Fitting transtibial and transfemoral prostheses in persons with a severe flexion contracture: problems and solutions – a systematic review

Figures & data

Figure 1. Flow diagram of study identification, inclusion and exclusion.

Table 1. Quality assessment results of 13 case reports based on the Joanna Briggs Institute critical appraisal checklist.

Authors, publication year (ref)	1.Were patient’s demographic characteristics clearly described?	2.Was the patient’s history clearly described and presented as a timeline?	3.Was the current clinical condition of the patient on presentation clearly described?	4.Were diagnostic tests or assessment methods and the results clearly described?	5.Was the intervention(s) or treatment procedure(s) clearly described?	6.Was the post-intervention clinical condition clearly described?	7.Were adverse events (harms) or unanticipated events identified and described?	8.Does the case report provide takeaway lessons?	Sum score
Trans tibial amputations:
Beliakov 1958 [34]	0	0	0	0	1	0	1	1	3
Alexander et al., 1965 [35]	1	1	1	0	1	1	0	1	6
Ruskin et al., 1970 [36]	1	1	1	0	1	0	0	1	5
Pennell et al., 1973 [37]	1	1	1	0	1	1	1	1	7
Titner 1973 [38]	1	1	1	0	1	1	0	1	6
Gajsak 1977 [39]	0	0	0	0	1	0	0	1	2
Bannister 1978 [40]	0	0	0	0	1	0	0	1	2
Alexander 1980 [41]	1	1	1	0	1	0	0	1	5
Hays et al., 1992 [42]	1	1	1	0	1	1	1	1	7
Kim et al., 2017 [43]	1	1	1	1	1	1	0	1	7
Trans femoral amputations:
Freed 1962 [44]	1	1	1	0	1	0	0	1	5
Lippmann 1967 [45]	1	1	1	0	1	1	1	1	7
Biedermann 1976 [46]	1	1	0	0	1	0	0	1	4

Ref: reference; TT: transtibial; TF: transfemoral; 0: study does not meet the criterion; 1: study meets the criterion.

Figure 2. A shows a socket connected with a crutch; B shows a socket connected with a thigh corset, a shank, and foot by metal sidebars; C shows a transtibial socket connected with a shank and a foot.

Figure 3. A shows a bent knee pylon; B shows a kneeling bearer connected with a peg leg.

Table 2. Summary of prostheses designs and fitting results.

Authors, publication year (ref)	Cases described	Prostheses characteristics and contracture treatment	Fitting result
Transtibial amputation:
Beliakov 1958 [34]	Forty- nine persons with a TT amputation with a knee flexion contracture ≤ 90°. Residual limb length ranged from 5 to 20 cm.	A TT leather socket was attached with a crutch via a hinge. The foot could be fitted to the end of the crutch (Figure 2(A)). At the back of the thigh part a belt attached the tibial part, holding the residual limb in the contracture angle. The belt length could be adjusted. A scale attached to the hinge showed the knee angle. The prosthesis should be used throughout the day with a break of 1 to 2 hours.	The best results were observed when fitting was combined with physiotherapy and other treatment methods such as therapeutic exercises, massage, a night splint. Users did not report pain. Range of motion after the prosthesis use was not reported.
Alexander et al., 1965 [35]	A 59-year-old male with a right TF and a left TT amputation, 60° hip flexion contracture on both sides and left 90°knee flexion contracture.	Prior to prosthesis fitting, manual stretching and pulleys failed to reduce the contracture. Release of the contracture by surgery was not chosen due to impaired local circulation. Temporary prostheses, made of a plaster of Paris socket and wooden shank, were given for training. A definitive TT socket was made of moulded leather with a thigh corset and fastened by Velcro straps. Metal sidebars with drop ring lock hinges were used to attach the TT socket with a shank and a conventional foot (Figure 2(B)). TF definitive socket was made out of wood and set at a 60° hip flexion. The sidebars with hinges locks attached the socket to the wooden distal thigh section. The locks could be manually unlocked when seated (Figure 4). Other prosthetic components included a Bock knee with friction lock, a pelvic band, and a single-axis foot. No details of other contracture treatments were given after prosthesis fitting.	After he was able to ambulate in parallel bars and a walker, definitive prostheses were made.
Ruskin et al., 1970 [36]	A 73-year-old male with a TT amputation, 30° hip and 60° knee flexion contractures.	After intensive physiotherapy (no details of the therapy), the hip flexion contracture was reduced to 10°, but the knee flexion contracture remained. A cushioned platform, made to carry the residual limb in 90° flexion, was attached to a crutch. The prosthesis was called a bent knee pylon (Figure 3(A)). A bent knee pylon has a pelvic belt and thigh strap for suspension. The definitive prosthesis consisted of a thigh corset and an open-end TT socket, metal sidebars with a knee lock, a shank, and a single axis foot. The open-end socket was used to avoid pressure on the residual limb. A fork strap was attached from the front of the shank to the thigh corset to aid knee extension.	He walked with a bent knee pylon using an axillary crutch. No details were reported on how long a bent knee pylon was used before the definitive prosthesis.
Pennell et al., 1973 [37]	Nine males with a TT, amputation, with a 15–40° knee flexion contracture.	Bent knee pylons were made for veterans in which a socket could not be used because of open wounds, scars, or split-thickness skin grafts over the residual limb and knee flexion contractures. The prosthesis consisted of a patellar platform connected to a crutch and suspended by a pelvic band (Figure 3(A)). Manual stretching and active range of motion exercises were mentioned parallel to the use of the bent knee pylons in some cases.	Six males gained both extension and flexion, and one gained flexion but extension was unchanged. In two males with knee joint injuries, knee range of motion decreased. A bent knee pylon was easy and cheap to make. The disadvantage is the cosmetic appearance. It is impossible to wear the bent knee pylon under clothing, and while sitting, it sticks out.
Titner 1973 [38]	A, 77-year-old male with TT amputation, 30° hip and 68° knee flexion contracture.	After 16 months of using a knee bearing crutch, the knee contracture had increased to 45°, a hip flexion contracture of 30° had developed, and hip abduction was limited to 20°. In December 1972, the knee range of motion had reduced to 0-68-73°. The prosthesis was constructed out of an ischial weight-bearing custom leather thigh corset, a patellar tendon bearing socket, and a SACH foot, with sidebars, similar to Figure 2(B) but with a knee extension aid.	He could walk with small and rapid steps with the prosthesis and knee range of motion increased 10° due to the prosthetic weight. At the time of the report, he had participated in gait training (no details of the training) for six weeks with good progress.
Gajsak 1977 [39]	An unknown number of persons with TT amputations with knee flexion contractures > 20°	The prostheses consisted of a thigh corset and a TT socket attached to metal sidebars that connect with a shank and a SACH foot (Figure 2(C)). Adjustments of the knee flexion angle could be made via the strap that attached the end of the socket with the front of the outer shank. No details of contracture treatments were given, other than prevention.	Use of the prosthesis could reduce contractures, but the authors suggested that the reduction depended on the individual’s condition.
Bannister 1978 [40]	An unknown number persons with a TT amputation with knee flexion contracture ≤ 90°	Possibilities of fitting TT prostheses included a socket or a padded platform connected to a wooden stick (a peg leg) or a shank and suspended by a thigh corset, pelvic belt, or an extended peg strapped to the thigh. The knee hinge joint is optional (Figures 3 and 6). If the knee is kneeled on a platform, the prosthesis is called “a kneeling bearer” (Figure 3(B)). No details of other contracture treatments were given.	A problem of using a kneeling bearer with metal sidebars was skin damage where the corset attached to the thigh due to the incongruence between the single mechanical axis (the hinge) and the anatomical polycentric knee axis [25]. Another disadvantage of the kneeling bearer was that the person’s knee always kneeled on the platform in 90°, and the available degree of the knee’s range of motion was not used or trained. In persons with adequate knee muscular power, the author suggested that the socket should be used instead of the kneeling bearer [25].
Alexander 1980 [41]	A male with right TF and left TT amputation with reduced hip and knee flexion contracture (a follow up on previous study, Alexander et al. 1965 [35].	When the knee flexion contracture reduced after two years of a TT and TF prosthesis use, a conventional patellar tendon bearing and Quadrilateral socket could be made. The contractures reduced despite the lack of active stretching which was intentionally minimized because contractures were believe to be irreversible.	NA
Hays et al., 1992 [42]	A 62-year-old male with TT amputation, with a 50° knee flexion contracture and residual limb length of 3 cm.	He was fitted with an endoskeletal TT prosthesis with a patellar tendon bearing socket design and a foot (Figure 2(C)). Padding made of polyurethane foam (PPT^®) was added to the inner socket over the entire anterior tibial area to protect the skin breakdown. A manual locking knee joint was added underneath the socket for close-quartered sitting after a month of prosthesis use. Prior to prosthetic fitting, a percutaneous hamstring release, intensive stretching and night splint was given, which reduced the contracture (70°) with 20°. After the prosthesis was fitted, no details of physiotherapy were reported. Using the prosthesis was described as therapeutic for the contracture.	Weight-bearing was dispersed over the entire anterior portion of the residual limb, and a thigh corset. He donned and doffed the prosthesis without the need to tailor his trousers since the residual limb length was very short. After 17 months, another similar prosthesis was made due to 10° reduction in a knee flexion contracture. At the time of reporting, he had used the prosthesis for two years. He ambulated independently without other assistive devices.
Kim et al., 2017 [43]	A 53-year-old male with a TT amputation, knee flexion contracture of (44°).	The prosthesis was total contact patellar tendon-bearing socket, pylon, Iceross liner (Comfort^®; Össur, United Kingdom), pin lock suspension (BK, Republic of Korea), and a hydraulic ankle-foot (Echelon^®; Endolite, United Kingdom). The sockets and pylon lengths were changed when the residual limb volume changed. Alignments had been adjusted four times during the four-months study period to accommodate the changes in flexion contracture. A prosthetist also adjusted the ankle module stiffness and damping according to his feedback when the prosthetic alignment changes. Adaptive training sessions were given to a person with a TT by a physical therapist five days per week for four months to strengthen the thigh muscles, improving standing balance, walking, and movement.	After four months of adaptive training, the 30° passive range of knee extension increased (knee range = 166°. Gait speed, cadence, stride length, and single limb support of the prosthetic limb increased, and gait asymmetries between sound and prosthetic side reduced. Functional level increased from being unable to walk safely on his own to being able to walk with varying speed independently.
Trans femoral amputations:
Freed 1962 [44]	A 43-year-old male with a TF amputation, with 25° hip flexion and 15° abduction contracture, and residual limb length of 18 cm.	The TF prosthesis consisted of Silesian bandage suspension, an Otto Bock knee, and a foot. With this prosthesis, he could not bend enough for prolonged sitting, driving an automobile, working, or participating in most recreational activities. Hinges with locks were attached between socket and thigh sections similarly to Figure 4. The lock was released by pulling a cable connected to the lock before sitting. No details of other interventions for contracture reduction were reported.	These hinges allow more flexion range of the prosthesis when seated.
Lippmann 1967 [45]	A 72-year-old male with a TF amputation, 40° hip flexion contracture. Other male is the same as reported by Alexander et al., 1965 [35].	After the transfemoral amputation, the contracture developed despite physical therapy (no details provided). The person was fitted with a TF prosthesis similar to Figure 4. No details of other contracture interventions after fitting a prosthesis were reported. The second male is described above (Alexander et al. 1965, 1980) [35,41].	At the time of discharge, he walked with Lofstrand crutches and could perform daily activities without reporting any problems. Due to a decrease in flexion contractures after approximately two years of using the prostheses, a patellar tendon bearing socket for the TT prosthesis and quadrilateral socket for the TF prosthesis could be made [41,45].
Biedermann 1976 [46]	A 60-year-old male with a TF amputation, severe hip flexion, and abduction contracture (unknown degrees but based on illustrations very likely to be more than 25 °) and a very short residual limb with scarring and splinters inside.	For 30 years, he had never worn a prosthesis. Despite the contracture. He received a trial prosthesis first, consisting of a quadrilateral socket, pelvic belt suspension, Lang knee, and Greissinger foot. Due to the very short residual limb, the plastic TF socket had a high lateral and anterior trim line. The ischial seat was cushioned to counteract a sensitive tuberosity. He used the trial prosthesis in the unfinished state and had it adjusted several times before he received the definitive prosthesis. No details of other contracture interventions after the prosthesis was given were reported.	How long the temporary prosthesis was used and which degree of hip flexion contracture was reached and when a definitive prosthesis was made was not reported.

Ref: reference; TT: transtibial; TF: transfemoral; NA: not applicable.

Figure 4. A bent transfemoral socket attached to the wooden shank via the sidebars with an extra joint allowing more flexion when seated.

Figure 5. A shows a transtibial amputee sitting with a bent knee prosthesis without an extra joint; B shows a transfemoral amputee sitting with a bent hip prosthesis with a flexion contracture plate; C shows compensation material to offset the socket; D and E show transtibial and transfemoral amputees with an extra joint underneath the socket to increase the seating cosmetic.

Figure 6. shows different degrees of transtibial socket flexion and path of the weight line dropping from mid socket and passing through the ankle. The distance between the 2 dotted lines shows the bulkiness of the socket in which the greatest distance is the bulkiest prosthesis. For the same residual limb length, the bulkiest is the most flexed socket (C > B > A), and for the same angle, it is the longer residual limb length (C > D).

Figure 7. shows different degrees of transfemoral socket flexion and path of the weight line dropping from trochanter, falling in front of the knee and passing through the ankle. The distance between the two dotted lines shows the bulkiness of the socket in which the greatest distance is the bulkiest prosthesis. For the same residual limb length, most bulkiness occurs in the most flexed socket (C > B > A) and, for the same angle, it occurs in the longer residual limb (C > D).

Beliakov PD. Prosthesis apparatus for elimination of flexion contracture of the knee joint after leg amputation. Ortop Travmatol Protez. 1958;19(1):62–63.

 PubMedGoogle Scholar

Alexander J, Herbison G. Prosthetic rehabilitation of a patient with bilateral hip-flexion contractures: report of a case. Arch Phys Med Rehabil. 1965;46(10):162–165.

 Google Scholar

Ruskin AP, Rosner H, Saperstein H. Bent-knee prosthesis. Geriatrics. 1970;25(7):109–114.

 PubMed Web of Science ®Google Scholar

Pennell CR, Mayfield GW. Bent knee pylon for the below-knee amputee. Bull Prosthet Res. 1973;10(19):77–83.

 PubMedGoogle Scholar

Titner H. Fitting and fabrication of a prosthesis for a severe flexion contracture: case study. Bull Prosthet Res. 1973;10(19):84–87.

 PubMedGoogle Scholar

Gajsak K. The problem of stumps in flexion contracture (author’s transl). Lijec Vjesn. 1977;99(6):143–144.

 PubMedGoogle Scholar

Bannister PJ. The prosthetic problems of below knee amputees with flexion contractures. Aust J Physiother. 1978;24(1):21–25.

 PubMedGoogle Scholar

Alexander J. Irreversible contractures: an impediment to prosthetic rehabilitation. Am Acad Orthotists Prosthetists. 1980;4(3):1–2.

 Google Scholar

Hays RD, Leimkuehler JP, Miknevich MA, et al. An alternative bent-knee prosthesis. Arch Phys Med Rehabil. 1992;73(11):1118–1121.

 PubMed Web of Science ®Google Scholar

Kim SB, Ko CY, Son J, et al. Relief of knee flexion contracture and gait improvement following adaptive training for an assist device in a transtibial amputee: a case study. J Back Musculoskelet Rehabil. 2017;30(2):371–381.

 PubMed Web of Science ®Google Scholar

Freed MM. Modified prosthesis compensating for above-knee amputation with fixed hip contracture. Arch Phys Med Rehabil. 1962;43:254–255.

 PubMedGoogle Scholar

Lippmann HI. Rehabilitation of the lower extremity amputee with marked flexion contractures: report of two cases. Arch Phys Med Rehabil. 1967;48(3):147–149.

 PubMedGoogle Scholar

Biedermann WG. Management of short above-knee amputees. Orthot Prosthetics. 1976;30(4):21–29.

 Google Scholar

Bowker JH. The art of prosthesis prescription. In: Atlas of limb prosthetics: surgical, prosthetic, and rehabilitation principles. 3rd ed. Rosemont (IL): American Academy of Orthopaedic Surgeons; 2004.

 Google Scholar