PROSTHESIS

Presented by
Dr. Chiranjeevi.J
MPT Neuro, FNR
 Prosthesis
 Prosthetics deals with the prescription, design,
fabrication & fitment of artificial limbs in a scientific
manner. Any artificial substitute which is meant to
replace the lost part of the body is called prosthesis.
 These may be internal or external.
 External prosthesis are artificial lower & upper limbs,
dentures & artificial eye.
 Internal prosthesis is replacement prosthesis for
joints & heart valves
 Prosthesis is given in cases of amputation. After
amputation these devices are used to replace the missing
part.
 Before fitting the prosthesis we have to assess the stump.
 Cause of the amputation
 Associated diseases
 Skin- ulcer
 Scar (adherent, healed)
 Sensation (absent, diminished,
hyper aesthesia)
 Circumference bulk, wasting, edema.
 Shape (conical, quadrilateral)
 Temperature
 Pain (type, location, duration)
 ROM of residual limb (remaining joints) &
other extremity (major joints)
 Muscle strength of major residual muscles
groups, other extremities.
Classification of lower limb
amputation:
Due to medical considerations the part of the limb or the whole
limb is amputated.
The classification of classical lower limb amputations is:
 hemipelvectomy (hind quarter amputation)
 Hip disarticulation.
 Above knee amputation.
 Below knee amputation.
 Simi’s amputation. (ankle level)
 Choparts amputation. (mid tarsal level)
 Lisfranc’s amputation. (tarso metatarsal level)
 Disarticulation of toes.
BIO engineering principles in the
fitting of artificial limbs for Amputees

 The application of bio engineering principles

for the study of ambulation and limb fitting
techniques are
 Modern surgical procedures in amputation
 Shape of Socket of artificial limbs
 Alignment studies of Artificial limbs
 Modern Surgical Procedures in
Amputation

 The criteria for selecting the level of amputation of a

limb are the extent of the disease or trauma and the
status of the vascularity.
But the consideration has to be given for
Length of the Stump
 Longer the stump, better in the leverage. It is easier
to stabilize an artificial limb with a longer stump
than with a short one. Hence, the surgeon aims for
the longest possible stump preserving as much vital
tissue as possible instead of selecting sites of
election for amputation
Preservation of Functioning Joints:
 It is necessary to preserve the joint as much
as possible. No mechanical joint can replace
human joint in efficiency , control, stability,
wear and tear to an equal extent. Loss of
joints results in instability due to the changes
in the line of weight bearing and centre of
gravity.
Preservation of stump musculature:
 For effective manipulation of an artificial limb, it
is necessary to have a good stump musculature and
good power. This is often achieved by special
surgical techniques, such as suturing the muscles in
an orderly way and fixing the muscles at the cut end
of the bone which is called as the “myodesis”
technique. It is made more powerful with a good
post-operative physiotherapy. Such as stump has
maximum dynamic power to operate an artificial
limb.
 Shape of socket of artificial limbs:
 For achieving maximum comfort and good
stability of the amputee with an artificial limb.
The shape of the socket should be:
– confirm to the shape and counter of the stump.
– Accommodate the differences in relative firmness
of the tissues of the stump.
– Accommodate for different tolerance to pressure.
– Have a relative inclination of supportive surface.
Alignment studies of artificial limbs:
 Alignment refers to the relative position of the
various parts of the prosthesis with respect to each
other. The alignment influences the magnitude and
distribution of forces applied to the stump by the
socket. Unless the alignment is perfect, the patient
cannot walk with a normal gait.
 Alignment has to be checked and adjusted in two
planes.
1.medio-lateral alignment
2. Anterior posterior alignment
 This is carried out by inserting an alignment device
below the socket. By making the amputee walk with
the trial limb alignment device in various positions
and maximum comfortable position in determined.
 During the final check out of the prosthesis the
alignment is rechecked. The position of the pelvic
band, the position of the joints and the line of weight
bearing are verified to see that they confirm to the
normal anatomical relationship.
Stump exercises
 Exercises for the stump are started even from the
third day after amputation. They are very essential
as they prevent many of the complications during the
post operative period.
 Free exercises are advocated which helps in wound
healing by improving activity and circulation.
 In case of bilateral amputee, hydrotherapy is of great
valve. Bilateral lower limb amputees should develop
the upper limb muscles well.
 Unilateral lower limb amputees have to develop the normal limb
also.
Isometric exercises for:
 Quadriceps in below knee amputations:
 Hip extensors & adductors in high AK Amp.
 Hip extensors & abductors in low AK Amp.

 Upper limb amputees are given intensive physiotherapy to

improve the muscle power in the elevators, depressors,
protractors, retractors of the shoulders. Because these groups
help the functioning of prosthesis.
Advantages of stump exercises:
 Increases the circulation in the stump & aids wound
healing.
 Promotes the venous drainage & prevents edema
of the stump.
 Prevents the development of stump deformity.
 Prevents joint stiffness.
 Keeps up & promotes the muscle power of the
stump.
 Prevents the phantom limb pain or phantom pain
sensation.
Classification of prosthesis.

 Prosthetic construction design is of:

 exoskeletal.
 endoskeletal.

Exoskeletal Prosthesis:
 Gains structural integrity from the outer laminated
shell. Usually made of resin. Which is quite durable,
over a filler material of wood or foam, which has
been shaped to provide cosmetic appearance of
prosthesis?
 Endoskeletal prosthesis:
 This is more modern in design. This was light
internal modular components & tubing to
provide strength & weight bearing
capabilities.
 It gains its structural integrity from the inner
endoskeleton-a pylon made of metal or
carbon fiber
 Materials used:
 Wood - Has several advantages; it is light weight, strong &
easy to work on.
 Leather – is soft, natural & biocompatible. It is however
expensive.
 Cloth - keeps skin dry, and acts as a cushion for the limb, by
absorbing shear forces.
 Plastics – increase strength & elasticity, but are unfortunately
not biocompatible. Many like polypropylene & polyethylene are
durable, cheap and easy to mould.
 Fiber glass- which is light in weight, but expensive.
Parts /components of prosthesis:

Lower limb.
 Suspension system.
 Socket
 Knee setup
 Shin piece
 Foot piece.
Suspension system:
 The prosthesis is suspended by means of
following suspension systems;

In case of below knee prosthesis:

 supra condylar cuff (PTB)
 supra condylar wedge & walls (PTS)
 a thigh corset (BK)
Above knee prosthesis:
 1. Socket is the important
part of the prosthesis which
connects the stump to the
prosthesis. The sockets
are either carved or
moulded
 .knee setup it consists of knee block knee
axis & a shank. The extension of the knee is
limited to 180 degrees by the extension stop
with in the unit. It should provide stability
during the early & middle part of the stance
phase & must allow bending during the latter
part of stance & swing phase as well as in
sitting & kneeling. It should be durable,
comfortable & cosmetically acceptable.
I.e. they can be fabricated either by wood or by
plastics.
 If wood is used the distal end of the socket is
open & continues to shank or shin. When
plastic is used the distal end is covered.
There are two types of knee axis:
 Single axis unit,
 Polycentric knee.
 The advantage of polycentric knee over a
single axis knee is that it is more stable when
loaded. It is employed for extremely short
above knee stump or bilateral above knee
amputation
 Shin piece (Shank)

The shank of the prosthesis may be made entirely of

wood except for its covering. Plastics/metal is used.
It holds the foot ankle assembly and socket in a fixed
relationship. The exterior finish of the wood shank is
usually an appropriately colored plastic laminate.
This has the advantages over the glued raw hide
covering. It provides:
 greater strength
 moisture resistance
 Uniformity of colour.
 Foot piece:
 The two most commonly used foot pieces are
– Single axis unit.
– SACH foot.
 Single axis unit: it consists of ankle joint which permits the
movements around one axis. 15 degrees of PF & 5 degrees
of DF.
 This range is achieved by the action of PF bumper which
corresponds to the action of the DF of the foot in the intact
limb & by the action of the DF bumper corresponds to the
action of the PF of the foot.
SACH/Rubber foot (Solid Ankle
Cushion Heel)

It allows some motion in all directions.

The cushion heel is available with
different degrees of compressibility
hard, medium & soft. It is selected on
the basis of the amputation level, body
built & ability to control prosthesis.
Advantages of SACH foot:
 It is simple
 Little maintenance
 Good appearance
 Quiet in operation
 Gait is near normal.
Double axis ankle:

 Double axis ankle poses the same PF & DF

as the single axis ankle. In addition it has a
second axis which permits inversion &
eversion of the foot.
 There four motions permitted are limited by
corresponding bumpers.
 It accommodates better to uneven ground
and permits greater stability in placement of
the foot both in standing and walking.
The disadvantages are:

 Bulkier
 Heavy
 Requires more maintenance
 Noisier
Prosthesis for Hemipelvectomy &
Hip disarticulation amputations.

Hip disarticulation
amputees comprise less
than 2% of total amputee
population. The two types
of conventional limbs are
 Saucer type
 Tilting table type.
Saucer type hip disarticulation prosthesis:
 It consists of a shallow socket (saucer type) hip joint
with pelvic band usually hip & knee lock is employed
for better stability. Suspension by a pelvic band &
single axis hip joint could be augmented by shoulder
straps. The stump tends to rotate with in the shallow
socket & the amputee sits directly on his buttocks
thus maintaining his buttocks thus maintaining pelvis.
Tilting table prosthesis
 It is similar to the saucer type of prosthesis
except the design of the socket. A leather or
plastic socket encases the stump & is
suspended by a pelvic belt & occasionally a
shoulder strap.
Canadian type H.D.P
 It is most commonly used. It is more functional better
looking and more comfortable than the saucer and
tilting table types.
 Design of the socket: the proximal brim of the socket
is brought as high as the 10th rib. The opening for
donning is made in the lateral wall on the
unamputated side. The stump is rigidly continued by
the thoracic cage.
Alignment of Canadian type
 Hip & knee joints of the Canadian type of prosthesis
are stabilized not only by the locks by unique
arrangement of joint locations. The hip joint is
located in front of the weight line. The knee joint is
located behind the weight line.
 A rubber hip extension stop is provided at the back
of the thigh piece to avoid hyperextension of the
prosthetic hip.
Prosthesis for knee disarticulation

 The most common prosthesis used is end bearing

prosthesis. But if the amputee is unable to bear
weight at the distal end of the stump Ischial seat is
provided to the socket.
 Its socket may be either of flexible plastic (or)
moulded by leather. The harnessing is by thigh lacer
(or) buckle and strap (or) by the Velcro straps. The
knee joint is attached to the medial & lateral side of
the socket & continues to shank
 Now a day’s piston type hydraulic swing
phase control unit is also used in the knee
joint. A SACH foot is generally used.
 Disarticulation through the knee gives a
stump advantages like:
 It has a broad weight bearing area.
 The end bearing stump offers better
proprioceptive impulses & stability in walking.
Patellar tendon bearing below
knee amputation

 In PTB prosthesis no lace (thigh

corset) & side hinges are used. It
has the plastic socket which is
designed such as 60% of the weight
is born over the patellar tendon, rest
of 40% is distributed over the
condyles and posterior wall of the
socket and it is suspended by a cuff
suspension. A SACH foot piece is
used.
 The ideal length of the below knee stump is 5
inches from the knee joints. If the stump is
too short PTB limb cannot be fitted. Then the
PTS limb (or) below knee limb with slip
socket is fitted to the short stump.
Patellar tendon supracondylar
Prosthesis

 This prosthesis is fitted to a very short stump.

The anterior medial and lateral wall is higher
than the PTB socket.
 The patella is encapsulated into the socket.
The posterior wall corresponds to the
popliteal crease level. A SACH foot is used.
Below knee with slip socket

 It consists of a thigh corset, a knee joint wooden oval

socket with foot piece. In addition to the above
components it consists of a leather slip socket which
fits to the stump & slips into the wooden socket.
Proximally it is attached to the thigh corset by elastic
webbing.
 The slip socket artificially extends the length of the
stump. Hence it increases the leverage to move
artificial limb.
Prosthesis for syme’s amputation

There are two types of prosthesis.

 Conventional syme’s prosthesis
 Canadian type syme’s prosthesis
Conventional syme’s prosthesis
 It consists of a long leather socket (corset
type) with anterior opening. It is reinforced
with steel side bars. The harnessing is by the
lacer system. The SACH foot is used.
Disadvantages:
 Cosmetically it is unacceptable
 It is heavy.
Canadian type symes Prosthesis
 It consists of resin (plastic) which is
reinforced by fiber glass. The opening with
window is provided to the medial (or)
posterior side of the socket. This opening is
provided to insert, the bulbous end of the
syme’s stump. The SACH foot is used.
Prosthesis for chopart’s amputation

 A choparts boot is fitted. It is boot for which

the ankle is covered. Back side opening is
provided. The anterior toe portion is filled up
be the cushion rubber.
Modern prosthesis

The utilization of plastics is one of the most important

trends in modern prosthetics. They are of low
temperature thermoplastics used now-a-days for the
fabrication of the socket.
They are:
 Plastazote
 Aquaplast
 Bioplastics
 Orthoplast
 Glassona
 These are in form of polyester sheet, some
are in the form of synthetic rubber sheets,
some are cellulose acetate plastic bandage
form. These plastic characteristics especially
in strength rigidly in appearance.
Modification of lower limb Prosthesis
to suit Indian condition

Above knee Prosthesis modified to permit

cross leg squatting.
 In conventional above knee prosthesis, the
thigh segment is made up of one single piece
from hip to the knee joint, in the modified
prosthesis the thigh segment consisting of
two separate pieces, one upper & other lower
with a turn table in between the two.
 During walking the turn table is locked with
the leg in neutral position. When he wants to
squat, he unlocks the turn table and sits. In
full squatting position, the distal segment is
at 90 degrees of external rotation. When he
gets up after extending the knee full, he
internally rotates the distal segment manually
and locks it in neutral position.
Below knee prosthesis modified for squatting with feet flat.
 The modifications in PTB prosthesis to make it squatting type
are
 The suspension cuff was suitably modified by providing elastic
piece in the middle of the cuff to accommodate the increase in
circumference of the thigh segment in squatting.
 The brim line of the posterior wall of the socket was lowered
well below the popliteal crease by 1inch to 1 1/2inch. It was
found that there was instability hence medial and lateral walls
of the socket is also raised.
 The posterior wall of the socket was made flexible to permit
compression of the calf by the thigh
Madras foot

 The madras foot is a foot piece developed at

madras and used for lower limb prosthesis to
facilitate bare foot walking. If the shoe is
removed, the alignment of the prosthesis with
respect to the body is disturbed. If the
amputees attempts to walk without a shoe he
will feel unstable.
Hence the SACH was
modified as,
 Extra rubber heel was
provided so that the shin
of the prosthesis is vertical
with out shoe.
 Shaped toes were
provided for cosmetic
acceptance.
 Hind foot was shaped to
have a tendo-achilles look.
 Special sole was provided to with stand wear
and tear due to prolonged walking.
 Skin shade was given to match the color of
the normal foot.
 Bare foot has better grip on the floor surface
than shaped foot. The amputees felt more
confident to walk which reduces the training
period.
Upper limb prosthesis
The prosthesis is prescribed according to
the level of amputation and its residual
function.
 The Below elbow prosthesis consists of:
 The terminal device
 wrist unit
 fore-arm socket
 Below elbow hinges
 Harness
 Control cable system
 Cuffs and pads
* “elbow unit” is used/ given for above elbow
prosthesis.
 Terminal device: The purpose of the terminal
device is to replace the grasp function of the hand.
 It is divided into
 Hooks
 Hands
Hooks: Commonly used terminal device is the split
type hooks. The amputee can open (or) close these
hooks. The hooks are having 2 fingers. This finger
like shape will permit the usual functions like
holdings, carrying, pulling and pushing the objects.
 There are two types of hooks available one is
voluntary opening and the other one is voluntary
closing. The voluntary opening type hooks are most
commonly used. The hooks are operated by means
of control cable system. The amputee exerts force
on the control cable to open the fingers against the
force of the rubber bands which acts as a spring to
close the fingers to provide prehension of pinch
force.
Hands: Hands may be divided into
 Cosmetic Hand
 voluntary closing hand
 voluntary opening hand
 Cosmetic glove which closely duplicate skin shape &
other features of the normal hand are used.
 The voluntary opening hands are most commonly
used and are available in various sizes. It has the
mechanism of three jaw chuck by moving the thumb
and first two fingers.
 Wrist unit: The functions of the unit are used for
attaching terminal device and its rotations
(supination & pronation) to place the device in the
best position to accomplish a desired activity.
Below elbow hinges: The function of below elbow
hinges is to connect the socket to a cuff on the upper
arm and is important for suspension and stability.
These are variety of hinges.
 Flexible hinge
 rigid hinge
 step up hinge
 The flexible hinge is used for long below elbow
amputee and wrist disarticulation where the sufficient
voluntary pronation & supination are available.
These flexible hinges will permit active pronation and
supination of fore-arm as well as flexion and
extension of the elbow.
 Rigid hinges are utilized for short-below elbow cases
where normal elbow flexion is present. Two types of
rigid hinges are available single axis and polycentric.
 Step up hinges are used together with a split
socket prosthesis for very short below elbow
cases where useable elbow flexion is limited.
These hinges permit the stump to drive the
prosthetic fore-arm through an increased
ROM.
 Cuffs and pads: Arm cuffs (or) triceps pads
are used on the upper arm with the
appropriate elbow hinges to connect the
socket to the harness and help furnish socket
suspension and stability. The triceps pad is
used with long below elbow wrist
disarticulation and transmetacarpel
prosthesis. The arm cuff is used in the
majority of short below elbow prosthesis.
 Below elbow harness and control system:
The functions of the below elbow harness are
to suspend the prosthesis from shoulders. So
the socket is firmly held on the stump. By
using the body motions shoulder flexion &
scapular abduction as source of power &
transmits this form via cable system to
operate the terminal device.
Myoelectric prosthesis
Thank you