HOSPITAL NACIONAL EDGARDO REBAGLIATI MARTINS

DEPARTAMENTO DE MEDICINA FSICA Y REHABILITACIN

AMPUTACIONES DEL MIEMBRO

INFERIOR Y DISPOSITIVOS
ORTOPDICOS

PRESENTADO POR:
MR E.T.C

Aim of prosthesis fitting

to substitute for a lost part and to

restore lost function.

In the lower extremity

prosthesis must permit
comfortable ambulation
minimal expenditure of energy.

Reduction of energy requirement

depends on minimizing the shift of
the center of gravity of the body
during gait
by a well-fitted socket and proper
alignment.

But for upper limb:

It is difficult to get the function as it
is not possible to replace the
Normal Hand

center of gravity of the

body during gait wheel
does not deviate from
straight line-hence
extreme efficient
Normal human locomotion
>2deviation of CG both
horizontally and vertically
hence also efficient

Power source of prosthesis

Body powered
amputation stump & other limbs
.

More distal the amputation

more the functional ability
( more natural limb
control the prosthesis).

Externally powered
electric or battery
used in the upper limb
prosthesis more.

Level of amputation and prosthesis

Toe disarticulation: toe filling rubber, foam,
wool as spacer to prevent hyperextension of
boot at toe break.
Transmetatarsal amputation: boot with long
steel shank, metatarsal pad and stiff insole.

Lisfranc's amputation: boot filled with stiff

insole
Chopart's amputation:
1. syme's model prosthesis
2. high collar shoe with toe filler

Syme's amputation: syme's prosthesis

Syme's prosthesis should have end bearing pad for
shock absorption. Types
1.full end bearing i.e. Conventional prosthesis:
Has leather socket and wooden foot piece
Most pts are unable tom bear long time standing
and distance walking
2.CANADIAN SYME'S PROSTHESIS: more distal end
bearing and less proximal PTB weight bearing
Medial window is given to pull bulbous end to the
socket. Also provides suspension over malleoli

SYME'S PROSTHESIS
3. closed expandable syme's prosthesis: more
PTB bearing and less end bearing
Prescribed for modified syme's amputation
where the lower end is less bulbous and there
is no need for any window
Advantages: better cosmesis and better
suspension

-Socket
-Suspension system
-Extension joints
(knee assembly)
-Shank/pylon

-Terminal device
(usually includes
foot and Ankle )

Suction&
Mechl close fitting

Socket WT bearing 2 types

1. End bearing

End of the stump bears the weight

2. Total Contact socket

load is distributed to entire stump

supports all the distal tissues within the closed system

As there is total contact proprioception will be good.

give good sensory feed back.

good control of stump

acts as a circulatory pump

. During stance phase , positive pressure encourages venous

return;

during swing phase ,negative pressure encourages distal

blood flow.

Total Contact socket

Used for most older patients
Offers partial suction
Suspended by pelvic belt and hip joint that is
attached to socket
A selsian bandage suspension preferred over pelvic
belt as the latter often interferes with sitting

suspension system -for

attaching socket to
body.
can be done by
a)belt ,straps or cuff

b)others

by suction prosthesis
by Mechanical close
fitting or silicon sock
helps to maintain
airtight seal

Silesian bandage

Hip
joint,pelvicband
waist belt

suspension system-Soft belts

Used as primary or auxiliary suspention
Traditional form is silesian belt
Simple
disadvantage
hygiene if it is non removable
Discomfort due to constrictive effect

Silesian bandage

Total elastic suspension (TES)

New ,made ofelasticneoprene lined with smooth Nylon
Belt fits around proximal 8 of prosthesis

Hip joint with pelvic band or belt

Provides rotational stability
significant mediolateral pelvic stability
Essential when abductors are week
and amputees are obese

Hip joint,pelvicband waist

belt

Suction socket prosthesis

held on by suction and close
anatomical fit
most suitable for above
knee.
eliminates the hip joint and
pelvis belt or shoulder
harness;
permits free rotator motion
about the hip
and eliminates piston action
of the stump in the socket ,
permitting greater toe
clearance and smoother gait.
No stump sock needed.

closely fitted
create negative pressure
during the swing phase
and positive pressure that
expels air through a flap
valve during the stance
phase.
The tight fit is applied at
the upper two and half or
three inches
and along the anterior wall
of the socket, the reminder
stump hangs free.
A groove in the anteromedial
wall accommodates the
adductor tendons.

Suction socket prosthesis

Indicated for
amputees for
smooth residual limb
contours

Volume fluctuants
such as weight gain
and fluid retention

contraindications

Disadvantages
Difficulty in
obtaining press fit
Ocassional lossof
suction in sitting
position
No medium for
absorbing
perspiration
Requirement of
volume and weight
stability

1. Axis system
2. Friction mechanism
3. stabilizers-

 Axis system
Single axis .
Axis of prosthetic knee is same as that of weighty
bearing axis
Flexion easier, But stance phase control difficult

Posterior off set axis

Axis of prosthetic knee is posterior
Flexion difficult, stance phase control easier

Polycentric.
variable center of rotation advantage in both
phases

 Friction mechanism
Constant friction

Hinge to dampen knee swing

Allows single speed walking
Most used in children
Not used for older or weaker

Variable friction-cadence control

Staggerd friction pads

More friction at extreme ranges,

Less friction at mid swing
Allows walkig at more speed ,but not durale
Medium friction
Oil (hydraulic) friction
Air (pneumatic)friction
Allows best gait pattern best for active patients-expensive

Constant friction

Medium
friction
(hydraulic)
friction

Friction mechanism
C-LEG
utilizes electronic
sensors
detect rate and range
of shank
Provides instant
friction adjustments
to changes in gait
pattern

Intelligent prosthesis (IP)

Programmed to each individual
user during walking to achieve
the smoothest, most energysaving pattern.
Reacts to speed changes
Intelligence does not extend to
understanding environmental
considerations
Ex. stairs, ramps or uneven
terrain.

 Stabilizers
Manual locking knee
left locked in extension,
unlocked whole sitting to permit flexion
Used in weak ,unstable patients primarily

Stabilizers
Manual locking

1. Endoskeleton
Modular prosthesis
2,Exo skeleton:

Endoskeleton:
centrally located tubular
structure
made of prefabricated.
Made of carbon fibers
the load bearing structure
The socket used over it
Adjustments can be easily
made
These are called Modular
prosthesis

Exo skeleton:
-conventional artificial
limbs outer visible skin
like
-Inner hollow structures.
-made of aluminum ,plastic
-adjustments are difficult
-accurate measurement
should be there in the
beginning it self.

 Providing contact between to

the ground the foot provides
shock absorption and stability
during stance
influences gait biomechanics
by its shape and stiffness.
This is because the
trajectory of the centre of
pressure (COP) and the angle
of the ground reaction forces
is determined by the shape
and stiffness of the foot and
needs to match the subjects
build in order to produce a
normal gait pattern.

The main problem

found in current
feet is durability,
endurance ranging
from 1632 months [
These results are
for adults and will
probably be worse
for children due to
higher activity levels
and scale effects.

Non articulated
articulated

Non articulated

Ex:1)sach Foot
(solid Ankle cushion Heal)
2)Madras foot
-modified sach
Post TA like look
-sponge between heel&ground
3)Jaipur foot
4) dynamic
-new
-spring in kee
l-energy stored and released

Articulated

SINGLE AXIS
MULTI AXIS

SACH Foot
(solid Ankle cushion Heal)
Some movementt in all directions
Useful when not used for heavy duty
Women/children
Not suitable for indian amputies
barefoot/squating cannot

Jaipur foot
Mcr&vulcanised rubber
Looks natural
Bare foot
walking/squating
possible/crossleg/rough
use
3level movmt
Inv/eversion possible
hence can walk on
uneven area
Cheap-durable-water
resistant

Single axis ankle and wood foot

Heavy duty activities, rapid plantar flexion at heal
strike

Commonly used varieties of prosthesis

AK prosthesis
preferred design quadrilateral socket
pelvic belt
Suction prosthesis

BK prosthesis
Patellar tendon bearing
Mechanical Fit
or with bar suspension system

Commonly used varieties of prosthesis

AK prosthesis
quadrilateral socket
medwall high,latwall flat10
deg adduction med inclination

pelvic belt
Suction prosthesis

BK prosthesis
Patellar tendan
bearing
60%pt 40% condyles,post wall
Med flare oftibiaalso wt bearing

Mechanical Fit or
with bar suspension
system

Slide the CROW into position,

ensuring that the heel is fully
seated within the CROW
The heel needs to be back all the
way and in contact with the
bottom of the footplate.
Check by looking along the sides
and the back where it is
separated above the heel.

Apply the front section of the

device,
making sure it's sides overlap
the back section

Apply the instep strap on

the front of the ankle

Fasten all remaining straps

Skin should be checked

for redness that does not
go away after
approximately
15 minutes.
Slight redness is common
over the instep and under
the ball of the foot.

The main objectives of the good

construction of the lower limb
prosthesis is to provide and ensure for
the user sufficient certainty, stability,
balance, and comfort during the stance
and during the walk to minimize the
energy cost and gait asymmetry.

Typical transtibial prosthesis

consists of a prosthetic foot, tube

adaptor, and transtibial socket

Typical transfemoral prosthesis

consists of a prosthetic foot, tube

adaptor, prosthetic knee joint, and
transfemoral socket.

Lower limb prostheses can be

exoskeletal (prosthesis with the

peripheral weight-bearing capacity, the
use of which facilitates the transfer of a
patients weight to the ground along the
devices circumference)

Most frequently used endoskeletal

modular (prosthesis with the central
weight-bearing capacity, the use of
which facilitates the transfer of a
patients weight to the ground a tubular
structure in the prosthesis centre).

Health condition assessment and

assignment to a functional regime is
carried out considering the following
aspects:
1. assessment of cardiovascular apparatus
efficiency, especially in terms of load tolerance,
2. muscular power of a person insured, muscle
tone, and locomotor finding,
3. self-sufficiency when applying an orthopaedic
prosthetic device,

4. mobility of a person insured with an

orthopaedic prosthetic device,
5. local finding on a residual limb and a
residual limbs bearing capacity,
6. psychological preconditions for the use
of prosthesis.

CONSTRUCCIN DE LA PRTESIS

In majority of individuals with both limbs,

the weight is distributed in the 50:50
ratio which facilitates ideal symmetric
loading of lower limb joints.

With amputations, the load is often

transferred through the tuberosity of the
ischium which is unsuitable due to
changed position of the centre of gravity
in the frontal plane; the centre of gravity
is moved laterally to the healthy limb
side.

By proper construction and a suitable

selection of components it can be
arranged that the TF prosthesis
transfers at least 40% of the individuals
body weight.

Stabilizing activity of the limb/prosthesis

depends on the amputation height, i.e.
on residual muscles that remained on
the residual limb.

Factors for the creation of

properly functioning prosthesis
1.- Selection of appropriate
components that depends primarily on
the physical and mental condition of the
user, users activity, and method of use.

The principal factors for the selection of

prosthetic components are:
patients weight
physical activity.

 2.-

Residual
limbs
conditions,
amputation height, residual limbs shape
(conic smaller circumference on the
distal part than on the proximal part,
pear-shaped, cylindrical the same
circumference on the distal and proximal
end), amputation scar, as well as other
problems or diseases.

Steps:
Basic construction
2. static and
3. dynamic correction
1.

when the prosthesis is constructed, it

should run through the centres of joints
of one limb.

Load line:
1. 2mm posterior from the hip joint,
2. 15mm anterior from the knee joint and
3. 60mm anterior from the ankle joint.

In the first phase, it is crucial to

determine the construction line (Fig. 4),
which is an arbitrary vertical line towards
which individual prosthesis components
are positioned according to certain rules
(Table 2).

Table 2 Positioning of components

according to certain rules
1.- BASIC CONSTRUCCIN

TT

TF

TF

2.- STATIC CORRECTION

TT

TF

In the static adjustment, it is important to

adjust the correct prosthesis length so
that both limbs are evenly loaded and
the pelvis is leveled.
Negative effect on the stance with a
prosthesis is influenced by the shift of
the load line caused by the plantar
flexion of the foot or moving the foot
forward.

3.- DYNAMIC CORRECTION

When a patients gait is assessed in the

sagittal and frontal planes, deviations
from the normal step cycle are
examined.
The deviations can be caused by
improper construction of the prosthesis
or by physical deficiencies, as well as a
patients mental condition.

During the gait with a prosthesis, the

first contact of the foot and the ground is
important, as well as transfer of load on
the foot.

The foot contact is carried out through

the heel so that the walking is as natural
as possible, and subsequently the entire
sole surface contacts the ground and
the load is transferred to the foot.

It is followed by the foot rolling away

from the ground and the push-off
through the toe, when the energy is
required for the swing phase.

In this phase, the important role is

played by the proper selection of a foot
(foot roll away from the ground,
adaptation to the surface, compensation
movements, energy accumulation and
expenditure) and a proper position of the
knee joint.

Particularly these components (foot and

knee joint) and their proper assembly
affect the final function of the prosthesis
and thus influence the users activity.

In the swing phase, the knee function is

important, as it is necessary to ensure
the movement from flexion to extension
(extension moment of the knee) which
facilitates the foot transition from plantar
flexion to dorsal flexion, i.e. the toe
elevation,
in
order
to
avoid
stumbling(tropiezos) and subsequent fall
of the user [1].

Biomechanics of the socket

The residual limb is placed in the socket

that provides rigid and stable attachment
to the limb, which is important for the
control thereof. The prosthesis socket
(Fig. 7) can be divided into 3 parts that
have different functions.

The top part is the so-called seating face.

The central part is actually the controlling
socket area with the function to ensure
correct movement and restrain it in the P-A
direction, which is important during the gait.
The last part is the distal socket end which,
in an ideal case, should transfer only 10%
of an individuals weight to avoid
inappropriate load transfer and subsequent
damage to soft tissues.

A socket must be able to

transfer the load,
ensure stability,
and provide efficient control during the
mobility.

In a standing position, the m. gluteus

medius is stretched; it ensures that the
pelvis is maintained in a balanced
position.
In a healthy individual, this process is
ensured by attaching the femur to the
ground by a lower limb
In case of the lower limb amputation,
this function is taken over by the
prosthetic socket.

Therefore, proper socket shape is

important, as well as its ML (mediallateral)and
AP
(anteroposterior)
dimensions, so that the femur can be
attached.

In a transverse oval socket of

transfemoral prostheses, the pressure
on the distal femur end increases and
the body is excessively bending aside to
reduce the pressure (Fig. 8 left, middle).

It is a non-physiological load transfer, as

the load is transferred through the
tuberosity of the ischium, which reduces
the arm of the exerted force and the
overturning moments are increased (Fig. 8
right ).

On the contrary,
the longitudinal oval socket facilitates
the physiological transfer, as the rotation
centre is in the hip joint and the pelvis
does not turn over (the pelvis is in a
balanced position) and no unnatural
stabilisation body movements are
required [5].

Ideal Orthosis / Prosthesis

Functional
Fits well
Light in weight
Easy to use
Cosmetically acceptable
Easily maintained/repaired
Ideally locally manufactured

PROSTETIC OPTIONS

*Wedge: a heel all the way under the shoe

BALANCE

GAIT

PROSTETIC OPTIONS
PROSTETIC OPTIONS

BALANCE

GAIT

BALANCE

GAIT

The six different

types of rocker
sole.
A, Mild.
B, Heel-to-toe.
C, Toe only.
D, Severe angle.
E, Negative heel.
F, Double.

* resilient: able to q
uickly return to a previous good condition.
* fastening: a device on a window, door, b
ox, etc. for keeping it c
losed

PROSTETIC OPTIONS

Keel= quilla

BALANCE

GAIT

Usual Shoe modifications

Heel Raise
Total Raise
Arch Support
Thomas Heel
Reverse C&E Heel
Sole Wedge
MT Bar
Toe wedge
Wedge: a piece of something, especially food, in
the shape of a triangle:

Floor Reaction Orthosis

Foot
Jaipur foot

Sach foot

Type of Lower Limb Stumps

End

Bearing stump

Side

bearing or Total

Contact

B.K. Prosthesis
Components
Suspension

Socket
Shank/Shin piece
Ankle and foot

Assembly

Suspension

Flexible
Cuff

A. Supracondylar
B. Sleeve
C. Suction

Brim Contour

A. Supracondylar
B. Supra Pateller
Thigh corset consists of
- 2 Metal Bars with knee joints
- Corset- Leather/Plastic

Socket
Hard socket for ideal B.K. Stump
Hard Socket with inner lining
Weight Bearing
Anteriorly
- Lower 3rd of patella

- Ligamentum patellee, tibial tuberosity

Posteriorly
Laterally

- Pop. Fosa
- Lat. condyle of tibia and head

of fibula

Medially

- Med.condyle of tibia

Shank/Shin Piece
Exoskeleton - Plastic resin and
wood
Endoskeleton - Metal/PVC tube

Ankle Foot Assembly

Non Articulated

Articulated
Single Axis

SACH
SAFE
STEN
CARBON COPY II

Multiple Axis

Above Knee Prosthesis

Components
Suspension
Socket

Knee Joint
Shank/Shin piece
Ankle foot assembly

Suspension
Suction
Silesian

belt
Pelvic belt with hip joint
Shoulder suspendor

Socket
Quadrilateral

used
Total

contact

- Commonly

Knee Joint Assembly

Conventional single axis knee - commonly used

Polycentric knee joint

Constant friction knee

Constant friction with friction lock

Syme Prosthesis
Conventional End weight bearing : Leather/plastic socket attached to SACH
foot
P.T.B. Syme prosthesis : - When heel pad
is not sufficient for weight bearing than P.T.B.
type Syme prosthesis is given.

Specifications of
Intelligent Knee Prosthesis

Vid 01

mg 21-22-23-24-25

DEC-2009

mg 26

107

Devices on the market

Competing companies&Products

The Icelandic company Ossur

Rheo Knee
The German company Otto Bock
C-leg

The Japan company Nabtesco

Hybrid Knee

mg 27

mg 29

mg 31

mg 28

DEC-2009

mg 30

mg 32

108

Devices on the market

Competing companies&Products Contd

Comparison Among High-end Knee Joints [8]

Hybrid-Knee
mg 33

C-Leg

mg 28

mg 32

mg 34

Rheo Knee

mg 35

Knee Weight

300

Weight Limit

125kg for up to K3, for K4

Frame:100kg

Max. Flexion Angle

Swing Phase Ctrl

PneumaticMicroprocessor

Magnetic FluidMicroprocessor

HydraulicMicroprocessor

Very Wide Cadence Responsive,

Smooth

Artificial Intelligence functionAI

Strong Extension Assist

HydraulicMRS

Magnetic FluidMicroprocessor

HydraulicMicroprocessor

Rotary-unit provide resistance whole

range of knee bending

Resistance of Magnetic Fluid is

relatively weaker than normal hydraulic
one.

Second Mode is available

Battery Life

For 2 yearsw/o Recharging

daysrechargeable

daysrechargeable

When Battery is
Flat

SW Normal Pneumatic Knee

ST: Keep same function

SWFree Motion
STNo Resistance (Dangerous)

SW: Lock Knee

ST: Lock Knee

Gait Sensor

MRS-SystemMechanical, Built-in

Strain GaugeBuilt-in

Strain Gauge Pylon

Adjuster

Compact Adapter

Pocket PC

PC

Stance Phase Ctrl

DEC-2009

mg 30

109
109

Specifications of
Intelligent Knee Prosthesis

Vid 01

mg 21-22-23-24-25

DEC-2009

mg 26

110

Devices on the market

Competing companies&Products

The Icelandic company Ossur

Rheo Knee
The German company Otto Bock
C-leg
The Japan company Nabtesco
Hybrid Knee

mg 27

mg 29

mg 31

mg 28

DEC-2009

mg 30

mg 32

111

Devices on the market

Competing companies&Products Contd

Comparison Among High-end Knee Joints [8]

Hybrid-Knee
mg 33

C-Leg

mg 28

mg 32

mg 34

Rheo Knee

mg 35

Knee Weight

300

Weight Limit

125kg for up to K3, for K4

Frame:100kg

Max. Flexion Angle

Swing Phase Ctrl

PneumaticMicroprocessor

Magnetic FluidMicroprocessor

HydraulicMicroprocessor

Very Wide Cadence Responsive,

Smooth

Artificial Intelligence functionAI

Strong Extension Assist

HydraulicMRS

Magnetic FluidMicroprocessor

HydraulicMicroprocessor

Rotary-unit provide resistance whole

range of knee bending

Resistance of Magnetic Fluid is

relatively weaker than normal hydraulic
one.

Second Mode is available

Battery Life

For 2 yearsw/o Recharging

daysrechargeable

daysrechargeable

When Battery is
Flat

SW Normal Pneumatic Knee

ST: Keep same function

SWFree Motion
STNo Resistance (Dangerous)

SW: Lock Knee

ST: Lock Knee

Gait Sensor

MRS-SystemMechanical, Built-in

Strain GaugeBuilt-in

Strain Gauge Pylon

Adjuster

Compact Adapter

Pocket PC

PC

Stance Phase Ctrl

DEC-2009

mg 30

112

GRACIAS