INDEX

DEPARTMENT OF
PHYSIOTHERAPY &
PARAMEDICAL SCIENCES
1

Transfemoral prosthesis
Presented by
Asst. Prof.
Dr. Neha Hardia Diwakar
(PT)
BPT, MPT
(Cardio)
 Components of Transfemoral prosthesis
2

⚫ Foot piece
⚫ Shank
⚫ Knee unit
⚫ Socket
⚫ Suspension
 Topics to be discussed
3

⚫ Socket
⚫ Knee unit
⚫ Alignment
⚫ Suspension system
⚫ Biomechanics
⚫ Major gait deviation
 Socket
4

Three types of socket used for Transfemoral

prosthesis

⚫ Quadrilateral socket
⚫ Ischial containment socket
⚫ Flexible socket
 Quadrilateral socket
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⚫ Introduced by university of California at Berkeley in

1950 to permit use of the remaining musculature
⚫ Appeared quadrilateral when viewed from
transverse plane
⚫ Having four walls with different functions
Quadrilateral socket

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 Functions
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Medial wall

⚫ It contains tissues medially and provide

counter pressure to lateral wall
⚫ Proximal brim is horizontal and parallel to floor
and distal end is contoured for total contact
⚫ Height of medial wall is same as that of
posterior wall to prevent adductor roll.
 Lateral wall
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⚫ Lateral wall must provide adequate lateral support

to the femur in midstance to prevent trendelenberg
sign as unamputated side is in swing phase.
⚫ The lateral wall rises 21/2 inches above the ischial
shelf to stablise the greater trochanter and prevent
medial socket displacement
 Anterior wall
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⚫ Anterior wall rises 21/2 inches above the ishial seat

⚫ The anterior medial corner contains a channel or
relief for adductor longus and gracilis tendon
 Posterior wall
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⚫ It provides a weight bearing surface for the ischial

tuberosity
⚫ The ischial tuberosity sits 1’’ medial from medial wall and
½ ‘’posterior on the ischial shelf
⚫ The posterior wall slopes 5-7degrees to increase
prosthetic functions in two ways-
1.To permit easier access to the ischial tuberosity so that
weight bearing may occur on the top of the posterior wall
on and around the ischial tuberosity.
2.To place the hip extensors in a stretched position enabling
them to move powerfully to extend the hip and stablise the
pelvis and prosthesis during weight bearing.
 Problems in quadrilateral socket
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⚫ Due to large m-l dimension, femur of residual limb abducts,

this femoral movement may result in lateral trunk bending
towards prosthetic side.
⚫ Wearers may complain of the socket being uncomfortable
with pressure over the ischial tuberosity.
⚫ Pressure concentration is more as smaller amount of
residual limb is contained in the socket.
 Ischial containment socket
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⚫ IC socket was developed in 1980

⚫ It is becoming the socket of choice in many areas of
the country
⚫ Narrow M-L and wider A-P dimension.
Ischial containment socket

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 Features
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⚫ Maintenance of normal femoral adduction angle and

narrow base gait.
⚫ Containment of ischial tuberosity and pubic ramus.
⚫ More optimal distribution of forces along femoral shaft.
⚫ The posterior brim of the IC socket is proximal to and
slightly posterior to the ischium .
⚫ The ischial tuberosity is contained in the socket, resulting
in a bony lock between the ischium, trochanter and lateral
distal aspect of the femur. This containment may provide a
stable mechanism to control M-Land rotational stability.
 MAS Socket
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⚫ Marlo Ortiz describes his design: "It is very important to

consider the angle of the ischial ramus. The ischial tuberosity
and part of the ramus as well as the medial aspect of the ramus
are encapsulated within the medial aspect of the socket
brim." Generally, the medial wall is lowered anteriorly to avoid
pressure on the ascending ramus; effectively ischioramal weight-
bearing eliminates the need for gluteal support, so those tissues
can be excluded from the socket, he explained.
⚫ In the M.A.S. design, the height of the posterior wall has been
lowered to the gluteal fold, so the entire muscle belly can be free
of the socket. "This will not only improve cosmesis but with this
configuration, we have found that ischial tuberosity and part of
the ischial ramus are encapsulated more effectively with no
restriction in hip movement," Ortiz said.
 FLEXIBLE SOCKET
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The flexible socket system consist of two parts:-

1.A pliable, transparent or translucent socket for

tissue containment.
2.A rigid, external supporting frame for weight
transmission.
❑ Also called called ISNY socket .
❑ Developed in cooperation with Een Holmgren in
Sweden.
FLEXIBLE SOCKET

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 Socket prescription
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Quad socket are most successful on long residual limb

with firm adductor musculature. The more of adductor
Magnus that is intact the more successful the quad socket
socket.
IC socket are more successful on short , fleshy residual
limb and better suited for high activity and sports
participation.
Flexible brims of the Ic socket are best for maximal ischial
ramus containment.
 KNEE UNIT
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⚫ Knee stability is the ability of the prosthetic knee

to remain extended and fully supportive during the
stance phase of walking. A particular prosthetic
knee is often recommended on the basis of
inherent knee stability required.
⚫ An individual with long residual limb and good hip
extensor muscle strength may use a knee unit
with less stability than individual with short
residual limb or weak hip extensor.
 Knee classification

⚫ Knee classification are divided according to

axes ,friction, braking or locking mechanism
and microprocessor control.
⚫ Functional classification-codes of joint types-
⚫ Single axis(c)-The rotation centre of the joint is
fixed in one point in all angular positions of the
knee.

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• Polycentric joint-The rotation centre has different
locations in different angular position of knee.
• Polycentric two bar linkage-it refers to the knee
where the stump and the shank glides against
each other. This constitutes a link which rotates
with the thigh as well as with the shank ,thus
making two joints.
• Polycentric four bar linkage-Stump and the
shank jointed by two links.
• This link bend at each of their end with the thigh
as well as with shank thus making four joint. it is
most popular .
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 Functional classification
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⚫ Codes of stance phase stabilizing mechanism

Hydraulic-The knee is locked by the oil flow in a hydraulic
system being shut off.
Mechanical lock-The knee joint is locked during whole
walking cycle i.e. pt walks with stiff knee.
Locking is automatic
Unlocking is manually.
Friction brake-Wt bearing load of the prosthesis causes
certain components to be deformed so that a braking
friction moment arises.
 Polycentric stable
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⚫ The rotation centre, while the knee is extended, lies

always behind a reference line joining the hip joint
and the heel.
⚫ The ground reaction force line at the heel strike
causes the knee to extend, and thus the knee is
stable without activation of hip extensors.
 Polycentric unstable
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⚫ The rotation centre ,while the knee is extended,

lies above the level of normal knee and in front of
a reference load line.
⚫ The ground reaction force at the instant of heel
contact is thus, inclined towards knee joint and the
knee is stabilized by activation of the hip extensors
⚫ Extension of the hip affects the resultant force line
of GRF so that if passes in front of knee centre ,
causing it to extend.
 Functional classification-codes
of swing phase control
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⚫ Extension bias-An elastic restraint provides a

progressive resistance against knee flexion and
helps in its extension. The restraint consists usually
of a metallic spring or an elastic band.
⚫ Constant friction-This provides a constant resistance
in the joint which reflects the normal swing function
of knee.
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⚫ Variable knee friction-This provides increments in

resistance according to positions of knee
mechanism doesn’t adjust itself a/c walking speed.
⚫ Hydraulic-The resistance increases with walking
speed thus presenting a good imitation of normal
knee movement.
⚫ Pneumatic-The resistance increases with walking
speed. This arises by resistance to flow in orifices
and compression of air at the same time. It
provides a good imitation of normal knee
movement.
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 Microprocessor Knees
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⚫ Microprocessor knees are a relatively new development in prosthetic

technology. Several such new knees are now available or in
development.
⚫ Onboard sensors detect movement and timing and then adjust a fluid /
air control cylinder accordingly. These microprocessor-controlled
knees lower the amount of effort amputees must use to control their
timing, resulting in a more natural gait.
⚫ It also automatically adjust the swing control according to the
functional demands with different speeds of walking or running.

⚫ Example: Otto Bock - C-Leg

Endolite - Adaptive
- Smart IP
- IP+
 STABLISATION LEVELS
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⚫ 0-UNSTABLE-Knee joint is stablised by hip extension even

though knee is fully extended. knee collapses if it is loaded
in flexed position
⚫ 1-low stability-compared with o level, need for hip
extension is reduced.
⚫ 2-stable-when knee is fully extended, no hip extension is
required to preserve stability.
⚫ 3-High stability extended-knee cant flex with hip flexor
while under load in an extended position, which prevents
any knee flexion before toe off.
⚫ 4-high stability-most stable .not collapses whether loaded
in flexed position.
⚫ 5-locked knee-pt walks with stiff knee.
 Functional/Financial considerations: Aetna
Classification
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⚫ Level 0: Does not have the ability or potential to ambulate or transfer safely with or
without assistance and a prosthesis does not enhance their quality of life or mobility.
⚫ Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation
on level surfaces at fixed cadence. Typical of the limited and unlimited household
ambulator.
⚫ Level 2: Has the ability or potential for ambulation with the ability to traverse low
level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the
limited community ambulator.
⚫ Level 3: Has the ability or potential for ambulation with variable cadence. Typical of
the community ambulator who has the ability to traverse most environmental
barriers and may have vocational, therapeutic, or exercise activity that demands
prosthetic utilization beyond simple locomotion.
⚫ Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic
ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the
prosthetic demands of the child, active adult, or athlete.
 Suspension System
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Various type of suspension is used to secure a trans-

femoral prosthesis to a residual limb. selection of
best suspension is critical to achieve a stable,
efficient cosmetic gait. An improperly fitting
suspension may result in discomfort skin breakdown
and falls.
 Types 0f suspension
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⚫ Suction –vacuum is created

⚫ With the advent of IC socket even a very short limb
can be fitted with suction suspension.
⚫ Auxiliary suspension may be used with suction .
⚫ Indication:- active stable individual with long residual
limb and no edema.
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 Soft belt
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1. TES:-made of elastic neoprene material lined with

smooth nylon material.
⚫ Fits on proximal end of socket and around the waist ,
fastening anteriorly.
⚫ Auxiliary suspension.
2.Silesian bandage :- made of cotton or webbing material.
⚫ Attached to prosthetic socket over trochanter, encircles
sound side pelvis terminates at vertical midline of the
anterior socket.
⚫ Contraindication-hip instability
⚫ Very short stump
⚫ Weak musculature
Silesian bandage TES BELT

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 Pelvic belt suspension
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⚫ Consists of a pelvic belt that passes between illiac crest

and GTof each hip and a joint that is positioned slightly
above and ahead of GT.
⚫ Advantage-permits satisfactory fit if suction cannot be used
due to scarring or weakness.
⚫ Disadvantage-Increased weight
Restricted motion of hip
increased maintenance due to mechanical
joint.
poor cosmetic appearance
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 BIOMECHANICS
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⚫ Socket design
⚫ Alignment
 Socket design
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⚫ Providing a good environment for stump inside

socket
⚫ Crossection at brim level shows its shape to
accommodate the complexity of stump to anatomy.
Reliefs for hams, Gmax, R-femoris and adductor
longus muscle need to be accommodated by the
shape of the brim.
⚫ It should also transmit the forces comfortably that
are produced between stump and socket.
 Mediolateral stability and use of hip abductor
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⚫ Socket must prevent the femur moving laterally for

stabilizing the pelvis.
⚫ If socket doesn’t provide lateral stabilization force-
excessive movement of end of femur.
⚫ It results in pain in distal end.
⚫ To reduce pain-amputee widens walking base and
sway his trunk over support line to reduce the
need of abductors to stablise the pelvis.
⚫ For socket to provide lateral force, a medial
counter force applied on medial side of socket
proximally.
 A-P FORCE DISTRIBUTION DURING
STANCE PHASE
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⚫ Socket design should control stability of knee joint

and influence movt. of knee during swing phase.
⚫ Elderly amputee-prescribed with safety or lock
knee
⚫ Young amputee- use hip musculature to control
prosthetic knee joint.
contd.
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⚫ During heel strike-hip extensors are active in

stabilizing knee joint. this is to be achieved without
excessive movement of femur within socket, there
must be counter force from the socket
anterioproximal and posteriodistal.
⚫ During midstance hip extensors are not active but
due to ant. Location of grf line knee is stabilized.
forces are same as in heel strike.
⚪ At push off-amputee should flex hip to initiate flexion of
knee. this changes the stump socket force distribution-
anteriodistal and posterio proximal force acts
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⚪ At push off-amputee should flex hip to initiate flexion of

knee.This changes the stump socket force distribution-
anterodistal and postero proximal force acts.

⚫ A cross-section at brim level shows its shape to

accommodate the complexity of stump anatomy.
 Alignment
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⚫ Alignment is the relative orientation of socket knee

and foot.
⚫ It influences on-
⑥ Force distribution between socket and stump as well
as on performance of amputee walking.
⑥ Knee stability.
 TYPES
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⚫ STATIC
⚫ DYNAMIC
 STATIC ALIGNMENT
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⚫ GERMAN SYSTEM-when plumb line passes

through centre of socket brim through or adjacent to
bisector of length of the foot with knee joint well
behind this line.
⚫ TKA SYSTEM-plumb line when passes from
trochanter passing through ankle joint with knee jt
on or behind this line.
 Contd.
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⚫ MKA SYSTEM-medial location of knee joint is

placed on line between the bisector of medial wall
and ankle jt.
⚫ As the knee jt placed in about 5 degree of external
rotation, the lateral location of knee joint is behind
this line.
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 DYNAMIC ALIGNMENT
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⚫ The force applied to the socket by residual limb is

not along grf line.
⚫ So there is tendency of angular rotation between
socket and stump
⚫ An inset foot applies pressure to proximal medial
and distal lateral aspect of limb
⚫ An out set foot exerts opposite force system
 Contd.
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⚫ The greater the inset or outset the greater the

tendency to change angular relationship of stump.
⚫ Dynamic alignment using adjustable shank or
adjustable prosthesis may be necessary for
decreasing rotation of prosthesis, improve comfort
and correct gait deviation.
 Common gait deviations
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⚫ Lateral trunk bending

Gait cycle-initial contact to midstance
Characteristics -excessive bending occurs laterally from the
midline , to prosthetic side.
Prosthetic cause-too short
improper lateral wall shape
high medial wall.
Musculoskeletal causes-hip abduction contracture
sensitive and painful limb
habit
 ABDUCTED GAIT
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Gait cycle-stance phase

Characteristics-wide base gait
Prosthetic cause-
▪ Too long
▪ High medial wall

Musculoskeletal cause-
▪ Hip abduction contracture
▪ habit
 Circumducted gait
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⚫ Gait cycle-through swing phase

Characteristics- prosthesis swing laterally in a wide area
Prosthetic causes
▪ too long
▪ Difficult to flex knee in swing phase.
▪ Loose suspension causing pistoning of prosthesis.
Musculoskeletal cause-
▪ hip abduction contracture
▪ Habit
▪ Residual limb discomfort
 vaulting
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⚫ Gait cycle-through swing phase

Characteristics -excessive planter flexion of sound ankle and
raising entire body vertically
Prosthetic causes-
▪ Too long
▪ Too much friction in knee.
▪ Foot set in planter flexion
Musculoskeletal cause-
▪ Habit due to insecurity
 Instability of knee
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⚫ Gait cycle-initial contact to midstance

Characteristics-knee buckles during early stance
Prosthetic cause-
▪ Knee joint far ahead of tka line
▪ Insufficient flexion in socket
Musculoskeletal cause-
▪ Hip extensor weakness
▪ Severe hip flexion contracture.
 Foot slap
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⚫ Gait cycle-initial contact to midstance

Characteristics-rapid decent of front of prosthetic foot ,
striking floor with slapping sound.
Prosthetic causes-
▪ Inadequate planter flexion resistance.
 Excessive trunk extension
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⚫ Gait cycle-during stance especially terminal stance to pre-swing.

Characteristics -lumbar lordosis is exaggerated and trunk is carried
backward.
Prosthetic cause-
▪ Insufficient socket flexion
▪ Insufficient support from ant. Wall of socket
Musculoskeletal cause
▪ Hip flexor tightness
▪ Weak hip extensors
▪ Weak abdominals causing ant pelvic tilt and compensatory post trunk
lean.
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