Winning the arms race: optimizing upper extremity amputations and advancements in prosthetic technology: erratum.

Significant advances in upper extremity prosthetic care and technology over the last decade have provided clinicians and their patients increased options for treatment and the potential for greater overall functionality. There has been unprecedented focus to the care, research, and technology of the upper extremity amputee in a relative short period of time. Service members injured in OIF/OEF receiving care for complicated upper extremity amputations have intensified the efforts to improve socket design, interfaces, suspension, and myoelectric function with multiple degrees of freedom as surgical advancement that optimize the intuitive function of the higher level upper extremity amputee. Academic and Government based research groups such as RIC under Dr. Todd Kuiken as well as DARPA and others have generated great interest in the area of surgical advancements coupled with advanced technology. These advanced technologies and unique surgical interventions are intended to provide patients with more intuitive function with myoelectric prostheses along with various advancing technologies of elbow, wrist and shoulder systems. Pattern grasp recognition using and array emg systems for more consistent operation of these advanced robotic technologies is one example that was directly generated from these efforts (Kuiken, Targeted muscle reinnervation a neural interface for artificial limbs, 2014; Dhillon, IEEE Trans Neural Syst Rehabil Eng 13:468–72, 2005). The increased availability of terminal devices with increased functional grasp patterns and conforming grips have provided patients options for more natural functionality of the myoelectric prosthesis for all levels. With all of these advancing technologies the understanding of optimized upper extremity amputee patient care is more important than ever before. Prior to utilization of these advanced technologies each respective clinician involved in the process must have a firm grasp of the protocols for a well-developed upper extremity plan of care for any patient. A well-educated and experienced clinical understanding for this particular patient group is vital to future success of the patient. Appropriate incorporation of optimized prosthetic design, patient education with a comprehensive team approach coupled these advanced technologies can prove challenging and require a well-designed and intentional method of patient care.

Since the beginning of documented medical history, amputation procedures, limb loss, and the myriad creative solutions attempted to care for these individuals have been reported. With the coalescence of multiple World Wars resulting in an ever-increasing number of individuals with limb loss and advancing medical technology, a need to innovate in this field has always been present. The complexity of the hand and upper extremity in self-care, communication, vocation, and exercise results in more demands of prostheses to mimic or replace these functions as opposed to the lower extremity, which is focused mostly on weight bearing and ambulation. As such, this need has pushed technological advances past the simpler passive or body-powered prostheses alone, now with externally powered and hybrid devices revolutionizing the way these appliances were implemented in everyday life. Despite the ever-advancing field of prosthetic technology, upper and lower extremity amputees alike still battle common challenges of pain, phantom limb sensation, and lack of prosthetic control and sensation. Targeted muscle reinnervation and regenerative peripheral nerve interface offer new surgical solutions to some of these challenges and are proving invaluable. As technology and surgical options continue to advance at an ever-rapid pace, a more thoughtful and individualized approach to the care of upper extremity limb loss is available. In this study, we review the history and evolution of upper extremity prostheses and discuss considerations in making optimal surgical and prosthetic decisions for upper extremity amputees.

The increasing number of individuals with limb loss worldwide highlights the need for advancements in prosthetic knee technology. To improve control and quality of life, integrating brain-computer communication with motor imagery offers a promising solution. This study introduces a hybrid system that combines electromyography (EMG) and functional near-infrared spectroscopy (fNIRS) to address these limitations and enhance the control of knee movements for individuals with above-knee amputations. The study involved an experiment with nine healthy male participants, consisting of two sessions: real execution and imagined execution using motor imagery. The OpenBCI Cyton board collected EMG signals corresponding to the desired movements, while fNIRS monitored brain activity in the prefrontal and motor cortices. The analysis of the simultaneous measurement of the muscular and hemodynamic responses demonstrated that combining these data sources significantly improved the classification accuracy compared to using each dataset alone. The results showed that integrating both the EMG and fNIRS data consistently achieved a higher classification accuracy. More specifically, the Support Vector Machine performed the best during the motor imagery tasks, with an average accuracy of 49.61%, while the Linear Discriminant Analysis excelled in the real execution tasks, achieving an average accuracy of 89.67%. This research validates the feasibility of using a hybrid approach with EMG and fNIRS to enable prosthetic knee control through motor imagery, representing a significant advancement potential in prosthetic technology.

A review of technology, materials and R&D challenges of upper limb prosthesis for improved user suitability

Targeted muscle reinnervation in upper extremity amputation in military hand surgery: A systematic review

In the mid-1990s, a number of key publications and meetings of experts identified major technical issues associated with prosthetic technologies intended for developing countries. These included inadequate durability of prosthetic feet, poor socket quality and prosthetic fit, improper alignment of prostheses, and inferior function of components. To examine the progress that has been made since then in addressing these issues, a comprehensive review of literature was performed. In total, 106 articles were selected and included in the review. The review examined prosthetic technologies categorized into feet and ankles, knees, sockets and suspension, and materials, structures, and alignment methods. Moreover, publications were categorized as technical development, clinical (lab-based) testing, or clinical field testing studies. The results reveal important work that has been carried out to develop and implement standardized outcome measures during field testing, allowing various existing prosthetic technologies to be evaluated in terms of their use, function, durability, and other factors. Progress has also been made toward addressing the aforementioned limitations of prosthetic technologies, however, more research and development is required. This includes improving the durability of the external cosmetic features of prosthetic feet, developing more functional prosthetic knee joints, and simplifying fabrication techniques to further improve outcomes associated with socket fit and prosthetic alignment. Research and development collaborations between developed and developing countries, and the dissemination of ongoing research, development, and evaluation activities are essential to the advancement of prosthetic technologies in these regions.

Technological advances from Industry 1.0 to 4.0, have exercised an increasing influence on prosthetic technology and practices. This paper explores the historical development of the sector within the greater context of industrial revolution. Over the course of the first and up the midpoint of the second industrial revolutions, Industry 1.0 and 2.0, the production and provision of prosthetic devices was an ad hoc process performed by a range of craftspeople. Historical events and technological innovation in the mid-part of Industry 2.0 created an inflection point resulting in the emergence of prosthetists who concentrated solely on hand crafting and fitting artificial limbs as a professional specialty. The third industrial revolution, Industry 3.0, began transforming prosthetic devices themselves. Static or body powered devices began to incorporate digital technology and myoelectric control options and hand carved wood sockets transitioned to laminated designs. Industry 4.0 continued digital advancements and augmenting them with data bases which to which machine learning (M/L) could be applied. This made it possible to use modeling software to better design various elements of prosthetic componentry in conjunction with new materials, additive manufacturing processes and mass customization capabilities. Digitization also began supporting clinical practices, allowing the development of clinical evaluation tools which were becoming a necessity as those paying for devices began requiring objective evidence that the prosthetic technology being paid for was clinically and functionally appropriate and cost effective. Two additional disruptive dynamics emerged. The first was the use of social media tools, allowing amputees to connect directly with engineers and tech developers and become participants in the prosthetic design process. The second was innovation in medical treatments, from diabetes treatments having the potential to reduce the number of lower limb amputations to Osseointegration techniques, which allow for the direct attachment of a prosthesis to a bone anchored implant. Both have the potential to impact prosthetic clinical and business models. Questions remains as to how current prosthetic clinical practitioners will respond and adapt as Industry 4.0 as it continues to shape the sector.

BACKGROUND: The design, provision, and assessment of prosthetic arm technologies and related services are all dependent on an understanding of how prosthetic arms are used in everyday life. This research examines the scientific literature on prosthetic arm technologies and approaches that have been used to evaluate upper limb prosthetic arms in daily life use. OBJECTIVE: The purpose of this review paper is to give an outline of current literature, which covers the selection, design, and choices of prosthetic arm technologies. METHODS: A structural search for the available technologies on the prosthetic arm was carried out. A research database search was carried out in PubMed, Web of Science, Scopus, Crossref, Google Scholar, and questionnaires were evaluated based on available prosthetic arm technologies, material, methodology, comfortability. RESULTS: From the proposed review, it is concluded that not all prosthetic technologies suit the patients because of the difference in injuries. Every prosthetic arm technology has its advantages and limitations depending on end-user requirements and comfortability. Based on the available literature, it is observed that amputees have been given equal importance to comfortability along with functionality. Consequently, amputees may opt for a prosthetic arm technology that is easy to use and comfortable rather than an advanced technology-based prosthetic arm but less with comfortability. CONCLUSION: An attempt has been made for extensive reviews for the various types of prosthetic systems, materials, usability, methodologies, comfortability, etc. Comparative studies on various types of available prosthetic arm technologies have been also carried out with pros and cons. More specifically, the proposed paper provides a significant review of the upper limb prosthetic arm’s current developments and their impacts.

INTRODUCTION For more than 150 years, the Department of Veterans Affairs (VA) has held the care provided to Veterans with limb amputations as a high priority. To many Americans, the Veteran with an amputation epitomizes the sacrifices made on our nation's behalf. The VA is dedicated to providing optimal care for these individuals in order to restore function and improve quality of life. This commitment has been reaffirmed over time through the passage of key legislation such as the Veterans Medical Programs Amendments of 1992 and the Veterans Health Care Eligibility Act of 1996 [1]. The life-changing effect of amputation on Veterans has also been acknowledged through the VA's long-standing commitment to amputation prevention programs [2]. In 2008, after years of planning and preparation, VA approved and began implementing the Amputation System of Care (ASoC) in order to enhance the quality and consistency of care provided to the Veteran with limb loss. In 2010, Dr. Sigford described this paradigm shift in VA amputation care and the implementation plan for the ASoC [3]. The driving force behind this program was the need to provide lifelong care for servicemembers with combat-related amputations from the military conflicts in Iraq and Afghanistan and for Veterans with amputations from diseases such as diabetes and peripheral vascular disease. The system is designed to provide the latest practices in medical care, prosthetic technology, and rehabilitation management in order to assist individuals with amputations in reaching their highest level of functional independence. In this article, we highlight the accomplishments and outcomes of the ASoC in the domains of program scope, organizational structure, clinical services, and additional performance metrics 5 yr after initial program implementation. PROGRAM SCOPE, ORGANIZATIONAL STRUCTURE, AND EVOLUTION The ASoC is an integrated, national healthcare delivery system. It provides patient-centered, gender-sensitive, age-appropriate, life-long, holistic care and care coordination for Veterans with limb amputations. Through the provision of quality rehabilitation and prosthetic care, the ASoC minimizes disability and enables the highest level of social, vocational, and recreational reintegration. The ASoC provides specialized expertise in amputation care through incorporating the latest practices in medical rehabilitation, therapy services, and prosthetic technology. This specialized expertise is provided in an interdisciplinary format lead by physician medical directors. Amputation rehabilitation coordinators assure coordination of services and provider communication both across the continuum of care and across facilities. These factors, along with specialized education and training, have enhanced the environment of care and created greater consistency in the delivery of rehabilitation services for Veterans with amputations. Achieving these goals provides the VA the opportunity to fulfill its vision to be a world leader in providing lifelong amputation care. The ASoC operates in close collaboration with the Department of Defense (DOD) amputation care programs. While the VA system of care has many features similar to the DOD amputation care programs, it also differs in several ways. Both the VA and DOD amputation care programs use a team approach to care and focus on individual treatment goals, can provide any prosthetic device that is commercially available, and are involved in collaborative research involving new prosthetic technology and treatment advances. The two systems differ in that the DOD specialized amputation care is focused primarily at three Advanced Rehabilitation Centers, whereas the VA system is more diffuse, using a tiered approach with services spread across 133 medical facilities. The DOD amputation care programs are focused primarily on providing initial prosthetic fitting and acute rehabilitation, whereas the VA system places a greater emphasis on lifelong care and care management. …

Advanced Upper Limb Prosthetic Devices: Implications for Upper Limb Prosthetic Rehabilitation

In order to obtain the desired outcomes, nanotechnology employs approaches to control shape, size, and texture of elements in the necessary nano scale. It was previously used primarily in the areas of substance chemical productions and physics; however this has changed through the advancement of new technologies. Over time, biological scientists became aware of its numerous benefits and investigated them in their respective fields. To assess current knowledge about nanocomposites and their applications in prosthetic dental technology. On this topic, an electronic systematic review was conducted in various databases (Google Scholar research, Science Direct reports, PubMed studies, and Web of Science data), as well as a hand search of the scientific literature. From 2014 to 2022, published work was collected, analysed, and relevant articles were chosen for inclusion in this review. Nanocomposites and their applications in prosthetic dental technology have been reported in several studies. More than 36 papers were chosen for this review based on their applicability. The findings suggest that current knowledge was adequate to recommend nanocomposites and their applications in prosthetic dental technology for routine laboratory use, with improvements in each of the current nano materials and procedures for prosthetic dental technology. Because of their physical and chemical properties, polymer nanocomposites were suitable for prosthetic restorations; however, careful processing methods, nano materials, laboratory skill, and a strict protocol for prosthetic restoration are required to improve the mechanical and physical properties.

Performing or completing an amputation creates an interesting paradox – primum non nocere through the removal of a major extremity. It seems contradictory to believe this simultaneously amazing and horrific process is for a patient’s medical benefit. Likewise, public encounters with amputees can be indelibly striking to the uninitiated – the person’s loss is both visible and palpable, the natural question being, “What happened?” While less than 20% of the nearly 200,000 amputations performed annually in the United States are done to treat the sequelae of trauma, posttraumatic amputees account for nearly half of all surviving amputees [14]. The reason for this discrepancy is that, sadly, amputations performed to treat the skeletal complications of vascular disease, diabetes, and cancer tend to occur late in the patients’ lives. By contrast, amputations for trauma generally are performed in younger, more-active patients, with nearly 1,000,000 posttraumatic amputees in the United States alone. Consequently, the surgical care, rehabilitation, and prosthetic care of this important patient population remains a critical public health issue. Trauma-related amputee care provides a unique opportunity to restore function to generally younger, active individuals with excellent premorbid status, high expectations, and long life expectancies. According to the Department of Defense Amputee database, the recent wars in Iraq and Afghanistan have produced more than 1600 wounded warriors who have sustained the loss of more than 2200 limbs. These numbers are remarkably similar to those observed in World War I and Korea, but dwarfed by World War II and the US Civil War at nearly 15,000 and 50,000 amputees, respectively [1, 3, 4, 8]. Despite ubiquitous personal body armor, rapid aeromedical evacuation, and the far forward movement of advanced medical resources resulting in greater survival of increasingly devastating injuries (including a majority of injury burden to the extremities), amputations continue to represent a minority of major battlefield injuries [7]. Even so, these patients represent an important minority. Unfortunately, amputation surgery is often viewed as a simple procedure with predictable outcomes, and therefore, frequently relegated to junior trainees. Amputations are further maligned as ablative treatment failures – less “sexy” than advanced, complex, and often novel limb salvage techniques. In reality, the procedures are anything but simple, the techniques nuanced and fraught with complications. Furthermore, amputation as a reconstructive procedure can often improve patient function and outcomes, and may be actively requested by some patients [10] – this is simply treatment, not failure. Most importantly, if functional and psychosocial outcomes following amputation are predictable, they are predictably poor for many patients [2, 5]. There is hope. As this symposium demonstrates, advances in amputation surgery, prosthetic technologies, and rehabilitation continue at an impressive pace. Despite the somewhat storied and lengthy history of both amputation surgery and prosthetics – many common procedures and prostheses utilized today are veritable antiques – the related fields are anything but stagnant. Indeed, recent years have seen the advancement and refinement of osseointegration technologies for direct skeletal attachment of prostheses, with promising results found in Europe [11, 13]. Targeted muscle reinnervation (TMR) techniques can now improve intuitive terminal device control, while also potentially decreasing neuroma-associated and/or phantom pain as suggested by two papers in this symposium [6, 9]. Advanced pattern recognition, myoelectric signal interpretation, and transformation systems are complementary technologies which yield greater output from TMR, as well as some nonTMR patients via two small chips. These chips are compatible with most commercially available myoelectric upper extremity prostheses. Translational research continues on other advanced techniques of terminal device control, including implantable myoelectric sensors, direct neural or cortical interfaces, and numerous haptic feedback technologies. More than 20 years have passed since the release of the first microprocessor knee, but recent prosthetic developments include powered lower extremity prostheses and newer prosthetic hands, wrists, and fingers with additional functions and degrees of freedom. Lower extremity myoelectric prostheses also are on the near horizon. In the meantime, functional outcome and gait studies remain important to maximize the results of rehabilitation, and to demonstrate objectively the benefit of recent surgical and prosthetic advancements. Lastly, vascularized composite tissue allotransplantation (such as the hand transplant) has become a reality. Although debate and concerns regarding patient selection, outcome quantification, immunosuppression and immunomodulation regimen optimization, and secondary health effects remain [12], proof-of-concept success has been achieved via impressive functional outcomes from patients at multiple investigational sites. Surgical, rehabilitative, and prosthetic technologies appear to be catching up with the functional potential of motivated amputees. There has never been a more exciting time to contribute to the care of these challenging and rewarding patients. If recent history is any indicator, we can look forward to many exciting advances in all fields related to amputation surgery and amputee care in the months and years to come.

Currently 2.1 million people in the United States live with limb loss, with 185,000 amputations occurring every year. Amputation numbers are expected to rise with increasing age, diabetes, and vascular disease in our population. Advancements in surgical techniques and prosthetic technology have created the potential for amputees to live active and productive lives. Connecting new amputees with peer support resourses has been shown to improve rehabilitation outcomes. Resources from the Amputee Coalition include the National Limb Loss Resource Center, the Certified Peer Visitor program, a support group network, publications, and advocacy programs. Insurance companies have increased limits on appropriate access to advanced surgical techniques and prosthetic technology. Data on the care of amputation has become dated with additional research needed on incidence, prevention, standards for rehabilitation, and outcomes for surgery and prosthetic devices. Advocacy efforts have been successful in passing laws mandating insurance coverage for prosthetic care in 21 states with a need for additional advocacy on state and federal levels. Team based care and collaboration across disciplines is key to successful outcomes for both individual patient care and for advocacy in our health care system.

Limb amputation is a growing health concern worldwide, driven largely by the rising incidence of vascular and metabolic diseases and military conflicts. In the past two decades, remarkable advancements in surgical techniques, prosthetic technologies, and rehabilitation strategies have made a profound impact on outcomes for individuals with limb loss. In this article, we explore the evolving landscape of limb care in the United States, highlighting innovations in prosthetic technology and amputation surgery including osseointegration, neuromuscular surgeries and interfaces, artificial intelligence, sensory feedback, and the importance of prosthetic embodiment. We discuss limb care systems and the continuum of limb loss rehabilitation, focusing on the need for coordinated models of patient-centered care. We present the demographic biases and healthcare disparities related to insurance coverage and reimbursement in the United States and the explore ethics and equitability considerations pertaining to prosthetic standard of care and advanced treatments for limb loss. Finally, we lay out the systemic reform, policy advocacy, and future research needed to ensure that everyone with limb loss has equitable access to the benefits of modern amputee care.

Against the backdrop of increasing subspecialization in medicine, the Chinese Journal of Reparative and Reconstructive Surgery has established itself as a crucial academic platform for clinical and basic research involving multidisciplinary integration, focusing on the interdisciplinary field of reparative and reconstructive surgery. The year 2026 will mark the 40th anniversary of the journal's founding. This article reviews its developmental trajectory and discusses the definition of limb reconstruction, the evolution of relevant academic societies, advancements in prosthetic technology, and the concept of extreme reconstruction. In its narrow sense, limb reconstruction addresses defects, infections, and deformities, while broadly, it encompasses comprehensive treatment requiring multidisciplinary collaboration. The evolution of international academic societies from the Association for the Study and Application of Methods of Ilizarov (ASAMI) to International Limb Lengthening and Reconstruction Society (ILLRS) reflects both divergence and convergence in technical philosophies, with Chinese scholars playing a proactive role in this process. Advances in prosthetic technology, particularly in intelligent bionic prostheses and osseointegrated mechanoneural prostheses, have raised the standards for the precision of amputation surgeries and stump reconstruction, thereby fostering the development of the "maximum limb reconstruction" philosophy. This philosophy emphasizes a coherent three-stage approach (early, intermediate, and late) that integrates microsurgery, Ilizarov techniques, infection control, and soft tissue repair to achieve optimal restoration of structure, function, and morphology. By concentrating on multidisciplinary integration, the Chinese Journal of Reparative and Reconstructive Surgery has contributed significantly to the development of a limb reconstruction system with Chinese characteristics and is poised to continue leading progress in technological integration and academic innovation within this field.