Journal of Rehabilitation Research & Development (JRRD)

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Volume 53 Number 2, 2016
   Pages 157 — 184

Abstract — Prosthetic interventions for people with transtibial amputation: Systematic review and meta-analysis of high-quality prospective literature and systematic reviews

M. Jason Highsmith, PhD, DPT, CP, FAAOP;1–3* Jason T. Kahle, MSMS, CPO, FAAOP;2 Rebecca M. Miro, PhD, MBA, CRA;2,4 Michael S. Orendurff, PhD;5 Amanda L. Lewandowski, DPT;6 John J. Orriola, MEd;7 Bryce Sutton, PhD;8 Jan P. Ertl, MD9

1Department of Veterans Affairs and Department of Defense Extremity Trauma and Amputation Center of Excellence, Washington, DC; 2School of Physical Therapy and Rehabilitation Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL; 3U.S. Army Reserves, 319th Minimal Care Detachment, Pinellas Park, FL; 4Center for Neuromusculoskeletal Research, Morsani College of Medicine, University of South Florida, Tampa, FL; 5Orthocare Innovations, Mountlake Terrace, WA; 6Select Physical Therapy, Brandon, FL; 7Shimberg Health Sciences Library, Morsani College of Medicine, University of South Florida, Tampa, FL; 8James A. Haley Veterans' Hospital, Tampa, FL; 9Department of Orthopaedic Surgery, School of Medicine, Indiana University, Indianapolis, IN

Abstract — Considering transtibial amputation (TTA) rehabilitation costs and complexity, high-quality literature should inform clinical practice. Systematic reviews (SRs) suggest this is not the case. This article's purpose was to review the highest-quality evidence available to guide clinical practice for TTA regarding five prosthetic intervention areas. Six databases were searched for high-quality SRs and prospective clinical trials (randomized clinical trials [RCTs]). Reviewers screened, sorted, rated (i.e., methodologic quality, bias risk), and extracted article data. Meta-analyses were conducted when possible. Thirty-one references were included (25 RCTs and 6 SRs). Five topical areas emerged (alignment, feet and ankles, interface, postoperative care, pylons). Twenty-three evidence statements were supported by level 2 evidence and eight by level 1 evidence. All RCTs reported randomization and reasonable data presentation. Concealed allocation and blinding were not widely used. Mean attrition was 11%. SRs included no meta-analyses. Functional level was poorly reported. Grouping feet and ankle components by functional classification enabled meta-analyses, though variance was considerable given the small sample sizes. Prosthetic interventions are generally safe for TTAs. High-quality literature enabled formulation of evidence statements to support select clinical practice areas, though quantity was lacking. Thus, numerous topics related to TTA care lack rigorous evidence. Although blinding in prosthetic research requires increased funding and effort, it could greatly improve the methodologic quality of prosthetic research.

Key words: amputee, below-knee, immediate postoperative prosthesis, prosthetic foot, pylon, residual limb, socket, torsion, valgus, varus.


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This article and any supplementary material should be cited as follows:
Highsmith MJ, Kahle JT, Miro RM, Orendurff MS, Lewandowski AL, Orriola JJ, Sutton B, Ertl JP. Prosthetic interventions for people with transtibial amputation: Systematic review and meta-analysis of high-quality prospective literature and systematic reviews. J Rehabil Res Dev. 2016;53(2):157–84.
http://dx.doi.org/10.1682/JRRD.2015.03.0046
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