Upper extremity amputations significantly impact an individual's physical capabilities, psychosocial well-being, and overall quality of life. The level at which an amputation is performed influences residual limb function, prosthetic compatibility, and long-term patient satisfaction. While surgical guidelines traditionally emphasize maximal limb preservation, prosthetists often advocate for amputation sites that optimize prosthetic fit and function, highlighting the need for a collaborative approach. This review examines the discrepancies between surgical and prosthetic recommendations for optimal amputation levels, from digit amputations to shoulder disarticulations, and explores their implications for prosthetic design, functionality, and patient outcomes. Various prosthetic options, including passive functional, body-powered, myoelectric, and hybrid devices, offer distinct advantages and limitations based on the level of amputation. Prosthetists emphasize the importance of residual limb length, not only for mechanical efficiency but also for achieving symmetry with the contralateral limb, minimizing discomfort, and enhancing control. Additionally, emerging technologies such as targeted muscle reinnervation (TMR) and advanced myoelectric prostheses are reshaping rehabilitation strategies, further underscoring the need for precise amputation planning. By integrating insights from both surgical and prosthetic perspectives, this review highlights the necessity of a multidisciplinary approach involving surgeons, prosthetists, rehabilitation specialists, and patients in the decision-making process. A greater emphasis on preoperative planning and interprofessional collaboration can improve prosthetic outcomes, reduce device rejection rates, and ultimately enhance the functional independence and well-being of individuals with upper extremity amputations.

Postoperative Psychiatric Outcomes After Upper-Extremity Amputations.

Malignant peripheral nerve sheath tumor (MPNST) is an infrequent type of sarcoma in dogs, representing a small portion of sarcomas in this species. Considering the rare occurrence of this tumor, combined with the challenges in establishing a definitive diagnosis, this study aimed to discuss the clinical, macroscopic, and microscopic aspects of this neoplasm in a dog through a case report. The patient exhibited lameness in the right thoracic limb and intense pain, even with continuous administration of analgesics and anti-inflammatory drugs. Computed tomography revealed an amorphous and heterogeneous structure in the right axillary region. Surgical excision and intraoperative biopsy were performed, confirming sarcoma. Due to the malignancy and invasiveness of the tumor, which was interwoven within the brachial plexus, shoulder disarticulation was performed. Macroscopically, the tumor was irregular, firm, and whitish/grayish. Histopathological examination suggested MPNST, characterized by a poorly defined neoplasm arranged in bundles, with epithelioid to elongated cells, pleomorphism, mitosis, and necrosis. Postoperatively, the patient continued to experience intense pain and proprioceptive deficits in the pelvic limbs. A follow-up computed tomography scan revealed a heterogeneous structure invading the neural foramen of the first thoracic vertebra and rib resorption. Given the poor prognosis, the owner opted for euthanasia. Despite its infrequent occurrence, MPNST should be included in the differential diagnosis of orthopedic and neurological conditions in dogs due to the importance of early diagnosis and surgical intervention in improving the quality of life.

Accurate and reliable digital twins of humans and wearable robots can revolutionize rehabilitation robotics. Here, we introduce MyoAssist 0.1, a sub-suite of MyoSuite focused on musculoskeletal simulation environments with assistive devices such as prosthetics and exoskeletons. This open-source platform enables the study and development of human-device interactions, control strategies, and assistive robotics. We present two new simulation environments: myoMPL featuring an arm amputee model with a robotic prosthetic arm, and myoOSL featuring a leg amputee model with a robotic prosthetic leg. The myoMPL environment features a bimanual manipulation task for a shoulder disarticulation amputee using a Modular Prosthetic Limb (MPL), where the task is to pick up an object with the biological hand, pass it to the prosthetic hand, and place it at a target location. The myoOSL environment simulates an above-knee amputee using the Open-Source Leg (OSL) to traverse challenging terrains such as rough surfaces, hills, and stairs. Despite some simplifications in modeling the nuanced constraints of human and prosthetic systems under real-world conditions, these environments provide a foundational simulation framework that supports interdisciplinary research on the interplay between musculoskeletal dynamics and assistive devices. Both myoMPL and myoOSL are featured in MyoChallenge, an annual competition at the NeurIPS conference. All code is accessible through the MyoSuite GitHub repository.

Background: Proximal amputations of major limbs due to malignant tumors have become rare, but they are still a valuable treatment option for palliation and, in some cases, can even be curative. The aim of this case report was to analyze the outcome of interscapular-thoracic amputation in an elderly patient. Case Report: Male patient, 85 years old, BMI of 1.77 kg/m², ASA III, with systemic arterial hypertension using losartan 50 mg daily. Smoker and history of deep vein thrombosis. History of hand ulcers, evolving to ulceration and bleeding. Squamous cell carcinoma biopsy. Indicated thoracic interscapular amputation (TIA) under regional associated with multimodal general anesthesia. Interscalene and serratus anterior block with ropivacaine 0.5% and use of US. Postoperative period in the ward without pain. Evolved during the three days without pain complaints. Conclusion: TIA in an 85-year-old patient, as a primary or palliative procedure, may be justified after a careful holistic evaluation of the case. Interscalene brachial plexus block associated with the serratus anterior plane with 0.5% ropivacaine and complemented with multimodal general anesthesia allowed shoulder disarticulation with adequate safety for the patient and comfort for the surgical team, excellent postoperative analgesia and no complications.

Introduction: Major limb amputations are among the most disabling surgical procedures currently performed. In particular, proximal limb amputations (PLAs) impose enormous functional and social challenges on patients and their families, as they leave minimal options for functional prostheses, especially in the low-resource settings. The authors report on the indications of a series of patients who underwent PLAs at a resource-limited hospital. Methods: Data from the hospital medical records and histopathology database of patients who underwent PLAs (forequarter, hindquarter amputations, or hip or shoulder disarticulations) at a hospital in a middle income country in the sub-Saharan African region over a 14-year period was retrospectively evaluated to determine the indications for surgical procedures and early outcomes. This article did not aim to assess the specific outcomes in this cohort, due to limited data. Results: A total 48 PLAs (nine forequarter amputations, five hemipelvectomies, and one shoulder and 18 hip disarticulations) were performed in 44 patients. The 27 males and 17 females had a mean age of 41 years. The most common indication was malignancy (63.6%) and the second most common was infection (16.8%). Conclusion: We assessed the indications for PLAs at our site, with the most common indication being malignancy. In addition to a lack of preventative screening for malignancy and effective infectious disease control, limited disability optimization and support in this community (ex . reliable prostheses) likely decrease surgical effectiveness. Therefore, PLA-associated risks in this cohort highlight the importance of early oncologic detection, infectious disease control, and chronic disease management in low-resource settings, where robust surgical outcome data are often unavailable.

The integration of artificial intelligence (AI) models in the classification of electromyographic (EMG) signals represents a significant advancement in the design of control systems for prostheses. This study explores the development of a portable system that classifies the electrical activity of three shoulder muscles in real time for actuator control, marking a milestone in the autonomy of prosthetic devices. Utilizing low-power microcontrollers, the system ensures continuous EMG signal recording, enhancing user mobility. Focusing on a case study-a 42-year-old man with left shoulder disarticulation-EMG activity was recorded over two days using a specifically designed electronic board. Data processing was performed using the Edge Impulse platform, renowned for its effectiveness in implementing AI on edge devices. The first day was dedicated to a training session with 150 repetitions spread across 30 trials and three different movements. Based on these data, the second day tested the AI model's ability to classify EMG signals in new movement executions in real time. The results demonstrate the potential of portable AI-based systems for prosthetic control, offering accurate and swift EMG signal classification that enhances prosthetic user functionality and experience. This study not only underscores the feasibility of real-time EMG signal classification but also paves the way for future research on practical applications and improvements in the quality of life for prosthetic users.

As a prosthesis made to compensate for the residual loss of the amputee’s limb, the shoulder disarticulation upper limb prosthesis replaces the missing arm function of the shoulder amputee to a certain extent. However, the current upper limb prosthesis mainly interacts with the outside world through the prosthetic hand for grasping and gripping, and the interaction between other parts and the environment is often neglected, which is not in line with the use habits of the human arm. To address this problem, this paper proposes a reinforcement learning–based method for controlling the forearm interaction of a shoulder-disconnected upper limb prosthesis, and analyzes and solves the forces during the interaction, reducing the impact of uncertainty on interaction actions and accelerating training while ensuring the stability of handheld items. We evaluated the performance of the control method during the interaction between the upper limb prosthesis and the external environment through simulation experiments. After the training, the bionic arm was able to push the object into the target range for different objects and pushing distance requirements, which showed the good control effect of the method. Also, the control method can be applied to improve the interaction between the robotic arm and the environment.

Shoulder disarticulation following of animal bites is not uncommon and is often performed for various indications, including vascular insufficiency. General anaesthesia is usually the preferred choice in optimized patients, with or without regional anaesthesia. Phantom limb pain is a distressing and frequently encountered condition following limb amputation. In addition to their well-established benefits, nerve blocks not only provide effective perioperative analgesia but may also reduce the incidence of phantom limb pain. In this case, we undertook shoulder disarticulation exclusively under regional anaesthesia, as the patient’s respiratory condition was not optimal for general anaesthesia. Keywords: Shoulder disarticulation, Regional anaesthesia, Subclavian perivascular block, Superficial cervical plexus block, Pectoserratus plane block.

Combined interscalene brachial plexus block and superficial cervical plexus block for shoulder disarticulation surgery in a terminal cancer patient.

Background: High-tension electrical burns are rare but devastating injuries with high mortality usually from overwhelming sepsis, poor cardiovascular support and multiple organ dysfunction syndrome. However, survivors of such burns have varying degrees of injuries with significant morbidity especially after radical amputation to save their lives. The objective of this case report was to present this rare scenario and highlight the importance of prompt intervention and acute surgical management that improves survival. Case Report: This was a descriptive case report of a 23-year-old male, a survivor of high-tension electrical burns (11,000 volts) to both upper limbs. He was immediately admitted into the intensive care unit with ventilatory support and multi-disciplinary approach to care. He had some investigations which included daily full blood count, serum electrolytes, urea and creatinine, clotting studies, blood sugar, urine analysis, lactate level, iron and creatine kinase studies, chest X-rays, electrocardiogram and abdominopelvic scan. He had multiple blood products transfusion; antibiotic therapy, staged surgeries including bilateral shoulder disarticulation to control sepsis and preserve life. He was discharged home with healed disarticulated shoulders and satisfactory clinical condition after 35 days on admission. Conclusion: Early resuscitation, cardiovascular support in the intensive care unit, urgent wound debridement and amputation of devitalized limb were life-saving interventions. These prompt care improved his survival chances following high -tension electrical burns.

Background: High-tension electrical burns are rare but devastating injuries with high mortality usually from overwhelming sepsis, poor cardiovascular support and multiple organ dysfunction syndrome. However, survivors of such burns have varying degrees of injuries with significant morbidity especially after radical amputation to save their lives. The objective of this case report was to present this rare scenario and highlight the importance of prompt intervention and acute surgical management that improves survival. Case Report: This was a descriptive case report of a 23-year-old male, a survivor of high-tension electrical burns (11,000 volts) to both upper limbs. He was immediately admitted into the intensive care unit with ventilatory support and multi-disciplinary approach to care. He had some investigations which included daily full blood count, serum electrolytes, urea and creatinine, clotting studies, blood sugar, urine analysis, lactate level, iron and creatine kinase studies, chest X-rays, electrocardiogram and abdominopelvic scan. He had multiple blood products transfusion; antibiotic therapy, staged surgeries including bilateral shoulder disarticulation to control sepsis and preserve life. He was discharged home with healed disarticulated shoulders and satisfactory clinical condition after 35 days on admission. Conclusion: Early resuscitation, cardiovascular support in the intensive care unit, urgent wound debridement and amputation of devitalized limb were life-saving interventions. These prompt care improved his survival chances following high -tension electrical burns.

Combined interscalene, superficial cervical plexus and thoracic intertransverse process blocks for surgical anaesthesia of the shoulder disarticulation.

Severe hand injuries resulting from accidents can lead to the traumatic loss of an upper limb. The provision of an assistive device, such as an arm prosthesis, can help patients regain their courage and motivation to engage with the public. This project aimed to integrate 3D scanning and printing technology to develop a customized passive arm prosthesis for individuals who have experienced shoulder disarticulation due to a traumatic accident. The fabrication of the arm prosthesis was specifically designed and tailored to meet each patient’s unique needs and preferences. The prosthesis design was created based on 3D scan files obtained from the patients. Finite element analysis was employed to analyze the design and determine the optimal materials to use, as well as to optimize the overall design. The finalized model was then converted into STL file format and G-code for the 3D printing process. To ensure ease of use, the entire arm prosthesis and a harness system were assembled, and multiple tests and fittings were conducted on the patient. Several prototypes of the arm prosthesis were fabricated to achieve the best fit for each individual patient.

BackgroundDespite the growing availability of multifunctional prosthetic hands, users’ control and overall functional abilities with these hands remain limited. The combination of pattern recognition control and targeted muscle reinnervation (TMR) surgery, an innovative technique where amputated nerves are transferred to reinnervate new muscle targets in the residual limb, has been used to improve prosthesis control of individuals with more proximal upper limb amputations (i.e., shoulder disarticulation and transhumeral amputation).ObjectiveThe goal of this study was to determine if prosthesis hand grasp control improves following transradial TMR surgery.MethodsEight participants were trained to use a multi-articulating hand prosthesis under myoelectric pattern recognition control. All participated in home usage trials pre- and post-TMR surgery. Upper limb outcome measures were collected following each home trial.ResultsThree outcome measures (Southampton Hand Assessment Procedure, Jebsen-Taylor Hand Function Test, and Box and Blocks Test) improved 9–12 months post-TMR surgery compared with pre-surgery measures. The Assessment of Capacity for Myoelectric Control and Activities Measure for Upper Limb Amputees outcome measures had no difference pre- and post-surgery. An offline electromyography analysis showed a decrease in grip classification error post-TMR surgery compared to pre-TMR surgery. Additionally, a majority of subjects noted qualitative improvements in their residual limb and phantom limb sensations post-TMR.ConclusionsThe potential for TMR surgery to result in more repeatable muscle contractions, possibly due to the reduction in pain levels and/or changes to phantom limb sensations, may increase functional use of many of the clinically available dexterous prosthetic hands.

Pan-plexus injuries with persistent pain and flail upper limbs present a bifocal nuisance to patients and pose serious treatment challenges to orthopaedic surgeons. Limb salvage procedures could be cumbersome, expensive, and mostly with poor functional outcomes. The timing and extent of ablation are key predictors of outcome and will depend on the available local expertise and clinical evidence. We present a 42-year farmer who walked into the clinic requesting limb ablation. We also discuss our treatment outcome in light of the available Literature. Shoulder disarticulation with excision of a neuroma can effectively reduce pain from a painful flail limb and improve the quality of life.

On optimal and varying decompositions for transradial contraction force prediction in upper-limb prosthesis

Pan-plexus injuries with persistent pain and flail upper limb present bifocal nuisance to patients and pose serious treatment challenges to orthopaedic surgeons. Limb salvage procedures could be cumbersome, expensive and mostly with poor functional outcomes. The timing and extent of ablation are key predictors to outcome and will depend on the available local expertise and clinical evidence. We present a 42year farmer who walked into the clinic requesting for limb ablation. We also discuss our treatment outcome in light of available literature.

Upper limb loss results in significant physical and psychological impairment and is a major financial burden for both patients and healthcare services. Current myoelectric prostheses rely on electromyographic (EMG) signals captured using surface electrodes placed directly over antagonistic muscles in the residual stump to drive a single degree of freedom in the prosthetic limb (e.g., hand open and close). In the absence of the appropriate muscle groups, patients rely on activation of biceps/triceps muscles alone (together with a mode switch) to control all degrees of freedom of the prosthesis. This is a non-physiological method of control since it is non-intuitive and contributes poorly to daily function. This leads to the high rate of prosthetic abandonment. Targeted muscle reinnervation (TMR) reroutes the ends of nerves in the amputation stump to nerves innervating “spare” muscles in the amputation stump or chest wall. These then become proxies for the missing muscles in the amputated limb. TMR has revolutionised prosthetic control, especially for high-level amputees (e.g., after shoulder disarticulation), resulting in more intuitive, fluid control of the prosthesis. TMR can also reduce the intensity of symptoms such as neuroma and phantom limb pain. Regenerative peripheral nerve interface (RPNI) is another technique for increasing the number of control signals without the limitations of finding suitable target muscles imposed by TMR. This involves wrapping a block of muscle around the free nerve ending, providing the regenerating axons with a target organ for reinnervation. These RPNIs act as signal amplifiers of the previously severed nerves and their EMG signals can be used to control prosthetic limbs. RPNI can also reduce neuroma and phantom limb pain. In this review article, we discuss the surgical technique of TMR and RPNI and present outcomes from our experience with TMR.

Soft tissue sarcomas are a diverse group of rare malignant tumours, mostly occurring in the lower extremities. Amputations are necessary for achieving local control when the soft tissue sarcomas are too large and/or have neurovascular involvement. Patients who require amputation have a poorer prognosis than those who undergo limb-salvage surgery. We investigated the tumour characteristics and the clinical outcomes in 55 patients with primary soft tissue sarcomas, who underwent amputation. We excluded patients with amputation performed distal to the wrist or ankle joints and those with recurrent soft tissue sarcomas. The mean tumour size was 11.1cm. Hip disarticulation was performed in 6 patients, 20 underwent above the knee amputation, 8 underwent knee disarticulation and 12 underwent below the knee amputation. Shoulder disarticulation was performed in three patients, five underwent above the elbow amputation, and one underwent below the elbow amputation. The 5-year disease-specific survival rate was 52.8%. The 5-year recurrence-free survival rate and 5-year metastasis-free survival rates were 90.1% and 38.5%, respectively. Larger tumour size, age and the distant metastases at first presentation were predictors of poor prognosis for survival in multivariate analysis. Twenty-eight patients could walk using artificial limbs. The level of amputation (above versus below the knee) showed a significant difference in achieving independent gait. Amputation is a useful treatment option for achieving local control in patients with large soft tissue sarcomas. Patients had an opportunity of walking, especially for those who underwent below the knee amputation.