Prosthesis

All limb prostheses consist of a suspension device, a socket, rigid components and a
terminal device (foot).
Some includes artificial joints.
Most amputees require a prosthetic sheath and socks cover the residual limb.
The prosthesis-patient interface is the fit and the geometry of the component is the
alignment
Preparatory/Temporary Prosthesis
A preparatory prosthesis is provided as a trial even to the patient whose potential success
of using prosthesis is uncertain.
The preparatory or temporary prosthesis is usually un-cosmetic, but is used during the
period of residual limb shrinkage.
The amputee uses the preparatory prosthesis until maximal shrinkage has been achieved,
this period usually extends from 3 to 6 months post-surgery.
when the ply off socks reach 10 to 15 numbers following residual limb shrinkage, a new
socket is given to the amputee and it may lead to pistoning.

Definitive/Permanent Prosthesis
The definitive or permanent prosthesis is cosmetically finished.
Its fit, alignment and components are chosen based on the amputees experience with the
preparatory prosthesis.
A test or check socket is made to test the fit of prosthesis prior to the fabrication of
definitive socket.
A weight gain of 5 lb can alter the fit of the prosthesis.
Diuretics, hemodialysis, chemotherapy and alcohol consumption can cause fluctuation in
residual limb size.
The definitive prosthesis typically requires replacement about every 3 years.
Partial foot amputation
for patient with toe amputation, wool, sponge rubber or foam should be inserted in the
shoe to serve as a spacer ant to prevent toe deformity.
for an amputated great toe, a long steel spring shank, a metatarsal pad and a rocker sole
improves function.
transmetatarsal amputation requires a custom-bolded insole and toe filer.the stiff insole
should be able to prevent shoe hypertension proximal to the natural toe break.

A thin, light -weight carbon fiber shank can be incorporated directly in the insert.
The slipper type prosthesis contains flexible and semi-flexible materials and provides a
plantar lever arm and cosmoses.

For the lisfranc or chop art amputee, a modified shoe or folded plastic socket, or a
combination of the two should be provided.
Modern slipper type protheses terminate at the ankle joint, whereas the older devices,
such as the prosthetic boot and ankle-foot orthosis (AFO), can extend up the ankle and
inhibition subtler and tibitalar motion.
the ground reaction force AFO with anterior and posterior plastic shell gives maximal
control with minimal ankle motion and some limited proximal weight bearing and is
indicated for the muscularly imbalanced, active or pressure -sensitive amputee.
Syme Amputation
Prosthetic prescription
Some prosthetic will have a removable medial window that allows the patient to push the
residua limb into the socket.
the window when replaced provides suspension over the malleoli
the prosthesis heel is soft which helps to accommodate lack of ankle motion.
Feet for the Syme amputation include all of the SACH-type (solid ankle cushion heel) feet
as well as some energy-sorting feet.
(they are similar to the feet of the same name described transtibial amputation but have
low profile)
Gait speed is typically decreased by 32% and oxygen consumption is increased by 13% per
distance walked in the vascular same amputee with a prosthesis, compared with normal
subjects without vascular disease.
The Boyd amputatio is fitted as a Syme amputation but it requires a contralateral shoe
lifet in adult because of leg length discrepancy.

Transtibial (below knee) Amputation

unlike some amputation the end of the transtibial residual limb can not bear total body
weight.
Transtibial residual limb as short as 2.5 inches can be successfully fitted with a prosthesis.
Distal fibular synostosis can be done to improve weight bearing in the traumatic amputee.
in patient with no walking or transfer potential , knee disarticulation is preferable to
transtibial amputation to prevent knee flexion contracture and distal residual limb
breakdown.

Prosthetic Prescription
Foot Ankle Assemblies
Prosthetic foot are classified in to five types:
1) the SACH foot
2) the singe-axis foot
3) the multi-axis foot
4) the solid ankle flexible keel foot and
5) the energy storing foot.

1) the SACH foot: has a cushioned heel that compresses during heel strike, simulating
plantar flexion and has a rigid anterior keel to roll over during late stance. It is light,
durable, inexpensive and is most often prescribed for juvenile and geriatric amputees.
2) the single-axis foot has a single mechanical axis for plantar flexion and dorsiflexion
motion limited by anterior and posterior bumpers, allowing quicker foot flat, which
results in a more stable knee. The single-axis foot has some biomechanics advantage in
gait over the SACH.
it is most commonly used in transferral prostheses but never in transtibial prostheses.
3) Multi-axis, such as the Greissinger, Endplate Multiplex and stationary attachment
flexible endoskeletal (SAFE) II allow dorsiflexion, plantar flexion, inversion, eversion and
transverse rotation.
Multi-axis feet are good for walking on uneven ground or for an excessively scarred and
sensitive residual limb because of better shock absorption.They are heavier, less durable
and more costly than SACH feet.
4) feet scubas the Kinsely store-energy (STEN) and Otto Block 1D10 Dynamic foot are
similar to the SACH foot but have a flexible anterior keel.
Solid ankle keel feet are lighter than multi-axis feet and provide limited inversion,
eversion and transverse rotation. They offer shock absorption in late stance and benefit
the moderately active or obese amputee.
Energy-storing feet (dynamic response feet) store and release energy as the limb is
weighted and unweighted giving a springy feeling.eg: Seattle foot,seattle light,carbon
copy II,carbon copy II light,carbon copy III, quantum foot, flex walk, flex foot and
springlike.

Energy-storing feet result in higher self-selected walking speed and are indicated for the
moe active amputee.

They can be slight more energy-efficient than SACH feet at normal speeds, with increase
relatively efficiency at higher speeds.
Shanks:
Exoskeletal (Crustance) and Endoskeletal (Modular)
Two basic design for the shank are 1) the exoskeletal and 2) the endoskeletal (modular).
The exoskeletal system has a hard outer plastic shell. It is very durable, but does not allow
alignment changes in the finished prosthesis.
The endoskeletal system has a pylon covered by contoured, soft foam. The endoskeletal
system is generally lighter and more cosmetic and can be more easily accessed for
adjustment and component change-out.
Socket Construction
Patellar Tendon-Bearing Socket
Total Surface Weight-Bearing Socket
the conventional total contact patellar tenon bearing (PTB) socket is characterised by a
bar in the anterior wall designed to apply pressure to the patellar tendon. The tramline
extends anteriorly to the mid patellar level,and can extend mediolaterally to the femoral
condyle and extends posteriorly to below the level of PTB bar.
Pressure-sensitive areas include the tibial crest, tubercle and condyles, the fibular head,
the distal tibia and fibula and the hamstring tendons.
Pressure area includes the patellar tendon, the pretibial muscle, the gastrocnemius-slues
muscle, the popletial fossa, the later flat aspect of the fibula and the medial tibial flare.
Despite the name patellar tendon-bearing, pressure should be distributed over the
pressure-tolerant ares and relieved over the pressure-sensitive areas.
The PTB socket is a total contact socket, because the distal part of the residual limb is in
contact with the socket with minimal end-weight bearing.

Bent Knee or Kneeling Prosthesis and Bypass Prosthesis

The bypass prosthesis receives all pressure from the thigh, ischium and gluteus and bypass
the tibia.
If the bypass is due to severe knee flexion contracture, it is called a bent knee or kneeling
prosthesis.
Protruding external knee hinge are necessary.
The biomechanics are the same as for the transferral prosthesis, with poorer osmosis.

Soft and Hard Sockets

A plastic socket without and insert is a hard socket and
when fitted with an insert it is a soft socket.
an insert provides extra protection for the residual limb but reduces the intimate contact
between limb and the prosthesis.
It is often fabricated from polyethylene foam, although, a silicon gel insert protects the
sensitive residual limb better. Insert should be prescribed when peripheral vascular
disease, extensive scarring or reduced subcutaneous tissue is present.
Inserts are almost always prescribed for transtibial prostheses.
Flexible Socket
Flexible sockets is made up of a softer, thermoplastic material, it sits in a rigid frame.
The term flexible refers to the socket material and not to the socket shape.
Suspension
Flexible Attachment
The supracondylar cuff is a simple cuff or strap fitted just above the femoral condyles to
suspend the prosthesis during swing phase.
It can have a Velcro or buckle closure.
A waist belt and elastic strap can be added for extra security.
Neoprene or rubber suspension sleeves provide excellent suspension, fitting snugly over
the proximal prosthesis and several inches up on the thigh.
Sleeves should not be used for very short residual limbs or for amputee who need added
knee stability with proximal trim lines.
Perspiration and hygiene [problems can occur, especially
kneeling shortens the life of the sleeve.

in hot, humid climates and

The silicon suction suspension system (3S, ICELESS, ALPS) is a thin -walled, highly
compliant, closed -end insert or liner of silicone.
The amputee rolls the silicone liner onto the bare residual limb, then attaches it to the
socket by a shuttle lock system.
The amputee pushes the residual limb into the prosthesis until a click (or Clicks ) is heard.
The amputee pushes a button to doff the socket.
The liner provides friction suspension and absorbs moderate impact and shear forces on
the residual limb.

The silicone suction suspension system is more expensive than most suspension system,
but it provides excellent suspension for the athlete and excellent skin protection for the
scarred residual limb.

Suction suspension is very difficult to achieve in the transtibial amputee due to the
presence of many bony channels but achieved by using a flexible socket.
Brim Contour.
Supracondylar;
the patellar tendon -bearing socket with supracondylar wedge (PTB-SC) has its medialateral trimlines extended above the femoral condyles for suspension.
A wedge is either built into the liner or is completely separate and is positioned above and
over the medial femoral condyle.
The PTB_SC provides extra mediolateral support and is helpful for short residual limbs and
in overweight amputee.
Supracondyalr/Suprapatellar
The patellar tendon-bearing socket with supracondylar/suprapatellar trim-line (PTB-SC/
SP) is a PTB_SC socket with supra patellar tramlines.
The supra patellar tramline helps suspend the prosthesis and increase socket wall support
of the expected stance phase virus moment
It is helpful for short residual limbs and for controlling gene recurvatum.
Thigh Corset
The patellar tendon-bearing socket with joints and corset (PTB w/J &C) has a femoral
corset to decrease residual limb weight bearing by 40% to 60%.
It gives less knee control and worsens gait and is therefore the socket suspension of last
resort.
It provides control of significantly lax collateral knee ligaments and protects the knee
from various stress during stance.
It also provides additional mediolateral support for the patient with a short residual limb.
The PTB w/ J&C relieves weight on a residual limb with poor pressure tolerance and it is
often used for amputees involve in heavy manual labor.
Transtibial Prosthetic Care
The amputee should be taught to adjust the prosthetic socks so that the patellar tendon
bar is over the midpoint of the patellar tendon.
The insert should be donned before the prosthesis is donned.

Inserting a clay ball the size of a pea, wrapped in plastic, at the bottom of the socket
during weight bearing is a way to test fit.
If the ball is partly but not totally flattened then distal contact ins adequate.

Knee Disarticulation
(Through-knee amputation)
Knee disarticulation is removal of the tibia and fibula at the knee.
As in the Syme procedure, knee disarticulation provides the capacity for partial endweight bearing.
Prosthetic Prescription
The socket is usually a modified quadrilateral socket with some ischial weight bearing and
a soft socket liner with supracondylar buildups tp provide suspension.
Proximal socket trimlines prevent socket rotation on the limb, though ischial weight
bearing is not an absolute requirement, if femoral condyles provide suspension.
The problem in prosthetic fitting of a knee disarticulation is that the prosthetic knees
centre of rotation needs to go through the distal residual limb.
The polycentric knee unlike the single -axis knee has an instantaneous centre of rotation
that changes and is proximal and posterior to the knee unit itself.
This allows greater knee stability, a more asymmetrical gait and equal knee length the
sitting.Fluid control can be added for the active amputee.

Transcondylar/Supracondylar Amputation
The amputation is done through the femoral condyles and the patella is attached directly
over the cut end of the femur. Gritti-Strokes amputation is a very difficult procedure and
is seldom used.
it provides partial end weight bearing and eliminates the bulbous prosthetic profile seen i
knee disarticulation.
Prosthetic Prescription
in the transcondylar and supracondylar amputation, a conventional single axis knee unit is
used although ,
The prosthetic thigh is slightly longer than the normal thigh.
Suspension is more difficult than the knee disarticulation.

with myoplasty produces a smoother more rounded cylindrical

residual limb though best results appears to be with myodesis
or bony attachment.
Muscle strength is proportional to its crossectional and its
length and shortened muscle in a shortened residual limb is
weaker.

Transferral (Above Knee) amputation

Prosthetic Prescription
The residual limb should be at least 8.5 to 13.6 cm in length, measured from the groin to
fit a transferral prosthetic but no absolute measurement is prescriptive because success is
dependent on soft tissue volume.
Foot Ankle Assemblies
as compared to transtibial amputee a transfemoral amputee needs softer plantar flexion
to enhance knee stability.
The single-axis foot provides more knee stability than the SACH foot, and is later as well.
If SACH foot is used, a softer heel is necessary.
An ankle unit torque absorber can be used to reduce transverse friction forces for the
short residual limb.
Shanks
The choice between an endoskeletal and exoskeletal shank is similar to that for transtibial
amputee.
Light weight or ultralight prostheses are prescribed generally for geriatric amputee.
Knee Unit
Knee units are either single axis or polycentric.
They are also mechanical or fluid -controlled.
All knee units except for the hydraulic stance control units such as the Mauch S-NS ,attempt to keep the knee flexion-extension fixed at one angle (without relative motion)
throughout the stance phase.
Mechanical Knee Unit
1)Conventional constant-frictionsingle axis knee ae light, durable and inexpensive. Singleaxis knees rely on alignment for stability and work best at one speed.

Excessive heel rise in early swing phase as well as terminal swing impact in late swing
phase, can occur at faster cadences.
The amputee must prevent knee buckling by activating the hip extensors.
The debilitated amputee or amputee with a short residual limb can adequately contract
the hip extensors and requires a knee that is set posteriorly to the trochanter-knee-ankle
(TKA) line.
This alignment has the disadvantage of causing increased energy expenditure compared to
other knee units.
2)A manual-locking knee provides maximum stability for the debilitated or elderly
amputee, but this is accompanied by the worst gait efficiency and increased energy
consumption.
This knee is typically reserved for those with weakness and for those who are likely to
sustain severe injuries if they fall.
3) Weight -activated stance control knee (limited slipper formerly, SAFETY knee) can
provide stable stance for up to 20 degrees of knee flexion by producing friction when
weight increases during stance.
This knee design is for amputee with weak hip extensors or for geriatric amputees.
The stance control is not automatic and the amputee must be able to initiate and
maintain control of the knee.
4) Four bar polycentric knee works well for patients with very long residual limb as well as
for those patient with poor stability due to short residual limbs, poor balance or weak hip
extensors. Fluid control can be added and some polycentric knees can be manually locked.
Extension aids are sometimes used with single-axis knees and polycentric knees and are
usually located within the shank.
The extension aid is usually a compressible spring with screw adjustment that give
constant resistance to knee flexion until flexion reaches 90 degrees, then it assists flexion.
Extension aids improve knee stability at the expense of gait efficiency.

Hydraulic and Pneumatic Control

(Fluid-Control) Knee Units
Both Hydraulic and Pneumatic Control (Fluid-Control) Knee Units are cadence-responsive
through cadence-dependent resistance.
Pneumatic units are air-filled and are lighter in weight, but they can not support the
heavier or more athletic amputee but the hydraulic units can.

Sockets
An adjustable hinged socket for the temporary prosthesis is an option that allows
adjustment for edema reduction.
The quadrilateral socket is the usual choice.The choice for socket shape in the definitive
prosthesis varies between the traditional quadrilateral socket and the newer ischial
containment socket.
Both the quadrilateral and ischial containment socket are total-contact socket with
ischiogluteal weight bearing.
Socket Shape
Quadrilateral Socket;
The traditional quadrilateral socket has flat horizontal posterior shelf on which the ischial
tuberosity and gluteal muscle rest.
There is an inward budge over the femoral triangle and a channel for rectus femurs.
The femoral triangle budge keeps the ischial tuberosity on the paoterior shelf.
Medially there is an anterior channel for the adductor longs tendon.
If an adductor roll of soft tissue is present over the medial brim the medial wall needs
higher extension or the roll needs to be pulled inside the socket.
The quadrilateral socket has a wide mediolateral and a narrow anteroposterior dimension
at the proximal socket edge.
Ischial Containment Socket
The ischial containment socket has a narrow mediolateral dimension and wide
anteroposterior dimension at the level of the ischial ramps.
As compare to the quadrilateral socket the ischial containment socket gives mediolateral
control or bony lock at the minor expense of increased anteroposterior movement.
Ischial containment socket does not alter femoral adduction angle within the socket as
compared to the quadrilateral socket.
Ischial containment socket gives more energy efficient ambulation at high speeds for the
active amputee and is helpful for the short residual limb or weak gluteus medius.
Bypass Prosthesis
For transfemoral amputees with a non-weight bearing lesion in the femur or insufficient
pressure tolerance of the residual limb a complete bypass of weight bearing allows fitting
of a hip disarticulation-type prosthesis.

Socket Material
Laminated and Flexible: traditional rigid plastic-laminate socket and a flexible
thermoplastic socket.
Flexible transfemoral socket consisting of two separate structures;
1) a thin, pliable, vacuum-formed thermoplastic socket to interface with tissues and
2) a rigid, outer supporting frame for weight transmission.
Soft ,flexible socket gives better total contact ,enables patients to sense external objects
through the socket and provides better heat dissipation.
They provide better suction suspension.
Suspension
Suspension system for the transferral amputee includes suction or partial suction, total
elastic suspension (TES) belt, Silesian band, hip joint with pelvic band and waist belt,
silicone suction suspension system and hypobaric silicon suction system.
Suction
The amputee usually dons a total suction prosthesis while standing.
the residual limb should be covered with a pull sock or elastic bandage.
the sock or bandage is passed through the valve hole and is used to pull the limb into
socket.
Alternatively a wet fit can be used.In this a gel, that turns into liquid or powder after the
prosthesis is donned, is used.
A one way valve placed in the valve hole seals the socket by allowing air to escape but
not to enter.
Total suction is the best suspension biomechanically but it requires minimal volume
fluctuation of the residual limb,good hand strength and dexterity, good balance and good
skin tissue integrity.
Any socket that has a suction valve but requires the user to wear prosthesis sock is called
partial suction.
Partial suction provides minimal suspension (except hypobaric silicone system) hence
auxiliary suspension is needed.
The hypobaric silicone suction system consists of prosthetic sock impregnated with a
proximal ring of silicone to provide an air seal for suction suspension.
once the residual limb is all the way in the socket, the amputee replaces the air valve.
The hypobaric system allows suction in looser fitting socket.
the silicone suspension system is a roll on silicone sock attached to the distal socket and is
only occasionally used for transferral amputee.

No suction
1) The TES belt is a neoprene belt attached to the prosthesis and pulled around the waist,
providing a relatively cosmetic auxiliary suspension.
2) The Silesian belt is a soft belt that encircle the pelvis and is attached proximally to the
postriolateral aspect of the socket wall and to the proximal anterior wall at the midline.
3) The hip joint with pelvic band and waist belt gives excellent mediolateral stability for
the frail amputee or for the amputee with a short residual limb but it is bulky, heavy,
constricting and cumbersome.
Placement of these suspension mechanism over bypass graft surgery site and issue in
pregnant women are contraindicated.

Hip Disarticulation and Transpelvic amputation (Hemipelvectomy)

A true hip disarticulation involves removal of the entire femur; however in practise the
proximal femur is usually left to provide prosthetic stabilisation and to avoid an
uncosmetic cavity .
Transpelvic amputation is the surgical removal of the lower limb and part or all of the
ileum.
Usually done for malignant tutor or uncontrolled infection and major trauma.
Prosthetic Prescription
a) The hip disarticulation amputee bears weight in the socket through the ischial
tuberosity and gluteal muscles.
The hip disarticulation socket usually has good contact just above the iliac crest inside the
rim, (through reduced-tramline socket designs are available for young and active
amputee)
Velcro socket closure secure the socket to the torso to prevent pistoning.
b) The transpelvic amputee bears weight on the soft tissue and lower rib cage.
The transpelvic socket requires careful contouring with gluteal bearing on the
contralateral side.
The proximal border of the socket can be trimmed below the traditional second rib margin
if distal contours provide precise fit.

Hip joint mechanisms for hip disarticulation and transpelvic amputee are similar.
The free hip joint has a posterior bumper extension stop and an anterior flexion stop but
allows no abduction or rotation.
the hip joint is made stable by placing it anteriorly

A hip extension assist and lock-able or four bar polycentric hip joint are options.
Knee units and prosthetic feet used in the transferral prosthesis may be used in the hip
disarticulation and transpelvic prosthesis.
Adding transverse rotation unit above the knee allows rotation of the distal prosthesis
which helps in donning and doffing shoes and also allows crossed legged sitting.
A torque absorber is can be used to prevent transverse shear forces at the socket limb
interface.
Due to the high energy requirements of hip disarticulation and transpelvic amputation
ambulation, motivation and cardiopulmonary status are extremely important for
prosthetic use.
Most young men abandon these prostheses in favour of crutch-walking : 50 % of women
retain the prostheses for cosmoses.
Translumbar Amputation
(hemicorporectomy)
It involves loss of the rectum and bladder as well as most of the body mass. A segment of
distal sigmoid colon can be used to creat a continent urinary diversion.
A colostomy is also done
the amputation is closed by approximating anterior abdominal ]]]]]]]]fascia with the
lumbodorsal fascia.
Prosthesis
Prosthesis component are similar to hip dis-articulation but they should be light weighted.
Successful ambulation is difficult.
Prosthesis training begins with a sitting device to increase sitting tolerance.
The socket must accommodate and allow free access to the ostomy stomas.
Attaching legs to the socket for limited ambulation impairs transfer hence a second socket
is needed if ambulation training is attempted.