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Fulltext Development and evaluation of new coupling system for lower limb prostheses with acoustic alarm system

Eshraghi A, Osman NA, Gholizadeh H, Ahmadian J, Rahmati B, Abas WA

Sci Rep, 2013;3:2270.
PMID: 23881340 DOI: 10.1038/srep02270

Individuals with lower limb amputation need a secure suspension system for their prosthetic devices. A new coupling system was developed that is capable of suspending the prosthesis. The system's safety is ensured through an acoustic alarm system. This article explains how the system works and provides an in vivo evaluation of the device with regard to pistoning during walking. The system was designed to be used with silicone liners and is based on the requirements of prosthetic suspension systems. Mechanical testing was performed using a universal testing machine. The pistoning during walking was measured using a motion analysis system. The new coupling device produced significantly less pistoning compared to a common suspension system (pin/lock). The safety alarm system would buzz if the suspension was going to fail. The new coupling system could securely suspend the prostheses in transtibial amputees and produced less vertical movement than the pin/lock system.

Matched MeSH terms: Lower Extremity*
Fulltext Estimation of body segmental orientation for prosthetic gait using a nonlinear autoregressive neural network with exogenous inputs

Tham LK, Al Kouzbary M, Al Kouzbary H, Liu J, Abu Osman NA

Phys Eng Sci Med, 2023 Dec;46(4):1723-1739.
PMID: 37870729 DOI: 10.1007/s13246-023-01332-6

Assessment of the prosthetic gait is an important clinical approach to evaluate the quality and functionality of the prescribed lower limb prosthesis as well as to monitor rehabilitation progresses following limb amputation. Limited access to quantitative assessment tools generally affects the repeatability and consistency of prosthetic gait assessments in clinical practice. The rapidly developing wearable technology industry provides an alternative to objectively quantify prosthetic gait in the unconstrained environment. This study employs a neural network-based model in estimating three-dimensional body segmental orientation of the lower limb amputees during gait. Using a wearable system with inertial sensors attached to the lower limb segments, thirteen individuals with lower limb amputation performed two-minute walk tests on a robotic foot and a passive foot. The proposed model replicates features of a complementary filter to estimate drift free three-dimensional orientation of the intact and prosthetic limbs. The results indicate minimal estimation biases and high correlation, validating the ability of the proposed model to reproduce the properties of a complementary filter while avoiding the drawbacks, most notably in the transverse plane due to gravitational acceleration and magnetic disturbance. Results of this study also demonstrates the capability of the well-trained model to accurately estimate segmental orientation, regardless of amputation level, in different types of locomotion task.

Matched MeSH terms: Lower Extremity*
Influential factors in stability of lower-limb amputees

Kamali M, Karimi MT, Eshraghi A, Omar H

Am J Phys Med Rehabil, 2013 Dec;92(12):1110-8.
PMID: 23900009 DOI: 10.1097/PHM.0b013e31829b4b7a

Lower-limb amputation is mainly a result of trauma, vascular disease, diabetes, or congenital disorders. Persons with amputation lose their ability to stand and walk on the basis of the level of amputation. Contribution of level of amputation, type of amputation, or cause of amputation to balance impairment has not been clearly defined. Furthermore, it is controversial how much the mentioned parameters influence standing stability. Therefore, the aim of this review article was to find the relationship between the abovementioned factors and balance impairment in the available literature. It was also aimed to find the possibility of improving standing stability by the use of different prosthesis components.

Matched MeSH terms: Lower Extremity/physiopathology*; Lower Extremity/surgery*
Outcomes of Free Muscle Flaps versus Free Fasciocutaneous Flaps for Lower Limb Reconstruction following Trauma: A Systematic Review and Meta-Analysis

Dow T, ElAbd R, McGuire C, Corkum J, Youha SA, Samargandi O, et al.

J Reconstr Microsurg, 2023 Sep;39(7):526-539.
PMID: 36577497 DOI: 10.1055/a-2003-8789

BACKGROUND: Free flap reconstruction of the lower limb following trauma often suffers higher complication rates than other areas of the body. The choice of muscle or fasciocutaneous free flap is an area of active debate.
METHODS: A systematic review of EMBASE, MEDLINE, PubMed, and Cochrane Register from inception to April 1, 2022 was performed. Articles were assessed using the methodological index for non-randomized studies instrument. The primary outcome was to assess and compare the major surgical outcomes of partial or total flap failure, reoperation, and amputation rates.
RESULTS: Seventeen studies were included. All studies were retrospective in nature, of level three evidence, and published between 1986 and 2021. The most common muscle and fasciocutaneous free flaps used were latissimus dorsi flap (38.1%) and anterolateral thigh (ALT) flap (64.8%), respectively. Meta-analysis found no significance difference in rates of total flap failure, takeback operations, or limb salvage, whereas partial flap failure rate was significantly lower for fasciocutaneous flaps. The majority of studies found no significant difference in complication rates, osteomyelitis, time to fracture union, or time to functional recovery. Most, 82.4% (14/17), of the included studies were of high methodological quality.
CONCLUSION: The rate of total flap failure, reoperation, or limb salvage is not significantly different between muscle and fasciocutaneous free flaps after lower limb reconstruction following trauma. Partial flap failure rates appear to be lower with fasciocutaneous free flaps. Outcomes traditionally thought to be managed better with muscle free flaps, such as osteomyelitis and rates of fracture union, were comparable.

Matched MeSH terms: Lower Extremity/injuries; Lower Extremity/surgery
Fulltext Improved Active Disturbance Rejection Control for Trajectory Tracking Control of Lower Limb Robotic Rehabilitation Exoskeleton

Aole S, Elamvazuthi I, Waghmare L, Patre B, Meriaudeau F

Sensors (Basel), 2020 Jun 30;20(13).
PMID: 32630115 DOI: 10.3390/s20133681

Neurological disorders such as cerebral paralysis, spinal cord injuries, and strokes, result in the impairment of motor control and induce functional difficulties to human beings like walking, standing, etc. Physical injuries due to accidents and muscular weaknesses caused by aging affect people and can cause them to lose their ability to perform daily routine functions. In order to help people recover or improve their dysfunctional activities and quality of life after accidents or strokes, assistive devices like exoskeletons and orthoses are developed. Control strategies for control of exoskeletons are developed with the desired intention of improving the quality of treatment. Amongst recent control strategies used for rehabilitation robots, active disturbance rejection control (ADRC) strategy is a systematic way out from a robust control paradox with possibilities and promises. In this modern era, we always try to find the solution in order to have minimum resources and maximum output, and in robotics-control, to approach the same condition observer-based control strategies is an added advantage where it uses a state estimation method which reduces the requirement of sensors that is used for measuring every state. This paper introduces improved active disturbance rejection control (I-ADRC) controllers as a combination of linear extended state observer (LESO), tracking differentiator (TD), and nonlinear state error feedback (NLSEF). The proposed controllers were evaluated through simulation by investigating the sagittal plane gait trajectory tracking performance of two degrees of freedom, Lower Limb Robotic Rehabilitation Exoskeleton (LLRRE). This multiple input multiple output (MIMO) LLRRE has two joints, one at the hip and other at the knee. In the simulation study, the proposed controllers show reduced trajectory tracking error, elimination of random, constant, and harmonic disturbances, robustness against parameter variations, and under the influence of noise, with improvement in performance indices, indicates its enhanced tracking performance. These promising simulation results would be validated experimentally in the next phase of research.

Matched MeSH terms: Lower Extremity*
Fulltext Rare cause of lower limb deep venous thrombosis: a case report

Khang NC, Hanif H, Zainal Ariffin A

Med J Malaysia, 2014 Jun;69(3):144-5.
PMID: 25326359 MyJurnal

deep venous thrombosis (dVT) in lower limbs caused by abdominal aortic aneurysm (AAA) is rare. A combination of anatomical obstruction with surrounding inflammatory tissue and reduced blood flow in venous limb were probably the main reasons for the occurrence of the dVT. we report a case of infra-renal AAA presented as lower limb dVT and symptomatic pulmonary embolism.

Matched MeSH terms: Lower Extremity
Fulltext Diagnostic Performance and Eye Movement Parameters during Radiographic Image Interpretation among Radiographers

Ibrahim, M. I., Mohd Norsuddin, N., Che Isa, I. N., Azman, N. F., Mohamad Shahimin, M.

Physics and Technology in Medicine, 2020;1(2):12-19.
MyJurnal

The radiographer's role in the imaging field is producing the best image to diagnose. Hence, this study is conducted to justify the ability of radiographers in terms of diagnostic performance and visual search patterns during radiographic image interpretation based on their experience. The musculoskeletal radiographic images were chosen as radiographers are expected to perform image interpretation in the red dot system as one of the expanded and extended roles of the radiographer. Sensitivity and specificity in the detection of abnormality are measured. The gaze plot, fixation count and duration are compared between groups of radiographers by using an eye tracker. 19 radiographic images consist of upper and lower extremities are used as stimuli in this study. The result from this study shows no significant difference in terms of sensitivity and specificity with a p-value of 0.818 and 0.146 respectively. For visual search pattern, two images have significant different in term of fixation count (Image 1, p = 0.017; Image 2, p = 0.042) and two images in fixation duration (Image 1, p = 0.001; Image 15, p = 0.021). The gaze plot is not different from an unstructured pattern and less coverage. In conclusion, the experience did not give an influence on the radiographic image interpretation. This may suggest that specific training in areas appropriate to the development of the radiographer could improve the image interpretation.

Matched MeSH terms: Lower Extremity
Fulltext Development of the pelvic and Lower Limb Immobilization Device: a Universiti Kebangsaan Malaysia (UKM) innovation project

Johar, M.J., Bala Krishnian M, Mohd Radhi, A., Saadah, N.A., Gan, K.B., Ismail, M.S.

Medicine & Health, 2012;7(1):1-11.
MyJurnal

Uncontrolled bleeding due to pelvic fractures contributes to trauma-related morbidity and mortality. Three main strategies that have been outlined to combat this condition which include reduction of pelvic volume that lead to tamponade-like effect, arresting haemorrhage through angioembolization of the major vessels, and stabilization of the pelvic bone with external fixation need to be initiated early. A prehospital device that allow these strategies will aid significantly in the management of the patient. At present most devices used to treat pelvic fractures in the pre-hospital setting do have its’ own advantages but also have some limitations. A characteristic ‘wish-list’ of a good pelvic and lower limb immobilization device was created and the research team from UKM takes the challenge to design and produce a device that concurs to it. A two phase development project that incorporate anthropometric, biomechanical, cadaveric and radiological study was carried out over a period of seven years. Finally, BRIMTM immobilizer, a new pelvic and lower limb immobilization device that is user friendly, tough, cost effective, radiolucent, light and reusable that answers most of the requirement of a good device was invented.

Matched MeSH terms: Lower Extremity
Contralateral Obturator Nerve to Femoral Nerve Transfer for Restoration of Knee Extension After Acute Flaccid Myelitis: A Case Report

Doi K, Sem SH, Hattori Y, Sakamoto S, Hayashi K, Maruyama A

JBJS Case Connect, 2019 Dec;9(4):e0073.
PMID: 31850914 DOI: 10.2106/JBJS.CC.19.00073

CASE: A 7-year-old boy presented with left femoral and obturator nerves (ONs) palsy after an asthmatic attack with a viral prodrome, and his right lower limb was unaffected. He was diagnosed with acute flaccid myelitis (AFM) after positive spinal magnetic resonance imaging findings. After contralateral ON to femoral nerve transfer (CONFNT), his left quadriceps was reinnervated at 5.5 months, full knee extension was recovered at 14 months, and good functional outcomes were achieved at 31 months.
CONCLUSIONS: This first clinical report on CONFNT demonstrated a feasible good alternative in treating young patients with AFM with unilateral L2-L4 palsy and short duration of deficit.

Matched MeSH terms: Lower Extremity/innervation; Lower Extremity/physiology; Lower Extremity/surgery
Lower limb fractures and their treatment

Robert EL

Malayan Medical Journal, 1932;7:33-8.

Matched MeSH terms: Lower Extremity
Fulltext Minimum number of inertial measurement units needed to identify significant variations in walk patterns of overweight individuals walking on irregular surfaces

Sikandar T, Rabbi MF, Ghazali KH, Altwijri O, Almijalli M, Ahamed NU

Sci Rep, 2023 Sep 27;13(1):16177.
PMID: 37758958 DOI: 10.1038/s41598-023-43428-9

Gait data collection from overweight individuals walking on irregular surfaces is a challenging task that can be addressed using inertial measurement unit (IMU) sensors. However, it is unclear how many IMUs are needed, particularly when body attachment locations are not standardized. In this study, we analysed data collected from six body locations, including the torso, upper and lower limbs, to determine which locations exhibit significant variation across different real-world irregular surfaces. We then used deep learning method to verify whether the IMU data recorded from the identified body locations could classify walk patterns across the surfaces. Our results revealed two combinations of body locations, including the thigh and shank (i.e., the left and right shank, and the right thigh and right shank), from which IMU data should be collected to accurately classify walking patterns over real-world irregular surfaces (with classification accuracies of 97.24 and 95.87%, respectively). Our findings suggest that the identified numbers and locations of IMUs could potentially reduce the amount of data recorded and processed to develop a fall prevention system for overweight individuals.

Matched MeSH terms: Lower Extremity
Letter to the editor regarding "Important tips and numbers on using the cortical step and diameter difference sign in assessing femoral rotation - Should we abandon the technique?"

Hwang PX, Wang CK

Injury, 2023 Nov;54(11):111038.
PMID: 37741171 DOI: 10.1016/j.injury.2023.111038

We have read the paper "Important tips and numbers on using the cortical step and diameter difference sign in assessing femoral rotation - Should we abandon the technique?" [1] with great interest. Restoring femoral rotation during intramedullary nailing can pose challenges to many experienced surgeons. Femur rotational side-to-side asymmetry which is greater than 10 ° will cause functional deficit. We propose a surgical technique which allows surgeons to evaluate and reduce the malrotated femur intraoperatively. This technique also improves the ergonomics of the surgery and can be used simultaneously with other femoral rotation evaluation techniques. LEVEL OF EVIDENCE: V.

Matched MeSH terms: Lower Extremity
Fulltext Does fear of re-injury affect the self-perceived level of lower limb functionality among soccer players with ACL reconstruction?: A cross-sectional study

Almansour A, Madkhali M, Alzhrani M, Alanazi A, Aldaihan MM, Alamri YH, et al.

Medicine (Baltimore), 2023 Nov 03;102(44):e35645.
PMID: 37933019 DOI: 10.1097/MD.0000000000035645

The fear of re-injury may persist after anterior cruciate ligament (ACL) reconstruction (ACLR) in professional soccer players (PSPs) even after a successful return to sport (RTS). This study aimed to determine the extent of this fear of re-injury and the impact of demographic variables and this fear of re-injury on the lower extremity functional scale (LEFS) scores in PSPs who had completed a successful RTS following ACLR. A cross-sectional survey design was used. Sixty-seven PSPs who had successfully RTS after ACLR, completed a demographic information sheet, the Athlete Fear-Avoidance Questionnaire (AFAQ), and the LEFS. The average AFAQ scores indicated low fear (M = 10.2, SD = 6.7), while high LEFS scores were observed (M = 67.1, SD = 12.4). There were significant strong negative correlations between LEFS and body mass index (BMI; rs [65] = -0.501, P = .001) and AFAQ and BMI (rs [65] = -0.378, P = .001). A hierarchical linear regression analysis found AFAQ to be a significant predictor of LEFS (b = -0.92, s.e. = 0.19, P = .001), with a total variance (adjusted R2) of 32.9%. PSPs' fear of re-injury post-ACLR significantly reduced their perceived levels of lower limb functionality. This study highlights the need to further explore and develop strategies to manage PSP fear of re-injury to improve sports-related performance post-ACLR.

Matched MeSH terms: Lower Extremity
Fulltext Piezoelectric bimorphs' characteristics as in-socket sensors for transfemoral amputees

El-Sayed AM, Hamzaid NA, Abu Osman NA

Sensors (Basel), 2014;14(12):23724-41.
PMID: 25513823 DOI: 10.3390/s141223724

Alternative sensory systems for the development of prosthetic knees are being increasingly highlighted nowadays, due to the rapid advancements in the field of lower limb prosthetics. This study presents the use of piezoelectric bimorphs as in-socket sensors for transfemoral amputees. An Instron machine was used in the calibration procedure and the corresponding output data were further analyzed to determine the static and dynamic characteristics of the piezoelectric bimorph. The piezoelectric bimorph showed appropriate static operating range, repeatability, hysteresis, and frequency response for application in lower prosthesis, with a force range of 0-100 N. To further validate this finding, an experiment was conducted with a single transfemoral amputee subject to measure the stump/socket pressure using the piezoelectric bimorph embedded inside the socket. The results showed that a maximum interface pressure of about 27 kPa occurred at the anterior proximal site compared to the anterior distal and posterior sites, consistent with values published in other studies. This paper highlighted the capacity of piezoelectric bimorphs to perform as in-socket sensors for transfemoral amputees. However, further experiments are recommended to be conducted with different amputees with different socket types.

Matched MeSH terms: Lower Extremity/physiopathology
Perception of lower extremity loading in stroke

Kumar SN, Joseph LH, Pharmy Jalil A

Clin Neurophysiol, 2015 Jul;126(7):1453-4.
PMID: 25468242 DOI: 10.1016/j.clinph.2014.09.031
Matched MeSH terms: Lower Extremity/physiopathology*
Fulltext Balance control in lower extremity amputees during quiet standing: a systematic review

Ku PX, Abu Osman NA, Wan Abas WA

Gait Posture, 2014 Feb;39(2):672-82.
PMID: 24331296 DOI: 10.1016/j.gaitpost.2013.07.006

Postural control has been widely evaluated for the normal population and different groups over the past 20 years. Numerous studies have investigated postural control in quiet standing posture among amputees. However, a comprehensive analysis is lacking on the possible contributing factors to balance. The present systematic review highlights the current findings on variables that contribute to balance instability for lower extremity amputees. The search strategy was performed on PubMed, Web of Science, Medline, Scopus, and CINAHL and then followed by additional manual searching via reference lists in the reviewed articles. The quality of the articles was evaluated using a methodological quality assessment tool. This review included and evaluated a total of 23 full-text articles. Despite the inconsistencies in the methodological design of the studies, all articles scored above the acceptable level in terms of quality. A majority of the studies revealed that lower extremity amputees have increased postural sway in the standing posture. Asymmetry in body weight, which is mainly distributed in the non-amputated leg, was described. Aside from the centre of pressure in postural control, sensory inputs may be a related topic for investigation in view of evidence on their contribution, particularly visual input. Other balance-related factors, such as stump length and patients' confidence level, were also neglected. Further research requires examination on the potential factors that affect postural control as the information of standing postural is still limited.

Matched MeSH terms: Lower Extremity/physiopathology*
Identifying gait asymmetry using gyroscopes--a cross-correlation and Normalized Symmetry Index approach

Gouwanda D, Senanayake SM

J Biomech, 2011 Mar 15;44(5):972-8.
PMID: 21306714 DOI: 10.1016/j.jbiomech.2010.12.013

Injury to a lower limb may disrupt natural walking and cause asymmetrical gait, therefore assessing the gait asymmetry has become one of the important procedures in gait analysis. This paper proposes the use of wireless gyroscopes as a new instrument to determine gait asymmetry. It also introduces two novel approaches: normalized cross-correlations (Cc(norm)) and Normalized Symmetry Index (SI(norm)). Cc(norm) evaluates the waveform patterns generated by the lower limb in each gait cycle. SI(norm) provides indications on the timing and magnitude of the bilateral differences between the limbs while addressing the drawbacks of the conventional methods. One-way ANOVA test reveals that Cc(norm) can be considered as single value indicator that determines the gait asymmetry (p<0.01). The experiment results showed that SI(norm) in asymmetrical gait were different from normal gait. SI(norm) in asymmetrical gait were found to be approximately 20% greater than SI(norm) in normal gait during pre-swing and initial swing.

Matched MeSH terms: Lower Extremity/pathology*
Cardiopulmonary bypass in surgery for complex-combined vascular malformation of the lower limb: case report

Ismail MS, Sharaf I, Thambidorai CR, Zainal A, Somasundaram S, Adeeb S, et al.

Pediatr Surg Int, 2005 May;21(5):392-5.
PMID: 15806424

A 16-year-old boy was referred with features of Parkes Weber syndrome (PWS) involving the right lower limb. He had presented at birth with cutaneous vascular malformations (VM) in the right thigh and at the age of 7 years developed congestive cardiac failure, which was controlled with drugs. He received alpha interferon and steroids during this period without any benefit. He defaulted follow-up and at 12 years of age presented with further enlargement of the VM in the right thigh and leg with skin and soft tissue thickening. At this stage, embolization and subsequent excision of the VM were tried, but the surgery was abandoned because of massive hemorrhage. Over the next 4 years, the boy became totally bedridden because of massive increase in the size of the limb, repeated hemorrhages, and secondary infection of the VM. Right hip disarticulation was considered the best option to improve his quality of life. To prevent uncontrollable hemorrhage during surgery, the disarticulation was done under cardiopulmonary bypass with low circulatory flow. Postoperatively, the patient required intensive care nursing for a week. He is presently ambulatory with crutches. Cardiopulmonary bypass with low flow has been used for treating posttraumatic arteriovenous malformations. However, its use in surgery for PWS has not been reported earlier.

Matched MeSH terms: Lower Extremity/blood supply*
Stature Estimation from Lower Limb Anthropometry using Linear Regression Analysis: A Study on the Malaysian Population

Abu Bakar SN, Aspalilah A, AbdelNasser I, Nurliza A, Hairuliza MJ, Swarhib M, et al.

Clin Ter, 2017 Mar-Apr;168(2):e84-e87.
PMID: 28383619 DOI: 10.7417/CT.2017.1988

INTRODUCTION: Stature is one of the characteristics that could be used to identify human, besides age, sex and racial affiliation. This is useful when the body found is either dismembered, mutilated or even decomposed, and helps in narrowing down the missing person's identity.

AIM: The main aim of the present study was to construct regression functions for stature estimation by using lower limb bones in the Malaysian population.

MATERIALS AND METHODS: The sample comprised 87 adult individuals (81 males, 6 females) aged between 20 to 79 years. The parameters such as thigh length, lower leg length, leg length, foot length, foot height and foot breadth were measured. They were measured by a ruler and measuring tape. Statistical analysis involved independent t-test to analyse the difference between lower limbs in male and female. The Pearson's correlation test was used to analyse correlations between lower limb parameters and stature, and the linear regressions were used to form equations. The paired t-test was used to compare between actual stature and estimated stature by using the equations formed.

RESULTS: Using independent t-test, there was a significant difference (p< 0.05) in the measurement between males and females with regard to leg length, thigh length, lower leg length, foot length and foot breadth. The thigh length, leg length and foot length were observed to have strong correlations with stature with p= 0.75, p= 0.81 and p= 0.69, respectively. Linear regressions were formulated for stature estimation. Paired t-test showed no significant difference between actual stature and estimated stature.

CONCLUSIONS: It is concluded that regression functions can be used to estimate stature to identify skeletal remains in the Malaysia population.

Matched MeSH terms: Lower Extremity; Bones of Lower Extremity
Fulltext Prognostic Factor of Lower Limb Amputation among Diabetic Foot Ulcer Patients in North-East Peninsular Malaysia

Rosedi A, Hairon SM, Abdullah NH, Yaacob NA

Int J Environ Res Public Health, 2022 Oct 31;19(21).
PMID: 36361092 DOI: 10.3390/ijerph192114212

Lower limb amputation (LLA) is a common complication of diabetic foot ulcer (DFU), which can lead to a higher 5-year mortality rate compared to all cancers combined. This study aimed to determine the prognostic factors of LLA among DFU patients in Kelantan from 2014 to 2018. A population-based study was conducted using secondary data obtained from the National Diabetic Registry (NDR). There were 362 cases that fulfilled the study criteria and were further analysed. The prognostic factors were determined by Multiple Cox Proportional Hazards Regression. There were 66 (18.2%) DFU patients who underwent LLA in this study, while 296 (81.8%) were censored. The results revealed that the factor leading to a higher risk of LLA was abnormal HDL-cholesterol levels (Adj. HR 2.18; 95% CI: 1.21, 3.92). Factors that led to a lower risk of LLA include DFU in patients aged 60 or more (Adj. HR 0.48; 95% CI: 0.27, 0.89) and obesity (Adj. HR 0.45; 95% CI: 0.22, 0.89). In conclusion, our model showed that abnormal HDL cholesterol was associated with a 2 times higher risk of LLA when adjusted for age and BMI. Any paradoxical phenomena should be addressed carefully to avoid wrong clinical decision making that can harm the patient.

Matched MeSH terms: Lower Extremity/surgery

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