Introduction: Reasons why patients refuse wearing their upper limb prostheses deserve to be studied.

Method: Amputees were recruited from the clinics as well as from health- and accident insurances and Veterans’ Service Offices. Questions covered the patients’ medical history of amputation, their prosthetic supply and their present living conditions. 454 participants returned the anonymous questionnaire and could be entered into the study.

Amputation was caused by war (287), civil trauma or illness (123) and congenital (44). Age ranged from 3 – 96 years, with mean of 67.8. Distribution regarding sex and side was 411m/43 f and and 211 right/223 left. 20 had bilateral amputation. In 216 patients the dominant side was affected. Level of amputation was: wrist 36, BE 164, elbow 9, AE 201, shoulder 23, forequarter 3, unknown 18.

Prosthetic devices were classified as passive (i.e. cosmetic and passive work prostheses) or active, i.e. electrically- or body-powered prostheses as well as the combination of the two.

In the statistical analysis null hypothesis was that no factor influences the acceptance rate. Significant differences are accepted when p< 0.05.

Results: Electrically-powered prostheses were accepted best. Cosmetic prostheses were accepted well when stigmatization in the context of ethnic origin or religious affiliation may be important.

Acceptance rate was influenced by: Country of origin, religious affiliation, sex, learned occupation, therapist involved in training, return to work, incapacity for work, job held after amputation, own initiative in initiating prosthetic care, loss of friends or partners, level of amputation and the combined parameters AE-amputation and non-dominant side.

No influence was found for education, age at amputation, marital status, side of amputation, recommendation of prosthesis, time until first prosthetic fitting, phantom pain and phantom feeling, return to sports or hobbies, consumption of tobacco, alcohol or sedatives.

Discussion: Looking at all patients, the rates of acceptance of the various prosthetic types equals those found in the relevant literature. However, this study is much more detailed, looking at many different parameters and their combinations and can therefore provide some guidance to the successful prescription of upper limb prostheses. Nowadays electrically-powered prostheses are generally better accepted than all other types and should therefore be provided more often.

Aims: Neuregenic osteoarthropathy often results in a deformity of the foot needing surgical intervention. Indications for surgery are reulcerations, deep infections and decompensation of the static structure of the foot architecture. External fixation is a promising technique for correction.

Methods: Between 1997 and 2003, 65 feet which could be examined retrospectively, were operated for neuroarthropathy in 21 women and 43 men. A diabetic polyneuropathy was present in 56 patients. In 59 cases, an external fixation was used while in nine cases Steinmann pins were used. Follow-up treatment consisted of mobilisation in a ankle-foot-orthosis (AFO) for up to a year.

Results: For diabetics, the mean duration of the disease was 24.8 years (Type 1) and 13.7 years (Type 2). All feet were at a stage 3 or 4 according to Levin and were classified as types II–V according to Sanders. In five cases there was luxation alone was observed, another nine cases exhibited a combination of luxation and osseous changes. Surgical revision was necessary in seven cases, sometimes repeatedly. As the illness progressed additional operations were necessary in 13 times. It became necessary in six cases due to loss of correction. The fitting of a prosthesis was necessary in two patients (three feet) following amputation. The mean duration was 752 days. Pin infections and disturbances in wound healing were commonly observed but could be treated successfully by conservative means. The occurrence of this complication was independent of previous ulcerations or infections. Within the first year after operation, 13.9% of the feet developed an ulcer. All of the patients could be mobilised with the help of an orthosis (47 cases) or orthopedic shoes (15 cases)

Conclusions: External fixation is a suitable and variable method for correcting malalignment of the foot in cases of neuroarthropathy. It has a low complication rate and can be used for rapidly developing as well as non-progressing osteoarthropathies. In general, a fibrous ankylosis is the result of treatment, which allows pain free mobilisation under full whight bearing. In suitable cases, with a good alignment of the foot and good patient cooperation, the use of the AFO can be changed to orthopedic shoes after about 12 months.

Aims: Minor foot amputations in diabetic subjects aim at the preservation of limb length and thus in keeping subject‘s ability to ambulate. Various surgical techniques are described and the clinical long-term outcome will be presented.

Methods: Between 1997 and 2004, 157 minor amputations and resections of the foot were performed in patients with diabetic foot syndrome. During follow-up focus was put on wound healing and rehabilitation, ambulation ability and the usage of mobility aids.

Results: In 112 patients 157 minor amputations of the foot have been performed. The mean frequency of reamputations was 52% with higher rate of failure in the forefoot compared with the hindfoot. In case of forefoot amputations orthopaedic shoes were regularly prescribed. In hindfoot amputations in general prostheses were fitted.

Conclusions: Amputations and resections of the foot have a long lasting tradition and deserve particular attention. Despite a relatively high risk of reamputation this intervention appears to be the only way to preserve limb length. As an essential prerequisite for a fortunate result of the treatment excellent quality of orthopaedic shoes and devices is mandatory.

Aims: Foot deformities following diabetic-neuropathic osteoarthropathy are often responsible for major amputations at the lower limbs. To preserve foot and lower limb length salvage procedures have to be introduced. Methods: In 59 patients with severe deformities of the foot (Sanders II-IV) surgical reposition and resection of necrotic bony substance has resulted in an axial correction of foot-malposition. Stabilization was effected using a fixateur externe device (Hoffmann II) over a period of 6 weeks. After removal of the fixateur externe stabilization of the lower leg was performed for another 6 weeks by means of orthotic devices. Results: Surgical reposition and stabilization in a total of 59 feet has resulted in 57 cases to conservation of the foot, in 2 cases later amputation was necessary. Immobilization in the fixateur externe resulted in a fast detumenescence of accompanying oedemas and in wound healing without special problems. Post-treatment examination after two years on the average revealed in all patients a stable pseudarthrosis without bony connection. 43 from 57 patients after about 6 months were provided with orthopaedic footwear. Conclusions: Surgical procedures which refrain from the use of implants and which do not increase arthropathic activities are capable to correct severe malpositioning of the foot without increasing the activity of arthropathy and result in superior long-term results in diabetic patients. They should therefore be applied with preference.

Aims: Better understanding of the influence of body mass to plantar peak pressure as a main biomechanical risk factor for ulcerations in the diabetic foot. To predict the effect of weight change on peak pressure. Methods: In-shoe peak pressure measurement (PEDAR, Novel) are performed in 5 patients with diabetic neuropathy and 5 controls: all wearing the same kind of ready made shoes with ready made standard fitting insoles of cork. Each subject is measured in 3 modes of weight simulation: normal weight, 20 kg weight increase (waistcoat with weight pieces) and 20 kg weight release by a movable overhead suspension covering a 6m walkway. Pace is selected individually after some pre-test walking to be comfortable in all 3 weight modes. For data analysis the plantar area of the foot is divided into 6 regions, particularly metatarsal region and heel. Results: No significant difference between diabetics and controls is found. In the most threatened regions (metatarsals and heel) peak pressure increases and decreases linearly with weight: A simulated weight change ± 20 kg increases/ decreases metatarsal peak pressure by ± 6.4 N/cm2. The corresponding figure for the heel region is ± 2.6 N/cm2. Conclusions: Weight increase or weight loss in the individual patient has at least in the metatarsal and heel region a significant effect to the plantar peak pressure. The linear relationship allows for a simple method of predicting the effect of weight change to peak pressure

Aims: Minor foot amputations in diabetic subjects aim at the preservation of limb length and thus in keeping subject’s ability to walk. Different surgical techniques will be described and clinical 5-years outcome will be presented. Methods: The study comprises subjects with diabetic-neuropathic osteoarthropathy (DNOAP) who underwent minor amputations or resections of the foot between 1996–2001. In all patients post-treatment examination has been performed. Focus was on wound healing, duration of rehabilitation process, walking ability and the use of mobility aids. Results: In 86 diabetic subjects 121 minor amputations of the foot have been carried out. The frequency of reamputations was 56% in the mean with a distinct accumulation in the area of forefoot amputations. For post-surgery treatment in case of forefoot amputations orthopaedic shoes have been prescribed; in case of hindfoot amputations orthopaedic devices were used. The activity pattern according to the criteria of Hoffer revealed walking ability in 92% of the patients. Conclusions: Amputations and resections of the foot have a long lasting tradition and they deserve particular attention. Although a relatively high frequency of reamputations must be admitted, they allow for the preservation of limb length. However, as an essential prerequisite a high standard in the fabrication of orthopaedic shoes and orthopaedic devices must be secured.