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PROSTHESIS

REHABILITATION
Definition of Prosthesis
A device designed to replace as far as possible the function
(and sometimes the appearance) of a missing limb or part
thereof.
Common Terminologies
Myodesis: direct suture of muscle or tendon to bone (via drill
holes)
Myoplasty: suturing agonist and antagonist muscles together
Residual limb: remaining portion of the amputated limb
Build-up: area of convexity designed for areas tolerant to
high pressure
Relief: area of concavity within the socket designed for high
pressure bony prominence areas
Traditional vs Newer
Componentry
Traditionally prostheses were made in
the form of exoskeleton, usually of wood
or plastic
Modern prostheses are endoskeletal
Constructed in a tube frame fashion
Flexible foam cover is used for the
outer surface
Elements adjustable individually and
detachable
Chief Goals of Prosthesis
Fitting
Limb substitution
Cosmesis
Locomotion (LL amputees)
Basic Principles of LL Amputation Surgery:
Preserve the knee joint whenever it is practical to
do so and fashion the stump at the lowest
practical level
Very short stumps make fitting extremely difficult.
However, very long transtibial stumps are prone
to circulation problems in the elderly dysvascular
patient
Elements to Consider in UL
Prostheses
The level of amputation
Cognition
Expected function required of prosthesis
The job of the patient, e.g. sedentary vs.
manual
Patients hobbies
Cosmesis, importance can be increased if
female or if the child grows up
Other considerations: finance
Socket and Suspensions
Socket Fitting: Introduction
No matter whether we are using an
advanced or traditional prosthetic
knee and foot, the socket remains an
important component of a
comfortable and well-functioning
prosthesis
It is the interface between the body
of the amputee and the distal
mechanical construction
Function of the Lower Limb
Socket (According to Foort)
To guide and link the residual limb to the prosthesis
n For transmission of support and control of forces
n The whole surface of the residual limb and its
muscular system
should be used for load transmission and guidance
of the prosthesis
n Provides wearing comfort
n If possible to provide sensory information used in
controlling the
prosthesis
n Protect the stump from the environment
Biomechanical Principles of Socket (According to Hall)

Proper contour and pressure relief for functioning


muscles, allowance
for dynamic changing contours
Application of stabilisation forces to locations
where no functioning muscles exist
Functioning muscles need be stretched to slightly
greater than length at rest to generate maximum
power
Pressure, if properly applied and evened out, can
be exerted over neurovascular
structures (such as the adductor canal in the
case of transfemoral quadrilateral socket)
Sockets for Transfemoral
Amputee
Quadrilateral Socket
Designed by University of California Berkeley
Quadrilateral refers to the special shape of
the four walls of the socket in axial view
Ischial tuberosity and gluteal musculature are
used as primary weight-bearing structures
The design takes into account changing limb
contours under dynamic conditions with
provision of space to contracting muscles
Function of the Four Walls
Anteromedially: Scarpas Bulge with
its inward contour provides counterforce
to maintain the ischium on the shelf
Anterolateral proximal convex contour
to accommodate contraction and bulk
of the quadriceps
Posterior shelf to support the ischial
tuberosity and gluteal muscles
Medial wall to support medial adductor
muscle mass with its adductor longus
tendon
Design Rationale
The design is more than just working on pressure and counter-
pressure of the muscle groups provided by the four walls, other
rationale include:
Lateral stabilisation
Total contact
Gluteal support
Proper allowance for differences in residual musculature
Key to Success
Adequate lateral femoral stabilisation is needed to ensure an
efficient gait (in transfemoral amputation)
To keep the femur in the adducted position, it is maintained by
the angle of the lateral wall and the dimension of the medio-
lateral wall
Femoral instability is exacerbated in mid-stance when the hip
abductors need to contract to prevent drooping of the pelvis or
Trendelenburg positioning
Notice that failure of femoral stabilisation may result in walking
with a wide base and truncal leaning laterally to the prosthesis
side in the stance phase to minimise the force on the lateral side
of the femur
Model showing the coverage offered
by quadrilateral design as opposed to the older
design
Ischial Containment
It was Long who came up with the idea of another type of
socket with ischial containment after noting radiographically
the not infrequent femoral malalignment and resultant lurch
despite the use of the quadrilateral socket (Fig. 10.1)
Design Rationale
Narrow the medio-lateral dimension in an attempt to better
stabilis and control the femur, keeping it more adducted
Containing the ischium may prevent the socket from
moving laterally on weight-bearing
Hence, the medial aspect of the ischium is now included in
the socket to a varying extent
Design rationale summary:
Provide more lateral stabilisation of the femur (Fig. 10.2)
Create bony lock between greater trochanter, ischium
and femoral shaft
Improve control of pelvis and trunk
Better comfort for the perineum
ISO Recommendation for Transfemoral Socket

Maintain normal femoral adduction as far as


possible to obtain more normal gait
Provide total contact
Enclose ramus and ischial tuberosity medially and
posteriorly respectively.
Thus, forces involved in the maintenance of
medial lateral stability will be borne by the pelvic
bone, creating a skeletal lock
Good distribution of forces along the femoral shaft
Decrease emphasis on maintaining narrow
anteroposterior diameter to maintain ischial
gluteal weight-bearing
Quadrilateral sockets may be better
for patients with firm adductor
musculature and a long residual limb
Ischial containment sockets may be
better for more active amputees with
short, fleshy residual limbs
Successful users of quadrilateral
sockets do not usually need to change
socket type
Flexible Icelandic Scandinavian New
York Socket

n Pioneered by
Kristinsson
Sometimes called
Scandinavian
Flexible Socket
Featuring a flexible
inner socket and
outer rigid frames
Some variations in Design Rationale
design have windows Improved sitting comfort
cut out in the outer Improved proprioception
frame to provide Possibly improved heat
pressure relief dissipation
The challenge: to find Improved muscle activity
Less heavy
the reasonably durable
Better suspension (if
thermoplastic material
suction is used)
offering the right
Easily interchange without
amount of flexibility loss of alignment
without expanding or (The only weak point is that
permanent deformation it may be less durable)
Sockets for the Transtibial Amputee
Total Contact Socket
Previously sometimes called patella
tendon-bearing socket
This is a misnomer since the patella
tendon does not bear high loads in this
type of socket: weight distribution is
quite even
There are relief areas for pressure points
like the fibula head, hamstrings, and a
wide tibial flare to even out the pressure
Icelandic Scandinavian New York
Socket
Featuring an outer rigid and inner flexible frame, as
just mentioned
Windows are present in the outer frame to provide
pressure relief
Not very durable
Adjuncts
Inserts like silicone gel may provide added protection
for the dysvascular patient or one with abundant
scars. These should not be too proud in case they
decrease surface contacts
A soft foam at the distal socket may decrease the
chance of verrucous hyperplasia formation
Suspension Systems
Proper suspension is important in its
contribution to the comfort and safety of
the prosthesis
For example, before World War II, many
traditional suspension systems made of
belts caused lots of vertical pistoning
and inefficient gait, abrasions, and distal
stump oedema, etc., thus demonstrating
the importance of proper suspension
Transfemoral Amputee
Silicon Liner with Shuttle Lock
Can be used for both transfemoral and transtibial
amputees
Can be used for all K-level users
Popular since advantages include: good
cushioning, torque control, total contact, less shear
on the stump, lessens distal oedema build-up
Prosthetic socks can be added as needed to
accommodate stump volume fluctuations
Good alternative for users with difficulty donning
the full suction socket
Suction Systems
Also popular means of suspension, works by
negative pressure and surface tension
Not usually used in transtibial amputees as the
local anatomy is not very suitable for a tight seal
Advantages include: good contact between
residual limb and socket, good level of comfort
and control
Highly active amputees may need additional
suspension belts
Drawback: DM patients with weak hand intrinsics
can have difficulty donning and doffing as well as
those with poor standing balance
New Seal-In Liner by Ossur
This new development is promising as the
user simply rolls on the liner, steps into the
socket, and an integrated hypobaric sealing
membrane (HSM) automatically creates a
firm suspension.
To remove the socket, the user just pushes a
button
Pistoning is decreased by the full-length
matrix; while the seal and distal pad enhance
rotational control, the HSM can conform to
the shape of the socket wall creating a quick
air-tight seal for easy donning
Total Elastic Suspension

Used sometimes in the elderly


The total elastic suspension system
is made of neoprene, usually
equipped with a sleeve that attaches
to the proximal prosthesis, then
encircles the trunk to the waist line
Can also be used as an auxiliary
suspension method as well
Belt

Still used especially sometimes in


children
Example: some children with
congenital anomalies, e.g. proximal
focal femoral deficiency (PFFD) and
weak hip muscles, a belt may serve
well in such cases
Transtibial Amputee
Silicone Suction with Shuttle Lock:
The pin-and-lock system is equally very
popularly used for transtibial amputees
Details were just discussed, essentially
features a stepless pin inside a unique
locking mechanism, which results in a
safe and non-pistoning suspension
Therapist helping the amputee to put
on the popular silicon suction with
locking pin
Completion of fitting of silicon suction
with shuttle lock
Suspension Sleeve
Works by adherence to the skin via
negative pressure, by using materials
like neoprene. The other end is fitted
to the proximal part of the prosthesis
Again, DM patients with weak
intrinsics can have donning difficulty
Supracondylar Cuff
Used to be popular in the past
The chief disadvantage is posing
danger for the dysvascular patient
from the constriction proximal to the
knee
Reserved mostly (very occasionally)
for K1 amputees, especially those
living in rural areas
Prosthetic Knees: Introduction
Selection of prosthetic knee system
depends on the patients
abilities,strength and balance
Before we discuss the various
designs, we need to recapitulate the
gait difficulties facing the
transfemoral amputation
Difficulties Concerning Gait
Facing the Transfemoral Amputee
Stance phase: quadriceps cannot provide
sagittal knee stability after this amputation
Swing phase: the knee with the prosthesis
must provide stability and swing at
appropriate rates to match the amputees
ability. An incorrect swing rate will result in
the patient hopping on the good side, thus
waiting for the knee unit to fully extend
before weight can be transferred to the
affected side.
Constant Friction Swing Phase
Control Knees
Constant friction=simplest form of swing
phase control
Increased friction will decrease swing rate
Degree of resistance set by prosthetist
As the patient gets accustomed to the
prosthesis, the prosthetist may need to
readjust the swing rate
Disadvantage: patients cadence is limited to
one speed (if the patient wants to ambulate
faster, the knee will flex excessively)
Fluid (Hydraulic) Control Systems
The fluid hydraulic system (Fig. 10.8) works on the
principle that fluid is relatively incompressible, and
forms the principle of many machines such as
shock absorbers
Similarly, if the patient has variable cadence, when
his velocity increases, we also need to increase
resistance in order to prevent excess knee flexion
In short, adequate fluid resistance is needed for the
prosthesis to keep up with the pace of the patient
Similarly, we do not want the knee with the
prosthesis to extend too rapidly either, because
although some patients like this feel (from
sensory feedback of the sudden jerk); this
phenomenon may predispose to premature wear of
the prosthesis.
Example of a prosthetic knee using
the hydraulic system
Hence, the hydraulic control knee
unit needs to incorporate in its
design both flexion and extension
resistance
The prosthetist then has to adjust the
level of resistance to the range of
velocities that will best suit our
patient
Alternative: Pneumatic Units
Can sometimes be used
Since gas is more compressible than
fluid, the range of resistance offered
will therefore be smaller
Another disadvantage is that the
prostheti response can be less smooth
since as was said, gas is more
compressible, although pneumatic
units are lighter
New Improved Design: Continuous
Resistance Adjustment
These marvellous new advanced knee
technologies were made possible only
because of breakthrough
microprocessor technology.
Here, a closer match of the resistance
needed by the active amputee is made
possible the microchip on board and
sensors adjust swing resistance up to
50 times each second.
Although these advanced systems
have both pneumatic and hydraulic
systems available; the hydraulic
system (e.g. Otto Bock C-leg Fig.
10.9, or Ossur Rheo Leg Fig. 10.10)
is more popular for obvious reasons
Otto-Bock C-leg descending stairs Rheo leg by the company Ossur

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