C H A P T E R
10
Rehabilitation: Gait,
Amputations,
Prostheses, Orthoses,
and Neurologic Injury
C O N T E N T S
I. Gait 551 IV. Orthoses 565
II. Amputations 554 V. Surgery for Stroke and Closed Head
III. Prostheses 559 Injury 566
I. Gait
A. Walking
1. Definitions—Walking is the repetitive process of
sequential lower limb motion to move the body
from one location to another while maintaining
upright stability. Walking is a cyclic, energy-
efficient activity. It requires that one foot be in
contact with the ground at all times (single-limb
support), with a period when both limbs are in
contact with the ground (double-limb support)
(Fig. 10–1). The step is the distance between ini-
tial swing and initial contact of the same limb.
Stride is initial contact to initial contact of the
same limb (Fig. 10–2). Velocity is a function of
cadence (steps per unit time) and stride length.
Running involves a period when neither limb is
in contact with the ground.
2. Phases—Prerequisites for normal gait include
stance-phase stability, swing-phase ground
clearance, the correct position of the foot
before initial contact, and energy-efficient step
length and speed. The stance phase occupies 60%
of the cycle, starting from initial contact and pro-
gressing through loading response, midstance,
Frank A. Gottschalk
VI. Spinal Cord Injury 567
VII. Postpolio Syndrome 568
terminal stance, and preswing. The swing phase
is 40% of the cycle and starts at initial swing
(toe-off) and proceeds with limb acceleration to
midswing, when the limb decelerates at terminal
swing before the next cycle (Figs. 10–3 and 10–4).
During initial swing, the hip and knee flex and the
ankle begins to dorsiflex.
B. Gait dynamics—The combined phases of gait contrib-
ute to an energy-efficient process by lessening excur-
sion of the center of body mass. The head, neck,
trunk, and arms represent 70% of body weight. The
trunk center of gravity of this mass is located just ante-
rior to T10, which is 33 cm above the hip joints in an
individual of average height (184 cm). The body’s line
of gravity is anterior to S2 and provides a reference for
the moment arm to the center of the joint under con-
sideration. The resulting gait pattern resembles a sinus-
oidal curve.
C. Determinants of gait (motion patterns)—In mechani-
cal terms there are six independent degrees of freedom.
1. Pelvic rotation—The pelvis rotates horizontally
about a vertical axis, alternately to the left and
551
552 Review of ORTHOPAEDICS
Stance
right
Swing
left
Initial Single-limb Terminal
double-limb stance double-limb
stance stance
right of the line of progression, lessening the
center-of-mass deviation in the horizontal plane
and reducing the impact at initial floor contact.
2. Pelvic list—The non–weight-bearing, contralateral
side drops 5 degrees, reducing superior deviation.
3. Knee flexion at loading—The stance-phase limb is
flexed 15 degrees to dampen the impact of initial
loading.
4. Foot and ankle motion—Through the subtalar
joint, damping of the loading response occurs,
leading to stability during midstance and efficiency
of propulsion at push-off.
5. Knee motion—The knee works together with the
foot and ankle to decrease necessary limb motion.
The knee flexes at initial contact and extends at
midstance.
6. Lateral pelvic displacement—This relates to the
transfer of body weight onto the limb. The
motion is 5 cm over the weight-bearing limb,
narrowing the base of support and increasing
stance-phase stability.
D. Muscle action—Agonist and antagonist muscle groups
work in concert during the gait cycle to effectively
advance the limb through space. The hip flexors
advance the limb forward during the swing phase
and are opposed during terminal swing, before initial
contact by the decelerating action of the hip extensors.
Most muscle activity is eccentric, which is muscle
lengthening while contracting, and allows an antago-
nist muscle to dampen the activity of an agonist and
act as a ‘‘shock absorber’’ (Fig. 10–5). Isocentric
contraction is muscle length remaining constant
Step
Stride
FIGURE 10^2 Step versus stride. (Adapted from Perry J: Gait
Analysis: Normal and Pathological Function, 1992, with permission
from SLACK, Inc.)
FIGURE 10^1 Subdivisions of
stance and their relationships to the
pattern of bilateral floor contact.
(Adapted from Perry J: Gait
Analysis: Normal and Pathological
Function, 1992, with permission
from SLACK, Inc.)
Swing
right
Stance
left
Swing Double-limb
stance
during contraction (Table 10–1). Some muscle activity
can be concentric, in which the muscle shortens
to move a joint through space.
E. Pathologic gait—Abnormal gait patterns are caused
by the following factors.
1. Muscle weakness or paralysis—Decreases the
ability to normally move a joint through space.
A walking pattern develops based on the specific
muscle or muscle group involved and the ability
of the individual to acquire a substitution pattern
to replace that muscle’s action (Table 10–2).
2. Neurologic conditions—May alter gait by produ-
cing muscle weakness, loss of balance, reduced
coordination between agonist and antagonist
muscle groups (i.e., spasticity), and joint contrac-
ture. Hip scissoring is associated with overactive
adductors, and knee flexion contracture may be
caused by hamstring spasticity. Equinus defor-
mity of the foot and ankle may result in a steppage
gait and back setting of the knee.
3. Pain in a limb—Creates an antalgic gait pattern, in
which the individual shortens the stance phase to
lessen the time that the painful limb is loaded. The
contralateral swing phase is more rapid.
4. Joint abnormalities—Alter gait by changing the
range of motion of that joint or producing pain.
Arthritis of the hip and knee may have joint con-
tractures and reduced range of motion. An anterior
cruciate–deficient knee has quadriceps-avoidance
gait, which is a net quadriceps moment during
midstance that is lower than normal.
5. Hemiplegia—Characterized by prolongation of
stance and double-limb support. Gait impairment
may be excessive plantar flexion, weakness, and
balance problems. Associated problems are ankle
equinus, limitation of knee flexion, and increased
hip flexion. Surgical correction of equinus is done
1 year after onset.
6. Crutches and canes—Devices that ameliorate insta-
bility and pain, respectively. Crutches increase
stability by providing two additional loading
points. A cane helps shift the center of gravity to
the affected side when the cane is used in the
 Rehabilitation: Gait, Amputations, Prostheses, Orthoses, and Neurologic Injury 553

FIGURE 10^3 Divisions of the

gait cycle. Clear and shaded bars
represent the duration of each
phase. (Adapted from Perry J: Gait
Analysis: Normal and Pathological
Function, 1992, with permission
Stance Swing from SLACK, Inc.)

FIGURE 10^4 Distance (A) and

time (duration) (B) dimensions of
the walking cycle. (From Inman VT,
Ralston H, Todd F: Human
Walking, p 26. Baltimore, Williams
& Wilkins, 1982.)

Right Left Right

heel heel heel
contact contact contact

Right step Left step Right step

length length length

Cycle length
A (stride)

Right Left Left Right Right Left

heel toe- heel toe- heel toe-
contact off contact off contact off

0% 50% 100%
Time, percent of cycle

Double Double Double

Right single support Left single support
support support support

Right stance phase Right swing phase

Left swing phase Left stance phase

B Cycle (stride) duration

554 Review of ORTHOPAEDICS

FIGURE 10^5 Effect of ankle motion, controlled by muscle action, on the pathway of the knee. The smooth and flattened pathway of the knee
during the stance phase is achieved by forces acting from the leg on the foot. Foot slap is restrained during initial lowering of the foot; afterward, the
plantar flexors raise the heel. (From Inman VT, Ralston H, Todd F: Human Walking, p 11. Baltimore, Williams & Wilkins, 1982.)

opposite hand. This decreases the joint reaction and is inversely proportional to the length of the
forces of the lower limb and reduces pain. residual limb and the number of functional joints
7. Arthritis—Forces across the knee may be 4-7 times preserved. With a proximal amputation, patients
those of body weight; 70% of the load across the have a decreased self-selected, maximum walking
knee occurs through the medial compartment. speed. Oxygen consumption increases the higher
the amputation (or the shorter the stump);
II. Amputations thus, the transfemoral amputee with peripheral vas-
A. Introduction—All or part of a limb is amputated to cular disease uses close to maximum energy expen-
treat peripheral vascular disease, trauma, tumor, diture during normal self-selected–velocity walking
infection, or a congenital anomaly. It is often an alter- (Table 10–3).
native to limb salvage and should be considered a C. Load transfer
reconstructive procedure. Because of the psychologi- 1. Soft tissue envelope—The soft tissue envelope
cal implications and the alteration of body self-image, acts as an interface between the bone of the resid-
a multidisciplinary-team approach should be insti- ual limb and the prosthetic socket. Ideally, it is
tuted to manage the patient. composed of a mobile, securely attached muscle
B. Metabolic cost of amputee gait—The metabolic cost of mass covering the bone end and full-thickness
walking is increased with proximal-level amputations skin that tolerates the direct pressures and ‘‘pis-
toning’’ (mobility) within the prosthetic socket. It
is rare for the prosthetic socket to achieve a per-
fect, intimate fit. A nonadherent soft tissue enve-
TABLE 10–1 MUSCLE ACTION AND FUNCTION lope allows some degree of mobility of the skin
and muscle, thus eliminating the shear forces that
Muscle Action Function produce tissue breakdown and ulceration.
Gluteus medius Eccentric Controls pelvic tilt (midstance)
2. Direct and indirect load transfer—Load transfer
Gluteus maximus Concentric Powers hip extension (i.e., weight bearing) occurs either directly or indi-
Iliopsoas Concentric Powers hip flexion rectly. Direct load transfer (i.e., terminal weight
Hip adductors Eccentric Control lateral sway (late stance) bearing) occurs in knee or ankle disarticulation
Hip abductors Eccentric Control pelvic tilt (midstance) (Syme amputation). For direct load transfer, inti-
Quadriceps Eccentric Stabilizes knee at heel-strike
Hamstrings Eccentric Control rate of knee extension macy of the prosthetic socket is necessary only for
(stance) suspension. When the amputation is performed
Tibialis anterior Concentric Dorsiflexes ankle at swing through a long bone (i.e., transfemoral or trans-
Eccentric Slows plantar flexion rate tibial), the end of the stump does not take all the
(heel-strike)
Gastrocnemius/soleus Eccentric Slows dorsiflexion rate (stance)
weight, and the load is transferred indirectly by the
total contact method. This process requires an

Predominant role. intimate fit of the prosthetic socket, 7-10 degrees
of flexion of the knee for transtibial amputation,
 Rehabilitation: Gait, Amputations, Prostheses, Orthoses, and Neurologic Injury 555

TABLE 10–2 GAIT ABNORMALITIES CAUSED BY MUSCLE WEAKNESS

Weak Muscle Phase Direction Type of Gait Treatment

Gluteus medius Stance Lateral Abductor lurch Cane
Gluteus maximus Stance Backward Lurch (hip hyperextension)
Quadriceps Stance Forward Lurch/back knee gait AFO
Swing Forward Abnormal hip rotation
Gastrocnemius/soleus Stance Forward Flatfoot (calcaneal) gait ± AFO
Swing Forward Delayed heel rise
Tibialis anterior Stance Forward Foot drop/slap AFO
Swing Forward Steppage gait

AFO, ankle-foot orthosis; ±, with or without.

and 5-10 degrees of adduction and flexion of the
femur for transfemoral amputation (Fig. 10–6).
D. Amputation wound healing—The healing of amputa-
tion wounds depends on several factors, which
include vascular supply, nutrition, and an adequate
immune status.
1. Nutrition and immune status—Patients with mal-
nutrition or immune deficiency have a high rate of
wound failure or infection. A serum albumin level
below 3.5 g/dL indicates a malnourished patient.
An absolute lymphocyte count below 1500/mm3
is a sign of immune deficiency. If possible, ampu-
tation surgery should be delayed in patients with
stable gangrene until these values can be
improved by nutritional support, usually in the
form of oral hyperalimentation. In severely
affected patients, nasogastric or percutaneous gas-
tric feeding tubes are sometimes essential. When
infection or severe ischemic pain requires urgent
surgery, open amputation at the most distal,
viable level, followed by open wound manage-
ment, can be accomplished until wound healing
can be optimized.
2. Vascular supply—Oxygenated blood is a prereq-
uisite for wound healing, and a hemoglobin con-
centration of more than 10 g/dL is necessary.
Amputation wounds generally heal by collateral
flow, so arteriography is rarely useful for predict-
ing wound healing.
a. Doppler ultrasonography—Standard Doppler
ultrasonography measures arterial pressure
and has been used as the measure of vascular
inflow to predict wound healing in the
TABLE 10–3 ENERGY EXPENDITURE FOR
AMBULATION
Amputation % Energy Speed
Level Above Baseline (m/min)
Long transtibial 10 70
Average transtibial 25 60
Short transtibial 40 50
Bilateral transtibial 41 50
Transfemoral 65 40
Wheelchair 0-8 70
ischemic limb. An absolute Doppler pressure
measurement of 70 mm Hg was originally
described as the minimum inflow to support
wound healing. The ischemic index is the
ratio of the Doppler pressure at the level
being tested to the brachial systolic pressure.
It is generally accepted that patients require an
ischemic index of 0.5 or greater at the surgical
level to support wound healing. The ischemic
index at the ankle (i.e., the ankle-brachial
index) is the most accepted method for assess-
ing adequate inflow to the ischemic limb. In
the normal limb, the area under the Doppler
waveform tracing is a measure of flow. These
values are falsely elevated and not predictive in
at least 15% of patients with diabetes and
peripheral vascular disease because of the
incompressibility and loss of compliance of
calcified peripheral arteries. The ischemic
index for toe pressure is more accurate in
these patients and, if greater than 0.45, is usu-
ally predictive of adequate blood flow.
b. Transcutaneous partial pressure of oxy-
gen—TcpO2 is the present gold standard for
measurement of vascular inflow. It records the
oxygen-delivering capacity of the vascular
system to the level of contemplated surgery.
Values greater than 40 mm Hg correlate with
acceptable wound-healing rates without the
false-positive values seen in noncompliant
peripheral vascular diseased vessels. Pressures
less than 20 mm Hg are predictive of poor heal-
ing potential.
E. Pediatric amputation—Pediatric amputations are usu-
ally the result of congenital limb deficiencies, trauma,
or tumors. Congenital amputations are the result of
failure of formation. The present classification system
is based on the original work of the 1975 Conference
O2 Cost of the International Society for Prosthetics and
(mL/kg/m) Orthotics (ISPO) and the subsequent standard devel-
oped by the International Organization for
0.17
0.20
Standardization (ISO). Deficiencies are either longi-
0.20 tudinal or transverse, with the potential for intercalary
.20 deficits. Amputation is rarely indicated in congenital
0.28 upper limb deficiency; even rudimentary appendages
0.16 can be functionally useful. In the lower limb, ampu-
tation of an unstable segment may allow direct load
556 Review of ORTHOPAEDICS
FIGURE 10^6 A, Direct load transfer is accomplished in the through-knee (left) and Syme ankle disarticulation (right) amputations. B, Indirect load
transfer is accomplished in above-knee amputations with either a standard quadrilateral socket (left) or an adducted, narrow mediolateral socket
(center). The below-knee amputation (right) transfers weight indirectly with the knee flexed approximately 10 degrees. (From Pinzur M: New concepts
in lower limb amputation and prosthetic management. Instr Course Lect 39:361, 1990.)
transfer and enhanced walking (e.g., Syme amputa-
tion for fibular hemimelia). In the growing child,
disarticulations should be performed only when it is
possible to maintain maximum residual limb length
and prevent terminal bony overgrowth. Such over-
growth usually occurs in the humerus, fibula, tibia,
and femur, in that order; it is typical in diaphyseal
amputations. Numerous surgical procedures have
been described to resolve this problem, but the best
method is surgical revision of the residual limb with
adequate resection of bone or autogenous osteochon-
dral stump capping (Fig. 10–7).
F. Amputation after trauma—The grading scales for
evaluating mangled extremities are not absolute
Cortical bone
Cancellous graft
Grafted “cap”
FIGURE 10^7 Diagram of the stump-capping procedure. The bone
end has been split longitudinally. (Adapted from Bernd L, Blasius K,
Lukoschek M, et al: The autologous stump plasty: treatment for bony
overgrowth in juvenile amputees. J Bone Joint Surg [Br] 73:203–206,
1991.)
predictors but provide reasonable guidelines for deter-
mining whether salvage is appropriate.
1. Indications—The absolute indication for amputa-
tion after trauma is an ischemic limb with
a vascular injury that cannot be repaired. The
guidelines for immediate or early amputation of
mangled limbs differ between upper and lower
limbs. Early amputation in the appropriate patient
may prevent emotional, marital, financial, and
addictive problems. Most grades IIIB and IIIC
tibia fractures occur in young males who are
laborers and may be more likely to return to gain-
ful employment after amputation and prosthetic
fitting. Sensation is not as crucial in the lower
limb as in the upper limb, and current prostheses
more closely approximate normal function.
a. Disadvantages of limb salvage—Severe open
tibia fractures that are managed by limb sal-
vage rather than amputation are often associ-
ated with high mortality and morbidity
owing to infection, increased energy expendi-
ture for ambulation, and decreased potential
to return to work. Gustillo-Anderson grades
IIIB and IIIC open fractures of the tibia and
fibula treated by limb salvage generally have
poor functional outcomes and multiple com-
plications and surgeries. The salvaged lower
extremity with an insensate plantar weight-
bearing surface (loss of posterior tibial
nerve), with associated major functional
muscle and bone loss, is unlikely to provide
a durable limb for stable walking and is a
potential source of early or late sepsis.
2. Contraindications
a. Upper limb—When a salvaged upper limb
remains sensate and has prehensile function,
it will often function better than an
 Rehabilitation: Gait, Amputations, Prostheses, Orthoses, and Neurologic Injury
amputation with prosthetic replacement.
Maintaining as much length as possible is
the key to subsequent prosthetic use.
b. Lower limb—Lack of plantar sensation is not
an indication to amputate because it may
result from neurapraxia that can resolve. In
the absence of other major factors, amputa-
tion should not be done.
G. Risk factors
1. Cognitive deficits—In order for patients to learn
to walk with a prosthesis and care for their stumps
and prostheses, they must possess certain cogni-
tive capacities: memory, attention, concentration,
and organization. Patients with cognitive deficits
or psychiatric disorders have a low likelihood of
becoming successful prosthesis users.
2. Diabetes—A majority of amputation patients are
diabetic, with inherent immune deficiency. The
most important risk factors for amputation in dia-
betic patients are the presence of peripheral
neuropathy and development of deformity and
infection.
3. Peripheral vascular disease—Most of the other
amputation patients are malnourished patients
with peripheral vascular disease of sufficient mag-
nitude to require amputation, and they have dis-
ease in their coronary and cerebral arteries.
Appropriate consultation with physical therapy,
social work, and psychology departments is impor-
tant to determine rehabilitation potential.
Medical consultation will help determine cardio-
pulmonary reserve. The vascular surgeon should
determine whether vascular reconstruction is feasi-
ble or appropriate. The biologic amputation level
is the most distal functional amputation level with
a high probability of supporting wound healing.
This level is determined by the presence of ade-
quate, viable local tissue to construct a residual
limb capable of supporting weight bearing; an ade-
quate vascular inflow; and serum albumin and a
total lymphocyte count sufficient to aid surgical
wound healing. The selection of an appropriate
amputation level is determined by combining the
biologic amputation level with the rehabilitation
potential in order to choose the level that
maximizes ultimate functional independence.
Morbidity and mortality rates have remained un-
changed for several decades. Thirty percent of pa-
tients with peripheral vascular disease die in the
first 3 months and nearly 50% within the first
year. Overall prosthetic use is 43%.
H. Musculoskeletal tumors
1. Goal of surgery—The primary goal of tumor
surgery is to remove the tumor with adequate
surgical margins.
2. Amputation versus limb salvage—Advances in
chemotherapy and allograft or prosthetic recon-
struction have made limb salvage a viable option
in extremity sarcomas. If adequate margins can be
achieved with limb salvage, the decision can then
be based on expected functional outcome. The
advantage of limb salvage versus amputation with
557
regard to energy expenditure to ambulate, quality-
of-life measures, and function with activities of
daily living is controversial in the literature.
Expected functional outcome should include the
psychosocial and body-image values associated
with limb salvage. These concerns should be
balanced with improved task performance and
lower concern for late mechanical injury associ-
ated with amputation and fitting of prosthetic
limbs.
I. Technical considerations—Skin flaps should be of full
thickness and avoid dissection between tissue planes.
Periosteal stripping should be sufficient to allow for
bone transection; this minimizes regenerative bone
overgrowth. Wounds should not be sutured under
tension. Muscles are best secured directly to bone
at resting tension (myodesis) rather than to antagonist
muscle (myoplasty). Stable residual limb muscle mass
can improve function by reducing atrophy and pro-
viding a stable soft tissue envelope over the end of
the bone. All transected nerves form neuromata. The
nerve end should come to lie deep in a soft tissue
envelope, away from potential pressure areas.
Crushing the nerve may contribute to postoperative
phantom or limb pain. Rigid dressings (postoperative)
help reduce swelling, decrease pain, and protect the
stump from trauma. Early prosthetic fitting is done
within 5 to 21 days after surgery in selected patients.
J. Complications
1. Pain—Phantom limb sensation, the feeling that
all or part of the amputated limb is present,
occurs in almost all adults who have undergone
amputation. It usually decreases with time.
Phantom pain is a burning, painful sensation in
the part having undergone amputation. It is
diminished by prosthetic use, physical therapy,
compression, and transcutaneous nerve stimula-
tion. A common cause of residual pain is complex
regional pain syndrome (reflex sympathetic dys-
trophy) or causalgia. Amputation should not be
performed for this condition. Localized stump
pain is often related to bony or soft tissue prob-
lems. Referred pain to the limb occurs in a fre-
quent number of cases.
2. Edema—Postoperative edema occurs after ampu-
tation. It may impede wound healing and place
significant tension on the tissues. Rigid dressings
and soft compression help reduce the problem.
Swelling occurring after stump maturation is usu-
ally caused by poor socket fit, medical problems,
or trauma. Persistence of chronic swelling may
lead to verrucous hyperplasia, a wartlike over-
growth of skin with pigmentation and serous
discharge. It should be treated by a total-contact
cast, which is changed regularly to accommodate
the reduced edema.
3. Joint contractures—These complications are usu-
ally noted as hip and knee flexion contractures,
which can be produced at the time of surgery by
anchoring the respective muscles to the joints in a
flexed position. They can be avoided by ensuring
correct positioning of the amputated limb.
558 Review of ORTHOPAEDICS

4. Wound failure to heal—This outcome occurs
most often in diabetic and vascular disease
patients. If the wound is not amenable to local
care, wedge excision of soft tissue and bone, with
closure and without tension, is the preferred
treatment.
K. Upper limb amputations (Fig. 10–8)
1. Wrist disarticulation
a. Advantages—Wrist disarticulation has two
advantages over transradial amputation: (1)
preservation of more forearm rotation because
of preservation of the distal radioulnar joint
and (2) improved prosthetic suspension
because of the flare of the distal radius.
Effective function can be obtained at this
level of amputation. Forearm rotation and
strength are directly related to the length of
the transradial (below-elbow) residual limb.
b. Disadvantages—Wrist disarticulation provides
challenges to the prosthetist that may out-
weigh its benefits. Cosmetically, the prosthetic
limb is longer than the contralateral limb, and
if myoelectric components are used, the
motor and battery cannot be hidden within
the prosthetic shank.
2. Transradial amputation or elbow disarticulation
—Patients with complete brachial plexus injury
and a nonfunctioning hand and forearm may be
best treated by a transradial amputation or elbow
disarticulation, which can be fitted with a pros-
thesis. The optimum length of the residual limb
is at the junction of the middle and distal thirds of
the forearm, where the soft tissue envelope can be
repaired by myodesis and the components of a
myoelectric prosthesis can be hidden within the
prosthetic shank. Because the patient can main-
tain function at this level prosthetically only by
being able to open and close the terminal
device, retention of the elbow joint is essential.
The length and shape of elbow disarticulation pro-
vides improved suspension and lever-arm capa-
city. To enhance suspension and reduce the
need for shoulder harnessing, a 45-60–degree
distal humeral osteotomy is performed.
Gangrene of the upper limb, when it is not due
to Raynaud or Buerger disease, represents end-
stage disease, especially in the diabetic patient.
These patients experience a high mortality rate
and do not survive beyond 24 months.
Localized amputations are unlikely to heal.
When surgery becomes necessary, amputation
should be performed at the transradial level to
achieve wound healing during the final months
of the patient’s life.

U1 Forequarter FIGURE 10^8 Composite illustration of common

U2 Shoulder disarticulation amputation levels.
U3 Short transhumeral
U4 Standard transhumeral
U5 Elbow disarticulation
U2 U6 Transradial
U1
U7 Wrist disarticulation
L1 Hemipelvectomy
L2 Hip disarticulation
U3 L3 Short transfemoral
L4 Medium transfemoral
U4 L5 Long transfemoral
L6 Supracondylar
U5 L7 Knee disarticulation
8 Short transtibial
U6 9 Standard transtibial
10 Low transtibial
11 Syme
U7 12 Boyd
13 Pirogoff
L1 L3 14 Chopart
L2
15 Lisfranc
L4 16 Transmetatarsal
17 Metatarsophalangeal disarticulation
18 Toe disarticulation
L5
L6
L7 14
15
8 16
9 17
11

10

12

13 18
 Rehabilitation: Gait, Amputations, Prostheses, Orthoses, and Neurologic Injury
L. Lower limb amputations (see Fig. 10–8)
1. Toe and ray amputation—Patients with ischemia
generally ambulate with a propulsive gait pattern,
so they suffer little disability from toe amputation.
Traumatic amputees lose some stability after toe
amputation in the late-stance phase. The great toe
should be amputated distal to the insertion of the
flexor hallucis brevis. Isolated second-toe amputa-
tion should be performed just distal to the prox-
imal phalanx metaphyseal flare, leaving it to act as
a buttress and prevent late hallux valgus. Patients
who undergo single outer (first or fifth) ray resec-
tions function well in standard shoes. Resection
of more than one ray leaves a narrow forefoot that
is difficult to fit in shoes and often results in a late
equinus deformity. Central ray resections are
complicated by prolonged wound healing and
rarely outperform midfoot amputation.
2. Transmetatarsal and Lisfranc tarsal-metatarsal
amputation—There is little functional difference
between these two. The long plantar flap acts as a
myocutaneous flap and is preferred to fish-mouth
dorsal-plantar flaps. Transmetatarsal amputation
should be performed through the proximal me-
taphyses to prevent late plantar pressure ulcers
under the residual bone ends. Percutaneous
Achilles tendon lengthening should be performed
with transmetatarsal and Lisfranc amputations to
prevent the late development of equinus or equi-
novarus. Late varus can be corrected with the trans-
fer of the tibialis anterior tendon to the neck of the
talus. Some authors have reported reasonable func-
tional outcomes with hindfoot amputation (i.e.,
Chopart or Boyd), but most experts recommend
avoiding these levels if possible in diabetic and vas-
cular disease patients. Although children have
been reported to function reasonably well, adults
retain an inadequate lever arm and are prone to
experience fixed equinus of the heel if Achilles
tendon lengthening and tibialis anterior tendon
transfer are not performed.
3. Ankle disarticulation (Syme amputation)—This
amputation allows direct load transfer and is
rarely complicated by late residual limb ulcers or
tissue breakdown. It provides a stable gait pattern
that rarely requires prosthetic gait training after
surgery. Surgery should be performed in one
stage, even in ischemic limbs with insensate heel
pads. A patent posterior tibial artery is necessary
to ensure healing. The malleoli and metaphyseal
flares should be removed from the tibia and fibula,
but the remaining tibial articular surface should
be retained to provide a resilient residual limb.
The heel pad should be secured to the tibia
either anteriorly through drill holes or posteriorly
by securing the Achilles tendon.
4. Transtibial (below-knee) amputation—A long pos-
terior myocutaneous flap is the preferred method
of creating a soft tissue envelope. The optimum
bone length is at least 12 cm below the knee
joint or longer if adequate gastrocnemius or
soleus muscle can be used to construct a durable
559
soft tissue envelope. Posterior muscle should be
secured to the beveled anterior tibia by myodesis.
Rigid dressings are preferred during the early post-
operative period, and early prosthetic fitting may
be started 5-21 days after surgery if the residual
limb is capable of transferring load and the patient
has a satisfactory physical reserve.
5. Knee disarticulation (through-knee amputation)—
The current technique uses a long posterior flap,
with gastrocnemius muscle as end-padding. The
alternative is to use sagittal skin flaps and cover
the end of the femur with gastrocnemius muscle
to act as a soft tissue envelope end-pad. The patella
tendon is sutured to the cruciate ligaments in the
notch, leaving the patella on the anterior femur.
This level is generally used in the nonwalker who
can support wound healing at the transtibial or
distal level. Knee disarticulation is muscle balanced
and provides an excellent weight-bearing platform
for sitting and a lever arm for bed to chair transfer.
When this amputation is performed in a potential
walker, it provides a residual limb for direct bed to
chair transfer (end-bearing).
6. Transfemoral (above-knee) amputation—This
amputation increases the energy cost for walking.
Transfemoral amputees with peripheral vascular
disease are unlikely to become good walkers, so
salvaging the limb at the knee disarticulation
(transtibial level) is critical to maintaining func-
tional walking independence. With greater femo-
ral length, the lever arm, suspension, and limb
advancement are optimized. The optimum trans-
femoral bone length is 12 cm above the knee joint
to accommodate the prosthetic knee. Adductor
myodesis is important for maintaining femoral
adduction during the stance phase in order to
allow optimum prosthetic function (Fig. 10–9).
The major deforming force is toward abduction
and flexion. Adductor myodesis at normal
muscle tension eliminates the problem of adduc-
tor roll in the groin. Transecting the adductor
magnus results in a loss of 70% of the adductor
pull (Fig. 10–10). Rigid dressings are difficult to
apply and maintain at this level. Elastic compres-
sion dressings are used and may be suspended
about the opposite iliac crest.
7. Hip disarticulation—This is infrequently per-
formed, and only an occasional few of these
amputees become meaningful prosthesis users
because of the high energy requirements for walk-
ing. Post-trauma or tumor patients occasionally
use the prosthesis for limited activity. These
patients sit in their prostheses and must use the
torso in order to achieve momentum for
‘‘throwing’’ the limb forward to advance it.
III. Prostheses
A. Upper limb
1. Upper limb biomechanics—The shoulder pro-
vides the center of the radius of the functional
sphere of the upper limb. The elbow acts as the
caliper to position the hand at a workable
560 Review of ORTHOPAEDICS

FIGURE 10^9 A, Diagram showing

attachment of the adductor magnus to the
lateral part of the femur. B, Diagram depicting
attachment of the quadriceps over the adductor
magnus. (From Gottschalk F: Transfemoral
amputation. In Bowker J, Michael J, eds: Atlas
of Limb Prosthetics, pp 479–486. St. Louis,
Mosby–Year Book, 1992.)

the lever arm necessary to ‘‘drive’’ the prosthesis

distance from that center in order to perform its through space.
tasks. In a normal arm, tasks performed with the 2. Benefits of limb salvage—Limb salvage is more
use of multiple joint segments usually occur important for the upper limb, where sensation
simultaneously, whereas upper limb prostheses is critical to function. An insensate prosthesis
perform these same tasks sequentially; thus, provides less function than a partially sensate,
joint- and residual-limb-length salvage is directly partially functional salvaged limb.
correlated with functional outcome. Motion at 3. Timing of prosthetic fitting—Prosthetic fitting
the retained joints is essential to maximize that should be done as soon as possible after ampu-
function. Residual limb length is important for tation, even before complete wound healing has
suspending the prosthetic socket and providing occurred. For transradial amputation, the
outcomes for prosthetic limb use vary from
70-85% when prosthetic fitting occurs within
cm 30 days of amputation, in contrast with less
0 than 30% when the fitting starts late.
4. Types of prostheses for different levels of
5 amputation
a. Midlength transradial amputation—
10 Myoelectric prostheses provide good cosme-
R1
sis and are used for sedentary work. They can
15 AB R2
R3
be used in any position, including overhead
760° activity, and are the most successful in the
20 AL midlength transradial amputee, for whom
70°
only the terminal device needs to be acti-
25 vated. Body-powered prostheses are used
for heavy labor. The terminal device is acti-
30 vated by shoulder flexion and abduction.
AM The optimum mechanical efficiency of
35 figure-8 harnesses requires that the harness
78° ring be at the spinous process of C7 and
40 slightly to the nonamputated side.
b. Elbow disarticulation and transhumeral
45 (above-elbow) amputations—When the
residual forearm is so short that it precludes
an adequate lever arm for driving the pros-
thesis through space, supracondylar sus-
pension (Munster socket) and step-up
FIGURE 10^10 Diagram of moment arms of the three adductor hinges can be used to augment function.
muscles. Loss of the distal attachment of the adductor magnus (AM) Elbow disarticulation and transhumeral
will result in a loss of 70% of the adductor pull. AB, adductor brevis;
AL, adductor longus. (From Gottschalk FA, Kourosh S, Stills M, et al:
(above-elbow) amputations require two
Does socket configuration influence the position of the femur motions to develop prehension, making
in above-knee amputation? J Prosthet Orthot 2:94–102, 1989.) these levels of amputation significantly less
 Rehabilitation: Gait, Amputations, Prostheses, Orthoses, and Neurologic Injury 561

efficient and the prosthesis heavier than they

are for amputation at the transradial level.
Elbow flexion and extension are controlled
by shoulder extension and depression.
Amputations at these levels provide mini-
mum function because the patient must
sequentially control two joints and a terminal
device. The best function with the least
weight at the lowest cost is provided by
hybrid prosthetic systems in which myoelec-
tric, traditional body-powered, and body-
driven switch components are combined.
c. Proximal transhumeral and shoulder
disarticulation amputations—When the
lever-arm capacity of the humerus is lost in
proximal transhumeral or shoulder disarticu-
lation amputations, limited function can be A B
achieved with a manual universal shoulder FIGURE 10^11 A, Flex Foot with carbon-fiber leaf and posterior
joint positioned with the opposite hand projection of the keel for heel-strike. B, Flex Foot with split-toe
and combined with lightweight hybrid configuration and spring-leaf design. (Courtesy of Flex Foot, Inc, Aliso
Viejo, CA.)
prosthetic components.
B. Lower limb
1. Prosthetic feet—Several designs are available and A sagittal split allows for moderate inver-
divided into five classes. sion or eversion.
a. Single-axis foot—The single-axis foot is (2) Nonarticulated dynamic-response foot
based on an ankle hinge that provides dorsi- —These can have short or long keels.
flexion and plantar flexion. The disadvan- Shortened keels are not as responsive
tages of the single-axis foot include poor and are indicated for the moderate-
durability and cosmesis. activity ambulator, whereas long keels
b. Solid-ankle, cushioned-heel (SACH) are for very-high-demand activities.
foot—This has been the standard for dec- Separate prosthetic feet for running and
ades and was appropriate for general use in lower-demand activities may be in-
low-demand patients. It may lead to overload dicated.
problems on the nonamputated foot, and its 2. Prosthetic shanks—These shanks provide the
use is being discontinued. structural link between or among prosthetic
c. Dynamic-response foot—The selection of components. Two varieties exist: endoskeletal,
the correct dynamic prosthetic foot requires with a soft exterior and load-bearing tubing
information about the patient’s height, inside (the most common), and exoskeletal,
weight, activity level, access for maintenance, with a hard load-bearing exterior shell. Rotator
cosmesis, and funding. The dynamic- units are sometimes added for patients involved
response feet, including the Seattle foot, in twisting activities (e.g., golf) or for sitting.
Carbon Copy II/III, and Flex Foot, allow 3. Prosthetic knees (Table 10–4)—These prosthe-
amputees to undertake most normal activ- ses are used in transfemoral and knee disarticu-
ities (Fig. 10–11). Dynamic-response feet lation and are chosen based on patient needs.
may be grouped into articulated feet and Prosthetic knees provide controlled knee motion
nonarticulated feet.
(1) Articulated dynamic-response foot—
These allow inversion/eversion and rota-
tion of the foot and are useful for activ-
ities on uneven surfaces. They may
absorb loads and decrease shear forces
to the residual limb. Most dynamic-
response feet have a flexible keel and
are the standard for general use (Fig.
10–12). The keel deforms under load,
becoming a spring and allowing dorsi-
flexion and thereby decreasing the
loading on the normal side and provid-
ing a springlike response for push-off.
Posterior projection of the keel provides FIGURE 10^12 Cosmetic appearance of a dynamic-response foot
a response at heel-strike for smooth (Seattle foot) and cross section showing internal configuration.
transition through the stance phase. (Courtesy of MIND, Seattle, WA.)
562 Review of ORTHOPAEDICS

TABLE 10–4 CHARACTERISTICS OF VARIOUS PROSTHETIC KNEES

Characteristics
Knee Type Action Advantages Disadvantages

Constant-friction Limits flexion Durable, long resistance Decreased stability

Variable- friction Varies with flexion Variable cadence Durability poor
Stance-control Friction brake Stability during stance Durability poor, difficult on stairs
Polycentric Instant center moves Stable, increased flexion Durability poor, heavy
Manual locking Must unlock to sit Maximum stability Abnormal gait
Fluid-control Deceleration in swing Variable cadence Weight, cost

in the prosthesis. Alignment stability (the posi- e. Variable-friction (cadence control) knee—
tion of the prosthetic knee in relation to the This device allows resistance to knee flexion to
patient’s line of weight bearing) is important to increase as the knee extends by employing a
the design and fitting of prosthetic knees. Placing number of staggered friction pads. This knee
the knee center of rotation posterior to the line of allows walking at different speeds but is neither
weight bearing allows control in the stance phase durable nor available in endoskeletal systems.
but makes flexion difficult. Alternatively, with f. Manual locking knee—This knee consists
the knee center of rotation anterior to the line of a constant-friction knee hinge with a pos-
of weight bearing, flexion is made easier but at itive lock in extension that can be unlocked
the expense of control. Only in the polycentric to allow functioning similar to that of a
knee is there the possibility of both options by constant-friction knee. The knee is often
having a variable center of rotation. Six basic left locked in extension for more stability.
types of knees are available. It has limited indications and is used
a. Polycentric (four-bar linkage) knee—This
prosthesis has a moving instant center of
rotation that provides for different stability
characteristics during the gait cycle and
may allow increased flexion for sitting. It is
recommended for patients with transfemoral
amputations, those with knee disarticula-
tions, and bilateral amputees (Fig. 10–13).
b. Stance-phase control (weight-activated
[safety]) knee—This knee functions like a
constant-friction knee during the swing
phase but ‘‘freezes’’ by application of high-fric-
tion housing when weight is applied to the
limb. Its use is reserved primarily for older
patients, those with very proximal amputa-
tions, or those walking on uneven terrain.
c. Fluid-control (hydraulic and pneumatic)
knee—This knee allows adjustment of
cadence response by changing resistance to
knee flexion via a piston mechanism. The
design prevents excessive flexion and is
extended earlier in the gait cycle, allowing a
more fluid gait. The knee is best used in
active patients who prefer greater utility
and variability at the expense of more weight.
d. Constant-friction knee—This knee prosthe-
sis is essentially a hinge that is designed to
dampen knee swing via a screw or rubber pad
that applies friction to the knee bolt. It is a knee
designed for general utility and may be used on
uneven terrain. It is the most common knee
used in childhood prostheses. Its major disad-
vantages are that it allows only single-speed
FIGURE 10^13 A, Stance-phase control unit for
walking and relies solely on alignment for transfemoral prosthesis. B, Modular endoskeletal four-bar
stance-phase stability and is therefore not knee with hydraulic swing-phase control unit. (Courtesy of
recommended for older, weaker patients. Otto Bock Orthopaedic Industries, Minneapolis.)
 Rehabilitation: Gait, Amputations, Prostheses, Orthoses, and Neurologic Injury
primarily in weak, unstable patients; those
just learning to use prostheses; and blind
amputees.
4. Suspension systems—Suspension is provided in
modern lower extremity prostheses primarily
through socket design and suspension sleeves.
Straps and belts are usually used for
supplementation.
a. Sockets—Sockets are prosthetic compo-
nents designed to provide comfortable
functional control and even pressure
distribution on the amputated stump.
Sockets can be hard (rigid or unlined)
or soft (lined with a resilient material and/
or flexible shell). In general, the suction-
and-socket contour is the primary suspen-
sion modality used. The suction socket
provides an airtight seal via a pressure differ-
ential between the socket and atmosphere.
Total-contact support of the residual limb
surface prevents edema formation. In total-
contact support, different areas have different
loads.
(1) Transfemoral sockets—Quadrilateral
sockets, in which the posterior brim
provides a shelf for the ischial tuberosity,
have been the classic suspension system.
However, the design made it difficult
to keep the femur in adduction.
Narrow mediolateral (ischial contain-
ment) sockets distribute the proximal
and medial concentrations of forces
more evenly as well as enhance rotational
control of the socket (Fig. 10–14).
AL
AL
Femur
IT
FIGURE 10^14 Comparison of transfemoral sockets. Note the
inclusion of the ischial tuberosity (IT) and the narrow mediolateral
design of newer contoured, adducted, trochanteric-controlled
alignment method (CAT-CAM) socket shown by the solid line. AL,
adductor longus. (Adapted from Sabolich J: Contoured adducted
trochanteric controlled alignment method. Clin Prosthet Orthop
9:13–17, 1985.)
563
The ischium and ramus are contained
within the socket of these more
anatomic, comfortable, and functional
designs. Socket design for transfemoral
prosthesis allows for 10 degrees of
adduction of the femur (to stretch the
gluteus medius, allowing adequate
strength for midstance stability) and
5 degrees of flexion (to stretch the
gluteus maximus, allowing greater hip
extension).
(2) Transtibial sockets—Weight bearing by
the patella tendon loads all areas of the
residual limb that are weight tolerant
(i.e., patella tendon, medial tibial flare,
anterior compartment, gastrocnemius
muscle, and fibular shaft). Weight-intol-
erant areas include the tibial crest and
tubercle, distal fibula and fibular head,
peroneal nerve, and hamstring tendons.
The patella tendon–bearing supracon-
dylar/suprapatellar socket has proximal
extensions over the distal femoral
condyles and patella. Total-surface
weight bearing is different from total con-
tact weight bearing. With total-
surface weight bearing, pressure is dis-
tributed more equally across the entire
surface of the transtibial residual limb,
and the interface liner material in the
socket is important. Urethane liners
cope with multidirectional forces by
easy material distortion and recovery to
the original shape. Another liner is made
of mineral oil gel with reinforcing fabric.
These liners provide good shock-absorb-
ing abilities and reduce skin problems.
The anterior wedge shape of the socket
helps control rotation of the socket on
the limb.
(3) Supracondylar suspension—This is
recommended when the residual limb
is less than 5 cm long. The socket is
designed to increase the surface area
for pressure distribution by raising
the medial and lateral socket brim.
A wedge may be used in the soft liner.
(4) Supracondylar-suprapatellar suspension
—This system encloses the patella in
the socket and has a bar proximal to
the patella. This design also provides me-
diolateral stability, and no additional
cuffs or straps are required. Corset-type
prostheses can lead to verrucous hyper-
plasia and thigh atrophy but reduce
socket loads, control the direction of
swing, and provide some additional
weight support.
b. Prosthetic sleeves—Prosthetic sleeves use
friction and negative pressure for suspension.
The sleeves fit snugly to the upper third
of the tibial prosthesis and are made from
564 Review of ORTHOPAEDICS

neoprene, latex, silicone, or thermoplastic

elastomers.
(1) Transtibial suspension—Gel-liner sus-
pension systems with a locking pin
constitute the preferred method of sus-
pension. Liners are made from silicone,
urethane, or thermoplastic elastomer.
The sleeve rolls onto the stump, and
the locking pin is then locked into the
socket (Fig. 10–15). The liners provide
suspension through suction and friction
and act as the socket interface. Prosthetic
socks worn over the liner accommodate
volume fluctuation. This suspension
allows unrestricted knee flexion and
minimal pistoning.
(2) Transfemoral suspension—Vacuum
(suction) suspension is frequently used.
It relies on surface tension, negative pres-
sure, and muscle contraction. A one-way
expulsion valve helps maintain negative
pressure, and no belts or straps are
required. Stable body weight is required
for this intimate fit. Roll-on silicone or
thermoplastic liners may be used with
or without locking pins. The all-elastic
suspension belt, which is made of neo- FIGURE 10^16 Total-elastic suspension belt for suspending a
prene, fastens around the waist and transfemoral socket. (Courtesy of Syncor Manufacturers,
spreads over a larger surface area Green Bay, WI.)
(Fig. 10–16). It is an excellent auxiliary
suspension. Silesian belts are used to by an ineffective suspension system.
prevent socket rotation in limbs with Pistoning in the stance phase is due to
redundant tissue. Such belts also prevent a poor socket fit or volume changes in the
the socket from slipping off when stump (may require a change in thickness of
suction sockets are fitted to short trans- the stump sock). Alignment problems are
femoral stumps and the patient sits. common (see Table 10–5). Pressure-related
5. Common prosthetic problems (Table 10–5) pain or redness should be corrected, with
a. Transtibial prostheses—Pistoning during relief of the prosthesis in the affected area.
the swing phase of gait is usually caused Other problems may be related to the
foot: Too soft a heel results in excessive
knee extension, whereas too hard a heel
causes knee flexion and lateral rotation
of the toes.
b. Transfemoral prostheses—Excessive pros-
thetic length and weak hip abductors or flex-
ors can lead to circumduction, vaulting,
and lateral trunk bending. Hip flexion

TABLE 10–5 PROSTHETIC FOOT GAIT

ABNORMALITIES

Foot Position Gait Abnormality

Inset Varus strain, pain (proximomedial, distolateral),
circumduction
Outset Valgus strain, pain (proximolateral, distomedial),
broad-based gait
Forward placement Increased knee extension (patellar pain)
but stable
Posterior placement Increased knee flexion/instability
Dorsiflexed foot Increased patellar pressure
Plantar-flexed foot Drop-off, patellar pressure
FIGURE 10^15 A, Gel liner suspension with locking pin.
B, Transtibial prosthesis with liner locked in place.
 Rehabilitation: Gait, Amputations, Prostheses, Orthoses, and Neurologic Injury
TABLE 10–6 TRANSFEMORAL PROSTHETIC GAIT
ABNORMALITIES
Gait Abnormality Prosthetic Problem
Lateral trunk bending Short prosthesis, weak abductors, poor fit
Abducted gait Poor socket fit medially
Circumducted gait Prosthesis too long, excess knee friction
Vaulted gait Prosthesis too long, poor suspension
Foot rotation at heel-strike Heel too stiff, loose socket
Short stance phase Painful stump, knee too loose
Knee instability Knee too anterior, foot too stiff
Mediolateral whip Excessive knee rotation, tight socket
Terminal snap Quadriceps weakness, insecure patient
Foot slap, knee Heel too soft
hyperextension
Knee flexion Heel too hard
Excessive lordosis Hip flexion contracture, socket problems
contractures and insufficient anterior socket
support can lead to excessive lumbar lordosis
(compensatory). Inadequate prosthetic knee
flexion can lead to a terminal knee snap.
A medial whip (heel-in, heel-out) can be
caused by a varus knee, excessive external
rotation of the knee axis, or muscle weak-
ness. A lateral whip (heel-out, heel-in) is
caused by the opposite (valgus knee, internal
rotation at knee, or muscle weakness).
Table 10–6 summarizes common transfemo-
ral prosthetic gait problems.
c. Stair climbing—In general, amputees ascend
stairs by leading with the normal limb and
descend by leading with the prosthetic limb
(‘‘the good goes up and the bad comes
down’’).
IV. Orthoses
A. Introduction—The primary function of an orthosis is
control of the motion of certain body segments.
Orthoses are used to protect long bones or unstable
joints, support flexible deformities, and occasionally
substitute for a functional task. They may be static,
dynamic, or a combination of these. With few excep-
tions, orthoses are not indicated for correction of
fixed deformities or for spastic deformities that
cannot be easily controlled manually. Orthoses are
named according to the joints they control and the
method used to obtain/maintain that control (e.g.,
a short leg, below-the-knee brace is an ankle-foot
orthosis (AFO).
B. Shoes—Specific shoes can be used by themselves or
in conjunction with foot orthoses. Extra-depth
shoes with a high toe box designed to dissipate
local pressures over bony prominences are recom-
mended for diabetic patients. The plantar surface of
an insensate foot is protected by use of a pressure-
dissipating material. A paralytic or flexible foot
deformity can be controlled with more rigid
orthoses. SACH heels absorb the shock of initial
loading and lessen the transmission of force to the
midfoot as the foot passes through the stance phase.
A rocker sole can lessen the bending forces on an
565
arthritic or stiff midfoot during midstance, as the foot
changes from accepting the weight-bearing load to
pushing off. It is useful in treating metatarsalgia,
hallux rigidus, and other forefoot problems. For the
rocker sole to be effective, it must be rigid. Medial
heel out-flaring is used to treat severe flatfoot of most
causes. A foot orthosis is also necessary.
C. Foot orthoses—Most foot orthoses are used to align
and support the foot; prevent, correct, or accommo-
date foot deformities; and improve foot function.
Three main types of foot orthosis are used: rigid,
semirigid, and soft. Rigid foot orthoses limit joint
motion and stabilize flexible deformities. Semirigid
orthoses have hinges and allow dorsiflexion and/or
plantar flexion of the ankle. Soft orthoses have the
best shock-absorbing ability and are used to accom-
modate fixed deformities of the feet, especially neu-
ropathic, dysvascular, and ulcerative disorders.
D. AFO—The most commonly prescribed lower limb
orthosis (AFO) is used to control the ankle joint. It
may be fabricated with metal bars attached to the
shoe or thermoplastic elastomer. The orthosis may
be rigid, preventing ankle motion, or it can allow free
or spring-assisted motion in either plane. After hind-
foot fusions, the primary orthotic goals are absorp-
tion of the ground reaction forces, protection of the
fusion sites, and protection of the midfoot. The ther-
moplastic foot section achieves mediolateral control
with high trimlines. When subtalar motion is pre-
sent, an articulating AFO permits motion by a
mechanical ankle joint design. The primary factors
in the selection of an orthotic joint include range of
motion, durability, adjustability, and the biomechan-
ical effect on the knee joint. A posterior leaf-spring
AFO provides ankle instability in stance phase.
E. Knee-ankle-foot orthosis (KAFO)—This orthosis
extends from the upper thigh to the foot. It is generally
used to control an unstable or paralyzed knee joint. It
provides mediolateral stability with the prescribed
amounts of flexion or extension control. A subset of
KAFOs are designated KOs (knee orthoses). KOs can
be made of elastic for the treatment of patellar pathol-
ogy or of metal and plastic for the treatment of an
unstable anterior cruciate ligament.
F. Hip-knee-ankle-foot orthosis (HKAFO)—This ortho-
sis provides hip and pelvic stability but is rarely used
by the adult paraplegic because of the cumbersome
nature of the orthosis and the magnitude of effort in
achieving minimum gains. Experimentally, it is being
used in conjunction with implanted electrodes and
the computerized functional stimulation of paraple-
gics. In children with upper-level lumbar myelome-
ningocele, the reciprocating gait orthoses are
modified HKAFOs that can be used for standing
and simulated walking.
G. Elbow orthoses—Hinged-elbow orthoses provide
minimum stability in the treatment of ligament
instability. Dynamic spring-loaded orthoses have
been successfully used in the treatment of flexion
and extension contractures.
H. Wrist-hand orthoses (WHOs)—The most common
use of wrist and hand orthoses today is for
566 Review of ORTHOPAEDICS
postoperative care after injury or reconstructive sur-
gery. These devices are static or dynamic. The oppo-
nens splint is successful in prepositioning the thumb
but impairs tactile sensation. Wrist-driven hand
orthoses are used in lower cervical quadriplegics.
They may be body powered by tenodesis action or
motor driven. Weight and cumbersomeness are the
major limiting factors.
I. Fracture braces—Fracture bracing remains a valuable
treatment option for isolated fractures of the tibia
and fibula. Prefabricated fracture orthoses can be
used in simple foot and ankle fractures, ankle
sprains, and simple hand injuries.
J. Pediatric orthoses—Many dynamic orthoses are used
by children to control motion without total immobi-
lization. The Pavlik harness has become the mainstay
for early treatment of developmental dislocation of
the hip. Several dynamic orthoses have been used
for containment in Perthes disease.
K. Spine orthoses
1. Cervical spine—Numerous orthoses are used to
immobilize the cervical spine. Effective immobi-
lization ranges from the various types of collars,
to posted orthoses that gain purchase about the
shoulders and under the chin, to the halo vest,
which achieves the most stability by the nature
of its fixation into the skull.
2. Thoracolumbar spine—Orthoses used to
mechanically stabilize the back, thus reducing
back pain, rely on increasing body cavity pres-
sure. Three-point orthoses achieve their control
by the length of their lever arm and the subse-
quent limitation of motion.
V. Surgery for Stroke and Closed Head Injury
A. Introduction—The orthopaedic surgeon can play a
role in the early management of adult-acquired spas-
ticity secondary to stroke or closed brain injury when
the spasticity interferes with the rehabilitation
program.
1. Nonsurgical treatment—Interventional modal-
ities may include orthotic prescription, serial
casting, and motor point nerve blocks with
short-acting (bupivacaine HCl) or long-acting
(phenol 6% in glycerol or Botox) agents.
Splinting a joint (e.g., the ankle) in the neutral
position is not sufficient to prevent the develop-
ment of a contracture (e.g., an equinus contrac-
ture). When functional joint ranging is
insufficient to control the deformity, intervention
is often indicated. Local anesthetic injection to
the posterior tibial nerve or sciatic nerve before
casting relieves pain and allows for maximum
correction of the deformity. Open nerve blocks
may be warranted to avoid injecting mixed
nerves with large sensory contributions.
2. Prerequisites for surgical treatment—Surgical
intervention in adult-acquired spasticity should
be delayed until the patient achieves maximum
spontaneous motor recovery (6 months for
stroke and 12-18 months for traumatic brain
injury). When patients reach a plateau in
functional progress or the deformity impedes fur-
ther progress, intervention may be considered.
Invasive procedures in this population should
be an adjunct to a standard functional rehabili-
tation program, not an alternative. When surgery
is considered as a method of improving function,
patients should be screened for cognitive defi-
cits, motivation, and body image awareness.
Patients should not be confused and must have
adequate short-term memory and the capacity
for new learning. In addition to specific cognitive
strengths, motivation is necessary for patients
to use functional gains and participate in their
rehabilitation program. Body image awareness
is essential in order for surgical intervention to
become meaningful and potentially beneficial.
Patients who lack the awareness of a limb or
its position in space should undergo therapy
directed toward improving these deficits before
undergoing surgical intervention.
B. Lower limb—Balance is the best predictor of a
patient’s ability to ambulate after acquired brain
injury. The mainstay of treatment for the dynamic
ankle equinus component of this gait deviation is
to achieve ankle stability in the neutral position
during initial floor contact (i.e., initial contact and
stance) as well as floor clearance during the swing
phase. An adjustable AFO with ankle dorsiflexion
and a plantar flexion stop at the neutral position is
often used during the recovery period, followed by a
rigid AFO once the patient has reached a plateau in
recovery. When the dynamic equinus overcomes the
holding power of the orthosis and patients ‘‘walk
out’’ of the brace, motor-balancing surgery is indi-
cated. The equinus deformity is treated by percuta-
neous tendo Achillis lengthening. The dynamic
varus-producing force in adults is the result of out-
of-phase tibialis anterior muscle activity during the
stance phase. This dynamic varus deformity is cor-
rected by either split or complete lateral transfer of
the tibialis anterior muscle.
C. Upper limb—There is a paucity of literature dealing
with acquired spasticity in the upper limb. Invasive
intervention can be considered for functional and
nonfunctional goals.
1. Nonfunctional goals—Surgical release of static
contracture is generally performed to comple-
ment nursing care or hygiene when the fixed
contracture and/or spastic component results
in skin maceration or breakdown.
2. Functional goals—One functional use of static
contracture release is to improve upper extrem-
ity ‘‘tracking’’ (i.e., arm swing) during walking.
Most upper extremity surgery performed in this
patient population has the goal of increasing
prehensile hand function. The goal may be
simply to improve placement, enabling use of
the hand as a ‘‘paperweight,’’ or to achieve
improved fine motor control. In patients
with prehensile potential, surgery may allow
the ‘‘one-handed’’ patient to be ‘‘two-handed’’
by increasing involved hand function from no
 Rehabilitation: Gait, Amputations, Prostheses, Orthoses, and Neurologic Injury 567

function to assistive or from assistive to
independent.
a. Screening—When the goal of surgery is to
improve function, patients must first be
screened for cognitive capacity, motivation,
and body image awareness. Patients
must have the cognitive skills and learning
capability to participate in their therapy
after surgery and to functionally make use
of their newly acquired skills at the
completion of their rehabilitation program.
If they are not motivated, they will not
participate in the prolonged effort necessary
to achieve meaningful functional improve-
ment. Patients with poor stereognosis or
neglect (i.e., poor body image awareness)
find that the involved hand ‘‘drifts’’ in
space and is not ‘‘available’’ for use if they
have not been carefully trained in visual com-
pensation techniques.
b. Grading—Once it has been determined that
the patient has the potential to make func-
tional upper extremity gains with surgery, he
or she is graded on the basis of hand place-
ment, proprioception and sensibility, and
voluntary motor control. Dynamic electro-
myography is used when delineation of
phasic motor activity is essential.
c. Methods—By means of fractional musculo-
tendinous or step-cut methods, muscle unit
lengthening of the agonist-deforming muscle
units is combined with motor-balancing
tendon transfers of the antagonists to achieve
muscle balance and improved prehensile
hand function.
VI. Spinal Cord Injury
A. Functional level—The functional level in a patient
with spinal cord injury is determined by the most
distal intact functional dermatome (sensory level)
and the most distal motor level at which most of
the muscles of that level function at least at a
‘‘fair’’ motor grade.
B. Mobility—The level at which spinal cord injury
occurs determines mobility (Table 10–7). C4 and
higher levels require high back and head support.
At C5, mouth-driven accessories can control a
motorized wheelchair. Various body-powered or
motor-driven orthoses, such as a ratchet wrist-hand
orthosis, can assist functional prehension. Manual
wheelchairs and the use of a flexor hinge wrist-
hand orthosis can be operated at C6 levels.
Transfers are dependent at C4, assisted at C5, and
independent at C6.
C. Activities of daily living—Patients at the C6 level can
groom and dress themselves. Patients at the C7 level
can cut meat. Bowel and bladder function can be
controlled via rectal stimulation and intermittent
catheterization.
D. Psychosocial factors—Men may be impotent but can
often achieve a reflex erection.
E. Autonomic dysreflexia—This potentially catastrophic
hypertensive event can occur with injuries above T5.
It is usually caused by an obstructed urinary catheter
or fecal impaction.
F. Surgery—Spinal fusion is frequently used to expedite
rehabilitation and prevent the late development of
pain or deformity at the fracture level. Anterior
and/or posterior fusion with internal fixation
should be performed soon after injury in order to
facilitate early rehabilitation. Spasticity and contrac-
ture can produce hygiene problems or the develop-
ment of pressure ulcers. Percutaneous (open) motor
nerve blocks with phenol can be used to treat these
deformities. When the deformity is a static contrac-
ture, muscle release or disarticulation may improve
sitting or transfer potential. Tendon transfers can be
used in the upper limb to eliminate the need for an

TABLE 10–7 TREATMENT OF SPINAL CORD INJURY BY FUNCTIONAL LEVEL

Functional Level Working Not Working Treatment/Mobility

Above C4 — Diaphragm, upper extremity Respirator dependent
muscles
C4 Diaphragm/trapezius Upper extremity muscles Wheelchair chin/puff
C5 Elbow flexors Below elbow Electric wheelchair, rachet
C6 Wrist extensors Elbow extensors Wheelchair, flexor hinge
C7 Elbow extensor Grasp Wheelchair, independent
C8 Finger flexors to middle finger
T1 Intrinsic muscles Abdominals/lower extremity Wheelchair, independent
muscles
T2-T12 Upper extremity muscles, abdominals Lower extremity muscles Wheelchair, HKAFO (nonfunctional
ambulation)
L1 Upper extremity muscles, abdominals, Lower extremity muscles KAFO; minimum ambulation
quadriceps
L2 Iliopsoas Knee/ankle KAFO, household ambulation
L3 Quadriceps Ankle AFO, community ambulation
L4 Tibialis anterior Toe, plantar flexors AFO, community ambulation
L5 EHL, EDL Plantar flexors AFO, independent
S1 Gastrocnemius/soleus Bowel/bladder ± Metatarsal bar

AFO, ankle-foot orthosis; EDL, extensor digitorum longus; EHL, extensor hallucis longus; HKAFO, hip-knee-ankle-foot orthosis; KAFO, knee-ankle-foot orthosis; ±, with or without.
568 Review of ORTHOPAEDICS
orthosis or allow the patient to achieve function
with an orthosis.
VII. Postpolio Syndrome
A. Cause—Polio is a viral disease affecting the anterior
horn cells of the spinal cord. Postpolio syndrome is
not a reactivation of the polio virus. It is an aging
phenomenon by which more nerve cells become
inactive. The syndrome occurs after middle age.
These patients use a high proportion of their capac-
ity for normal activities of daily living. With aging
Selected Bibliography
GAIT
Inman VT, Ralston H, Todd F: Human Walking. Baltimore, Williams &
Wilkins, 1981.
Perry J: Gait Analysis: Normal and Pathological Function. New York, Slack
[McGraw-Hill], 1992.
Ounpuu S: The biomechanics of running: A kinematic and kinetic analysis.
Instr Course Lect 39:305, 1990.
AMPUTATIONS AND PROSTHESES
Smith D, Bowker J, Michael J, eds: Atlas of Amputations and Limb
Deficiencies. Rosemont, IL, American Academy of Orthopaedic
Surgeons, 2004.
Pinzur M, Gold J, Schwartz D, et al: Energy demands for walking in dysvas-
cular amputees as related to the level of amputation. Orthopaedics
15:1033, 1992.
Waters RL, Perry J, Antonelli D, et al: Energy cost of walking of
amputees: The influence of level of amputation. J Bone Joint Surg [Am]
58:42, 1976.
Wyss C, Harrington R, Burgess E, Matsen F: Transcutaneous oxygen tension
as a predictor of success after an amputation. J Bone Joint Surg [Am]
70:203, 1988.
Gottschalk F, ed: Symposium on amputation. Clin Orthop 361:2, 1999.
Day H: The Proposed International Terminology for the Classification of
Congenital Limb Deficiencies—The Recommendations of a Working
Group of ISPO. London, Spastics International Medical Publications,
Heinemann Medical Books [Philadelphia, JB Lippincott, 1975].
and the drop-off of muscle units, they no longer
have the reserves to perform their daily activities.
B. Treatment—Treatment comprises prescribed lim-
ited exercise combined with periods of rest, so mus-
cles are maintained but not overtaxed. Standard
polio surgeries, combining contracture release,
arthrodesis, and tendon transfer, are indicated
when the deformity overcomes functional capacity.
The use of lightweight orthoses is important in
helping patients to remain functionally
independent.
Bernd L, Blasius K, Lukoschek M, et al: The autologous stump plasty:
Treatment for bony overgrowth in juvenile amputees. J Bone Joint Surg
[Br] 73:203, 1991.
Gottschalk F: Traumatic amputations. In Bucholz RW, Heckman JD, eds:
Fractures in Adults, pp 391–414. Philadelphia, Lippincott Williams &
Wilkins, 2001.
Gottschalk F, Fisher D: Complications of amputation. In Conenwett JL,
Gloviczki P, Johnston KW, et al, eds: Rutherford Vascular Surgery,
pp 2213–2248. Philadelphia, WB Saunders, 2000.
Lagaard S, McElfresh E, Premer R: Gangrene of the upper extremity in dia-
betic patients. J Bone Joint Surg [Am] 71:257, 1989.
Gottschalk F, Kourosh S, Stills M, et al: Does socket configuration influence
the position of the femur in above-knee amputation? J Prosthet Orthot
2:94, 1989.
ORTHOSES
Goldberg B, Hsu J, eds: Atlas of Orthoses and Assistive Devices, AAOS,
3rd ed. St. Louis, Mosby–Year Book, 1997.
STROKE AND CLOSED HEAD INJURY
Braun R: Stroke and brain injury. In Green D, ed: Operative Hand Surgery,
pp 227–254. New York, Churchill Livingstone, 1988.
Pinzur M, Sherman R, Dimonte-Levine P, et al: Adult-onset hemiplegia:
Changes in gait after muscle-balancing procedures to correct the equinus
deformity. J Bone Joint Surg [Am] 68:1249, 1986.