BELOW KNEE (TRANS-TIBIAL) PROSTHESIS

FIGURE :- BELOW KNEE PROSTHESIS

Most prosthesis for amputation between knee and ankle consist of three major parts:

A socket A shank or Shin A foot

Socket
The most common socket used is some form of PatellarTendon-Bearing (PTB) design where all of the weight of the amputee is carried through the stump. The PTB socket totally encloses the stump and usually contains a soft liner to provide a cushioning effect, although many amputees prefer a hard socket because it is considered cooler. Suspension The Prosthetic may be held in place in a number of ways:

By a cuff above the knee cap By the shape of the brim of the socket By an elastic sleeve or flexible inner liner attached mechanically to the prosthesis.

There are other sockets available for transtibial amputees like the Iceross system, which works on the suction socket system. Sockets are manufactured out of Acrylic Resin.

Fabrication of a Below-Knee Prosthesis

Whether the prosthesis is to be crustacean or end skeletal (often called "modular") type, the prosthetist usually begins by wrapping the stump with plaster-of-Paris bandages to obtain a negative mold. A positive model is made by filling the negative mold with a mixture of plasterof-Paris and water, and allowing it to harden. After modification of the model to provide the proper characteristics to the finished socket, a plastic socket is formed over it. The first one is usually a test, or check, socket made of a transparent plastic to determine if further modifications are needed. A new method being used by many prosthetists for obtaining a modified model of the stump involves use of a computer and automatic machinery. Known a CAD/CAM (Computer-AidedDesign/Computer-Aided-Manufacturing), this method permits prosthetists to modify the model more easily since it does not require making and carving an actual plaster model. The socket is mounted on an adjustable leg for walking trials, and when both the prosthetist and the amputee are satisfied, the limb is ready for the finishing procedures. The exoskeletal shank may be of plastic-covered wood or all plastic. The endoskeletal type uses carved foam rubber over the supporting pylon and the entire prosthesis is encased in a either a latex or fabric stocking. Steps in the fabrication of a plastic prosthesis for a below-knee (transtibial) amputee:

Figure:

A.A negative mold of the stump is made by wrapping it with a wet plaster-of-Paris bandage. B. A positive model of the stump is made by filling the cast with a mixture of plaster of Paris and water. C. After modifications have been made to the model by the prosthetist to make sure that the pressures m the socket will be correct, a test, or check socket, is made by forming a heated sheet of clear plastic over the model. D.The clear plastic socket is tried on to make sure that it fits properly. E. A new positive model is made by filling the clear socket with a mixture of plaster of Paris and water. F. The socket to be used on the definitive prosthesis is formed over the model by using either a mixture of plastic resin and cloth or by forming a heated sheet of plastic over the model.

G.The definitive socket is attached to a pylon that can be adjusted for alignment and walking trials can be made. H.The finished prosthesis maybe either exoskeletal or endoskeletal.

THE SYME PROSTHESIS

The prosthesis for the patient with Syme's amputation is similar to the below-knee prosthesis except that the socket also serves as the shank. Because of the short space between the end of the stump and the floor, a special type of foot, usually a modification of one of the popular designs, has to be used. Also, because of the shape of the stump, no extra provision for suspension is necessary. Two types of sockets are in general use: the plastic socket with an expandable liner, and the plastic socket with a medial opening. Both types were designed for easy entry, yet take advantage of the shape of the stump to provide suspension. Although the end of the stump can take more weight, or load, than in the case of below-knee amputees, it is necessary to shape the upper part of the socket like the PTB so that much of the load can be taken at the knee during walking and standing.

Figure:

TRAINING
Although the below-knee and Syme's amputee have normal knee function training in their use is necessary if optimum gait and comfort are to be obtained. Early training is provided by the prosthetist during fitting trials. Physical therapists usually provide the additional training as required. The new prosthesis should be worn initially for short periods and wearing time increased each day depending upon individual situations. One of the greatest problems in obtaining good performance and maximum comfort is caused by over weight of the amputee. Fluctuations in body weight are reflected in the stump where changes in volume result in poor fit, discomfort, and consequently poor performance. A reasonable exercise program and a sensible diet are important factors in the health

and well being of everyone, but even more so in the case of amputees. Slight reduction in size of the stump can be accommodated by adjustments to the socket, but the prosthetist can do little about expanding the size of a socket and almost any increase in size of the stump means a new prosthesis.

CARE OF THE STUMP

The stump must be washed daily to avoid irritations and infection. Mild soap and warm water are recommended. The interior of plastic sockets also must be kept clean by washing daily with warm water and a mild soap. Use of detergents should be avoided at all times. Some amputees have found a hair dryer to be useful in drying the stump and preparing the socket for donning. Prosthetic socks must be applied carefully to avoid wrinkles, and should be replaced daily with newly laundered ones; more often in warm, humid weather. They should be washed in warm water with a mild soap. Manufacturers recommend that socks be rotated on at least a three- or four-day schedule to allow the fibers to retain their original position. Reductions in the size of the stump can be accommodated by adding one or more prosthetic socks. Prosthetic socks are woven especially for their intended use and are available in three thicknesses and a variety of sizes. The thicknesses generally available are designated 3-ply, 5ply, and 6-ply. With this combination, various thicknesses can be obtained as follows:

One 3-ply = One 5-ply = Two 3-ply = One 3-ply + one 5-ply = 8 plies

3 5 6

plies plies plies;

One 6-ply sock can be used instead of two 3-ply socks. Some amputees have found that use of a one-ply cotton filler sock provides a satisfactory way to obtain a still finer adjustment in thickness. If the amputee has trouble in obtaining comfort by a combination of prosthetic socks, he should consult his prosthetist immediately. Frequent adjustments are often required in the first year. When the prosthesis does not feel comfortable during standing and walking, it should be removed and reapplied. If discomfort persists, the prosthetist should be consulted.

MAINTENANCE OF THE PROSTHESIS

When a non-articulating foot is used, there is very little maintenance required for the below-knee prosthesis other than keeping it clean inside and out. Articulated feet generally need to be lubricated at regular intervals. The heel height of the shoe is a very important factor in the alignment of the prosthesis. Therefore, when shoes are changed, it is important that the effective heel height be the same as on the shoes used previously. The effective heel height is obtained by subtracting the thickness of the sole (B) from the apparent heel height (A) as shown below. For the same reason, the heels of the shoes should be replaced frequently so that wear will not result in alignment changes.

Also, a badly worn shoe will increase the wear on a prosthetic foot. Prostheses should not be worn without shoes. Not only will the temporary misalignment cause excessive stress on the stump and knee joint, but the wear on the foot will result in permanent misalignment. Most prostheses are water-resistant but few are waterproof. If the foot becomes wet, the shoe should be removed as soon as possible to facilitate drying. When the amputee has any doubt about the fit, alignment, or condition of the prosthesis or stump, he should consult with his prosthetist immediately.

DEFINITIONS
PREPARATORY PROSTHESIS. An unfinished functional replacement for an amputated limb, fitted and aligned in accordance with sound biomechanical principles, which is worn for a limited period of time to accelerate the rehabilitation process.

Pylon. A rigid member, usually tubular, between the socket

or knee unit and the foot to provide support.

Rigid Dressing. A plaster wrap over the stump, usually

applied in the operating or recovery room immediately following surgery, for the purpose of controlling edema (swelling) and pain. It is preferable, but not necessary, that the rigid dressing be shaped in accordance with the basic biomechanical principles of socket design.

Early Prosthetic Fitting.

A procedure in which a preparatory prosthesis is provided for the amputee immediately after removal of the sutures.

Modular Prosthesis. An artificial limb assembled from

components, usually of the endoskeletal type where the supporting member, or pylon, is covered with a soft foam or other light material shaped and finished to resemble the natural limb.

Definitive, or "Permanent", Prosthesis. A replacement for a missing limb or part of a limb which meets accepted check-out standards for comfort, fit, alignment, function, appearance, and durability, Check or Test Socket. A temporary socket, often transparent, made over the plaster model to aid in obtaining a proper fit. Requirements for a patient to wear prosthesis:

The stump must be well formed and round at the distal end. The stump must be well heeled with no open wounds. Good muscle tone. No Swelling. Full movement of hip and knee. Not more than 10kg over weight. Must be able to have good balance and walk on crutches. Stump must be able to carry weight . Must be motivated. Must be able to afford the prosthesis.

There are more transtibial amputees than any other type. Surgeons preserve the knee joint whenever it is practical to do so and will fashion the stump at the lowest practical level. Very short stumps make fitting extremely difficult and very long below knee stumps are prone to circulation problems. Ankle Foot Mechanisms A variety of artificial foot designs is available, each having its advantages and disadvantages. Feet currently available can be divided into two classes:

Articulated Those with moving joints Non articulated Without moving joints

Articulated feet Articulated feet require more maintenance and are slightly heavier than most non articulated kind. Single Axis The single axis foot (one joint) provides for ankle action that is controlled by two rubber bumpers either of which can be changed to permit more or less motion needed. It is often used to assist in keeping the knee stable. Multi Axis The multi-axis foot is often recommended for people who have to walk on uneven surfaces because it allows some motion about all three axis of the ankle. It is slightly heavier that the other types of feet and is apt to require more maintenance as well.

SACH The simplest type of non articulated foot is the SACH (Soft Ankle Cushioned Heel) foot. The keel is rigid. Ankle action is provided by the soft rubber heel which compresses under load during the early part of stance phase of walking. The rubber heel wedges are available in three densities: soft, medium and hard. The Soft Ankle Cushioned heels feet are joint-less and are generally manufactured out of Pedilen Foam. These feet available on the market are namely the Dynamic and the Dynamic Plus feet. Flex Foot The Solid Ankle Flexible Endo-Skeletal foot has the same action as the SACH plus the ability for the sole to conform to slightly irregular surfaces and thus makes it easier for the amputee to walk over uneven terrain. Feet of this type make walking easier because of the flexibility, and are sometimes called flexible keel feet. Heel Heights The heel height of the shoe is a very important factor in the alignment of the prosthesis. Therefore, when shoes are changed, it is important that the effective heel height be the same as on the shoes used previously. The effective heel height is obtained by subtracting the thickness of the sole from the apparent heel height. For the same reason, the heels of the shoes should be replaced frequently so that wear will not result in alignment changes. Also, a badly worn shoe will increase the wear on a prosthetic foot. Prosthesis should not be worn without shoes. Not only will the temporary

misalignment cause excessive stress on the stump and knee joint, but the wear on the foot will result in permanent misalignment. REHABILITATION In general the earlier prosthesis is fitted the better it is for the amputee. One of the most trying challenges facing the amputee and the treatment team is Edema (or swelling of the stump) owing to the accumulation of fluids. Edema will be present to some extend in all cases, and it makes fitting of theprosthesis difficult, but certain measures can be taken to reduce the amount of Edema. The use of rigid dressing seems to control edema. After the rigid dressing has been removed and when a prosthesis is not being worn, elastic bandages are used to keep the edema from developing. STUMP WRAPPING Wrapping the stump with elastic bandages has a lot of benefits including:

Eliminates swelling. Waiting for prosthesis. Legs not stable yet Get leg in socket every morning. Leg cant fit into socket, have an abrasion and not wearing prosthesis. Stump pain at night.

For the average adult, one or two elastic bandages four inches wide are used. It is important that the bandage is not too tight or too loose. There should be no wrinkles in the bandage and it should be high enough up the leg. There must be no open wounds on the stump while the leg is bandaged.

The stump should be bandaged constantly, but the bandage should be changed every four to six hours. It must never be kept in place for more than 12 hours without re-bandaging. If throbbing should occur the bandage must be removed and rewrapped. Special elastic Shrinker Socks are available for use instead of elastic bandages, and while not considered by some to be as effective as properly applied bandage, a Shrinker Sock is better than a poorly applied elastic bandage.

EXERCISE
Although the below knee amputees have normal knee function, training in their use is necessary if optimum gait and comfort are to be obtained. Early training is provided by the Prosthetist during fitting trails. Physical Therapists usually provide the additional training as required. The new prosthesis should be worn initially for short periods and wearing time increased each day depending upon individual situations.

STUMP SOCKS
Most Prosthetic Socks are woven from virgin wool, but socks of synthetic yarns are also used. They are worn on the stump inside the socket of the prosthesis. Two thicknesses are available in stump socks:

3 Ply; and 5 Ply.

The patient should pull the socks on firmly and evenly so that no wrinkles occur. The seam should not be on any bony areas. Prosthetic Socks must be changed daily to reduce the chance of irritation of the skin and dermatitis.

Socks should be donned in the right sequence to gradually increase the thickness. If the socks thickness goes higher than 15 ply it normally means loss of muscle mass and that a new socket should be constructed. The socks should be adjusted when necessary, normally when fluid changes occur in the stump. Normally in the following circumstances:

Heat Increased fluid intake Non wrapping of leg at night Letting leg hang down without prosthetic Changes in daily activity.

Add sock if:

Excess weight/ pressure under patella Excess weight/ pressure under amputated Tibia Stump feels loose under pressure.

Subtract a sock if:

The stump is not deep enough in the socket Excess pressure at Tibia head

PROSTHETIC HYGIENE
The patient should bathe and wash the stump daily. Preferably in the evening as the irritation might cause swelling and the leg could not fit in the socket. Do not shave the stump as it might cause irritation. Patient should hand wash the stump socks with warm water and non detergent soap. Lay the socks flat to dry. Do not wash

socks in machine or dryer. Wipe out the socket daily with a damp cloth, mild soap or alcohol.
BANDAGING TECHNIQUE

Start with the bandage held in place on the inside of the thigh just above the knee and unroll the bandage so that it is laid diagonally down the outer side of the stump while maintaining about two thirds of the maximum stretch of the bandage. Bring the bandage over the inner end of the stump and diagonally up the outer side of the stump.

Bring the bandage under the back of the knee, continue over the upper part of the kneecap and down under the back of the knee. Bring the bandage diagonally down the back of the stump and around over the stump. Continue up the back of the stump to the starting point on the inside of the thigh and repeat the sequence in a manner so that the entire stump is covered by the time the roll is used up. The end of the bandage is held in place with the special clips that are provided. It is important that the tightest part of the bandage be at the end of the stump. If your amputation is planned, the various aspects and the rehabilitation program will be explained to you. On the other hand if your amputation is the result of an accident or sudden trauma you will not get this information until

afterwards and you will also find that counseling will be offered to help overcome the psychological effects. The rehabilitation team are usually well organised group with a lot of valuable experience who will discuss with you whether a prosthesis is feasible and what type will be suitable. Immediately after surgery, measures are taken to prevent secondary disabilities, especially the tightening of the muscle, tendons, ligaments, or skin that could prevent the normal movement of the hip or knee. Exercises for general conditioning, stretching of the hip and knee, and strengthening of all extremities are started as soon as the you are medically stable. Exercises will be set that you can do in bed or in a chair and you will begin standing and balancing exercises with parallel bars as soon as possible. Generally it has to be recognised that age will play a major part in how much mobility you gain on your new prosthesis and younger people may attain quite high levels. There will be days when your stump is sore or you do not feel so good and a wheelchair will be required instead of your artificial leg. Unilateral amputation (One limb): Walking requires a 10 to 40% increase in effort after below-the-knee amputation and a 60 to 100% increase after above-theknee amputation. To compensate, older people generally walk more slowly. As a general rule, you can achieve most of the things that you could have done prior to the amputation with a well-fitting prosthesis and good rehabilitation. Mobility after a below-the-knee amputation differs greatly from that of an above-the-knee amputation. People who have had a below-the-knee amputation and

are fitted with a prosthesis usually become mobile quite quickly. Elderly people who have had an above-the-knee amputation may find that they do not have the energy, flexibility and skills required to deal with an above-theknee prosthesis and to control the knee joint, and may find a fixed knee easier to use. Bilateral amputation (Two Limbs): Amputation of both legs is not so common and is usually the result of a trauma. As with unilateral amputation, what can be achieved depends on whether the amputations are above or below the knee. If you have a bilateral below-the-knee amputation with well-fitting prostheses you should be able to walk again without a cane. As a bilateral abovethe-knee amputee with prostheses you will probably be able to walk with the support of two canes. Older people with bilateral above-the-knee amputations may not have the necessary energy or strength to walk with prostheses. Amputees with one below-the-knee and one above-theknee amputation can generally walk using the one functional knee joint in the same way that a unilateral above-the-knee amputee with a prosthesis would do. Regardless of the level of the amputations, walking distance is generally limited and a wheelchair may be needed, especially outdoors and for long distances.

Stump Conditioning and Prostheses

Immediately after the amputation the stump will be swollen and it takes a while for this swelling to reduce, usually about a month. To help taper the stump and prevent swelling from the excessive accumulation of fluid in tissue you will be encouraged to wear an elastic stump shrinker or elastic bandages.

Early walking with a temporary prosthesis enables you to be active, accelerates stump shrinkage, prevents joint stiffness, and helps to reduce phantom limb pain. Using a temporary prosthesis or walking aid, you can start walking exercises between parallel bars and progress to walking with sticks until a permanent prosthesis is made. The permanent prosthesis will be made to suit your needs and ability, and you will not get more than you need as every extra bit adds additional weight to the leg. The manufacture of a permanent prosthesis will only take place once the stump has shrunk properly. For most patients with a below-the-knee amputation the prosthesis amounts to a socket, pylon and foot with ankle, that is kept in place by a sock that fits over the knee joint.. For above-the-knee amputees there are several knee options available and the socket is secured by a belt which fits around the waist. There are also silicon suspensions that allow the limb to be fitted with out the need for belts.

Complications
Stump pain is a common complaint and is only felt in the stump. You need to differentiated this from phantom limb pain. Mild to severe pain may be felt when the stump is manipulated by medical staff when being examined or when a prosthesis is used. Pain can also be caused by a socket that is not fitting very well, which may be caused by swelling of the stump or a change in body weight. However, the most common causes are nerve damage or bone formations at the site of the amputation. Nerve ends can be encouraged to settle with well fitting socks, whereas bone formations usually require further surgery.

Phantom limb pain can occur if the patient had a painful condition before amputation, although with good surgery techniques and post operative pain control this can be avoided. Treatments such as simultaneous exercise of both legs, massage of the stump, percussion of the stump with fingers, and ultrasound are effective in reducing or eliminating this condition. Phantom limb sensation is a painless awareness of the amputated limb, sometimes accompanied by mild tingling. Most amputees experience this sensation, which may last several months or years, but usually disappears without treatment. Frequently, amputees sense only part of the missing limb, often the foot, which is the last phantom sensation to disappear. Some amputees can even describe the position of the foot. Phantom limb sensation is not harmful; however, amputees, without thinking commonly attempt to stand particularly when they wake at night to go to the bathroom.