OJHAS Vol. 7, Issue 2: (2008
Relation of Stump Length with Various Gait Parameters in Trans-tibial
Koyel Majumdar, Junior Research Fellow, National Institute for
Orthopaedically Handicapped, Kolkata
Lenka PK, Lecturer (P& O), National Institute for
Orthopaedically Handicapped, Kolkata
Mondal RK, JRF co-ordinator, National Institute for
Orthopaedically Handicapped, Kolkata
Kumar R, Director, National Institute for
Orthopaedically Handicapped, Kolkata
Triberwala DN, Director, School of bioscience &Engg.,
Address For Correspondence
Department of Research
National Institute for
(Under Ministry of Social
Justice & Empowerment, Govt. of India),
B-T Road, Bon Hooghly,
Majumdar K, Lenka PK, Mondal RK, Kumar R, Triberwala DN. Relation of Stump Length with Various Gait Parameters in trans-tibial Amputees. Online J Health Allied Scs.
Submitted: Feb 18, 2008; Accepted:
Jul 10, 2008; Published: Jul 21, 2008
The purpose of this paper is evaluating the impact of stump
length of unilateral below knee amputees (BKA) on different gait parameters.
Nine unilateral BKA were chosen and divided into three groups comprising
patients with short, medium, and long stump length. Each of them underwent
gait analysis test by Computer Dynography (CDG) system to measure the
gait parameters. It was found that the ground reaction force is higher
in the patients with medium stump length whereas the velocity, step
length both for the prosthetic and sound limb and cadence were high
in longer stump length. Statistical analysis shows a significant difference
(p<0.05) between the gait parameters of BKA with medium and longer
stump length. The patients with longer stump length were more efficient
than medium and short stump patients as they consumed comparatively
lesser energy while walking with self-selected velocity and conventional
(Solid ankle cushioned heel) SACH foot.
Stump length, Gait analysis, Trans-tibial amputee
depends on good initial healing of the stump that also needs to be of
the correct length and shape. Incorrect
stump length and stumps with excess tissue are significant and can have
a permanent influence on the successful fitting of prosthesis.[1,2] In
most of the studies, gait analysis was used as a tool for prosthesis
design and also for a proper alignment to the prosthetic devices considering
several important gait parameters.[3,4] But very few studies have
focused about a comparison of gait variables and characteristics of
the EMG signal among below-knee amputees with various stump length.
The prosthetic component design, selection, and alignment of amputee’s
prosthesis are all directed towards obtaining optimal gait.
In this way the residual limb anatomy is a strongly considerable factor
in ensuring successful rehabilitation.
A study revealed that in case of an amputation of lower limb, if the
stump has sufficient length, a below-knee amputation has the best gait
efficiency and prosthesis fit. If the stump is too short, a lengthening
procedure may be beneficial. In this study we showed
that there were some differences in gait efficiency-regarding the velocity,
energy consumption, and with different stride parameters in spite of
using a well fitted prosthesis device. With a short trans-tibial amputation,
the energy expenditure level increases by 40%, and by 10% if it is too
In case of below-knee
amputation, it was recommended that at least 8 cm below the tibial plateau
be retained to allow optimal control of the socket and end-bearing.
Physiological cost index
(PCI) is a cardiopulmonary factor as an indicator of energy cost described
by MacGregor, 1981. In this study we investigated and quantified
the difference in the gait parameters, electromyography characteristics
of Vastus Lateralis muscle as well as PCI data among the patients with
different stump length. Joan E. Sanders,  found that interface force
between the socket and stump were highly sensitive to the stump length.
Results from this analysis showed a more efficient gait with patients
of longer stump length than the patients with medium and short stump
Nine traumatic trans-tibial amputees were selected for this study purpose
after scanning thirty six individuals with Transtibial amputation. A
written consent, received from each of the subject, proves their spontaneous
permission. The descriptive data of subjects were shown in Table-I.
The subjects were confident to walk with the prosthesis, without any
additional aid. None of them had any residual limb pain, sores, swelling
and contracture etc. All subjects were fitted with conventional SACH
The gait analysis system,
Ultraflex Infotronic [11-14], was used for data collection.
Pair of foot sensors called CDG (Computer Dynography) shoes was used
to collect force distribution. Disposable surface EMG electrodes were
used to record bilateral quadriceps (Vastus Lateralis) EMG. The foot
sensor and EMG data were digitally acquired at a sampling frequency
of 100 HZ and 1000HZ respectively and stored in portable data logger
unit. The ECG system was used to record Heart Rate. The digitally collected
EMG raw data were processed using MATLAB 7.0.
Gait analysis was performed
with the self selected velocity of the subjects after a short trial
period of free walking. Subjects (nine) were divided into three groups
as per their stump length normalized with their Sound limb height: Group-I
-patients with short stump length (range 18.9%-28.6% of sound limb);
Group-II -patients with medium stump length (range 32.3%-38.3% of sound
limb) and Group-III-patients with long stump length (range 54.2%-64.6%
of sound limb).
Table 1: Group-wise
descriptive data of the subjects
Group -III (long )
Mean ± std
Mean ± std
Mean ± std|
as a % of Sound limb
An index was derived
from the ratio of difference of active heart rate with rest to the velocity.
This index reflects about the gait efficiency of the subject. Although
the other research papers calculated the energy cost by oxygen uptake
methods, the instruments are cumbersome, expensive, and not available
in many clinics. The
statistical analysis was done by the help of statistical analysis software
MS Excel. Analysis of variance (ANOVA) single factor test, paired T-test
were used to analyze the data.
gait parameters were considered in all three groups of stump length
comprising - short, medium and long stump amputees.
Stump length and
Energy index of
the subjects with long stump length was always less then the subjects with short
and medium stump length, after a fixed work done. Walking in self selected
velocity for a fixed time interval was the specific work here. The energy index
decreased with the increment of stump length. A significant difference was found
for this parameter as a result of statistical analysis.
1: relation of Energy index and velocity with
Stump length and velocity:
greater in case of the patients with longer stump length. It increased with
increasing stump length, was supported by the difference in average cadence
among three groups.
Stump length and cadence:
among cadence of three different groups was calculated that shows a significant
difference with p<0.025. Cadence of the subjects was increased normally with
increasing stump length.
2: Relation between velocity, cadence and stride length with stump length.
Stump length and step length:
Stump length as % of sound limb height
||Stride length (meter)|
In a complete
gait cycle, the distance from one heel contact to opposite heel contact is the
step length. During normal gait, equal right and left step lengths are taken.
Considering different stump length, a significant difference in step length
between sound and prosthetic limb was observed in case of short and medium stump
length. The graph showed that Difference in step length between normal and
prosthetic limb is shorter in case of patients with long stump length.
Group-III-with long stump length had a significantly shorter sound limb step
length; however group-II, comprising of patients with medium stump length had a
significantly greater sound limb step length. But the statistical analysis shows
that there is no significant difference in the step length of three different
Stump length and step length relationship
length and Ground Reaction Force (GRF):
forces at each instance of the stance phase were calculated as the percentage
of body weight for normalization while walking at self selected speed
with conventional SACH foot. GRF graph proved this fact that a greater
peak vertical force in short stump length group
was appeared in 80% than 20% of gait cycle. GRF pattern of long stump length
patients showed a more similar ‘M’ shape curve with little bit greater impulse
in push-off phase. This indicated a more energy storing gait in long stump
3: GRF in different stump length for prosthetic limb
Stump length and Stride
correlation was observed between Group-II and Group-III. Relatively the stride
duration correlation coefficient between these two groups was 0.4483 (p<0.02).
The P-value for stride duration within three groups was p<0.03 which indicated a
significant difference among three groups.
EMG and stump length:
Normally over ground, the mean EMG peak of Vastus
Lateralis (VL) activity at natural speed was in early stance. A second
peak occurred in late swing in preparation for initial contact.
The data normalization was carried out by adopting the maximum mean
value of each subject’s EMG over the stride period as the reference
value (100%). Each stride was divided into 10% interval and average
peak amplitude of ten strides for each subject was given a value 100%
as adopted by Knutsson and Richards. Each sub phase (10% of Gait Cycle) was expressed
as a percentage of mean peak amplitude. The average value of amplitude
expressed in percentage of Maximum Gait Contraction (MGC) was calculated
for each 10% of gait cycle. The EMG pattern of the subjects of the
all three groups had peaks in the 0 to 30% region of the gait cycle.
These EMG patterns are almost similar in both legs. The only difference was the
amplitudes higher in normal limb.
4: Vastus lateralis EMG of the sound limb and amputee limb
A previous study had
discussed that the successful rehabilitation of the amputee on a prosthetic
limb depends on stump quality. Thus, this study had only been confined
to observe the impact of stump length on different gait parameters and EMG.
result showed that the energy index reduced with the increasing the
stump length, agrees with MERTENS P et al, 2001 and other works.[6,15-19]
The ideal mechanical advantage for a lever, like all other Simple
machines is the length of effort arm divided by the length of resistance
arm. According to this predicted theory below-knee amputees with longer
stump length, where knee joint act as the fulcrum, have a resistance
limb length longer than the effort limb length which cooperates to get
a greater leverage arc. The greater leverage arc results a long step
length. Where in case of short stump length patients the mechanical
advantage is limited because of the shortening of resistance limb length. It is obvious that a longer stump allows a better cantilever function
in lifting the prosthesis, requiring less energy.
Whereas velocity increased linearly with the increase in length of the
stump. This indicated the more degree of motion with longer stump.
Cadence of the individual
group had a significant difference (p<0.025) and it increased with
the increase in stump length. Similarly, stride length, step length
also increased with the stump length augmentation whereas stride duration
Regarding Ground reaction
force (GRF), it had been noted that during the heel strike more force
were generated with longer stump length. It was observed that the heel
strike force increased with the increase in stump length. Whereas, during
the period of the Toe-off, on an average same force were generated.
Here, the EMG study showed the same pattern in both the sound and prostheses
limb, only mean amplitude increased with the increase in the stump length
for the initial peak and decreased at the second peak. Initial peak
indicated early phase of the stance. Strong muscle contraction occurred
during early stance phase as stump length increased. The second peak
during late swing depicted the preparation of next initial contact.
Study showed that there were weak contractions during the above phase,
indicated towards less energy consumption for longer stump length.
From our present study
we could able to conclude that, in case of a below-knee amputation,
gait parameters have a direct relationship with the stump length of
the amputees. The amputee with a longer stump length (54.2%-64.6% of
the sound limb length) performed more efficient gait in terms of less
energy consumption, more velocity and more cadence respective to the
shorter stump length patients. Moreover, in case of below-knee amputation,
a longer amputation stump allows the use of a patella-tendon-bearing
suction prosthesis instead of a thigh-bearing prosthesis, providing
better skin protection and a more efficient gait. Along with other
parameters, stump length is one of the considerable parameter in gait
efficiency and prosthesis fitting in case of trans-tibial amputee. Longer
the stump length productive will be the prosthesis efficiency.
We are thankful to National
Institute for the Orthopaedically Handicapped, Ministry of Social Justice
& Empowerment, Govt. of India and Jadavpur University, for supporting
this experimental study.
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