BACKGROUND: Spinal curvature in adolescent idiopathic scoliosis (AIS) is associated with a reduction in standing height. While height loss due to scoliosis and height gain following surgical correction are well described, little is known about immediate height change during scoliosis brace fitting and its relationship to in-brace skeletal correction. In-brace Cobb angle correction remains a primary indicator of brace effectiveness; however, no radiation-free clinical tool exists to support early assessment during fitting. OBJECTIVE: To investigate whether immediate standing height change during scoliosis brace fitting is associated with in-brace Cobb angle correction. METHODOLOGY: A retrospective audit was conducted on 60 adolescents with idiopathic scoliosis (13 males, 47 females; mean age 12.4 ± 1.7 years; mean standing height 156.6 ± 10.7 cm) treated at The London Orthotic Consultancy in Kingston, UK. Clinical data were collected between January and October 2022. Standing height was measured immediately before and after brace fitting, and Cobb angles were assessed at baseline and in-brace. Correlation and simple linear regression analyses were performed to explore the relationship between height change and in-brace correction. RESULTS: The mean baseline Cobb angle was 38.0 ± 10.7°, correcting to a mean in-brace Cobb angle of 10.3 ± 9.4°, corresponding to a mean absolute Cobb angle correction of 27.8 ± 9.9° and mean percentage correction of 74.3 ± 19.2%. Mean height gain at fitting was 1.24 ± 0.74 cm (range −0.2 to 3.5 cm). Descriptive analyses included the full cohort (n = 60), including participants demonstrating radiographic over-correction (n = 6). Following exclusion of cases demonstrating radiographic over-correction (>100%), a moderate positive association was observed (R = 0.45, p = 0.001). Sex-specific subgroup analysis was not performed due to limited statistical power. CONCLUSION: Immediate height gain during scoliosis brace fitting demonstrates a moderate association with in-brace skeletal correction and may serve as a simple, radiation-free clinical indicator of mechanical brace response. Height measurement should be interpreted as an adjunct to, rather than a replacement for, radiographic assessment. Prospective studies using multivariable predictive models are warranted to further evaluate its clinical utility. Layman's Abstract Scoliosis is a condition in which the spine curves sideways. In children and adolescents, this curvature can make a person appear slightly shorter because the spine is not fully upright. One of the main goals of brace treatment is to straighten the spine as much as possible while the child is still growing. Currently, the main way to check how well a brace is working is by taking an X-ray, but repeated X-rays expose young patients to radiation. This study explored whether a simple measurement, standing height, could provide useful information during a brace fitting appointment without using radiation. We reviewed the clinical records of 60 adolescents with idiopathic scoliosis (13 males and 47 females) who were treated at The London Orthotic Consultancy in Kingston, UK. The average age of the patients was 12.4 years, and their average standing height was 156.6 cm. The data were collected between January and October 2022. During the brace fitting appointment, each patient’s height was measured immediately before and after putting on the brace. X-rays were also taken to measure how much the spinal curve improved while wearing the brace. On average, patients became about 1.24 cm taller when the brace was first fitted, although the change ranged from a decrease of 0.2 cm to an increase of 3.5 cm. The average spinal curve improved from 38° before bracing to 10° while wearing the brace, corresponding to an average absolute correction of 28° and an average percentage correction of 74%. In general, larger increases in height were associated with greater straightening of the spine seen on X-rays. These findings suggest that measuring height during a brace fitting appointment may provide clinicians with a quick, safe, and radiation-free way to gain early insight into how well a brace is working. Although height measurement cannot replace X-rays, it may help clinicians make better decisions during brace fitting and potentially reduce unnecessary radiation exposure for young patients with scoliosis. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/46645/35062 How To Cite: Courtney A, Walmsley S, Bishop T, Bernard J, Darren L, Jones R.K, et al. Immediate height gain during scoliosis brace fitting as a predictor of in-brace skeletal correction: A non-radiographic clinical indicator. Can Prosthet Orthot J. 2026;9(2):3. https://doi.org/10.33137/cpoj.v9i2.46645 Corresponding Author: Anna Courtney, Affiliation: The London Orthotic Consultancy, Kingston upon Thames, United Kingdom. E-Mails: anna.courtney@londonorthotics.co.uk ORCID ID: https://orcid.org/0009-0009-0726-1186
Despite major advances in prosthetic components, digital workflows, and manufacturing technologies, substantial variability continues to exist in prosthetic interface outcomes. Socket fit, tissue tolerance, user comfort, and long-term functional success remain difficult to predict and standardize across individuals and clinical settings. While contemporary technologies such as CAD/CAM, pressure scanning, additive manufacturing, and emerging artificial intelligence applications may improve manufacturing precision and reproducibility, they do not fully address the biological and biomechanical complexities that influence interface performance. Residual limb tissues, suspension systems, gait mechanics, skin adaptation, and individual user characteristics interact dynamically throughout prosthetic use, limiting the ability of shape capture and manufacturing processes alone to determine successful outcomes. This perspective paper argues that prosthetic interface management should be viewed as a dynamic biological and biomechanical process rather than primarily a manufacturing challenge. Building upon a systems-based understanding of the interface, the paper proposes that successful outcomes emerge from the interaction between socket design, liner characteristics, suspension mechanisms, tissue biology, gait dynamics, and clinical decision-making. The paper further highlights the unique role of the prosthetist in observing long-term outcomes and emphasizes the continued importance of clinical expertise in an increasingly digital environment. Future progress in prosthetic interface management will likely depend on integrating technological innovation with rehabilitation science, biomechanics, tissue biology, and outcome-focused clinical practice. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/47748/35116 How To Cite: Johannesson A.G. Beyond shape capture: The dynamic transtibial prosthetic interface and the continuing role of clinical expertise. Can Prosthet Orthot J. 2026;9(2):1. https://doi.org/10.33137/cpoj.v9i2.47748 Corresponding Author: Dr. Anton G. Johannesson, PhD, CPO Affiliations: Össur Clinics EMEA, Stockholm, Sweden. E-Mail: ajohannesson@ossur.com ORCID ID: https://orcid.org/0000-0001-8729-458X
BACKGROUND: Silicone cosmetic prostheses play a significant role in improving body image and reducing psychosocial issues among individuals with partial hand amputation; however, high weight and insufficient stiffness are their primary limitations. OBJECTIVES: To design a novel silicone cosmetic prosthesis with a lightweight and durable internal structure using 3D printing and to evaluate its impact on user satisfaction and functional ability scores. METHODOLOGY: This pilot semi-experimental pre–post study was conducted between February and September 2024 at a prosthetics and orthotics center in Tehran, on 7 individuals (4 males, 3 females; mean age 27.9 ± 7.6 years) with unilateral partial hand amputation. For each participant, a silicone cosmetic prosthesis with a 3D-printed internal thermoplastic polyurethane (TPU) structure was fabricated. User satisfaction was assessed using the TAPES questionnaire, and functional ability was evaluated using the DASH questionnaire. Prosthesis stiffness was measured using a force–displacement test, and fatigue resistance was assessed through a displacement-controlled cyclic loading test (25 mm) until failure. Outcomes were compared with participants’ existing conventional full-silicone prostheses. RESULTS: The results indicated that the TPU prosthesis was lighter than the full-silicone prosthesis (0.200 ± 0.05 vs. 0.29 ± 0.09 kg; p = 0.001), stiffer (81.43 ± 27.07 vs. 27.29 ± 10.83 N; p = 0.028), and more resistant to fatigue in the tested sample (36,500 vs. 13,800 cycles). The mean DASH score was lower for the TPU prosthesis (43.69 ± 11.67 vs. 53.09 ± 11.56; p = 0.012), indicating superior functional ability. Additionally, overall satisfaction (TAPES) and separately measured satisfaction with prosthesis stiffness were higher in the TPU prosthesis. Participants reported longer daily wear time with the TPU prosthesis. CONCLUSION: In this pilot sample, silicone prostheses incorporating a 3D-printed internal TPU structure demonstrated improved mechanical and functional outcomes compared to conventional full-silicone prostheses. Despite the limitation of small sample size, these preliminary findings highlight the potential value of integrating lightweight and durable materials through 3D printing in the design of cosmetic partial-hand prostheses. Future studies with larger sample sizes are necessary to confirm and generalize these results. Layman's Abstract Losing part of the hand can affect not only daily function but also self-confidence and quality of life. Many individuals with partial hand amputation use silicone cosmetic prostheses to restore the natural appearance of the hand. Although these prostheses look realistic, they are often heavy and may not provide enough stiffness to assist with daily activities. In this study, we designed a new type of silicone cosmetic prosthesis that includes a lightweight internal structure made from thermoplastic polyurethane (TPU) using 3D printing technology. Seven individuals with unilateral partial hand amputation tested both the conventional full-silicone prosthesis and the new TPU-based design. The results showed that the prosthesis with the 3D-printed TPU internal structure was lighter, stiffer, and more resistant to repeated bending over time compared to the conventional model. Participants reported better functional ability, higher overall satisfaction, and better satisfaction with stiffness when using the TPU prosthesis. They also reported longer daily use of the TPU prosthesis. These findings suggest that combining silicone with a lightweight 3D-printed internal structure may improve comfort, durability, and daily function for individuals with partial hand amputation. Larger studies are needed to confirm these results. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/47092/35110 How To Cite: Mohammad Zadeh M, Jalali M, Khaghani A. Innovative 3D-printed internal structure in silicone partial-hand prostheses: Enhancing function and mechanical performance. Can Prosthet Orthot J. 2026;9(1):10. https://doi.org/10.33137/cpoj.v9i1.47092 Corresponding Author: Alireza Khaghani, PhD Affiliation: Rehabilitation Research Center, Department of Orthotics and Prosthetics, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran. E-Mail: Khaghani.a@iums.ac.ir ORCID ID: https://orcid.org/0000-0002-7585-3062
BACKGROUND: Restoring function and mobility after transfemoral amputation (TFA) is crucial for prosthesis use and heavily relies on muscle morphology and function in the residual limb. After amputation, the loss of distal muscle insertions alters morphology and might impair (muscle) functioning. OBJECTIVE: To provide a comprehensive and critically appraised overview of the existing evidence on muscle morphology and function of the residual limb following TFA. METHODOLOGY: A literature search was conducted in PubMed, Embase, and CINAHL, including articles published up to September 15, 2025. Language was restricted to English, Dutch and German. Articles were eligible if they included individuals with a TFA and objectively measured outcomes related to muscle morphology and/or function. Methodological quality was assessed using the Joanna Briggs Institute critical appraisal checklist and the review followed the PRISMA guidelines. RESULTS: Out of 1832 identified articles, 24 met the inclusion criteria. Eight articles reported outcomes related to muscle morphology while sixteen articles reported outcomes on muscle function. All articles assessing muscle volume and cross-sectional area reported reductions in most residual-limb muscle groups compared to the intact limb. Across articles assessing muscle function, the residual limb generated reduced hip flexion, extension, and abduction torques compared to the intact and/or control limb, while adduction torque diminished only at lower isokinetic speeds. The magnitude of alterations varied greatly between articles. No article investigated both muscle morphology and function. Therefore, the interrelationship between these outcomes could not be determined. CONCLUSION: The literature shows that muscle morphology and function are significantly altered in the residual limb following TFA, although reported effects vary across articles and muscle groups. Study heterogeneity limited exploration of factors that could account for this variation. This needs future study. Future research also should combine assessments of muscle morphology and function to better understand these variations. Layman's Abstract People who undergo an above‑knee amputation rely heavily on the strength and health of the remaining muscles in their upper leg to walk and use a prosthesis. After the amputation, some muscles lose their normal attachment to the bone, which can change how these muscles work. To better understand these changes, we reviewed studies that measured muscle structure or muscle strength in people with an above‑knee amputation. A search of three databases (PubMed, Embase, and CINAHL) was conducted. Out of 1,832 articles, 24 studies met the criteria to be included. Overall, these studies showed that the remaining leg muscles are often weaker and smaller than those in the intact limb or in people without an amputation. Many studies found reduced strength when lifting the leg forward, backward, or sideways. Most studies also reported smaller muscle size and more fatty tissue in the muscles of the residual limb. However, the amount of change differed widely between studies, and the reasons for these differences are still unclear. None of the studies measured muscle strength and muscle structure together in the same individuals, making it difficult to understand how these two aspects are related. Overall, this review shows that an above‑knee amputation affects how strong the remaining muscles are and how they are built, but the causes of the differences seen from person to person remain unknown. Future research should measure muscle strength and muscle structure together and look at personal and surgery‑related factors to better understand how these muscles adapt after amputation. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/47289/35029 How To Cite: Kroes C.M, Schelhaas R, Dekker R, Geertzen J.H.B, van Kammen K, Houdijk H. Muscle morphology and function following a transfemoral amputation: A systematic review. Can Prosthet Orthot J. 2026;9(1):9. https://doi.org/10.33137/cpoj.v9i1.47289 Corresponding Author: Claudia M. Kroes, PhD Affiliations: 1) Department of Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; 2) Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. E-Mail: c.m.kroes@umcg.nl ORCID ID: https://orcid.org/0009-0001-3403-5899
BACKGROUND: Stroke, traumatic brain injury, cerebral palsy, and other neuromuscular impairments can result in foot drop, which reduces toe clearance, increases fall risk, and limits mobility. Ankle-foot orthoses (AFOs) are frequently prescribed to address foot drop. Sensorimotor foot orthoses (SMFOs) represent an alternative approach intended to influence muscle activation through sensory stimulation; however, evidence supporting their combined use with AFOs remains limited. OBJECTIVE: To evaluate the feasibility of a subsequent Randomized Controlled Trial (RCT) comparing a prefabricated carbon-fiber AFO worn with and without an SMFO in individuals with neuromuscular or musculoskeletal conditions. METHODOLOGY: A six-month randomized crossover pilot trial was conducted from February to July 2025 at the Department of Rehabilitation Science and Technology, University of Pittsburgh. Three participants with neuromuscular or musculoskeletal conditions were enrolled. The two conditions compared were a prefabricated carbon-fiber AFO (F5 AFO, Thrive Orthopedics, USA) worn alone and the same AFO worn in combination with a custom-made SMFO designed to activate muscles through exteroceptor and proprioceptor stimulation (Springer Aktiv, Germany). The primary outcome was average daily step count measured by a wearable pedometer. Secondary outcomes included gait performance using the Two-Minute Walk Test (2MWT), dynamic balance using the Narrowing Beam Walking Test (NBWT), mobility using the Rivermead Mobility Index (RMI), and device experience assessed via an Ecological Momentary Assessment (EMA) survey. FINDINGS: Three subjects enrolled; one withdrew due to difficulty finding footwear that accommodated the SMFO when worn in combination with the AFO. Two participants completed the study (mean age = 65 years), responded to approximately 77% of EMA prompts, and reported no adverse events. Step count was higher in the SMFO+AFO condition for one participant (1,952 vs. 116 steps) and comparable between conditions for the other (884 vs. 933 steps). Differences on the NBWT and RMI were minimal across conditions; RMI scores were at ceiling for both participants. On the 2MWT, Participant 1 walked 470 m with the AFO alone and 404 m with the combined condition, while Participant 2 walked 303 m and 294 m, respectively. EMA ratings for comfort, function, and satisfaction were higher, and inhibiting effects and wear time were lower with the combined condition throughout the study period. CONCLUSION: The protocol was feasible, safe, and acceptable to participants, with no adverse events and minimal participation burden. These findings support the design of a larger RCT to confirm these preliminary observations. Layman's Abstract Foot drop is a common condition in people who have experienced stroke, traumatic brain injury, cerebral palsy, or other neurological or musculoskeletal conditions. It affects the ability to lift the foot during walking, increasing the risk of tripping and falling. A newer type of insert, called a sensorimotor foot orthosis (SMFO), is designed to influence muscle activity through sensory stimulation. Research on the practicality of combining an SMFO with a standard ankle-foot orthosis (AFO) remains limited. This pilot study looked at whether it would be practical to carry out a larger study comparing an AFO used alone versus an AFO used together with an SMFO. Three participants enrolled in a six-month crossover trial, to try both conditions. Two completed the study (mean age = 65 years); one withdrew due to difficulty finding footwear that accommodated the SMFO when worn in combination with the AFO. The results showed that one participant took more steps when using the combined setup (1,952 vs. 116 steps), while the other participant showed only a small difference between conditions (884 vs. 933 steps). Differences on balance and mobility tests were minimal. On the walking distance test, Participant 1 walked 470 m with the AFO alone and 404 m with the combined condition, while Participant 2 walked 303 m and 294 m, respectively. Participants responded to approximately 77% of daily survey prompts and reported higher ratings of comfort, function, and satisfaction, lower inhibiting effects, and lower wear time, with the combined approach. No safety concerns were observed. The protocol was feasible, safe, and acceptable to participants, with minimal participation burden. The results support conducting a larger study to determine whether combining these devices improves clinical outcomes. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/47162/35016 How To Cite: Aljohani Y, Alamri A, Fiedler G. Feasibility of combining a sensorimotor foot orthosis with a prefabricated carbon-fiber ankle-foot orthosis: A pilot study. Can Prosthet Orthot J. 2026;9(1):8. https://doi.org/10.33137/cpoj.v9i1.47162 Corresponding Author: Yasir Aljohani, PO, MSPO Affiliations: 1) Department of Prosthetics and Orthotics, College of Medical Rehabilitation Sciences, Taibah University, Madinah, Saudi Arabia; 2) Department of Rehabilitation Science and Technology, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, USA. E-Mail: yaa54@pitt.edu ORCID ID: https://orcid.org/0000-0002-6603-1526
BACKGROUND: Waiting times for lower limb prosthesis in the public healthcare sector of South Africa can exceed 12-months. A cause of long waiting times is shortage of prosthetic components. However, sometimes prostheses are abandoned. Recycling components from unused prostheses to mitigate the shortage of components has not been studied. OBJECTIVE: This study aimed to determine the reasons for lower limb prosthesis abandonment and to explore the possibility of recovering unused prostheses for component recycling in the public healthcare sector of the Eastern Cape Province, South Africa. METHODOLOGY: A cross-sectional survey was conducted among individuals who had stopped using or had an unused lower limb prosthesis. Participants were recruited using total population sampling from three public hospitals with Orthotics and Prosthetics centres in the Eastern Cape. During routine follow-up (July–August 2025), 92 individuals who had received a lower limb prosthesis between January 2021 and January 2025, or their next of kin where applicable, were contacted. Individuals still using their prosthesis and children (<18 years) were excluded. The remaining 45 non-users or next of kin were invited to participate. A self-developed structured questionnaire was administered via short (10–15 minute) interviews, and data were analyzed descriptively using SPSS (version 31). FINDINGS: A total of 43 participants aged 18–77 years (median 54; interquartile range 24), including 54% (n=23) male participants, consented to participate and completed the interviews. Twenty-two participants (51%) reported poorly fitting sockets as the reason for non-use. Forty-two (98%) participants were in favour of recycling components. Forty (93%) of the unused prostheses were modular. The majority were transtibial (81%), followed by transfemoral (12%) and knee disarticulation (7%). The main barrier to recycling identified was damaged components (19%). Thirty-nine (91%) prostheses were recovered from which 190 components can possibly be recycled. CONCLUSION: The findings extend existing knowledge on prosthesis abandonment and highlight an opportunity to implement component recycling practices to improve access, reduce waiting times, and lower costs in low-resource settings with high prosthetic service demand. The study may have important implications for prosthetic service delivery and policy in the Eastern Cape and South Africa. Layman's Abstract In South Africa’s public healthcare system, people with a lower limb amputation may wait more than a year to receive an artificial limb (prosthesis). One major reason is a shortage of prosthetic parts. This study explored why some people stop using their prostheses and whether parts from these prostheses could be collected and reused. Participants were recruited from three hospitals in the Eastern Cape that provide orthotics and prosthetics (O&P) services. As part of routine follow-up, between 28 July and 22 August 2025, clinic staff contacted 92 people who had previously received a lower limb prosthesis, or a family member if the person was unavailable. Forty-five people could take part in the study because they were no longer using their prosthesis. Of these, 43 agreed to participate. Each person took part in a short interview lasting about 10–15 minutes, and their answers were summarized. Participants were between 18 and 77 years old. Twenty-two people stopped using their prosthesis because it did not fit properly. Forty-two participants supported the idea of reusing parts from prostheses. The most common reason that prevented reuse was damage to parts (19%). In total, 39 prostheses were collected, and from these, about 190 parts could potentially be reused. These findings suggest that recycling of prosthetic components is acceptable to users. Recycling offers a practical solution to component shortages in resource-limited healthcare settings and may support better prosthetic care in South Africa. Policymakers and clinicians together with prosthetic users should develop ways to include recycling into routine prosthetic practice. Further research is needed to develop guidelines that take cultural beliefs into account and ensure that reused prosthetic parts are safe and of good quality. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/47107/34964 How To Cite: Goxo X.L, Visagie S, Ned L. Lower limb prosthesis abandonment and recycling of used components in the public healthcare sector of the Eastern Cape Province of South Africa. Can Prosthet Orthot J. 2026; 9(1): 7. https://doi.org/10.33137/cpoj.v9i1.47107 Corresponding Author: Xolani Lennox Goxo, Affiliation: Division of Disability and Rehabilitation Studies, Faculty of Medicine and Health Sciences, Stellenbosch, University, Cape Town, South Africa. E-Mails: 20225393@sun.ac.za; XolaniG@dut.ac.za ORCID ID: https://orcid.org/0009-0000-4408-1381
BACKGROUND: Enhancing health-related quality of life (HRQoL) is a fundamental objective of healthcare delivery. Individuals with amputation might encounter physical, psychological, and social challenges in daily life which might be influenced by the type of prosthetic knee provided. OBJECTIVE: To understand the experience-based HRQoL of amputees who were using a microprocessor-controlled prosthetic knee (MPK). METHODOLOGY: Amputees using an MPK for at least 3 months (C-Leg or Genium/Genium X3) participated in an online survey. In 2022 1,868 MPK user were invited to participate in the study via both desktop and mobile platforms of a German manufacturer database. HRQoL was assessed with the EuroQol 5-Dimension 5-Level (EQ-5D-5L) instrument. The data was analyzed descriptively and by measures of central tendency. FINDINGS: 512 participants (19.7% female, mean age 54 years (standard deviation 12.6)) responded and fully completed the EQ-5D-5L. The leading cause of amputation was trauma (56.1%), followed by tumor (15.6%) and peripheral arterial disease (PAD, 11.3%). 18.2% reported being completely problem-free. 2.9% had a hip disarticulation, 68.0% a transfemoral amputation, 26.6% a knee disarticulation and 2.5% a bilateral amputation. The share of “no problems” was 53.3% for mobility, 88.1% for self-care, 61.5% for usual activities, 25.0% for pain or discomfort, and 67.4% for anxiety/depression. The total mean index score based on the German value set was 0.84 (maximum score 1). The total mean visual analogue scale (VAS) score was 77.4 with variations observed for age and health status. CONCLUSION: Amputees with an MPK experienced very few issues in the self-care dimension but faced more challenges in the pain/discomfort and mobility dimensions. Utilities were similar to the general German norm reporting one medical condition. MPKs enable individuals to achieve quality of life outcomes that are comparable to those observed in the general population. Layman's Abstract We wanted to learn how amputees who use a special prosthetic knee controlled by a microprocessor (“MPK”) in their prosthesis feel about their quality of life. In 2022, 1,868 people who use an MPK from a German manufacturer were invited to take part in an online survey. About one in five participants (19.7%) were women. Most respondents had an above-the-knee amputation (68.0%), while about a quarter had a knee disarticulation (26.6%). A small number had a hip disarticulation (2.9%) or amputations on both sides (2.5%). A tool known as the EQ-5D-5L was used to measure their quality of life. Answers were evaluated descriptively and to identify patterns. A total of 512 people with an average age around 54 years responded to the quality-of-life questionnaires. Most of them lost their limbs due to an accident. About 18% of them said they had no problems at all. The most common problems they faced were related to pain, discomfort, and mobility. On average, their quality-of-life score was 0.84 out of a maximum of 1, where 1 means perfect health. This score is similar to what people in Germany with one chronic medical condition typically report. People using an MPK generally have few problems taking care of themselves but struggle more with pain and moving around. Their overall quality of life is similar as that of the general German population. MPKs enable individuals to achieve quality of life outcomes that are comparable to those observed in the general population. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/46403/34874 How To Cite: Brüggenjürgen B, Kannenberg A, Stukenborg-Colsman C, Hahn A. Health-related quality of life in amputees with a microprocessor-controlled prosthetic knee measured by the EQ-5D-5L. Canadian Prosthetics & Orthotics Journal. 2026; Volume 9, Issue 1, No. 4. https://doi.org/10.33137/cpoj.v9i1.46403 Corresponding Author: Prof. Dr. med. Bernd Brüggenjürgen, MPH Affiliation: Institute for Health Services Research and Technical Orthopedics, Orthopedic Department - Medical School Hannover (MHH) at DIAKOVERE Annastift Hospital, Hannover, Germany. E-Mail: brueggenjuergen.bernd@mh-hannover.de ORCID ID: https://orcid.org/0000-0002-8866-0809
Over the past decade, digital workflows and 3D printing have shifted from emerging innovations to mainstream considerations within prosthetics and orthotics (P&O). While these technologies promise improved reproducibility, enhanced documentation, and new design possibilities, their sustained integration into clinical practice has revealed both meaningful benefits and significant challenges. Drawing on nearly ten years of clinical adoption within a busy orthotic practice, this professional opinion article reflects on the lived realities of incorporating digital pathways and additive manufacturing into patient care. Areas of durable benefit include improved design consistency, digital traceability, and educational value. However, total cost of ownership, workflow fragility, material limitations at fitting, and evolving workforce expectations present ongoing considerations. Importantly, digital tools have not eliminated clinical craftsmanship but have reshaped where and how it occurs. As artificial intelligence and data-driven systems emerge, the profession faces renewed responsibility to ensure that digital transformation strengthens, rather than dilutes, clinical reasoning and professional identity. Thoughtful, clinician-led adoption remains essential to sustaining patient-centred care in an increasingly digital environment.
Canada lacks a national data source on individuals with limb loss and limb difference (LLD), which limits understanding of incidence, prevalence, risk factors, etiology, and healthcare outcomes. In the absence of standardized data collection, the provision of LLD healthcare services in Canada remains inconsistent. The objective of this study was to gather key interest groups’ perspectives on the development of a Canadian LLD registry. Invitees were identified through professional networks and snowball recruitment techniques. A two-round modified Delphi approach was utilized to identify key LLD registry domains via a pre-meeting survey followed by a virtual workshop on February 14, 2024. Of 96 invitees, 53 completed the survey, and 64 attended the workshop (63 from Canada and 1 from the United States). Five key LLD registry domains were identified: representation, standardization, practice-based evidence, research and innovation, and policy and funding. Inclusivity of diverse populations, national outcome measures adoption, and integration of psychosocial and clinical data was emphasized. Foreseen challenges included privacy concerns, necessary infrastructure, and resources to ensure long-term sustainability. Despite these challenges, a Canadian LLD registry could support advocacy, strengthen practice-based evidence, enhance research collaboration, improve clinical care, and inform population-level policies. Efforts to develop the registry are ongoing. Layman's Abstract Canada currently lacks a national registry of individuals with limb loss and limb difference (LLD), which limits our understanding of how many Canadians have limb loss or limb difference, and the effectiveness of healthcare services. Without consistent national data collection, it is impossible to understand regional differences in care, including prosthetic interventions and rehabilitation. This initiative gathered insights from representatives of the LLD community on establishing a Canadian LLD registry to improve research, healthcare delivery, and advocacy. Ninety-six LLD experts and professionals were identified to participate in a two-stage process that included a survey and virtual workshop. Fifty-three individuals (55%) completed the survey. On February 14, 2024, 64 (67%) individuals (63 Canadian and 1 American) attended the virtual workshop. The workshop included presentations on the development of the American Limb Loss and Preservation registry and the Canadian Rick Hansen Spinal Cord Injury registry, and measuring Canadian LLD outcomes. The meeting explored the feasibility, vision, and strategies for creating a Canadian LLD registry. Findings from the survey and workshop showed strong support for the registry, and workshop attendees discussed a number of critical areas for its development and sustainability. While some challenges regarding privacy, infrastructure, and sustainability still need to be addressed, there was agreement among meeting attendees on a strategy to start planning a registry. A Canadian registry would support advocacy efforts, enhance clinical care, encourage collaborative research, and provide essential data about care nationwide to ensure that the health and social care needs of the LLD community are met. Work is continuing to create and fund a Canadian LLD registry. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/46909/34865 How To Cite: Mayo A.L, Hitzig S.L, Zidarov D, MacKay C, Kaufman K.R, Noonan V.K, et al. A national strategy for a Canadian limb loss and limb difference registry. Canadian Prosthetics & Orthotics Journal. 2026; Volume 9, Issue 1, No. 3. https://doi.org/10.33137/cpoj.v9i1.46909 Corresponding Author: Dr. Amanda L. Mayo, MD, MHSc, FRCPC, Affiliations: 1) St. John’s Rehab, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; 2) St. John’s Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; 3) Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. E-Mail: amanda.mayo@sunnybrook.ca ORCID ID: https://orcid.org/0000-0001-7061-2529
A previous health-utility analysis of microprocessor-controlled prosthetic knees (MPKs) in the Netherlands used a very short evaluation period of only 6 months resulting in an extremely high incremental cost-utility ratio (ICUR) of €457,063 per quality-adjusted life year (QALY) gained. However, for proper health-economic analyses, an appropriate time horizon, usually the useful life of an intervention, must be chosen to avoid biased results. Therefore, we performed a basic cost-utility analysis (CUA) extrapolating and properly discounting the utility and cost data reported by that article over the useful lifetime of MPKs of 6 years and found an ICUR of €17,945 per QALY. To further refine the CUA, we conducted a modeling study of the ICUR of the MPKs over a timeframe from 6 months to 25 years using existing and published population models for Germany and Sweden. In the modeling study, the ICUR was higher for the Netherlands with €37,567 per QALY than for Germany (€18,276 per QALY) or Sweden (€11,147 per QALY) but below the Dutch threshold for willingness to pay of €50,000 per QALY for people with a lower-limb amputation. Thus, the MPKs were cost-effective for the Dutch healthcare system in all scenarios of the cost-utility analysis. Our analysis showed that time had a much bigger impact on the ICUR than utility with the MPKs becoming cost-effective with the ICUR falling below the €50,000-per-QALY threshold after 4-5 years of use. Thus, a proper time horizon covering the useful lifetime of an intervention is key for health-economic analyses to prevent potentially misleading results and unjustified detrimental decisions for patients.
BACKGROUND: Prevalence of deformational plagiocephaly (DP) has increased since the “Back to sleep” campaign to counter sudden infant death syndrome. Cranial remolding orthosis (CRO) is commonly used to manage severe DP in infants, yet evidence from randomized controlled trials (RCT) remains limited. OBJECTIVES: This pilot RCT aimed to assess the feasibility of a future large-scale RCT on cranial remolding orthosis for severe DP in infants aged 4 to 7 months. Specific objectives included evaluating recruitment, retention, coordination, and parental acceptability. A secondary objective was exploring trends in cranial shape outcomes between groups over 6- and 12-week periods. METHODOLOGY: Seventy-eight infants were screened at a single pediatric tertiary-care center between December 2023 and June 2024, and 31 families were approached for consent after initial clinical evaluation. Following consent, head shape severity was assessed using three-dimensional surface imaging, and seven infants were excluded prior to randomization due to insufficient severity. Twenty-four infants were randomized to receive immediate (n = 12) or delayed (six-week delay) (n = 12) CRO. One participant randomized to the delayed arm received the orthosis earlier than planned due to a protocol deviation. Feasibility metrics included recruitment timelines, protocol adherence, appointment coordination, and parental acceptability. Exploratory efficacy analyses evaluated cranial vault asymmetry (CVA), cranial vault asymmetry index (CVAI), oblique diameter diagonal difference (ODDI), cranioproportional index (CI), Argenta severity scores, and parent-reported head shape perception and satisfaction. FINDINGS: Of the 24 randomized infants, 20 were male and four were female. Mean age at enrollment was 5.3 ± 0.9 months in the intervention arm and 5.1 ± 0.9 months in the control arm. Recruitment and retention targets were met within seven months despite scheduling challenges. Parental satisfaction was high (mean score of 4.5 ± 0.1 on a 5-point scale), and all families reported willingness to repeat treatment despite common but minor side effects, including sweating, orthosis odor, and mild skin irritation. Significant improvements over time were observed in CVA, ODDI, and CI (all p < 0.001), with no significant between-group differences observed at 6 or 12 weeks. CONCLUSION: This pilot trial confirmed the feasibility and acceptability of conducting a larger RCT on CRO for DP, demonstrating successful recruitment, retention, and protocol implementation. Cranial symmetry improved over time in both groups, with no statistically significant differences observed between immediate and delayed treatment arms over the 12-week period. Future larger studies are needed to assess clinical effectiveness and should consider broader inclusion criteria, refined measurement techniques, and dedicated coordination to address scheduling challenges and ensure rigorous implementation and generalizability. Layman's Abstract Certain babies develop a flattened head shape, known as deformational plagiocephaly, when they spend long periods lying on their backs. This head shape has become more frequent since the recommendation for babies to sleep on their backs was introduced. Milder cases often improve over time, but severe cases may need a custom-made helmet (cranial remolding orthosis) to reshape the skull. This study tested whether it would be doable to conduct a larger clinical trial to evaluate how well helmet therapy works for infants with severe head flattening. Of 78 children screened, 31 infants were recruited, of whom 24 infants aged 4 to 7 months met eligibility criteria after head shape confirmation using three-dimensional imaging. Twelve infants started helmet therapy immediately, and 12 began treatment after a six-week delay. The study assessed ease of family recruitment and assignation to either group, ease of study coordination, how acceptable the treatment was to parents, and if measurable changes in head shape could be detected after 6 and 12 weeks. Recruitment and follow-up were successful, and parents reported high satisfaction with treatment despite minor, temporary side effects such as sweating, helmet odor, or mild skin irritation. Head shape improved in both groups over time, but no differences were seen between infants who started helmet therapy immediately versus after a six-week delay, suggesting that no clear short-term advantage of starting treatment earlier was observed in this pilot study. These results show that a larger study on helmet therapy for severe deformational plagiocephaly is doable and acceptable to families. Future research should include a broader range of infants and use refined measurement techniques to better determine helmet therapy effectiveness. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/46298/34762 How To Cite: Amir-Yazdani P, Alhaeik R, Gimeno M, Fontaine K, Bursuc A, Weil A.G, et al. Feasibility of a pilot randomized controlled trial on cranial remolding orthosis for severe deformational plagiocephaly. Canadian Prosthetics & Orthotics Journal. 2026; Volume 9, Issue 1, No. 1. https://doi.org/10.33137/cpoj.v9i1.46298 Corresponding Author: Pegah Amir-Yazdani, MD Affiliation: 1) Department of Pediatrics, Division of Physical Medicine and Rehabilitation, Faculty of Medicine, Centre hospitalier universitaire Sainte-Justine, Montreal, Canada; 2) Faculty of Medicine, University of Montreal, Montreal, Canada. E-Mail: pegah.amir.yazdani@umontreal.ca ORCID ID: https://orcid.org/0009-0006-9088-1623
Bracing remains the cornerstone of non-surgical management for adolescent idiopathic scoliosis (AIS) with an aim to minimize the risk of progression and to avoid spine surgery. In Canada however, one third to half of patients present with curve magnitudes too severe for optimal brace treatment, resulting in higher than necessary surgical volumes. High-cost spine surgeries are fully funded while non-surgical management is not. This Professional Opinion article highlights systemic barriers to early detection that limit opportunity for non-surgical management in Canada and ultimately drive up healthcare spending. In Canada, there is an urgent need for a coordinated national strategy to re-establish routine scoliosis screening, ensure equitable public funding for treatment and expand professional training in non-surgical spinal care. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/46590/34720 How To Cite: Lebel A, Kline M, Boucher J, Carberry J, Adulovic N, Dermott JA. Bracing and non-surgical management of scoliosis in Canada: Early detection, access inequities, and the need for interdisciplinary reform. Canadian Prosthetics & Orthotics Journal. 2025; Volume 8, Issue 2, No. 9. https://doi.org/10.33137/cpoj.v8i2.46590 Corresponding Author: Andrea Lebel, MSc, PT Affiliation: Scoliosis Physiotherapy & Posture Centre, Ottawa, ON, Canada. E-Mail: scoliosisphysiotherapy@gmail.com ORCID ID: https://orcid.org/0009-0002-9488-4291
BACKGROUND: Individuals with lower limb amputation (LLA) often experience reduced physical capacity and increased aerobic demands during activities of daily living (ADL), which may impact participation and quality of life. Measuring the relative aerobic load of ADL is essential to set realistic rehabilitation goals, however data on short and non-steady-state ADL tasks in this population are limited. OBJECTIVES: To evaluate the feasibility of a newly developed protocol for assessing the relative aerobic load of five selected ADL tasks in individuals with LLA, and to determine the applicability of the excess post-exercise oxygen consumption (EPOC) method for these measurements. METHODOLOGY: Six individuals with unilateral LLA (mean age 59 ± 9 years; five males), including three with transtibial, one with knee disarticulation, and two with transfemoral amputation, all classified as K2–K3 ambulators, were recruited for this pilot study and underwent a cardiopulmonary exercise test (CPET) during the first assessment session. During the second assessment session, within a two-week interval, participants were asked to perform five standardized tests reflecting ADL tasks: the 6-Minute Walk Test (6MWT), Timed Up and Go Test (TUGT), Glittre ADL test, stair ascent, and stair descent. Oxygen consumption was measured using the COSMED K5 system. For each task, average oxygen consumption was computed as the total oxygen uptake during activity and recovery (EPOC) divided by total time, and relative aerobic load was defined as percentage of first ventilatory threshold (%V̇O2-VT1). Data analysis involved descriptive feasibility assessment and intraclass correlation to examine consistency of relative aerobic load across tasks. FINDINGS: The protocol showed to be feasible and no (serious) adverse events occurred during the study and 5 out of 6 participants were able to complete the protocol, demonstrating its practicality. The EPOC method was successfully applied to both short and longer-duration ADL tasks. The results showed relative aerobic loads exceeding 100% V̇O₂-VT₁ for most ADL tasks, indicating substantial physical effort. Agreement of the rankings of the different tasks between participants was observed (intraclass correlation coefficient (ICC) = 0.73, 95% confidence interval (CI) = 0.01-0.97), although the wide confidence interval indicates considerable uncertainty. CONCLUSION: This protocol enables the assessment of relative aerobic load in a heterogeneous group of individuals with LLA and highlights the importance of individualized assessment. Given the large variability in V̇O₂peak and V̇O₂-VT₁ between participants, a generic level of physiological burden for each task cannot be given, instead individualized assessment is crucial to accurately determine physiological burden and avoid under- or overestimation of exercise intensity. The findings support the development of individualized rehabilitation programs tailored to individual capabilities and limitations, potentially improving participation and quality of life. Additionally, future studies with larger cohorts are needed to provide more robust reliability estimates and strengthen the generalizability of these findings. Layman's Abstract Individuals with a lower limb amputation (LLA) often have lower physical ability and need extra effort to do everyday activities such as walking or climbing stairs. This extra effort can lead to fatigue and affect their independence and quality of life. To improve rehabilitation, it is important to understand how physically demanding these activities are. In this pilot study, six individuals with LLA participated in a new test protocol. At the first assessment session, they completed a fitness test. At the second assessment session, conducted within a two-week interval, they performed five common daily tasks: 1) walking for six minutes, 2) standing up and sitting down, 3) climbing stairs, 4) descending stairs, and 5) completing a functional activity course. During these tasks, they wore a portable device that measured oxygen use, showing how hard their body was working. The study showed that the protocol was safe and practical, and five of the six participants completed all tasks without difficulty. It also showed that a method called EPOC (excess post-exercise oxygen consumption) can measure the effort of short and irregular activities such as those above, which is usually hard to assess. Results revealed that most tasks required very high effort, which could lead to fatigue. Importantly, the effort varied greatly between individuals, highlighting the need for individualized assessments. Understanding these physiological differences can help healthcare professionals design rehabilitation programs tailored to each individual’s abilities. This approach can reduce fatigue, improve independence, and hopefully enhance quality of life for individuals with LLA. Future studies with larger groups are needed to confirm these findings and provide stronger evidence of their reliability. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/46249/34696 How To Cite: van Schaik L, van Kammen K, Huiberts S.W.M, Geertzen J.H.B, Houdijk H, Dekker R. Relative aerobic load of daily activities in individuals with lower limb amputation: A pilot study. Canadian Prosthetics & Orthotics Journal. 2025; Volume 8, Issue 2, No. 8. https://doi.org/10.33137/cpoj.v8i2.46249 Corresponding Author: Loeke van Schaik, PhD Affiliation: University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands. E-Mail: L.van.Schaik@umcg.nl ORCID ID: https://orcid.org/0000-0001-5288-1143
We responded to comments by Brüggenjürgen et al. (https://doi.org/10.33137/cpoj.v8i2.46339) regarding our study on cost-effectiveness of different prosthesis types (https://doi.org/10.33137/cpoj.v8i2.45823). We explained why small effect differences lead to high ICUR values and clarify our costing approach. We emphasized the need for future studies on prosthesis life-cycle, long-term outcomes, and improved quality-of-life measures for more accurate evaluations. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/46486/34608 How To Cite: Bosman C.E, van der Sluis C.K, Vrieling A.H, Geertzen J.H.B, Seves B.L, Groen H. Response to the letter to the editor regarding “Health economic evaluation of microprocessor and non-microprocessor-controlled prosthetic knees". Canadian Prosthetics & Orthotics Journal. 2025; Volume 8, Issue 2, No. 7. https://doi.org/10.33137/cpoj.v8i2.46486 Corresponding Author: Professor Henk Groen, Affiliation: Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. E-Mail: h.groen01@umcg.nl ORCID ID: https://orcid.org/0000-0002-6629-318X
This corrigendum corrects a reference mis-citation in the article "Invisible struggles: Exploring challenges faced by women with amputation in India" (Can Prosthet Orthot J 2024;7(1):5. https://doi.org/10.33137/cpoj.v7i1.44002 CORRIGENDUM INVISIBLE STRUGGLES: EXPLORING CHALLENGES FACED BY WOMEN WITH AMPUTATION IN INDIA In the article mentioned above¹, published in Volume 7, Issue 1, 2024, the authors cited Mishra et al. (2020)² for the following statement: “The 2019 Global Burden of Diseases (GBD) report highlighted that India sees about 23,500 new cases of people with amputation each year, with men making up the majority—around 20,200—while approximately 3,300 are women.” These statistics were incorrectly attributed to the 2019 Global Burden of Diseases (GBD) report and were originally reported in Mohan D (1986).³ These figures do not represent current national statistics. How to cite: Corrigendum: Invisible struggles: Exploring challenges faced by women with amputation in India. Can Prosthet Orthot J. 2025; Volume 8, Issue 2, No. 5. https://doi.org/10.33137/cpoj.v8i2.46384
BACKGROUND: A transfemoral bone-anchored prosthesis (TF-BAP) can be fitted with non-microprocessor-controlled knees (N-MPKs), or with microprocessor-controlled knees, which can be passive (P-MPKs) or active (A-MPKs). The next generation of A-MPKs, including powered knees, is emerging. The understanding of the loading applied on TF-BAP fitted with these A-MPKs is limited. OBJECTIVE: This cross-sectional study aimed to characterize the load applied on instrumented TF-BAP fitted with an A-MPK (Power Knee, Össur, Iceland) during standardized daily activities. Furthermore, some load characteristics applied during walking were compared with TF-BAP fitted with N-MPK and P-MPK reported in the literature using similar approach. METHODOLOGY: Thirteen males fitted with a transfemoral press-fit osseointegrated implant participated in this study between 2021 and 2022. Forces and moments applied on the instrumented TF-BAP, fitted with a Power Knee (PKA01) and Pro-Flex (LP, XC) or Balance S feet (ÖSSUR, Iceland), were measured wirelessly using an iPecsLab (RTC Electronics, USA) during walking, ascending and descending ramp and stairs. We followed a 28-step process to characterize the loading pattern considering spatiotemporal gaits variables as well as loading boundaries and extrema. FINDINGS: Overall, 1,327 steps were analyzed. The cadence ranged between 34 ± 6 and 49 ± 13 strides/min. The maximum forces and moments recorded on the long, anteroposterior and mediolateral axes of the transducer were 1,258 N, 331 N and 234 N as well as 19 Nm, 74 Nm and 91 Nm, respectively. CONCLUSION: The Power Knee, combined with Pro-Flex or Balance S feet, may improve participants’ capacity to ambulate. Comparations with reference values indicated that transitions from N-MPKs or P-MPKs to the Power Knee are considered safe and likely to improve efficiency. This study contributed to evidence-based recommendations of TF-BAP fitted with powered knees. Hopefully, this work will advance clinical practice guidelines for the growing population choosing bionic solutions. Layman's Abstract Advanced prosthetic knees play a key role in achieving rehabilitation success when a bionic limb is attached directly to the remaining bone in people with lower limb loss. The next generation of bionic knees, called powered knees, is emerging. Indeed, they become more frequently prescribed for individuals fitted with implant inserted into their bone. However, more scientific evidence is required to confirm the safety and efficacy of these knees before they can be accepted as the standard of care. Consequently, this study examined the forces applied between a powered knee and the implant in the residual bone, measured directly using a wireless device embedded in the prosthesis. Thirteen individuals with transfemoral amputations participated in the study between 2021 and 2022. The mechanical constraint was directly measured using a wireless device embedded into the prosthesis. The outcomes were benchmark against reference data provided in the literature. The outcomes of this study confirmed that the newly developed component, Power Knee, is both safe and potentially effective in restoring gait for users of bionic limbs. This work also improves standard methods for evaluating how prosthetic components mechanically affect the implant-bone interface in direct skeletal attachment of bionic limbs. Overall, this work will, hopefully, contribute to the development of clinical practice guidelines for the rehabilitation of the growing population choosing bionic solutions. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/45790/34428 How To Cite: Frossard L, Laux S, Geada M, Tronicke L, Fridriksson T, Lechler K. Evidence-based recommendation of a powered knee for transfemoral bone-anchored prostheses: A cross-sectional study. Canadian Prosthetics & Orthotics Journal. 2025; Volume 8, Issue 2, No. 4. Https://doi.org/10.33137/cpoj.v8i2.45790 Corresponding Author: Professor Laurent Frossard, (PhD) Affiliation: 1) YourResearchProject Pty Ltd, Brisbane, Australia; 2) Griffith University, Southport, Australia; 3) Queensland University of Technology, Brisbane, Australia; 4) University of the Sunshine Coast, Sippy Downs, Australia. E-Mail: laurentfrossard@outlook.com ORCID ID: https://orcid.org/0000-0002-0248-9589
BACKGROUND: Use of a microprocessor-controlled knee (MPK) compared to a non-microprocessor-controlled knee (NMPK) can lead to improved walking ability, confidence and satisfaction. However, the MPK is more expensive than the NMPK and it is unknown whether the higher costs outweigh the potential benefits. OBJECTIVE: To evaluate the cost-utility and cost-effectiveness of MPKs and NMPKs from a societal perspective in the Netherlands. METHODOLOGY: Participants completed the Dutch version of the EuroQol - five dimensions - five levels (EQ-5D-5L) to assess health-related quality of life, three subscales (ambulation, utility and well-being) of the Prosthesis Evaluation Questionnaire (PEQ) to assess prosthesis-related quality of life and a cost-questionnaire from societal perspective. Incremental cost-utility ratio (ICUR) and incremental cost-effectiveness ratio (ICER) were calculated and the ICUR was compared with the Dutch willingness-to-pay threshold. Bootstrapping was used to estimate statistical uncertainty, and multiple imputation was applied to account for missing values. FINDINGS: In total, 111 participants were included (37 female, 73 male, 1 unknown; 71 transfemoral, 39 knee disarticulation, 1 unknown; age 64 ± 13 years; 49 NMPK users, 62 MPK users). The cost-utility analysis demonstrated that the MPK yielded an increase of 0.032 quality adjusted life years (QALY) but at considerably higher costs. The mean cost difference was € 14,626, resulting in a mean ICUR of € 457,063 per QALY gained. The cost difference was mainly driven by acquisition costs but was partially compensated by lower costs of work absence, health care consumption and household care. CONCLUSION: The cost-effectiveness analyses demonstrated that the MPK is likely to provide benefits in term of prosthesis-specific quality of life, but at higher costs. However, short-term improvement in health-related quality of life was too small to result in substantial QALY gain to offset the higher costs of the MPK and result in an incremental cost-utility ratio below the generally accepted willingness-to-pay thresholds. Layman's Abstract In this study, we compared two types of prosthetic knees that are used by people with a lower limb amputation. One is a high-tech version that uses a built-in computer sensor to help control movement (called a microprocessor controlled knee or MPK) and the other is a simpler, mechanical version (called a non-microprocessor controlled knee or NMPK). MPKs can help people walk more easily and feel more confident, but have a much higher acquisition cost. We compared the costs and benefits of both types of knees by studying 111 people who were either using an MPK or NMPK in their daily life. They completed surveys about their health, how they felt about their prosthesis, their healthcare use and work. Results showed that the people using an MPK reported better experiences in terms of mobility and satisfaction with their prosthesis. However, while the MPK did also improve quality of life a little bit, the improvement was small compared to how much more it costs. While the MPK helped reduce some other costs like time of work and healthcare use, the overall benefit wasn’t enough to make it cost-effective by current standards in the Netherlands. In conclusion, while the MPK offers some advantages, they may not be enough to justify the higher price, at least not in the short term. More research could help us understand whether the benefits grow over time. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/45823/34424 How To Cite: Bosman C.E, van der Sluis C.K, Vrieling A.H, Geertzen J.H.B, Seves B.L, Groen H. Health economic evaluation of microprocessor and non-microprocessor controlled prosthetic knees. Canadian Prosthetics & Orthotics Journal. 2025; Volume 8, Issue 2, No. 3. https://doi.org/10.33137/cpoj.v8i2.45823 Corresponding Author: Charlotte E. Bosman, PhD Affiliation: Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. E-Mail: c.e.bosman@umcg.nl ORCID ID: https://orcid.org/0000-0001-7950-5893
BACKGROUND: Accurate placement of anatomical markers is essential for valid three-dimensional (3D) gait analysis, yet individuals with lower-limb amputation (LLA) pose unique challenges due to altered anatomy, prosthetic interfaces, and increased adiposity. OBJECTIVE: This study assessed within- and between-session reliability of pelvis marker placement and static posture kinematics in adults with unilateral LLA. METHODOLOGY: Fourteen adults with unilateral LLA (age: 58 ± 15 years, height: 174.6 ± 7.5 cm, body mass: 91.1 ± 27.7 kg, BMI: 29.6 ± 7.5 kg/m²; eleven transtibial, three transfemoral) participated in two sessions spaced 3–13 months apart. Reliability of marker distances and static posture kinematics were assessed using intraclass correlation coefficients (ICC) and standard error of measurement (SEM). FINDINGS: Within-session reliability of pelvis marker distances was good to excellent (ICC ≥ 0.78), whereas between-session reliability was lower (ICC as low as 0.14), particularly for posterior superior iliac spine markers. Pelvis kinematics demonstrated moderate reliability within sessions (average ICC ≈ 0.71), but trunk kinematics showed poor reliability. SEM values were low (<5°), suggesting acceptable absolute consistency despite variable ICCs, likely driven by postural changes and prosthetic factors. CONCLUSION: Findings support reliable pelvis marker placement within sessions but highlight challenges for longitudinal consistency. Multiple trial collections and standardised posture protocols are recommended to improve long-term reliability. Layman's Abstract Accurately placing small reflective markers on the body is very important for correctly measuring how people move during three-dimensional (3D) gait (walking) analysis. However, this can be more difficult in people with lower-limb amputations (LLA) because their anatomy is different, they use artificial limbs, and body shapes can vary. This study looked at how consistently these markers can be placed on the pelvis in adults with unilateral LLA. Fourteen adults participated in two sessions spaced 3–13 months apart. We assessed the consistency of the marker positions comparing them within and between sessions. We found that pelvis marker placement was quite reliable when tested in the same session, but less consistent between sessions, especially for markers placed on the back of the pelvis. The overall body posture and trunk positions also varied more between sessions. Even so, the size of the differences was small, meaning that the results were still fairly reliable to extract information about the motion. Findings support reliable pelvis marker placement within sessions but highlight challenges across longer time periods. Multiple trial collections and standardised posture guidelines are recommended to improve long-term reliability. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/46063/34419 How To Cite: Withey A, Cazzola D, Tabor A, Seminati E. Within- and between-session reliability of pelvic marker placement and posture in lower-limb amputees. Canadian Prosthetics & Orthotics Journal. 2025; Volume 8, Issue 2, No. 2. https://doi.org/10.33137/cpoj.v8i2.46063 Corresponding Author: Alexandra Withey, Affiliation: Affiliation: Department for Health, University of Bath, Bath, UK. E-Mail: anmw20@bath.ac.uk ORCID ID: https://orcid.org/0000-0001-9422-2306
BACKGROUND: Evaluating prosthetic socket fit and function relies on accurately simulating load transfer between the residual limb and the socket. This limb can be either real (of a study participant) or a mock residual limb that simulates in vivo properties. Mock limbs minimize reliance on resource-intensive clinical trials; however, most are static in size, limiting their use in testing clinical outcomes like socket adjustability. OBJECTIVE: To design and validate a biofidelic mock limb, capable of real-time, controllable volume adjustments of up to ±5% limb volume. METHODOLOGY: Water-filled bladders were embedded within a transtibial residual limb model made of a dual-durometer urethane composition, mimicking deep and soft tissue. An Arduino-controlled syringe system was used to actuate volume adjustments. The method was validated through repeatability tests at different rates of volume change, cycling through expansion, holding at maximum volume, and contraction. Volume change was quantified by measuring interfacial pressures between the limb and a static socket. FINDINGS: The limb was fabricated with readily available materials for less than CAD 400. Volume change rate had minimal effect on interfacial pressure throughout the testing cycle, and minimal hysteresis was found between expansion and contraction periods. Repeatability was high, with a coefficient of variation of normalized pressure remaining below 10.4% over three repeated tests. CONCLUSION: The proposed biofidelic limb was validated for its ability to mimic volume change in a transtibial residual limb. The design enables easy replication or customization to simulate different limb physiologies and anatomies. The limb allows for controllable bench-top testing during prototyping of adjustable sockets or other devices, thus bringing devices to clinical use sooner. Layman's Abstract For individuals with a lower-limb amputation, their prosthetic socket—the component that connects their residual limb to the prosthesis—needs to fit well to be comfortable and to function properly. However, the size of a residual limb can change throughout the day due to factors like activity and diet, which can affect the socket fit. Evaluating how prosthetic sockets adapt to residual limb volume changes is important, but doing so through clinical testing with human participants requires extensive resources and involves test conditions that are hard to control. A “mock” residual limb was introduced that simulated real-time, controllable limb volume changes, reducing the need for amputee participants in prosthetic socket testing. The mock limb used water-filled bladders within a soft urethane composition, and the bladder size was controlled by a motorized syringe system, allowing it to expand or contract by up to 5%. The limb’s ability to reliably repeat its volume changes was validated. This tool can help researchers quickly test adjustable prosthetic sockets and other wearable devices in a lab setting, thereby accelerating device development and reducing dependence on clinical testing. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/45759/34271 How To Cite: Phillips C, Nagpal A, Azhari F. A biofidelic mock residual limb for prosthetic socket testing. Canadian Prosthetics & Orthotics Journal. 2025; Volume 8, Issue 2, No. 1. DOI:10.33137/cpoj.v8i1.45759 Corresponding Author: Fae Azhari, PhD Affiliation: Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Canada. E-Mail: fae.azhari@utoronto.ca ORCID ID: https://orcid.org/0000-0003-2559-8566
