Well explained slides about lower limb prosthesis of knee and hip after transfemoral ans transtibial amputation. Hip disarticulation and bilateral amputation not discussed
2. PROSTHESIS
Device to replace part of the limb or complete limb
“substitute”
Prosthetist: Health care professional who designs, fabricates and fits limb
prosthesis
3. Aim of prosthesis
To substitute for a lost part
To restore lost function
Comfortable ambulation
Minimal/reduce of expenditure of energy
Minimizing the shift of the center of gravity of the body during gait
4. GOOD STUMP
Proper length
Proper shape
Complete skin coverage
Healthy scar
Good muscle power
Good range of motion for joints
No neuroma
No phantom pain or sensation
5. PREPROSTHETIC TRAINING
Training in
Active rom exercise
Proper positioning of stump
Muscle strengthening
Skin care
Crutch training
Wheel chair training
Self care
Patient and family education
6. PROSTHETIC TRAINING
Prosthetic fitting – alignment check , pressure point relief , color check
Donning and doffing caring
Skin care training
Gait training
Maintenance of prosthesis
7. IMMEDIATE POST OPERATIVE
PROSTHESIS
Described by Berlemont
On conclusion of amputation temporary prosthesis given
Most common – rigid plaster cast molded like PTB to which pylon and foot attached
Physio started in 24-48 hours
8. Advantage
Reduce edema and pain
Prevent muscle contracture and atrophy
Reduce chance of phantom pain and speeds up rehabilitation
Disadvantages
Increased chance of wound gaping
Delayed wound healing
Infection
10. TRANSTIBIAL AMPUTATION .
Ideal length- five inches from tibial tubercle
Minimum length – two inches from tibial tubercle
Types
Ultra short (below tibial tubercle)
Short(upper 1/3rd tibia)
Standard (junction of upper and middle 1/3rd )
Long(jun of lower and middle 1/3rd)
Wound healing inversely related to length of stump
12. SOCKET
Encloses the stump
Forms connection b/w stump and artificial limb
Protects the stump and transmits forces
PLUG FIT SOCKETS – open ended and stump fits in like
a plug fits in drain
14. Conventional Below Knee Socket
Used in elderly patients with unstable knee
Person with quardriceps weakening
Fabricated like no pressure over distal tibia ,
fibula head and tibial crest
Requires external knee joint and thigh corset
Disadvantages
Skin irritation from friction
Stump chocking by edema by constriction from
superior portion socket
15. PATELLAR TENDON BEARING SOCKET
To load the weight in pressure tolerant areas like patellar tendon and medial tibial
flare.
Commonly used
Total contact socket
60 % weight – patellar tendon
40% - medial tibial flare
16. Name – because of BAR that is built in to patella tendon (midway b/w
patella and tibial tubercle)
Socket aligned at 5° of knee flexion
lateral and posterior brim – level of adducter tubercle
Posterior brim – proximal to patella bar to provide stability
and to prevent the limb from sliding too far to socket
17. TOTAL SURFACE BEARING SOCKET
To distribute weight over entire surface of limb
Strategic allotment of weight by molding the contours
according to type of tissue and anticipated loading.
18. PATELLAR TENDON BEARING SUPRAPATELLAR
SUPRACONDYLAR SOCKET
Anterior trim line – suprapatellar
Medial and lateral – supracondylar
Gives good suspension
Forms quadriceps bar
In patients with short stump and genu recurvatum
19. SLIP SOCKET
Two layers
External – wooden or plastic socket
Internal – fine leather
Uses
Short stump
Painful scars
20. BENT KNEE SOCKET
Indication – patients having FFD of stump
Up to 20 ° can be accommodated
21. INTERFACE MATERIALS
Separate limb from socket
Mimic soft tissue to provide extra cushioning
Advantage
Provide shock absorption
Protect from shear forces
Wicks away moisture
Types
Socks and sheaths
Inner gel foams
Flexible inner socket
22. SUSPENSION
The method of connecting a prosthesis to residual limb
Suspension designed according to activity level, comfort and safety
If suspension not adequate – motion occur between socket and limb – called
pistoning
23. SUSPENSION - TYPES
SUPRACODYLAR CUFF
In cooperates prosthesis to supracondylar region
Most common
Closed by velcro or buckle closure
With PTB called PTB SC
30. Osseous Integration :-
Direct structural and functional connection between living bone
and a prosthetic device.
Eliminates the need for a traditional socket-type prosthesis
Surgically implant a rod in the bone that can connect to any
prosthesis through an external connection.
31. SHIN PIECE
Substitute for the human leg
Transmit body weight from the socket of the prosthesis to the prosthetic
foot.
Types
Exoskeltal
Moulded Hard plastic shell
Disadvantage – fixed alignment after finishing.
32. Endoskeletal
Modular in type
Has pylon (shape of skeleton)
Cosmetic foam in shape of leg.
Adv – lighter , cosmetic, alignment after finishing , parts can be changed
33. ANKLE FOOT ASSEMBLY
Designed to provide support during standing/walking and shock absorption as well
Types
SOLID ANKLE CUSHION HEEL (SACH)
SINGLE AXIS FOOT
MULTI AXIS FOOT
SOLID ANKLE FLEXIBLE KEEL FOOT
ENERGY STORING FOOT
34. SOLID ANKLE CUSHION HEEL (SACH)
Commonest one
No ankle joint
Solid heel made of wood or metal
Cushion heel – rubber heel edge or alternating hard
and soft rubber layers
Cushion heel compresses during heel strike –stimulate
plantar flexion
Light weight , durable and little maintenance
Modifications - MADRAS FOOT/ JAIPUR FOOT
35. MADRAS FOOT
Modification of SACH
Space between heel and ground filled with sponge rubber
Toes shaped like normal
Tendo achilles like shape made
Rubber sole for bare foot walking
36. JAIPUR FOOT
Solid ankle joint
Made of galvinized rubber with shaping of toes
37. SINGLE AXIS FOOT
Have bumpers made of hard rubber
When heel strikes plantar flexion and then foot flat
38. MULTI AXIS FOOT
All movements possible
Good shock absorption
Good for walking in uneven surface and even in scarred stump
39. SOLID ANKLE FLEXIBLE KEEL FOOT
Similar to SACH
Use flexible keel
Good shock absorption
In obese ones
40. ENERGY STORING FOOT
Dynamic response foot
Shock absorbing leaf spring or carbon steel used
Absorb energy on heel contact
Release in terminal stance providing propultion
42. KNEE DISARTICULATION VS
TARNSFEMORAL AMPUTATION
KNEE DISARTICULATION TRANSFEMORAL
RESIDUAL STUMP LONG AND BULBOUS SHORT AND CONICAL
DONNING DIFFICULT EASY
SUSPENSION ENHANCE – DUE TO SHAPE CHALLENGING
PROSTHETIC KNEE CONTROL EASY DIFFICULT
ENERGY COST FOR
AMBULATION (inv to length)
LESS MORE
44. TRANSFEMORAL AMPUTATION -
PRINCIPLES
Amputation between femoral condyles and greater trochanter
Preserve as much as length as possible
Countering abduction force of G. MED and G.MIN – suturing adductors to femur
46. SOCKET
Quadrilateral Socket
By UNIVERSITY OF CALIFORNIA
Have four distinct walls
Flat posterior Ischial seat – major weight bearing area
To give weight during stance phase
47. Anterior wall contoured to direct force posteriorly to Scarpa’s
triangle –to keep ischium in position
A-P dimension narrowed than M-L dimension
48. ISCHIAL CONTAINMENT SOCKET
Different types – depends on structures contained
A-P dimension more than M-L dimension to prevent
abduction
CAT – CAM- contoured anterior trochanteric controlled
alignment method- to maintain femur in adducted
position and to control socket rotation by containing
ischial tuberocity
49. QUARDRILATRAL SOCKET ISCHIAL CONTAINMENT SOCKET
Ischial seat for weight bearing No ischial seat
Weight bearing area less More weight bearing area
Lateromedial dimension more Lateromedial dimension less
A-P dimesion less A-P dimension more
Poor pelvic control and rotational Good pelvic control and rotational
stability
Less energy efficient more energy efficient
In standard stumps In short stumps and gluteus medius
weakness
50. MARLO ANATOMICAL SOCKET
Provide skeletal support along medial ischio ramal complex
Encapsulate ischial tuberocity and ramus
Low posterior and gluteal trim line.
Allow to sit on gluteus maximus
51. ELEVATED VACCUM SOCKET
Low trim lines(subischial)
Good comfort and rom
2-4 inches below ischial tuberosity
52.
53. SUSPENSION
Traditional pull in suction suspension
Roll on suspension liners
Shuttle lock systems
Cushion liner with air expulsion valve
Silesian belt
Total elastic suspension belt
Pelvic belt
55. KNEE JOINT PROSTHESIS- TYPES
SINGLE AXIS KNEE UNITS
Simple hinge
Fixed center of rotation
Cadence responsive minimal
Allow flexion and extension
No mechanical stability
Give support during stance not during swing
Light weight , durable and low maintanace
Not good for ones having short stump
For patients with primary residual limb who can voluntary stabilize the knee through active hip
extension against posterior wall of prosthesis
56. POLYCENTRIC KNEE JOINT
Moving center of rotation
Rotates in more than one axis
During swing phase, it leads to shortening of distal prosthesis enhancing toe
clearance
Good for long residual limb or knee disarticulation patients
Good stance phase stability – so in short stump ones and hip extensor weakness
patients
Less durable than single axis
57. WEIGHT ACTIVATED STANCE CONTROL
KNEE UNITS
Braking mechanism when weight applied
To prevent unwanted knee flexion while standing
Can be adjusted according to individual pattern
If initial contact made when knee not completely extended (in
uneven surface) provides additional stability and prevent buckling
Acts like single unit in swing phase
For recently amputated ones , short residual limbs and extensor
weakness
58. MANUAL LOCKING KNEE UNITS
For ones who rely on stability during stance
Single axis knee with a locking mechanism
Locks when knee fully extended
Compromise toe clearance in swing
So less height than contralateral leg
Usually walk with knee locked in extension
59. HYDRAULIC KNEES
Cadence responsive good
Provides frictional resistance by the flow of hydraulic fluid
Provides variable resistance – provides almost a normal gait
High cost , higher maintenance needed , weight and difficulty
during cold time
SNS system – swing and stance control system – weight
bearing stance control and swing phase controll
60. PNEUMAIC KNEE PROSTHESIS
LIKE HYDRAULIC
Less weight , maintainance cost less
Less cadence control than hydraulic
61. INTELLIGENT PROSTHESIS PLUS
Microprocessor swing phase control knee
Sensors monitor knee position during swing and pressure sensors detecting
ground related forces during stance
62.
63. TRANSVERSE ROTATORS
To sit crossed leg.
External button pushed to unlock it
gets locked automatically when knee back to neutral
64. COMPLICATIONS
General Issues
• Choke syndrome
• caused by obstructed venous outflow due to a socketthat is too snug
• acute phase
Red indurated skin with orange-peel appearance
chronic phase
hemosiderin deposits and venous stasis ulcers
65. Skin problems
Contact dermatitis
most commonly caused by liner, socks, and suspension mechanism
treatment
remove the offending item with symptomatic treatment
Cysts and excess sweating
66. Painful residual limb
possible causes include bony prominences, poorly
fitting prostheses, neuroma formation, and insufficient
soft tissue coverage
Total contaat csupposed to be no voids or air pockets between limb and socket.. To increase the surface area of residuum to avoid the need of thigh corset and external knee joint
5 flexion allow ba rto act as weight bearing. Tibia medial side broadens and when lateral pressure given can accept loading.
Strategic allotment of weight ore to soft tissue and less to bony primence. While wlaking neg oreseuure at a swing to high pressure during stance, . Also shear and normal forces act. Shaer imited by interface. Normal force acts opposite.
Sp gives med lat stability. 2cm proximal to condyles. So no movement. Ptb sc difficukt to don because f size diff.
Long found that the amputess have trendelenberg gait and not at abducted. So longs decided
Post wall up to ischail tube , ant wall 5 cm above post wall, lat up to ant wall ,
Limb have tenderlelenbrg gait and muscle function noyt good. So ivan long thouhjt bt laertla shift during walkin and he thought aligning femur end through mid f knee and ankle it can b ceared. He incred ap and educed ml.
Silesian belt can cause rotartion . Tesb distal one at proximal part of the stump and the proximal around the waist. Old age people and for . Pb and hj provide rotation stability
(the forward speed of shin changes when gait speed changes)
