley JG, De Asha AR, Johnson L, et al. Understanding adaptive gait in lower-limb amputees: insights from multivariate analyses. J Neuroengineering Rehabil 2013; 10: 98.
    4. Sedki I, Moore R. Patient evaluation of the Echelon foot using the Seattle Prosthesis Evaluation Questionnaire. Prosthet Orthot Int 2013; 37: 250–254.
    5. Rogers JP, Strike SC, Wallace ES. The effect of prosthetic torsional stiffness on the golf swing kinematics of a left and a right-sided trans-tibial amputee. Prosthet Orthot Int 2004; 28: 121–131.
    6. Kobayashi T, Orendurff MS, Boone DA. Dynamic alignment of transtibial prostheses through visualization of socket reaction moments. Prosthet Orthot Int 2015; 39: 512–516.
    7. Wright D, Marks L, Payne R. A comparative study of the physiological costs of walking in ten bilateral amputees. Prosthet Orthot Int 2008; 32: 57–67.
    8. Vanicek N, Strike SC, Polman R. Kinematic differences exist between transtibial amputee fallers and non-fallers during downwards step transitioning. Prosthet Orthot Int 2015; 39: 322–332.
    9. Barnett C, Vanicek N, Polman R, et al. Kinematic gait adaptations in unilateral transtibial amputees during rehabilitation. Prosthet Orthot Int 2009; 33: 135–147.
    10. Emmelot C, Spauwen P, Hol W, et al. Case study: Trans tibial amputation for reflex sympathetic dystrophy: Postoperative management. Prosthet Orthot Int 2000; 24: 79–82.
    11. Boonstra A, Fidler V, Eisma W. Walking speed of normal subjects and amputees: aspects of validity of gait analysis. Prosthet Orthot Int 1993; 17: 78–82.
    12. Datta D, Harris I, Heller B, et al. Gait, cost and time implications for changing from PTB to ICEX® sockets. Prosthet Orthot Int 2004; 28: 115–120.
    13. de Castro MP, Soares D, Mendes E, et al. Center of pressure analysis during gait of elderly adult transfemoral amputees. JPO J Prosthet Orthot 2013; 25: 68–75.
    14. Major MJ, Scham J, Orendurff M. The effects of common footwear on stance-phase mechanical properties of the prosthetic foot-shoe system. Prosthet Orthot Int 2018; 42: 198–207.
    15. McNealy LL, A. Gard S. Effect of prosthetic ankle units on the gait of persons with bilateral trans-femoral amputations. Prosthet Orthot Int 2008; 32: 111–126.
    16. Su P-F, Gard SA, Lipschutz RD, et al. Gait characteristics of persons with bilateral transtibial amputations. J Rehabil Res Dev 2007; 44: 491–502.
    17. Boonstra A, Fidler V, Spits G, et al. Comparison of gait using a Multiflex foot versus a Quantum foot in knee disarticulation amputees. Prosthet Orthot Int 1993; 17: 90–94.
    18. Gard SA, Su P-F, Lipschutz RD, et al. The Effect of Prosthetic Ankle Units on Roll-Over Shape Characteristics During Walking in Persons with Bilateral Transtibial Amputations. J Rehabil Res Dev 2011; 48: 1037.
    19. Major MJ, Stine RL, Gard SA. The effects of walking speed and prosthetic ankle adapters on upper extremity dynamics and stability-related parameters in bilateral transtibial amputee gait. Gait Posture 2013; 38: 858–863.
    20. Van der Linden M, Solomonidis S, Spence W, et al. A methodology for studying the effects of various types of prosthetic feet on the biomechanics of trans-femoral amputee gait. J Biomech 1999; 32: 877–889.
    21. Graham LE, Datta D, Heller B, et al. A comparative study of conventional and energy-storing prosthetic feet in high-functioning transfemoral amputees. Arch Phys Med Rehabil 2007; 88: 801–806.
    22. Mizuno N, Aoyama T, Nakajima A, et al. Functional evaluation by gait analysis of various ankle-foot assemblies used by below-knee amputees. Prosthet Orthot Int 1992; 16: 174–182.
  • Navigator

    Clinical Outcomes using Navigator

    • Shorter keel allows for more consistent rollover radius of curvature, regardless of changing footwear1
    • The most energy efficient radius of curvature for a rollover shape has been identified as 30% of the walker’s leg length. For a person of a typical adult height between 1.5m and 1.8m, this equates to approximately 245-290mm. Navigator has a rollover shape of ~250mm1.

    Clinical Outcomes using Multiflex-style ankles

    • Low stiffness at weight acceptance leads to early foot-flat and greater stability for lower mobility patients15
    • No loss of stability during standing with Multiflex than fixed ankle/foot16
    • Easier to walk on uneven ground with Multiflex than fixed ankle/foot16,17
    • Easier to walk up a slope with Multiflex than fixed ankle/foot16
    • Little to no difference in gait mechanics compared to flexible, “energy storing” prosthetic feet18
    • Increased prosthetic ankle range-of-motion with Multiflex compared to fixed ankle/foot16,17,19-21
    • Increased prosthetic ankle power with Multiflex compared to fixed ankle/foot17
    • Prosthetic rollover shape closer to natural biomechanics than fixed ankle/foot19
    • Users can walk longer distances and report “smoother” gait with Multiflex compared to fixed ankle/foot17
    • Benefits in mobility for bilateral users17,19-21
    • Equivalent socket comfort to higher technology, energy-storing feet22
    • Improved stance phase timing symmetry with Multiflex compared to fixed ankle/foot21
    • Reduced sound limb loading with Multiflex compared to fixed ankle/foot21

    Majority of users rate Multiflex as either “good” or “acceptable”23 and prefer Multiflex to fixed ankle/foot17

    Multiflex was the “habitual” foot for all or majority of participants in 13 different studies2-14.

    References

    1. Curtze C, Hof AL, van Keeken HG, et al. Comparative roll-over analysis of prosthetic feet. J Biomech 2009; 42: 1746–1753.
    2. Moore R. Patient Evaluation of a Novel Prosthetic Foot with Hydraulic Ankle Aimed at Persons with Amputation with Lower Activity Levels. JPO J Prosthet Orthot 2017; 29: 44–47.
    3. Moore R. Effect on stance phase timing asymmetry in individuals with amputation using hydraulic ankle units. JPO J Prosthet Orthot 2016; 28: 44–48.
    4. Buckley JG, De Asha AR, Johnson L, et al. Understanding adaptive gait in lower-limb amputees: insights from multivariate analyses. J Neuroengineering Rehabil 2013; 10: 98.
    5. Sedki I, Moore R. Patient evaluation of the Echelon foot using the Seattle Prosthesis Evaluation Questionnaire. Prosthet Orthot Int 2013; 37: 250–254.
    6. Rogers JP, Strike SC, Wallace ES. The effect of prosthetic torsional stiffness on the golf swing kinematics of a left and a right‐sided trans‐tibial amputee. Prosthet Orthot Int 2004; 28: 121–131.
    7. Kobayashi T, Orendurff MS, Boone DA. Dynamic alignment of transtibial prostheses through visualization of socket reaction moments. Prosthet Orthot Int 2015; 39: 512–516.
    8. Wright DA, Marks L, Payne RC. A comparative study of the physiological costs of walking in ten bilateral amputees. Prosthet Orthot Int 2008; 32: 57–67.
    9. Vanicek N, Strike SC, Polman R. Kinematic differences exist between transtibial amputee fallers and non-fallers during downwards step transitioning - Natalie Vanicek, Siobhán C Strike, Remco Polman, 2015. Prosthet Orthot Int 2015; 39: 322–332.
    10. Barnett CT, Vanicek N, Polman R, et al. Kinematic gait adaptations in unilateral transtibial amputees during rehabilitation: Prosthetics and Orthotics International: Vol 33, No 2. Prosthet Orthot Int 2009; 33: 135–147.
    11. Emmelot CH, Spauwen PHM, Hol W, et al. Case study: Trans‐tibial amputation for reflex sympathetic dystrophy: Postoperative management. Prosthet Orthot Int 2000; 24: 79–82.
    12. Boonstra AM, Fidler V, Eisma WH. Walking speed of normal subjects and amputees: Aspects of validity of gait analysis. Prosthet Orthot Int 1993; 17: 78–82.
    13. Datta DD, Harris I, Heller B, et al. Gait, cost and time implications for changing from PTB to ICEX® sockets. Prosthet Orthot Int 2004; 28: 115–120.
    14. Castro M de, Soares D, Mendes E, et al. Center of Pressure Analysis During Gait of Elderly Adult Transfemoral Amputees. J Prosthet Orthot 2013; 25: 68–75.
    15. Major MJ, Scham J, Orendurff M. The effects of common footwear on stance-phase mechanical properties of the prosthetic foot-shoe system. Prosthet Orthot Int 2018; 42: 198–207.
    16. McNealy LL, Gard SA. Effect of prosthetic ankle units on the gait of persons with bilateral trans-femoral amputations. Prosthet Orthot Int 2008; 32: 111–126.
    17. Su P-F, Gard SA, Lipschutz RD, et al. Gait characteristics of persons with bilateral transtibial amputations. J Rehabil Res Dev 2007; 44: 491–502.
    18. Boonstra A, Fidler V, Spits G, et al. Comparison of gait using a Multiflex foot versus a Quantum foot in knee disarticulation amputees. Prosthet Orthot Int 1993; 17: 90–94.
    19. Gard SA, Su P-F, Lipschutz RD, et al. The Effect of Prosthetic Ankle Units on Roll-Over Shape Characteristics During Walking in Persons with Bilateral Transtibial Amputations. J Rehabil Res Dev 2011; 48: 1037.
    20. Major MJ, Stine RL, Gard SA. The effects of walking speed and prosthetic ankle adapters on upper extremity dynamics and stability-related parameters in bilateral transtibial amputee gait. Gait Posture 2013; 38: 858–863.
    21. Van der Linden ML, Solomonidis SE, Spence WD, et al. A methodology for studying the effects of various types of prosthetic feet on the biomechanics of trans-femoral amputee gait. J Biomech 1999; 32: 877–889.
    22. Graham LE, Datta D, Heller B, et al. A comparative study of conventional and energy-storing prosthetic feet in high-functioning transfemoral amputees. Arch Phys Med Rehabil 2007; 88: 801–806.
    23. Mizuno N, Aoyama T, Nakajima A, et al. Functional evaluation by gait analysis of various ankle-foot assemblies used by below-knee amputees. Prosthet Orthot Int 1992; 16: 174–182.
  • Orion3

    Improvements in Clinical Outcomes using microprocessor-controlled prosthetic knees

    • Significantly reduced number of falls1,2
    • Reduced centre-of-pressure fluctuations by 9-11% with standing support active when standing on sloped ground3
    • Less cognitive demand during walking, leading to reduced postural sway4
    • Increased walking speed5
    • Easier to walk at different speeds6
    • Higher scores in mobility-related patient-reported outcome measures7
    • More natural gait6,8
    • Easier to walk on slopes6
    • Reduced energy expenditure compared to mechanical knees9-13
    • Equivalent energy expenditure to other MPKs14
    • Reduced self-perceived effort6,8
    • Energy expenditure closer to that of able-bodied control subjects15
    • Able to walk further before becoming tired6
    • Better step length symmetry5
    • Reduced loading asymmetry with standing support active when standing on sloped ground3
    • Reduced fear of falling1
    • Reduced limitations due to an emotional problem8
    • Preference over other prosthetic knees1,14
    • Reductions in direct and indirect healthcare costs when using an MPK16

    References

    1. Kaufman KR, Bernhardt KA, Symms K. Functional assessment and satisfaction of transfemoral amputees with low mobility (FASTK2): A clinical trial of microprocessor-controlled vs. non-microprocessor-controlled knees. Clin Biomech 2018; 58: 116–122.
    2. Campbell JH, Stevens PM, Wurdeman SR. OASIS 1: Retrospective analysis of four different microprocessor knee types. Journal of Rehabilitation and Assistive Technologies Engineering. 2020;7:2055668320968476.
    3. McGrath M, Laszczak P, Zahedi S, et al. Microprocessor knees with ‘standing support’ and articulating, hydraulic ankles improve balance control and inter-limb loading during quiet standing. J Rehabil Assist Technol Eng 2018; 5: 2055668318795396.
    4. Heller BW, Datta D, Howitt J. A pilot study comparing the cognitive demand of walking for transfemoral amputees using the Intelligent Prosthesis with that using conventionally damped knees. Clin Rehabil 2000; 14: 518–522.
    5. Chin T, Maeda Y, Sawamura S, et al. Successful prosthetic fitting of elderly trans-femoral amputees with Intelligent Prosthesis (IP): a clinical pilot study. Prosthet Orthot Int 2007; 31: 271–276.
    6. Datta D, Howitt J. Conventional versus microchip controlled pneumatic swing phase control for trans-femoral amputees: user’s verdict. Prosthet Orthot Int 1998; 22: 129–135.
    7. Wurdeman SR, Stevens PM, Campbell JH. Mobility analysis of amputees (MAAT 3): Matching individuals based on comorbid health reveals improved function for above-knee prosthesis users with microprocessor knee technology. Assist Technol 2018; 1–7.
    8. Saglam Y, Gulenc B, Birisik F, et al. The quality of life analysis of knee prosthesis with complete microprocessor control in trans-femoral amputees. Acta Orthop Traumatol Turc 2017; 51: 466e469.
    9. Chin T, Sawamura S, Shiba R, et al. Energy expenditure during walking in amputees after disarticulation of the hip: a microprocessor-controlled swing-phase control knee versus a mechanical-controlled stance-phase control knee. J Bone Joint Surg Br 2005; 87: 117–119.
    10. Datta D, Heller B, Howitt J. A comparative evaluation of oxygen consumption and gait pattern in amputees using Intelligent Prostheses and conventionally damped knee swing-phase control. Clin Rehabil 2005; 19: 398–403.
    11. Buckley JG, Spence WD, Solomonidis SE. Energy cost of walking: comparison of “intelligent prosthesis” with conventional mechanism. Arch Phys Med Rehabil 1997; 78: 330–333.
    12. Taylor MB, Clark E, Offord EA, et al. A comparison of energy expenditure by a high level trans-femoral amputee using the Intelligent Prosthesis and conventionally damped prosthetic limbs. Prosthet Orthot Int 1996; 20: 116–121.
    13. Kirker S, Keymer S, Talbot J, et al. An assessment of the intelligent knee prosthesis. Clin Rehabil 1996; 10: 267–273.
    14. Chin T, Machida K, Sawamura S, et al. Comparison of different microprocessor controlled knee joints on the energy consumption during walking in trans-femoral amputees: intelligent knee prosthesis (IP) versus C-leg. Prosthet Orthot Int 2006; 30: 73–80.
    15. Chin T, Sawamura S, Shiba R, et al. Effect of an Intelligent Prosthesis (IP) on the walking ability of young transfemoral amputees: comparison of IP users with able-bodied people. Am J Phys Med Rehabil 2003; 82: 447–451.
    16. Chen C, Hanson M, Chaturvedi R, et al. Economic benefits of microprocessor controlled prosthetic knees: a modeling study. J Neuroengineering Rehabil 2018; 15: 62.
  • Senior

    Clinical Outcomes using Senior feet

    Low stiffness at weight acceptance leads to early foot-flat and greater stability for lower mobility patients1

    • Satisfactory for patients with limited mobility in order to maintain mobility level2
    • Lightweight keel increases ease of use and is ideal for elderly users or those with limited strength2
      B. Senior’s design of a footshell with a moulded keel, incorporating an integral pyramid, maximises strength of the foot whilst minimising its weight.
    • Durability tests confirm foot to be long-lasting for those with low mobility levels3
    • 54% satisfaction rate2
    • Satisfaction rates increase within the bilateral population2

    References

    1. Turcot K, Sagawa Jr Y, Lacraz A, et al. Comparison of the International Committee of the Red Cross foot with the solid ankle cushion heel foot during gait: a randomized double-blind study. Arch Phys Med Rehabil 2013; 94: 1490–1497.
    2. Dudkiewicz I, Pisarenko B, Herman A, et al. Satisfaction rates amongst elderly amputees provided with a static prosthetic foot. Disabil Rehabil 2011; 33: 1963–1967.
    3. Sasaki K, Pinitlertsakun J, Rattanakoch J, et al. The development and testing of a modified natural rubber CR solid ankle–cushion heel prosthetic foot for developing countries. J Rehabil Assist Technol Eng 2017; 4: 2055668317712978.
  • Silcare Breathe Cushion

    Clinical Outcomes using Sweat Management liners

    • Improvements in residual limb health problems and wound healing1,2
    • Fewer residual skin issues2
    • Reduction in pain in residual and phantom limb2
    • Improved heat dissipation compared to other temperature regulation solutions3
    • Removes sweat from skin interface1,2,4
    • Perforations do not damage the skin4
    • Patients reported a preference for their perforated liners1,4
    • Reduces the need to remove prosthesis throughout the day to dry residual limb4

    There are two published literature reviews that discuss different aspects of lower limb prosthetic liner technology5,6.

    • The main purpose of prosthetic liners is to cushion the transfer of loads from the prosthetic socket to the residual limb5.
    • Based on load-displacement data from the compressive stiffness tests, silicone was one of three materials that were recommended for situations where it is desirable for the liner to maintain thickness and volume since these materials had the least non-recovered strain5,7.
    • Under cyclic compressive loading, silicone was one of two materials that had the greatest cycles to failure under compressive loading, while the Pedilin and polyurethane samples lasted orders of magnitude less5,8.
    • Prosthetic liners and sockets are highly resistive to heat conduction and could be a major contributor to elevated skin temperatures5,9.
    • There are reduced residual limb pressures with the silicone liner compared to other conditions (no liner; soft inserts) suggesting that silicone has an ability to distribute pressure evenly to the residual limb4,10.
    • In terms of patient outcomes, there was no clear preference between silicone and Pelite liners5,11.

    References

    1. McGrath M, McCarthy J, Gallego A, et al. The influence of perforated prosthetic liners on residual limb wound healing: a case report. Can Prosthet Orthot J 2019; 2(1)
    2. Davies KC, McGrath M, Stenson A, Savage Z, Moser D, Zahedi S. Using perforated liners to combat the detrimental effects of excessive sweating in lower limb prosthesis users. Can Prosthet Orthot J. 2020;3(2).
    3. Williams RJ, Washington ED, Miodownik M, et al. The effect of liner design and materials selection on prosthesis interface heat dissipation. Prosthet Orthot Int 2018; 42: 275–279.
    4. Caldwell R, Fatone S. Technique for perforating a prosthetic liner to expel sweat. JPO J Prosthet Orthot 2017; 29: 145–147.
    5. Klute GK, Glaister BC, Berge JS. Prosthetic liners for lower limb amputees: a review of the literature. Prosthet Orthot Int 2010; 34: 146–153.
    6. Richardson A, Dillon MP. User experience of transtibial prosthetic liners: a systematic review. Prosthet Orthot Int 2017; 41: 6–18.
    7. Sanders JE, Greve JM, Mitchell SB, et al. Material properties of commonly-used interface materials and their static coefficients of friction with skin and socks. J Rehabil Res Dev 1998; 35: 161–176.
    8. Emrich R, Slater K. Comparative analysis of below-knee prosthetic socket liner materials. J Med Eng Technol 1998; 22: 94–98.
    9. Klute GK, Rowe GI, Mamishev AV, et al. The thermal conductivity of prosthetic sockets and liners. Prosthet Orthot Int 2007; 31: 292–299.
    10. Sonck WA, Cockrell JL, Koepke GH. Effect of liner materials on interface pressures in below-knee prostheses. Arch Phys Med Rehabil 1970; 51: 666.
    11. Lee WC, Zhang M, Mak AF. Regional differences in pain threshold and tolerance of the transtibial residual limb: including the effects of age and interface material. Arch Phys Med Rehabil 2005; 86: 641–649.
  • Silcare Breathe Locking

    Clinical Outcomes using Sweat Management liners

    • Improvements in residual limb health problems and wound healing1,2
    • Fewer residual skin issues2
    • Reduction in pain in residual and phantom limb2
    • Improved heat dissipation compared to other temperature regulation solutions3
    • Removes sweat from skin interface1,2,4
    • Perforations do not damage the skin4
    • Patients reported a preference for their perforated liners1,4
    • Reduces the need to remove prosthesis throughout the day to dry residual limb4

    There are two published literature reviews that discuss different aspects of lower limb prosthetic liner technology5,6.

    • The main purpose of prosthetic liners is to cushion the transfer of loads from the prosthetic socket to the residual limb5.
    • Based on load-displacement data from the compressive stiffness tests, silicone was one of three materials that were recommended for situations where it is desirable for the liner to maintain thickness and volume since these materials had the least non-recovered strain5,7.
    • Under cyclic compressive loading, silicone was one of two materials that had the greatest cycles to failure under compressive loading, while the Pedilin and polyurethane samples lasted orders of magnitude less5,8.
    • Prosthetic liners and sockets are highly resistive to heat conduction and could be a major contributor to elevated skin temperatures5,9.
    • There are reduced residual limb pressures with the silicone liner compared to other conditions (no liner; soft inserts) suggesting that silicone has an ability to distribute pressure evenly to the residual limb4,10.
    • In terms of patient outcomes, there was no clear preference between silicone and Pelite liners5,11.

    References

    1. McGrath M, McCarthy J, Gallego A, et al. The influence of perforated prosthetic liners on residual limb wound healing: a case report. Can Prosthet Orthot J 2019; 2(1)
    2. Davies KC, McGrath M, Stenson A, Savage Z, Moser D, Zahedi S. Using perforated liners to combat the detrimental effects of excessive sweating in lower limb prosthesis users. Can Prosthet Orthot J. 2020;3(2).
    3. Williams RJ, Washington ED, Miodownik M, et al. The effect of liner design and materials selection on prosthesis interface heat dissipation. Prosthet Orthot Int 2018; 42: 275–279.
    4. Caldwell R, Fatone S. Technique for perforating a prosthetic liner to expel sweat. JPO J Prosthet Orthot 2017; 29: 145–147.
    5. Klute GK, Glaister BC, Berge JS. Prosthetic liners for lower limb amputees: a review of the literature. Prosthet Orthot Int 2010; 34: 146–153.
    6. Richardson A, Dillon MP. User experience of transtibial prosthetic liners: a systematic review. Prosthet Orthot Int 2017; 41: 6–18.
    7. Sanders JE, Greve JM, Mitchell SB, et al. Material properties of commonly-used interface materials and their static coefficients of friction with skin and socks. J Rehabil Res Dev 1998; 35: 161–176.
    8. Emrich R, Slater K. Comparative analysis of below-knee prosthetic socket liner materials. J Med Eng Technol 1998; 22: 94–98.
    9. Klute GK, Rowe GI, Mamishev AV, et al. The thermal conductivity of prosthetic sockets and liners. Prosthet Orthot Int 2007; 31: 292–299.
    10. Sonck WA, Cockrell JL, Koepke GH. Effect of liner materials on interface pressures in below-knee prostheses. Arch Phys Med Rehabil 1970; 51: 666.
    11. Lee WC, Zhang M, Mak AF. Regional differences in pain threshold and tolerance of the transtibial residual limb: including the effects of age and interface material. Arch Phys Med Rehabil 2005; 86: 641–649.
  • SmartIP

    Improvements in Clinical Outcomes using prosthetic knees with microprocessor-controlled swing phase

    • Less cognitive demand during walking, leading to reduced postural sway1
    • Increased walking speed2-5
    • Easier to walk at different speeds4,6
    • More natural gait4
    • Easier to walk on slopes4,6
    • Reduced energy expenditure compared to (non-MPK) mechanical knees3-8
    • Equivalent energy expenditure to other MPKs (swing and stance controlled)9
    • Reduced self-perceived effort4,6
    • Energy expenditure closer to that of able-bodied control subjects10
    • Able to walk further before becoming tired4
    • Better step length symmetry2,6
    • Preference over other prosthetic knees4,6

    References

    1. Heller BW, Datta D, Howitt J. A pilot study comparing the cognitive demand of walking for transfemoral amputees using the Intelligent Prosthesis with that using conventionally damped knees. Clin Rehabil 2000; 14: 518–522.
    2. Chin T, Maeda Y, Sawamura S, et al. Successful prosthetic fitting of elderly trans-femoral amputees with Intelligent Prosthesis (IP): a clinical pilot study. Prosthet Orthot Int 2007; 31: 271–276.
    3. Datta D, Heller B, Howitt J. A comparative evaluation of oxygen consumption and gait pattern in amputees using Intelligent Prostheses and conventionally damped knee swing-phase control. Clin Rehabil 2005; 19: 398–403.
    4. Datta D, Howitt J. Conventional versus microchip controlled pneumatic swing phase control for trans-femoral amputees: user’s verdict. Prosthet Orthot Int 1998; 22: 129–135.
    5. Buckley JG, Spence WD, Solomonidis SE. Energy cost of walking: comparison of “intelligent prosthesis” with conventional mechanism. Arch Phys Med Rehabil 1997; 78: 330–333.
    6. Kirker S, Keymer S, Talbot J, et al. An assessment of the intelligent knee prosthesis. Clin Rehabil 1996; 10: 267–273.
    7. Chin T, Sawamura S, Shiba R, et al. Energy expenditure during walking in amputees after disarticulation of the hip: a microprocessor-controlled swing-phase control knee versus a mechanical-controlled stance-phase control knee. J Bone Joint Surg Br 2005; 87: 117–119.
    8. Taylor MB, Clark E, Offord EA, et al. A comparison of energy expenditure by a high level trans-femoral amputee using the Intelligent Prosthesis and conventionally damped prosthetic limbs. Prosthet Orthot Int 1996; 20: 116–121.
    9. Chin T, Machida K, Sawamura S, et al. Comparison of different microprocessor controlled knee joints on the energy consumption during walking in trans-femoral amputees: intelligent knee prosthesis (IP) versus C-leg. Prosthet Orthot Int 2006; 30: 73–80.
    10. Chin T, Sawamura S, Shiba R, et al. Effect of an Intelligent Prosthesis (IP) on the walking ability of young transfemoral amputees: comparison of IP users with able-bodied people. Am J Phys Med Rehabil 2003; 82: 447–451.
  • SuperSACH

    Clinical Outcomes using SACH feet

    • Low stiffness at weight acceptance leads to early foot-flat and greater stability for lower mobility patients1
    • Satisfactory for patients with limited mobility in order to maintain mobility level2
    • Lightweight keel increases ease of use and is ideal for elderly users or those with limited strength2
    • Durability tests confirm foot to be long-lasting for those with low mobility levels3
    • 54% satisfaction rate2
    • Satisfaction rates increase within the bilateral population2

    References

    1. Turcot K, Sagawa Jr Y, Lacraz A, et al. Comparison of the International Committee of the Red Cross foot with the solid ankle cushion heel foot during gait: a randomized double-blind study. Arch Phys Med Rehabil 2013; 94: 1490–1497.
    2. Dudkiewicz I, Pisarenko B, Herman A, et al. Satisfaction rates amongst elderly amputees provided with a static prosthetic foot. Disabil Rehabil 2011; 33: 1963–1967.
    3. Sasaki K, Pinitlertsakun J, Rattanakoch J, et al. The development and testing of a modified natural rubber CR solid ankle–cushion heel prosthetic foot for developing countries. J Rehabil Assist Technol Eng 2017; 4: 2055668317712978.
  • TT Pro

    Improvements in Clinical Outcomes using shock-absorbing pylon/torque absorber compared to rigid pylon

    • Reduced back pain during twisting movements e.g. golf swings1
    • Reduced compensatory knee flexion at loading response2
    • No reduction in step activity3
    • Blatchford torsion adaptors match the able-bodied rotational range4
    • Reduced loading rate on prosthetic limb5, particularly at fast walking speeds6
    • Users feel less pressure on their residual limb7
    • Patient preference, citing improved comfort, smoothness of gait and easier stairs descent5

    References

    1. Rogers JP, Strike SC, Wallace ES. The effect of prosthetic torsional stiffness on the golf swing kinematics of a left and a right-sided trans-tibial amputee. Prosthet Orthot Int 2004; 28: 121–131.
    2. Berge JS, Czerniecki JM, Klute GK. Efficacy of shock-absorbing versus rigid pylons for impact reduction in transtibial amputees based on laboratory, field, and outcome metrics. J Rehabil Res Dev 2005; 42: 795.
    3. Klute GK, Berge JS, Orendurff MS, et al. Prosthetic intervention effects on activity of lower-extremity amputees. Arch Phys Med Rehabil 2006; 87: 717–722.
    4. Flick KC, Orendurff MS, Berge JS, et al. Comparison of human turning gait with the mechanical performance of lower limb prosthetic transverse rotation adapters. Prosthet Orthot Int 2005; 29: 73–81.
    5. Gard SA, Konz RJ. The effect of a shock-absorbing pylon on the gait of persons with unilateral transtibial amputation. J Rehabil Res Dev 2003; 40: 109–124.
    6. Boutwell E, Stine R, Gard S. Shock absorption during transtibial amputee gait: Does longitudinal prosthetic stiffness play a role? Prosthet Orthot Int 2017; 41: 178–185.
    7. Adderson JA, Parker KE, Macleod DA, et al. Effect of a shock-absorbing pylon on transmission of heel strike forces during the gait of people with unilateral trans-tibial amputations: a pilot study. Prosthet Orthot Int 2007; 31: 384–393.