Clinical Evidence Finder – Lower Limb Prosthetics

• Improved gait performance
  • Faster self-selected walking speed¹
  • Smoother centre-of-pressure progression¹
• Keel and ankle designed for Activities of Daily Living
  • Easier sit-to-stand²

• Mean 34% reduction in stance phase timing asymmetry³
• Maximum 86% reduction in stance phase timing asymmetry³
• More symmetrical inter-limb loading¹

• Patient reported outcome measures indicate improvements
  • Mean improvement across all Prosthesis Evaluation Questionnaire domains⁴

• Shorter keel allows for more consistent rollover radius of curvature, regardless of changing footwear⁵
• The most energy efficient radius of curvature for a rollover shape has been identified as 30% of the walker’s leg length. For a person of a typical adult height between 1.5m and 1.8m, this equates to approximately 245-290mm. The Avalon keel design has a rollover shape of ~250mm⁵.

• Improved gait performance
  • Faster self-selected walking speed¹
  • Smoother centre-of-pressure progression¹
• Keel and ankle designed for Activities of Daily Living
  • Easier sit-to-stand²

• Mean 34% reduction in stance phase timing asymmetry³
• Maximum 86% reduction in stance phase timing asymmetry³
• More symmetrical inter-limb loading¹

• Patient reported outcome measures indicate improvements
  • Mean improvement across all Prosthesis Evaluation Questionnaire domains⁴

• Fewer falls and less chance of multiple falls
  • No trans-tibial EVS users reported multiple falls, while 75% of the non-EVS users did⁵
• Better balance in functional clinical tests
  • Significant improvements in the Berg Balance Scale (BBS), the Four Square Step Test (FSST) and the Timed-Up-and-Go (TUG) test⁶
• Better balance reported in patient-reported outcome measures
  • Improvements in the Activity Balance Confidence (ABC) scale questionnaire⁷

• Fewer gait compensations^8-10
• Knee contact forces not significantly different to those of able-bodied controls¹¹

• Decreased pistoning
  • Reductions of over 69% and 83%, compared to suction^10,12 and pin-lock¹³ suspensions, respectively, with other researchers and practitioners reporting similar observations^7,8,14,15
• Maintain residual limb volume
  • Suction suspension = mean 6.5% loss in volume; EVS = mean 3.7% increase in volume (N.B. it is possible that the increase may have been due to the fact that these individuals attended the clinic wearing their regular prostheses before using the EVS system).¹⁰
  • Other studies have since confirmed the observation that residuum volume loss is prevented by EVS^8,16-19

• Healthier residual limb tissue and skin
  • Higher trans-cutaneous oxygen measurement after activity²⁰
  • Decreased trans-epidermal water loss after activity²⁰
  • Decreased attenuated reactive hyperemia²⁰
• Reduced interface pressures
  • Pressures reduced by a mean of 4% compared to suction suspension²¹
  • Pressure impulses reduced by a mean of 7.5% compared to suction suspension²¹
• Improved wound management
  • Continued prosthesis use while the wounds healed^22-24
  • Wounds heal more quickly with EVS than other suspension methods²⁵
• Less painful than other suspension methods
  • Expert opinion⁸ and clinical case studies²⁶ agree that EVS is less painful and more comfortable than other suspension methods.
  • Improved Socket Comfort Score compared to other suspension methods⁵

• Patients are more satisfied wearing their prosthesis^{5,7,8,15,23,26-28}

• Shorter keel allows for more consistent rollover radius of curvature, regardless of changing footwear²⁹
• The most energy efficient radius of curvature for a rollover shape has been identified as 30% of the walker’s leg length. For a person of a typical adult height between 1.5m and 1.8m, this equates to approximately 245-290mm. The Avalon keel design has a rollover shape of ~250mm²⁹.

Vacuum levels generated:

When sensory control of the lower limb joints is lost, it is essential that the replacement behaves predictably. Consistency of performance is vital in providing prosthetic confidence. In terms of socket suspension method, this means providing the same good connection throughout a gait cycle, from one step to the next, and day-to-day, over the lifetime of the socket.

The difference between the vacuum levels generated by suction suspension, and that generated when using EVS, can be demonstrated by using a negative pressure gauge³⁰. Figure 1 illustrates these measurements. Commonly, when the user bears weight on their prosthesis during stance phase, with suction suspension, the magnitude of the vacuum is low. When the leg is lifted into swing phase, the vacuum increases in magnitude, holding the socket to the residual limb. Comparatively, EVS retains a high level during stance phase – higher, in fact, than the peak swing phase vacuum with suction. Additionally, the difference between stance and swing phase is less pronounced, so that the vacuum level is more consistent throughout the gait cycle. For the amputee illustrated in the graph³⁰, EVS gave an approximate 85% increase in peak vacuum magnitude and an approximate 67% reduction in the ‘amplitude’ of the vacuum measurement signal.

Figure 1: Negative pressure within the socket when walking using a one-way valve suction suspension (grey) and an elevated vacuum (EV) suspension. N.B. Data recorded with Echelon Vac system.

The difference in vacuum generated by the AvalonVAC, compared to that generated by the Echelon Vac, is shown in Figure 2. Despite differences in the method used (keel vs springs, different socket, different pressure gauge), when the same patient was asked to walk at ‘K2 walking speed’ (~2km/h, short steps), the trend of vacuum level to number of steps taken was comparable to when measured at ‘K3 walking speed’ (4-5km/h) with Echelon Vac.

Figure 2: Comparison of the EchelonVAC and AvalonVAC vacuum generation by number of steps (regardless of walking speed).

• High mean radius of curvature for Esprit-style e-carbon feet²: “The larger the radius of curvature, the more stable is the foot”

• Allow variable running speeds³
• Increased self-selected walking speed⁴
• Elite-style e-carbon feet (L code VL5987) or VT units demonstrate the second highest mobility levels, behind only microprocessor feet⁵

• Users demonstrate confidence in prosthetic loading during high activity⁶
• Improved prosthetic push-off work compared to SACH feet⁷
• Increased prosthetic positive work done⁴

• High degree of user satisfaction, particularly with high activity users⁸

• Increased mean prosthetic minimum toe clearance^2,4, reducing the likelihood of tripping.
• Fully satisfies stance phase stability³

• Acceptable cosmetics for knee disarticulation amputees and trans-femoral amputees with long residua¹
• Meets all the design requirements for paediatric patients³

There are two published literature reviews that discuss different aspects of lower limb prosthetic liner technology^1,2.

• The main purpose of prosthetic liners is to cushion the transfer of loads from the prosthetic socket to the residual limb¹.
• Based on load-displacement data from the compressive stiffness tests, silicone was one of three materials that were recommended for situations where it is desirable for the liner to maintain thickness and volume since these materials had the least non-recovered strain^1,3.
• Under cyclic compressive loading, silicone was one of two materials that had the greatest cycles to failure under compressive loading, while the Pedilin and polyurethane samples lasted orders of magnitude less^1,4.
• Prosthetic liners and sockets are highly resistive to heat conduction and could be a major contributor to elevated skin temperatures^1,5.
• There are reduced residual limb pressures with the silicone liner compared to other conditions (no liner; soft inserts) suggesting that silicone has an ability to distribute pressure evenly to the residual limb^1,6.
• In terms of patient outcomes, there was no clear preference between silicone and Pelite liners^1,7.

• Reduced risk of tripping and falls
  • Increased minimum toe clearance during swing phase^1,2
• Improving standing balance on a slope
  • 24-25% reduction in mean inter-limb centre-of-pressure root mean square (COP RMS)³

• Reduced energy expenditure during walking
  • Mean 11.8% reduction in energy use on level ground, across all walking speeds⁴
  • Mean 20.2% reduction in energy use on slopes, across all gradients⁴
  • Mean 8.3% faster walking speed for the same amount of effort⁴

• Improved gait performance
  • Faster self-selected walking speed^2,5-7
  • Higher PLUS-M scores than FlexFoot and FlexWalk style feet⁸
• Improved ground compliance when walking on slopes
  • Increased plantarflexion peak during level walking, fast level walking and cambered walking⁹
  • Increased dorsiflexion peak during level walking, fast level walking and cambered walking⁹
• Less of a prosthetic “dead spot” during gait
  • Reduced aggregate negative COP displacement⁵
  • Centre-of-pressure passes anterior to the shank statistically significantly earlier in stance⁵
  • Increased minimum instantaneous COM velocity during prosthetic-limb single support phase⁵
  • Reduced peak negative COP velocity⁷
  • Reduced COP posterior travel distance⁷
• Improved ground compliance when walking on slopes
  • Increased plantarflexion range during slope descent¹⁰
  • Increased dorsiflexion range during slope ascent¹⁰

• Helps protect vulnerable residual limb tissue, reducing likelihood of damage
  • Reduced peak stresses on residual limb¹¹
  • Reduced stress RMS on residual limb¹¹
  • Reduced loading rates on residual limb¹¹

• Greater contribution of prosthetic limb to support during walking
  • Increased residual knee negative work⁶
• Reduced reliance on sound limb for support during walking
  • Reduced intact limb peak hip flexion moment⁶
  • Reduced intact limb peak dorsiflexion moment⁶
  • Reduced intact ankle negative work and total work⁶
  • Reduced intact limb total joint work⁶
• Better symmetry of loading between prosthetic and sound limbs during standing on a slope
  • Degree of asymmetry closer to zero for 5/5 amputees³
• Reduced residual and sound joint moments during standing of a slope
  • Significant reductions in both prosthetic and sound support moments¹²
• Less pressure on the sole of the contralateral foot
  • Peak plantar-pressure¹³
• Improved gait symmetry
  • Reduced stance phase timing asymmetry¹⁴

• Patient reported outcome measures indicate improvements
  • Mean improvement across all Prosthesis Evaluation Questionnaire domains¹⁵
  • Bilateral patients showed highest mean improvement in satisfaction¹⁵
• Subjective user preference for hydraulic ankle
  • 13/13 participants preferred hydraulic ankle¹³

• Reduced risk of tripping and falls
  • Increased minimum toe clearance during swing phase^1,2
• Improving standing balance on a slope
  • 24-25% reduction in mean inter-limb centre-of-pressure root mean square (COP RMS)³

• Reduced energy expenditure during walking
  • Mean 11.8% reduction in energy use on level ground, across all walking speeds⁴
  • Mean 20.2% reduction in energy use on slopes, across all gradients⁴
  • Mean 8.3% faster walking speed for the same amount of effort⁴

• Improved gait performance
  • Faster self-selected walking speed^2,5-7
  • Higher PLUS-M scores than FlexFoot and FlexWalk style feet⁸
• Improved ground compliance when walking on slopes
  • Increased plantarflexion peak during level walking, fast level walking and cambered walking⁹
  • Increased dorsiflexion peak during level walking, fast level walking and cambered walking⁹
• Less of a prosthetic “dead spot” during gait
  • Reduced aggregate negative COP displacement⁵
  • Centre-of-pressure passes anterior to the shank statistically significantly earlier in stance⁵
  • Increased minimum instantaneous COM velocity during prosthetic-limb single support phase⁵
  • Reduced peak negative COP velocity⁷
  • Reduced COP posterior travel distance⁷
• Improved ground compliance when walking on slopes
  • Increased plantarflexion range during slope descent¹⁰
  • Increased dorsiflexion range during slope ascent¹⁰

• Helps protect vulnerable residual limb tissue, reducing likelihood of damage
  • Reduced peak stresses on residual limb¹¹
  • Reduced stress RMS on residual limb¹¹
  • Reduced loading rates on residual limb¹¹

• Greater contribution of prosthetic limb to support during walking
  • Increased residual knee negative work⁶
• Reduced reliance on sound limb for support during walking
  • Reduced intact limb peak hip flexion moment⁶
  • Reduced intact limb peak dorsiflexion moment⁶
  • Reduced intact ankle negative work and total work⁶
  • Reduced intact limb total joint work⁶
• Better symmetry of loading between prosthetic and sound limbs during standing on a slope
  • Degree of asymmetry closer to zero for 5/5 amputees³
• Reduced residual and sound joint moments during standing of a slope
  • Significant reductions in both prosthetic and sound support moments¹²
• Less pressure on the sole of the contralateral foot
  • Peak plantar-pressure¹³
• Improved gait symmetry
  • Reduced stance phase timing asymmetry¹⁴

• Patient reported outcome measures indicate improvements
  • Mean improvement across all Prosthesis Evaluation Questionnaire domains¹⁵
  • Bilateral patients showed highest mean improvement in satisfaction¹⁵
• Subjective user preference for hydraulic ankle
  • 13/13 participants preferred hydraulic ankle¹³

• Fewer falls and less chance of multiple falls
  • No trans-tibial EVS users reported multiple falls, while 75% of the non-EV users did¹⁶
• Better balance in functional clinical tests
  • Significant improvements in the Berg Balance Scale (BBS), the Four Square Step Test (FSST) and the Timed-Up-and-Go (TUG) test¹⁷
• Better balance reported in patient-reported outcome measures
  • Improvements in the Activity Balance Confidence (ABC) scale questionnaire¹⁸

• Fewer gait compensations^19-21
• Knee contact forces not significantly different to those of able-bodied controls²²

• Decreased pistoning
  • Reductions of over 69% and 83%, compared to suction^21,23 and pin-lock²⁴ suspensions, respectively, with other researchers and practitioners reporting similar observations^18,19,25,26
• Maintain residual limb volume
  • Suction suspension = mean 6.5% loss in volume; EVS = mean 3.7% increase in volume (N.B. it is possible that the increase may have been due to the fact that these individuals attended the clinic wearing their regular prostheses before using the EVS system)²¹
  • Other studies have since confirmed the observation that residuum volume loss is prevented by EVS^19,27-30

• Healthier residual limb tissue and skin
  • Higher trans-cutaneous oxygen measurement after activity³¹
  • Decreased trans-epidermal water loss after activity³¹
  • Decreased attenuated reactive hyperemia³¹
• Reduced interface pressures
  • Pressures reduced by a mean of 4% compared to suction suspension³²
  • Pressure impulses reduced by a mean of 7.5% compared to suction suspension³²
• Improved wound management
  • Continued prosthesis use while the wounds healed^33-35
  • Wounds heal more quickly with EVS than other suspension methods³⁶
• Less painful than other suspension methods
  • Expert opinion¹⁹ and clinical case studies³⁷ agree that EVS is less painful and more comfortable than other suspension methods.
  • Improved Socket Comfort Score compared to other suspension methods³⁸

• Patients are more satisfied wearing their prosthesis^{18,19,26,34,37-38}.

Vacuum levels generated:

When sensory control of the lower limb joints is lost, it is essential that the replacement behaves predictably. Consistency of performance is vital in providing prosthetic confidence. In terms of socket suspension method, this means providing the same good connection throughout a gait cycle, from one step to the next, and day-to-day, over the lifetime of the socket.

The difference between the vacuum levels generated by suction suspension, and that generated when using EVS, can be demonstrated by using a negative pressure gauge³⁰. Figure 1 illustrates these measurements. Commonly, when the user bears weight on their prosthesis during stance phase, with suction suspension, the magnitude of the vacuum is low. When the leg is lifted into swing phase, the vacuum increases in magnitude, holding the socket to the residual limb. Comparatively, EVS retains a high level during stance phase – higher, in fact, than the peak swing phase vacuum with suction. Additionally, the difference between stance and swing phase is less pronounced, so that the vacuum level is more consistent throughout the gait cycle. For the amputee illustrated in the graph³⁰, EVS gave an approximate 85% increase in peak vacuum magnitude and an approximate 67% reduction in the ‘amplitude’ of the vacuum measurement signal.

Figure 1: Negative pressure within the socket when walking using a one-way valve suction suspension (grey) and an elevated vacuum (EV) suspension. N.B. Data recorded with Echelon Vac system.

The difference in vacuum generated by the AvalonVAC, compared to that generated by the Echelon Vac, is shown in Figure 2. Despite differences in the method used (keel vs springs, different socket, different pressure gauge), when the same patient was asked to walk at ‘K2 walking speed’ (~2km/h, short steps), the trend of vacuum level to number of steps taken was comparable to when measured at ‘K3 walking speed’ (4-5km/h) with Echelon Vac.

Figure 2: Comparison of the EchelonVAC and AvalonVAC vacuum generation by number of steps (regardless of walking speed).

• Reduced risk of tripping and falls
  • Increased minimum toe clearance during swing phase^1,2
• Improving standing balance on a slope
  • 24-25% reduction in mean inter-limb centre-of-pressure root mean square (COP RMS)³

• Reduced energy expenditure during walking
  • Mean 11.8% reduction in energy use on level ground, across all walking speeds⁴
  • Mean 20.2% reduction in energy use on slopes, across all gradients⁴
  • Mean 8.3% faster walking speed for the same amount of effort⁴

• Improved gait performance
  • Faster self-selected walking speed^2,5-7
  • Higher PLUS-M scores than FlexFoot and FlexWalk style feet⁸
• Improved ground compliance when walking on slopes
  • Increased plantarflexion peak during level walking, fast level walking and cambered walking⁹
  • Increased dorsiflexion peak during level walking, fast level walking and cambered walking⁹
• Less of a prosthetic “dead spot” during gait
  • Reduced aggregate negative COP displacement⁵
  • Centre-of-pressure passes anterior to the shank statistically significantly earlier in stance⁵
  • Increased minimum instantaneous COM velocity during prosthetic-limb single support phase⁵
  • Reduced peak negative COP velocity⁷
  • Reduced COP posterior travel distance⁷
• Improved ground compliance when walking on slopes
  • Increased plantarflexion range during slope descent¹⁰
  • Increased dorsiflexion range during slope ascent¹⁰

• Helps protect vulnerable residual limb tissue, reducing likelihood of damage
  • Reduced peak stresses on residual limb¹¹
  • Reduced stress RMS on residual limb¹¹
  • Reduced loading rates on residual limb¹¹

• Greater contribution of prosthetic limb to support during walking
  • Increased residual knee negative work⁶
• Reduced reliance on sound limb for support during walking
  • Reduced intact limb peak hip flexion moment⁶
  • Reduced intact limb peak dorsiflexion moment⁶
  • Reduced intact ankle negative work and total work⁶
  • Reduced intact limb total joint work⁶
• Better symmetry of loading between prosthetic and sound limbs during standing on a slope
  • Degree of asymmetry closer to zero for 5/5 amputees³
• Reduced residual and sound joint moments during standing of a slope
  • Significant reductions in both prosthetic and sound support moments¹²
• Less pressure on the sole of the contralateral foot
  • Peak plantar-pressure¹³
• Improved gait symmetry
  • Reduced stance phase timing asymmetry¹⁴

• Patient reported outcome measures indicate improvements
  • Mean improvement across all Prosthesis Evaluation Questionnaire domains¹⁵
  • Bilateral patients showed highest mean improvement in satisfaction¹⁵
• Subjective user preference for hydraulic ankle
  • 13/13 participants preferred hydraulic ankle¹³

Reduced back pain during twisting movements e.g. golf swings¹⁶

• Reduced compensatory knee flexion at loading response¹⁷
• No reduction in step activity¹⁸
• Blatchford torsion adaptors match the able-bodied rotational range¹⁹

• Reduced loading rate on prosthetic limb²⁰, particularly at fast walking speeds²¹
• Users feel less pressure on their residual limb²²

• Patient preference, citing improved comfort, smoothness of gait and easier stairs descent²⁰

• Reduced risk of tripping and falls
  • Increased minimum toe clearance during swing phase^1,2
• Improved knee stability on the prosthetic side during slope descent
  • Increased mid-stance external prosthetic knee extensor moment³
• Improving standing balance on a slope
  • 24-25% reduction in mean inter-limb centre-of-pressure root mean square (COP RMS)⁴

• Reduced energy expenditure during walking
  • Mean 11.8% reduction in energy use on level ground, across all walking speeds⁵
  • Mean 20.2% reduction in energy use on slopes, across all gradients⁵
  • Mean 8.3% faster walking speed for the same amount of effort⁵

• Improved gait performance
  • Faster self-selected walking speed^2,6-9
• Improved ground compliance when walking on slopes
  • Increased plantarflexion peak during level walking, fast level walking and cambered walking¹⁰
  • Increased dorsiflexion peak during level walking, fast level walking and cambered walking¹⁰
• Less of a prosthetic “dead spot” during gait
  • Reduced aggregate negative COP displacement⁷
  • Centre-of-pressure passes anterior to the shank statistically significantly earlier in stance⁷
  • Increased minimum instantaneous COM velocity during prosthetic-limb single support phase⁷
  • Reduced peak negative COP velocity⁹
  • Reduced COP posterior travel distance⁹
• Improved ground compliance when walking on slopes
  • Increased plantarflexion range during slope descent³
  • Increased dorsiflexion range during slope ascent³
• Less effort on residual hip for trans-femoral amputees on varied terrains
  • Reduced the mean hip extension and flexion moments¹¹
• Effects consistent over time
  • Same gait variable changes in two gait lab sessions one year apart⁶
  • Magnitude of changes comparable between sessions⁶
• Brake mode during slope descent to control momentum build up
  • Reduced mean prosthetic shank angular velocity in single support¹²
  • Increased Unified Deformable Segment (prosthetic ‘ankle’) negative work¹²
• Less gait compensation movements during slope descent
  • Reduced residual knee flexion at loading response¹²

• Helps protect vulnerable residual limb tissue, reducing likelihood of damage
  • Reduced peak stresses on residual limb¹³
  • Reduced stress RMS on residual limb¹³
  • Reduced loading rates on residual limb¹³

• Greater contribution of prosthetic limb to support during walking
  • Increased residual knee peak extension moment⁶
  • Decreased residual knee peak flexion moment⁶
  • Increased residual knee negative work⁸
• Reduced reliance on sound limb for support during walking
  • Reduced intact limb peak hip flexion moment⁸
  • Reduced intact limb peak dorsiflexion moment⁸
  • Reduced intact ankle negative work and total work⁸
  • Reduced intact limb total joint work⁸
• Better symmetry of loading between prosthetic and sound limbs during standing on a slope
  • Degree of asymmetry closer to zero for 5/5 amputees⁴
• Reduced residual and sound joint moments during standing of a slope
  • Significant reductions in both prosthetic and sound support moments¹⁴
• Reduced residual joint moments during standing of a slope for bilateral amputees
  • Significant reductions in prosthetic support moment¹⁴
  • Permitted ‘natural’ ground reaction vector sagittal plane position, relative to knee joint centres¹⁴
• Less pressure on the sole of the contralateral foot
  • Peak plantar-pressure¹⁵
• Improved gait symmetry
  • Reduced stance phase timing asymmetry¹⁶

• Patient reported outcome measures indicate improvements
  • Mean improvement across all Prosthesis Evaluation Questionnaire domains¹⁷
  • Bilateral patients showed highest mean improvement in satisfaction¹⁷
• Subjective user preference for hydraulic ankle
  • 13/13 participants preferred hydraulic ankle¹⁵

• Improved knee stability on the prosthetic side during slope descent
  • Increased mid-stance external prosthetic knee extensor moment³

• Improved ground compliance when walking down slopes
  • Reduced time to foot flat¹²
• Brake mode during slope descent increases resistance to dorsiflexion to control momentum build up
  • Reduced dorsiflexion range during slope descent³
  • Reduced mean prosthetic shank angular velocity in single support¹²
  • Increased Unified Deformable Segment (prosthetic ‘ankle’) negative work¹²
  • Transition from dorsiflexion to plantarflexion moment occurs earlier in stance phase¹⁸
  • Increase in mean prosthetic ‘ankle’ plantarflexion moment integral¹⁸
• Assist mode during slope ascent decreases resistance to dorsiflexion to allow easier progression
  • Transition from dorsiflexion to plantarflexion moment occurs later in stance phase¹⁸
  • Decrease in mean prosthetic ‘ankle’ plantarflexion moment integral¹⁸
• Less gait compensation movements during slope descent
  • Reduced residual knee flexion at loading response¹²

• Greater reliance on prosthetic side for bodyweight support during slope descent
  • Increased support moment integral¹⁸
• Less reliance on sound side for bodyweight support during slope descent
  • Decreased support moment integral¹⁸
• Less reliance on sound side for bodyweight support during slope ascent
  • Decreased support moment integral¹⁸
• Reduced sound joint moments during standing of a slope
  • Significant reductions in sound support moment¹⁴
• Reduced residual joint moments during standing of a slope for bilateral amputees
  • Significant reductions in prosthetic support moment¹⁴
  • Permitted ‘natural’ ground reaction vector sagittal plane position, relative to knee joint centres¹⁴

• Reduced risk of tripping and falls
  • Increased minimum toe clearance during swing phase^1,2
• Improved knee stability on the prosthetic side during slope descent
  • Increased mid-stance external prosthetic knee extensor moment³
• Improving standing balance on a slope
  • 24-25% reduction in mean inter-limb centre-of-pressure root mean square (COP RMS)⁴

• Reduced energy expenditure during walking
  • Mean 11.8% reduction in energy use on level ground, across all walking speeds⁵
  • Mean 20.2% reduction in energy use on slopes, across all gradients⁵
  • Mean 8.3% faster walking speed for the same amount of effort⁵

• Improved gait performance
  • Faster self-selected walking speed^2,6-9
• Improved ground compliance when walking on slopes
  • Increased plantarflexion peak during level walking, fast level walking and cambered walking¹⁰
  • Increased dorsiflexion peak during level walking, fast level walking and cambered walking¹⁰
• Less of a prosthetic “dead spot” during gait
  • Reduced aggregate negative COP displacement⁷
  • Centre-of-pressure passes anterior to the shank statistically significantly earlier in stance⁷
  • Increased minimum instantaneous COM velocity during prosthetic-limb single support phase⁷
  • Reduced peak negative COP velocity⁹
  • Reduced COP posterior travel distance⁹
• Improved ground compliance when walking on slopes
  • Increased plantarflexion range during slope descent³
  • Increased dorsiflexion range during slope ascent³
• Less effort on residual hip for trans-femoral amputees on varied terrains
  • Reduced the mean hip extension and flexion moments¹¹
• Effects consistent over time
  • Same gait variable changes in two gait lab sessions one year apart⁶
  • Magnitude of changes comparable between sessions⁶
• Brake mode during slope descent to control momentum build up
  • Reduced mean prosthetic shank angular velocity in single support¹²
  • Increased Unified Deformable Segment (prosthetic ‘ankle’) negative work¹²
• Less gait compensation movements during slope descent
  • Reduced residual knee flexion at loading response¹²

• Helps protect vulnerable residual limb tissue, reducing likelihood of damage
  • Reduced peak stresses on residual limb¹³
  • Reduced stress RMS on residual limb¹³
  • Reduced loading rates on residual limb¹³

• Greater contribution of prosthetic limb to support during walking
  • Increased residual knee peak extension moment⁶
  • Decreased residual knee peak flexion moment⁶
  • Increased residual knee negative work⁸
• Reduced reliance on sound limb for support during walking
  • Reduced intact limb peak hip flexion moment⁸
  • Reduced intact limb peak dorsiflexion moment⁸
  • Reduced intact ankle negative work and total work⁸
  • Reduced intact limb total joint work⁸
• Better symmetry of loading between prosthetic and sound limbs during standing on a slope
  • Degree of asymmetry closer to zero for 5/5 amputees⁴
• Reduced residual and sound joint moments during standing of a slope
  • Significant reductions in both prosthetic and sound support moments¹⁴
• Reduced residual joint moments during standing of a slope for bilateral amputees
  • Significant reductions in prosthetic support moment¹⁴
  • Permitted ‘natural’ ground reaction vector sagittal plane position, relative to knee joint centres¹⁴
• Less pressure on the sole of the contralateral foot
  • Peak plantar-pressure¹⁵
• Improved gait symmetry
  • Reduced stance phase timing asymmetry¹⁶

• Patient reported outcome measures indicate improvements
  • Mean improvement across all Prosthesis Evaluation Questionnaire domains¹⁷
  • Bilateral patients showed highest mean improvement in satisfaction¹⁷
• Subjective user preference for hydraulic ankle
  • 13/13 participants preferred hydraulic ankle¹⁵

• Improved knee stability on the prosthetic side during slope descent
  • Increased mid-stance external prosthetic knee extensor moment³

• Improved ground compliance when walking down slopes
  • Reduced time to foot flat¹²
• Brake mode during slope descent increases resistance to dorsiflexion to control momentum build up
  • Reduced dorsiflexion range during slope descent³
  • Reduced mean prosthetic shank angular velocity in single support¹²
  • Increased Unified Deformable Segment (prosthetic ‘ankle’) negative work¹²
  • Transition from dorsiflexion to plantarflexion moment occurs earlier in stance phase¹⁸
  • Increase in mean prosthetic ‘ankle’ plantarflexion moment integral¹⁸
• Assist mode during slope ascent decreases resistance to dorsiflexion to allow easier progression
  • Transition from dorsiflexion to plantarflexion moment occurs later in stance phase¹⁸
  • Decrease in mean prosthetic ‘ankle’ plantarflexion moment integral¹⁸
• Less gait compensation movements during slope descent

Reduced residual knee flexion at loading response¹²

• Greater reliance on prosthetic side for bodyweight support during slope descent
  • Increased support moment integral¹⁸
• Less reliance on sound side for bodyweight support during slope descent
  • Decreased support moment integral¹⁸
• Less reliance on sound side for bodyweight support during slope ascent
  • Decreased support moment integral¹⁸
• Reduced sound joint moments during standing of a slope
  • Significant reductions in sound support moment¹⁴
• Reduced residual joint moments during standing of a slope for bilateral amputees
  • Significant reductions in prosthetic support moment¹⁴
  • Permitted ‘natural’ ground reaction vector sagittal plane position, relative to knee joint centres¹⁴

• High mean radius of curvature for Esprit-style e-carbon feet²: “The larger the radius of curvature, the more stable is the foot”

• Allow variable running speeds³
• Increased self-selected walking speed⁴
• Elite-style e-carbon feet (L code VL5987) or VT units demonstrate the second highest mobility levels, behind only microprocessor feet⁵

• Users demonstrate confidence in prosthetic loading during high activity⁶
• Improved prosthetic push-off work compared to SACH feet⁷
• Increased prosthetic positive work done⁴

• High degree of user satisfaction, particularly with high activity users⁸

• High mean radius of curvature for Esprit-style e-carbon feet²: “The larger the radius of curvature, the more stable is the foot”

• Allow variable running speeds³
• Increased self-selected walking speed⁴
• Elite-style e-carbon feet (L code VL5987) or VT units demonstrate the second highest mobility levels, behind only microprocessor feet⁵

• Users demonstrate confidence in prosthetic loading during high activity⁶
• Improved prosthetic push-off work compared to SACH feet⁷
• Increased prosthetic positive work done⁴

• High degree of user satisfaction, particularly with high activity users⁸

• Reduced back pain during twisting movements e.g. golf swings⁹

• Reduced compensatory knee flexion at loading response¹⁰
• No reduction in step activity¹¹
• Blatchford torsion adaptors match the able-bodied rotational range¹²

• Reduced loading rate on prosthetic limb¹³, particularly at fast walking speeds¹⁴
• Users feel less pressure on their residual limb¹⁵

• Patient preference, citing improved comfort, smoothness of gait and easier stairs descent¹³

• High mean radius of curvature for Esprit-style e-carbon feet²: “The larger the radius of curvature, the more stable is the foot”

• Allow variable running speeds³
• Increased self-selected walking speed⁴
• Elite-style e-carbon feet (L code VL5987) or VT units demonstrate the second highest mobility levels, behind only microprocessor feet⁵

• Users demonstrate confidence in prosthetic loading during high activity⁶
• Improved prosthetic push-off work compared to SACH feet⁷
• Increased prosthetic positive work done⁴

• High degree of user satisfaction, particularly with high activity users⁸

• High mean radius of curvature for Esprit-style e-carbon feet²: “The larger the radius of curvature, the more stable is the foot”

• Allow variable running speeds³
• Increased self-selected walking speed⁴
• Elite-style e-carbon feet (L code VL5987) or VT units demonstrate the second highest mobility levels, behind only microprocessor feet⁵

• Users demonstrate confidence in prosthetic loading during high activity⁶
• Improved prosthetic push-off work compared to SACH feet⁷
• Increased prosthetic positive work done⁴

• High degree of user satisfaction, particularly with high activity users⁸

• Reduced back pain during twisting movements e.g. golf swings⁹

• Reduced compensatory knee flexion at loading response¹⁰
• No reduction in step activity¹¹
• Blatchford torsion adaptors match the able-bodied rotational range¹²

• Reduced loading rate on prosthetic limb¹³, particularly at fast walking speeds¹⁴
• Users feel less pressure on their residual limb¹⁵

• Patient preference, citing improved comfort, smoothness of gait and easier stairs descent¹³

• High mean radius of curvature for Esprit-style e-carbon feet²: “The larger the radius of curvature, the more stable is the foot”

• Allow variable running speeds³
• Increased self-selected walking speed⁴
• Elite-style e-carbon feet (L code VL5987) or VT units demonstrate the second highest mobility levels, behind only microprocessor feet⁵

• Users demonstrate confidence in prosthetic loading during high activity⁶
• Improved prosthetic push-off work compared to SACH feet⁷
• Increased prosthetic positive work done⁴

• High degree of user satisfaction, particularly with high activity users⁸

• Low stiffness at weight acceptance leads to early foot-flat and greater stability for lower mobility patients²²
• No loss of stability during standing with Multiflex than fixed ankle/foot²³
• Easier to walk on uneven ground with Multiflex than fixed ankle/foot^23,24
• Easier to walk up a slope with Multiflex than fixed ankle/foot²³

• Little to no difference in gait mechanics compared to flexible, “energy storing” prosthetic feet²⁵
• Increased prosthetic ankle range-of-motion with Multiflex compared to fixed ankle/foot^23,24,26-28
• Increased prosthetic ankle power with Multiflex compared to fixed ankle/foot²⁴
• Prosthetic rollover shape closer to natural biomechanics than fixed ankle/foot²⁶
• Users can walk longer distances and report “smoother” gait with Multiflex compared to fixed ankle/foot²⁴
• Benefits in mobility for bilateral users^23,24,26,27
• Mixed objective results when user group was more active than is recommended for Multiflex^29,30 so may benefit more from a similar but higher activity foot like Epirus.

• Equivalent socket comfort to higher technology, energy-storing feet²⁹

• Improved stance phase timing symmetry with Multiflex compared to fixed ankle/foot²⁸
• Reduced sound limb loading with Multiflex compared to fixed ankle/foot²⁸

• Mixed subjective feedback around preferences when user group was more active than is recommended for Multiflex²⁵ so may benefit more from a similar but higher activity foot like Epirus.
• Majority of users rate Multiflex as either “good” or “acceptable”³¹ and prefer Multiflex to fixed ankle/foot²⁴

• High mean radius of curvature for Esprit-style e-carbon feet²: “The larger the radius of curvature, the more stable is the foot”

• Allow variable running speeds³
• Increased self-selected walking speed⁴
• Elite-style e-carbon feet (L code VL5987) or VT units demonstrate the second highest mobility levels, behind only microprocessor feet⁵

• Users demonstrate confidence in prosthetic loading during high activity⁶
• Improved prosthetic push-off work compared to SACH feet⁷
• Increased prosthetic positive work done⁴

• High degree of user satisfaction, particularly with high activity users⁸

• High mean radius of curvature for Esprit-style e-carbon feet²: “The larger the radius of curvature, the more stable is the foot”

• Allow variable running speeds³
• Increased self-selected walking speed⁴
• Elite-style e-carbon feet (L code VL5987) or VT units demonstrate the second highest mobility levels, behind only microprocessor feet⁵

• Users demonstrate confidence in prosthetic loading during high activity⁶
• Improved prosthetic push-off work compared to SACH feet⁷
• Increased prosthetic positive work done⁴

• High degree of user satisfaction, particularly with high activity users⁸

• Increased mean prosthetic minimum toe clearance^2,4, reducing the likelihood of tripping.
• Fully satisfies stance phase stability³

• Acceptable cosmetics for knee disarticulation amputees and trans-femoral amputees with long residua¹
• Meets all the design requirements for paediatric patients³

• Significantly reduced number of falls^1,2
• Reduced centre-of-pressure fluctuations by 9-11% with standing support active when standing on sloped ground³
• Less cognitive demand during walking, leading to reduced postural sway⁴

• Increased walking speed⁵
• Easier to walk at different speeds⁶
• Higher scores in mobility-related patient-reported outcome measures⁷
• More natural gait^6,8
• Easier to walk on slopes⁶

• Reduced energy expenditure compared to mechanical knees^9-13
• Equivalent energy expenditure to other MPKs¹⁴
• Reduced self-perceived effort^6,8
• Energy expenditure closer to that of able-bodied control subjects¹⁵
• Able to walk further before becoming tired⁶

• Better step length symmetry⁵
• Reduced loading asymmetry with standing support active when standing on sloped ground³

• Reduced fear of falling¹
• Reduced limitations due to an emotional problem⁸
• Preference over other prosthetic knees^1,6
• Greater prosthetic confidence in slope descent and gait termination¹⁶

• Reductions in direct and indirect healthcare costs when using an MPK¹⁷

• Reduced risk of tripping and falls
  • Increased minimum toe clearance during swing phase^18,19
• Improved knee stability on the prosthetic side during slope descent
  • Increased mid-stance external prosthetic knee extensor moment²⁰
• Improving standing balance on a slope
  • 24-25% reduction in mean inter-limb centre-of-pressure root mean square (COP RMS)³

• Reduced energy expenditure during walking
  • Mean 11.8% reduction in energy use on level ground, across all walking speeds²¹
  • Mean 20.2% reduction in energy use on slopes, across all gradients²¹
  • Mean 8.3% faster walking speed for the same amount of effort²¹

• Improved gait performance
  • Faster self-selected walking speed^18,22-25
• Improved ground compliance when walking on slopes
  • Increased plantarflexion peak during level walking, fast level walking and cambered walking²⁶
  • Increased dorsiflexion peak during level walking, fast level walking and cambered walking²⁶
• Less of a prosthetic “dead spot” during gait
  • Reduced aggregate negative COP displacement²³
  • Centre-of-pressure passes anterior to the shank statistically significantly earlier in stance²³
  • Increased minimum instantaneous COM velocity during prosthetic-limb single support phase²³
  • Reduced peak negative COP velocity²⁵
  • Reduced COP posterior travel distance²⁵
• Improved ground compliance when walking on slopes
  • Increased plantarflexion range during slope descent¹⁹
  • Increased dorsiflexion range during slope ascent¹⁹
• Less effort on residual hip for trans-femoral amputees on varied terrains
  • Reduced the mean hip extension and flexion moments²⁷
• Effects consistent over time
  • Same gait variable changes in two gait lab sessions one year apart²²
  • Magnitude of changes comparable between sessions²²
• Brake mode during slope descent to control momentum build up
  • Reduced mean prosthetic shank angular velocity in single support²⁸
  • Increased Unified Deformable Segment (prosthetic ‘ankle’) negative work²⁸
• Less gait compensation movements during slope descent
  • Reduced residual knee flexion at loading response²⁸

• Helps protect vulnerable residual limb tissue, reducing likelihood of damage
  • Reduced peak stresses on residual limb²⁹
  • Reduced stress RMS on residual limb²⁹
  • Reduced loading rates on residual limb²⁹

• Greater contribution of prosthetic limb to support during walking
  • Increased residual knee peak extension moment²²
  • Decreased residual knee peak flexion moment²²
  • Increased residual knee negative work²⁴
• Reduced reliance on sound limb for support during walking
  • Reduced intact limb peak hip flexion moment²⁴
  • Reduced intact limb peak dorsiflexion moment²⁴
  • Reduced intact ankle negative work and total work²⁴
  • Reduced intact limb total joint work²⁴
• Better symmetry of loading between prosthetic and sound limbs during standing on a slope
  • Degree of asymmetry closer to zero for 5/5 amputees²⁰
• Reduced residual and sound joint moments during standing of a slope
  • Significant reductions in both prosthetic and sound support moments³⁰
• Reduced residual joint moments during standing of a slope for bilateral amputees
  • Significant reductions in prosthetic support moment³⁰
  • Permitted ‘natural’ ground reaction vector sagittal plane position, relative to knee joint centres³⁰
• Less pressure on the sole of the contralateral foot
  • Peak plantar-pressure³¹
• Improved gait symmetry
  • Reduced stance phase timing asymmetry³²

• Patient reported outcome measures indicate improvements
  • Mean improvement across all Prosthesis Evaluation Questionnaire domains³³
  • Bilateral patients showed highest mean improvement in satisfaction³³
• Subjective user preference for hydraulic ankle
  • 13/13 participants preferred hydraulic ankle³¹

• Improved knee stability on the prosthetic side during slope descent
  • Increased mid-stance external prosthetic knee extensor moment¹⁹

• Improved ground compliance when walking down slopes
  • Reduced time to foot flat²⁸
• Brake mode during slope descent increases resistance to dorsiflexion to control momentum build up
  • Reduced dorsiflexion range during slope descent¹⁹
  • Reduced mean prosthetic shank angular velocity in single support²⁸
  • Increased Unified Deformable Segment (prosthetic ‘ankle’) negative work²⁸
  • Transition from dorsiflexion to plantarflexion moment occurs earlier in stance phase³⁴
  • Increase in mean prosthetic ‘ankle’ plantarflexion moment integral³⁴
• Assist mode during slope ascent decreases resistance to dorsiflexion to allow easier progression
  • Transition from dorsiflexion to plantarflexion moment occurs later in stance phase³⁴
  • Decrease in mean prosthetic ‘ankle’ plantarflexion moment integral³⁴
• Less gait compensation movements during slope descent
  • Reduced residual knee flexion at loading response²⁸

• Greater reliance on prosthetic side for bodyweight support during slope descent
  • Increased support moment integral³⁴
• Less reliance on sound side for bodyweight support during slope descent
  • Decreased support moment integral³⁴
• Less reliance on sound side for bodyweight support during slope ascent
  • Decreased support moment integral³⁴
• Reduced sound joint moments during standing of a slope
  • Significant reductions in sound support moment³⁰
• Reduced residual joint moments during standing of a slope for bilateral amputees
  • Significant reductions in prosthetic support moment³⁰
  • Permitted ‘natural’ ground reaction vector sagittal plane position, relative to knee joint centres³⁰

• Greater prosthetic confidence in slope descent and gait termination¹⁶

• High mean radius of curvature for Esprit-style e-carbon feet²: “The larger the radius of curvature, the more stable is the foot”

• Allow variable running speeds³
• Increased self-selected walking speed⁴
• Elite-style e-carbon feet (L code VL5987) or VT units demonstrate the second highest mobility levels, behind only microprocessor feet⁵

• Users demonstrate confidence in prosthetic loading during high activity⁶
• Improved prosthetic push-off work compared to SACH feet⁷
• Increased prosthetic positive work done⁴

• High degree of user satisfaction, particularly with high activity users⁸

• Low stiffness at weight acceptance leads to early foot-flat and greater stability for lower mobility patients¹⁴
• No loss of stability during standing with Multiflex than fixed ankle/foot¹⁵
• Easier to walk on uneven ground with Multiflex than fixed ankle/foot^15,16
• Easier to walk up a slope with Multiflex than fixed ankle/foot¹⁵

• Little to no difference in gait mechanics compared to flexible, “energy storing” prosthetic feet¹⁷
• Increased prosthetic ankle range-of-motion with Multiflex compared to fixed ankle/foot^15,16,18-20
• Increased prosthetic ankle power with Multiflex compared to fixed ankle/foot for bilateral users¹⁶
• Prosthetic rollover shape closer to natural biomechanics than fixed ankle/foot¹⁸
• Bilateral users can walk longer distances and report “smoother” gait with Multiflex compared to fixed ankle/foot¹⁶
• Benefits in mobility for bilateral users^15,16,18,19

• Equivalent socket comfort to higher technology, energy-storing feet²¹

• Improved stance phase timing symmetry with Multiflex compared to fixed ankle/foot²⁰
• Reduced sound limb loading with Multiflex compared to fixed ankle/foot²⁰

• Majority of users rate Multiflex as either “good” or “acceptable”²² and bilateral users prefer Multiflex to fixed ankle/foot¹⁶

• Shorter keel allows for more consistent rollover radius of curvature, regardless of changing footwear¹
• The most energy efficient radius of curvature for a rollover shape has been identified as 30% of the walker’s leg length. For a person of a typical adult height between 1.5m and 1.8m, this equates to approximately 245-290mm. Navigator has a rollover shape of ~250mm¹.

• Low stiffness at weight acceptance leads to early foot-flat and greater stability for lower mobility patients¹⁵
• No loss of stability during standing with Multiflex than fixed ankle/foot¹⁶
• Easier to walk on uneven ground with Multiflex than fixed ankle/foot^16,17
• Easier to walk up a slope with Multiflex than fixed ankle/foot¹⁶

• Little to no difference in gait mechanics compared to flexible, “energy storing” prosthetic feet¹⁸
• Increased prosthetic ankle range-of-motion with Multiflex compared to fixed ankle/foot^16,17,19-21
• Increased prosthetic ankle power with Multiflex compared to fixed ankle/foot¹⁷
• Prosthetic rollover shape closer to natural biomechanics than fixed ankle/foot¹⁹
• Users can walk longer distances and report “smoother” gait with Multiflex compared to fixed ankle/foot¹⁷
• Benefits in mobility for bilateral users^17,19-21

• Equivalent socket comfort to higher technology, energy-storing feet²²

• Improved stance phase timing symmetry with Multiflex compared to fixed ankle/foot²¹
• Reduced sound limb loading with Multiflex compared to fixed ankle/foot²¹

Majority of users rate Multiflex as either “good” or “acceptable”²³ and prefer Multiflex to fixed ankle/foot¹⁷

• Significantly reduced number of falls^1,2
• Reduced centre-of-pressure fluctuations by 9-11% with standing support active when standing on sloped ground³
• Less cognitive demand during walking, leading to reduced postural sway⁴

• Increased walking speed⁵
• Easier to walk at different speeds⁶
• Higher scores in mobility-related patient-reported outcome measures⁷
• More natural gait^6,8
• Easier to walk on slopes⁶

• Reduced energy expenditure compared to mechanical knees^9-13
• Equivalent energy expenditure to other MPKs¹⁴
• Reduced self-perceived effort^6,8
• Energy expenditure closer to that of able-bodied control subjects¹⁵
• Able to walk further before becoming tired⁶

• Better step length symmetry⁵
• Reduced loading asymmetry with standing support active when standing on sloped ground³

• Reduced fear of falling¹
• Reduced limitations due to an emotional problem⁷
• Preference over other prosthetic knees^1,14

• Reductions in direct and indirect healthcare costs when using an MPK¹⁶

Low stiffness at weight acceptance leads to early foot-flat and greater stability for lower mobility patients¹

• Satisfactory for patients with limited mobility in order to maintain mobility level²
• Lightweight keel increases ease of use and is ideal for elderly users or those with limited strength²
  B. Senior’s design of a footshell with a moulded keel, incorporating an integral pyramid, maximises strength of the foot whilst minimising its weight.
• Durability tests confirm foot to be long-lasting for those with low mobility levels³

• 54% satisfaction rate²
• Satisfaction rates increase within the bilateral population²

• Improvements in residual limb health problems and wound healing^1,2
• Fewer residual skin issues²
• Reduction in pain in residual and phantom limb²
• Improved heat dissipation compared to other temperature regulation solutions³
• Removes sweat from skin interface^1,2,4
• Perforations do not damage the skin⁴

• Patients reported a preference for their perforated liners^1,4
• Reduces the need to remove prosthesis throughout the day to dry residual limb⁴

There are two published literature reviews that discuss different aspects of lower limb prosthetic liner technology^5,6.

• The main purpose of prosthetic liners is to cushion the transfer of loads from the prosthetic socket to the residual limb⁵.
• Based on load-displacement data from the compressive stiffness tests, silicone was one of three materials that were recommended for situations where it is desirable for the liner to maintain thickness and volume since these materials had the least non-recovered strain^5,7.
• Under cyclic compressive loading, silicone was one of two materials that had the greatest cycles to failure under compressive loading, while the Pedilin and polyurethane samples lasted orders of magnitude less^5,8.
• Prosthetic liners and sockets are highly resistive to heat conduction and could be a major contributor to elevated skin temperatures^5,9.
• There are reduced residual limb pressures with the silicone liner compared to other conditions (no liner; soft inserts) suggesting that silicone has an ability to distribute pressure evenly to the residual limb^4,10.
• In terms of patient outcomes, there was no clear preference between silicone and Pelite liners^5,11.

• Improvements in residual limb health problems and wound healing^1,2
• Fewer residual skin issues²
• Reduction in pain in residual and phantom limb²
• Improved heat dissipation compared to other temperature regulation solutions³
• Removes sweat from skin interface^1,2,4
• Perforations do not damage the skin⁴

• Patients reported a preference for their perforated liners^1,4
• Reduces the need to remove prosthesis throughout the day to dry residual limb⁴

There are two published literature reviews that discuss different aspects of lower limb prosthetic liner technology^5,6.

• The main purpose of prosthetic liners is to cushion the transfer of loads from the prosthetic socket to the residual limb⁵.
• Based on load-displacement data from the compressive stiffness tests, silicone was one of three materials that were recommended for situations where it is desirable for the liner to maintain thickness and volume since these materials had the least non-recovered strain^5,7.
• Under cyclic compressive loading, silicone was one of two materials that had the greatest cycles to failure under compressive loading, while the Pedilin and polyurethane samples lasted orders of magnitude less^5,8.
• Prosthetic liners and sockets are highly resistive to heat conduction and could be a major contributor to elevated skin temperatures^5,9.
• There are reduced residual limb pressures with the silicone liner compared to other conditions (no liner; soft inserts) suggesting that silicone has an ability to distribute pressure evenly to the residual limb^4,10.
• In terms of patient outcomes, there was no clear preference between silicone and Pelite liners^5,11.

• Less cognitive demand during walking, leading to reduced postural sway¹

• Increased walking speed^2-5
• Easier to walk at different speeds^4,6
• More natural gait⁴
• Easier to walk on slopes^4,6

• Reduced energy expenditure compared to (non-MPK) mechanical knees^3-8
• Equivalent energy expenditure to other MPKs (swing and stance controlled)⁹
• Reduced self-perceived effort^4,6
• Energy expenditure closer to that of able-bodied control subjects¹⁰
• Able to walk further before becoming tired⁴

• Better step length symmetry^2,6

• Preference over other prosthetic knees^4,6

• Low stiffness at weight acceptance leads to early foot-flat and greater stability for lower mobility patients¹

• Satisfactory for patients with limited mobility in order to maintain mobility level²
• Lightweight keel increases ease of use and is ideal for elderly users or those with limited strength²
• Durability tests confirm foot to be long-lasting for those with low mobility levels³

• 54% satisfaction rate²
• Satisfaction rates increase within the bilateral population²

• Reduced back pain during twisting movements e.g. golf swings¹

• Reduced compensatory knee flexion at loading response²
• No reduction in step activity³
• Blatchford torsion adaptors match the able-bodied rotational range⁴

• Reduced loading rate on prosthetic limb⁵, particularly at fast walking speeds⁶
• Users feel less pressure on their residual limb⁷

• Patient preference, citing improved comfort, smoothness of gait and easier stairs descent⁵