LE PROSTHETICS

Prosthesis vs Orthosis

 A prosthesis is a device or an artificial

substitute designed to replace, as much
as possible, the function or appearance
of a missing limb or body part
 An orthosis is a device designed to
supplement or augment the function of
an existing limb or body part.
 Biomechanical principles

• 3 point force system

• Pressure tolerance of tissues
• Alignment of joint axes
 Biomechanical principles

 The prosthesis should replicate the

kinematics and functions of normal gait
 The prosthesis should encase the stump in a
socket which spreads the force of weight
bearing over pressure tolerant structures
and relieve pressure from sensitive areas
 The prosthesis should be lightweight,
durable and allow performance of ADLs
 Factors for a Successful Outcome
with Prosthetics
 The prosthesis must be comfortable to
wear, easy to don and doff, light weight,
durable, and cosmetically pleasing
 The prosthesis must function well
mechanically and have low maintenance
requirements
 The patient must be properly motivated
 Prosthetic use must be discussed
preoperatively with the patient
 Considerations in choosing a
prosthesis
 Amputation level
 Expected function of the prosthesis
 Cognitive function of the patient
 Patient's vocation
 Patient's avocational interests
 Cosmetic importance of the prosthesis
 Patient's financial resources
 Minimal functional requirements
for a LE prosthesis

 Sufficient trunk control

 Good upper body strength
 Static and dynamic balance
 Adequate posture
 Goals in prosthesis use

 Stability
 Ease of movement
 Energy efficiency
 Appearance of a natural gait
 Etiology of Amputations

 Vascular diseases and Infections:

70-75%
 Trauma: 22%
 Tumors: 5%
 Congenital deformities: 3%
 Ideal Levels of Amputations

• Toe amputations
• Ray resections
• Transmetatarsal amputations
• SYME amputations
• Transtibial amputations (level proximal
to the junction of the middle & distal
3rds of the leg)
 Ideal Levels of Amputations

• Knee disarticulation
• Transfemoral (level 5cm or more
proximal to the level of the knee joint,
with femoral condyles excised)
• Hip disarticulation
• Hemipelvectomy
Levels of Amputation
Transtibial amputations

 Short BK: < 33%

 Medium BK: 33-
66%
 Long BK: > 66%
 Transfemoral

 Hip disarticulation -
at or above the
greater trochanter
 Short AK: < 33%
 Medium AK: 33-66%
 Long AK: > 66%
 Transfemoral vs. Transtibial

 Stump shape: Conical Cylindrical

 Closure: Fish mouth Posterior flap
 Wound healing: Faster Longer time
 Contracture: Hip Knee FLEXION
flexion,
abduction
 Transtibial (BKA): Pressure
Sensitive Areas
 fibular head
 anterodistal end of
stump
 tibial crest
 tibial tubercle and
condyles
 distal tibia and fibula
 hamstring tendons
 Transtibial (BKA) Pressure
Tolerant Areas
 patellar tendon
 popliteal fossa
 pretibial muscles
 gastrocsoleus
muscles
 lateral flat aspect of
fibula
 medial tibial flare
 Stump Care
• Clean daily with tepid water and
mild soap once suture is removed
• Pat dry completely before using
shrinkage device
• Gentle massage to decrease
sensitivity to pressure
• Deep friction massage
perpendicular to scar to prevent
 Stump Care

• Use thin layer of emollient to

decrease friction from massage
but avoid thick creams
• Discourage shaving of residual
limb
 Stump Bandaging

 Elastic bandages are the least effective

shrinkage device
 Improperly applied bandages can cause
circumferential condtriction with distal
edema
 BKA – use double length 4 in.
 AKA- use double length 6 in.
BASIC PARTS OF LE PROSTHESIS
 Parts of a BKA Prosthesis

• SUSPENSION DEVICE
• SOCKET

• SHANK

• FOOT-ANKLE
ASSEMBLY
Parts of an AKA Prosthesis

• SUSPENSION DEVICE
• SOCKET

• KNEE UNIT

• SHANK

• FOOT-ANKLE
ASSEMBLY
FOOT-ANKLE ASSEMBLY
 FOOT ANKLE ASSEMBLY

• Substitutes for the anatomic

foot and ankle
• Provides a base for weight-
bearing
• Absorbs shock at heel contact
• Provides for MTP hyper-
extension late in stance phase
• Resembles the general contour
Foot – Ankle Assembly
 A. Foot-ankle assembly

1. Non-articulated
 Attached directly to the shank

(no ankle joint)

a. Solid Ankle Cushion Heel (SACH)
 Most common

 Decreased mediolateral and

transverse motion
b. SACH foot with external keel
• KEEL – weight bearing structure
• Increase mediolateral stability/
decrease motion
• Main disadvantage – delay
in foot flat, increase knee flexion
SOLID ANKLE CUSHION
HEEL (SACH) FOOT
 c. Stationary Attachment/
Flexible Endoskeleton (SAFE)

• Multi-axis
• Increased frontal and transverse plane
motion
• Components:
1. Rigid bolt block
2. Flexible keel
3. Long plantar ligament band
 STATIONARY ATTACHMENT/
FLEXIBLE ENDOSKELETON (SAFE)
 d. Stored Energy (STEN) Foot

• 3 piece keel joined by rubber plugs

• Similar to SACH, heavier,
• Types:
1) Seattle foot
2) Carbon copy II
3) Quantum
4) Flex walk/ flex foot
SEATTLE FOOT
CARBON COPY II
QUANTUM FOOT
FLEX WALK
 2. Articulated Foot Assemblies
• Allows motion between foot and shank
• Plantar flex at early stance
• Heavier, becomes loose and noisy
a. Single axis assembly – PF to 15°,
anterior DF to 5°
b. Multiple axis assembly – permits movement
in any direction
ARTICULATED
COMPONENTS
SHANK
 SHANK

• Maintains spatial relationship

between the socket and the
foot
• Transmits load from the socket
above to the foot below
SHANK
 Shank

1. Exoskeleton (Crustacean)
 Light plastic, foam, wood

 hollowed
2. Endoskeleton (Modular)
 Metal/ plastic tube

 With soft cosmetic cover

 Lightweight, adjustable

 Very expensive
SOCKETS
 SOCKETS

 Functions of a prosthetic socket:

1. Comfortable total contact interface
with the residual limb
2. Efficient energy transfer from the
residuum to the prosthesis
3. Secure suspension
4. Cosmesis
 Socket
 2 layers:
1. Inner – contoured to the residuum
- flexible plastic materials
- held in place by velcro
2. External/ Frame – gives length and
shape
- where components are attached
- thermoplasts
 Socket
 Transmits forces from the residual limb
to the prosthesis
 Pressure tolerant areas:
1. Patellar tendon
2. Tibial flares
3. Shaft of the fibula
4. Popliteal space
5. Around tibial crest
 TRANSTIBIAL
AMPUTATIONS SOCKETS
• Patellar Tendon Bearing (PTB)
socket
• SOFT SOCKET
• HARD SOCKET
• FLEXIBLE SOCKET
 Transtibial (BKA) Sockets

a. Patellar Tendon Bearing (PTB)

 Intimate fit over the entire

stump
 Prevents edema

 Better sensory feedback

 SOFT LINER/ INSERT

b. Hard Socket
 Variant of PTB

 Soft insert is eliminated

 Not used for elderly amputee with

poor tissue covering, sensitive tissue

and vascular problems.
c. Icelandic-Swedish-NY (ISNY) PTB
 Flexible thermoplastic PTB socket –

for tissue containment

 Carbon fiber reinforced laminated

frame – weight transmission

 TRANSFEMORAL
AMPUTATION SOCKETS

• Quadrilateral * Ischial
Containment
 AKA Socket

a. Quadrilateral shaped (4 side walls)

1) Posterior – weightbearing
2) Anterior
QUADRILATERAL TOTAL
SUCTION SOCKETS
b. Ischial containment shape socket
• Ischial tuberosity within the socket

• Posterior and medial walls higher

• Narrow mediolateral dimensions

• For very short amputation

• For younger and more active patients

KNEE UNITS
KNEE UNITS
SINGLE-AXIS KNEE UNITS

• Single Axis Knee

Unit
• Manual Locking
Knee
• Mechanical
Locking Knee
 WEIGHT ACTIVATED
STANCE CONTROL KNEE
FOUR BAR POLYCENTRIC
KNEE
POLYCENTRIC KNEE
 HYDRAULIC
AND
PNEUMATIC
(FLUID
CONTROLLED)
BREAK FOR 10 MIN
SUSPENSION SYSTEM
 D. Suspension systems
A. Harness – cuff suspension
B. Self suspension – use bony prominences
C. Semisuction - hypobaric
• use socks with silicone bands
• 1 way valve
• accomodates changes in limb volume
D. Suction - use negative pressure
• residuum mature, stable volume
 D. Suspension systems

1. Harness/ Cuff suspension

• Resists knee
hyperextension
• (+) medial and
lateral walls
• Superior to the patella
 2. Self-suspension

a. Supracondylar system
• High medial and lateral

walls
• Encompass femoral

condyles
• Wedge suspension or

soft insert
• (+) mediolateral stability
b. Supracondylar/ Suprapatellar (SC/SP)
• High medial, lateral

and anterior walls

• Covers entire patella

• Mediolateral stability +

resists genu recurvatum

c. Thigh corset
• Attached to the socket and shank

by sidebars with knee joint assembly

• Supports part of the body weight

• Provides mediolateral stability and

sensory feedback
ELASTIC SLEEVE SUPRACONDYLAR CUFF
SUPRACONDYLAR/
SUPRA PATELLAR THIGH CORSET
SUSPENSION
SUCTION
 Suction

• For well-shaped and strong stumps

• For younger and more active patients
• (+) one way valve that expels air on
stance phase
• Close fit brim / no socks
 Partial suction with auxilliary
suspension
• With suction valve and
silesian bandage / pelvic belt
• For stumps with volume that fluctuates
• Difficult to don
PARTIAL SUCTION SOCKET
SUSPENSION
SUSPENSION DEVICE:
TRANSTIBIAL
 SUSPENSION DEVICE:
TRANSFEMORAL PROSTHESIS
SILESIAN BANDAGE, PELVIC BELT, SPECIAL DEVICES
 Silesian Bandage

• Webbing band encircling torso

• Lateral proximal socket (level of greater
trochanter)
• Control rotation and lateral instability
 Pelvic belt
• Used with partial suction or by itself
• Leather or fabric strap with metal or
plastic bands with hip joint
• Controls rotation and mediolateral
stability
• For short, weak, poorly shaped stumps
• For timid and uncoordinated patients
• Restricts hip motion, interferes with
sitting and heavy
 Special devices

1. Shoulder harness
2. Lumbosacral girdle
• For excessive obesity, pregnancy,

deformities and skin disorders or scar

tissue
• For patients who cannot tolerate sockets
 Energy Expenditure

LEVEL OF AMPUTATION % GREATER THAN

NORMAL
SINGLE BKA 10-40%

DOUBLE BKA 41%

SINGLE AKA 65%

 Energy Expenditure

LEVEL OF AMPUTATION % GREATER THAN

NORMAL
DOUBLE AKA 110%

SINGLE AKA & BKA 75%

CRUTCH AMBULATION 60%

WITHOUT
PROSTHESIS
 SPEED OF WALKING

NORMAL BKA AKA

3.0 mph 2.0-2.5mph 1.5 mph
 Physical Therapy
Management

1. Preoperative
2. Postoperative-preprosthetic
3. Prosthetic Prescription
4. Prosthetic Assessment
5. Prosthetic Training
 Prosthetic Training

• Donning and doffing correctly

• Developing a good sense of
balance and coordination
• Gait retraining (safe and
symmetrical manner)
• Other ambulatory and self-care
activities
 Sequence of Prosthetic
Training
• parallel bars
• sit-to-stand transfers
• balance -> limited weight-
bearing
• knee control
• lateral weight shifting
• forward progression
• advanced gait training with gait
 Sequence of Prosthetic
Training
• train in different terrain
• level ground  ramps  curbs 
stairs  clearing obstacles  falling
safely and floor-to-standing
transfers
• In stair climbing and ramp
walking
• Ascend with sound foot
• Descend with prosthetic foot
 FUNCTIONAL OUTCOMES

 Transfemoral Prosthetic
Restoration
 Transtibial Prosthetic
Restoration
 FUNCTIONAL OUTCOMES FOR
TRANSFEMORAL PROSTHESES
1. Ambulation with prosthesis on level and uneven
surfaces, stairs, ramps and curbs
2. Ambulation with minimal or no gait aids
3. Independent with dressing
4. Independent in donning and doffing prosthesis
5. Independent in stump wrapping or applying a
shrinker
6. Able to drive
7. Can participate in shopping activities
 FUNCTIONAL OUTCOMES FOR
TRANSFEMORAL PROSTHESES
8. Has returned to previous work, with or without
modifications
9. Can stand for up to two continuous hours
10. Can sit for up to two continuous hours
11. Can arise from the kneeling position
12. Comfortable with falling techniques and can arise
from the floor
13. Can hunt, fish, run, bicycle if part of previous
lifestyle
 FUNCTIONAL OUTCOMES FOR
TRANSFEMORAL PROSTHESES
14. Knows how to purchase properly fitting footwear
for remaining foot
15. Knows proper skin and nail care for remaining
foot
16. Can safely perform aerobic conditioning programs
17. Stairs are generally climbed one at a time
18. Can run (if amputee desires, has adequate
cardiopulmonary reserve and residual limb length)
19. Uses no more than a cane for ambulation
 PROSTHESES FOR
SPECIFIC AMPUTATIONS
I. Partial foot

a. Small toe amputation

 Minimal/ no functional effect

 Prosthesis: soft filler or none

b. Hallux/ complete metatarsal
disarticulation
 Decreased push-off during late stance

 Prosthesis:

a. Molded insole with arch support

and toe filler
b. flexible spring steel plate
3. Transmetatarsal/ Tarsometatarsal
amputation (Lisfranc)
 Metatarsal heads – anterior weight

bearing structures
 Transmetatarsal amputation

 PROBLEM: PRESCRIPTION
a. Equinus - rigid, molded
sole plate
b. Sensitive distal end - distal padding
c. Decreased push off - toe break, toe
filler
d. Stump end breaks
down the shoe arch - metatarsal bar
4. Midtarsal (Chopart)
 Only calcaneus and talus remains

 Prescription:

a. Plastic socket extending

above the malleoli
b. Posterior opening
c. SACH heel
 II. Symes amputation

 Tibia/ Fibula – ankle disarticulation

 With weight bearing capacity
 Long lever for prosthesis control
 Uncosmetic, poor healing, spur
formation
 Symes prosthesis

A. Basic design:
1. Shank
2. Flexible build-ups
B. Canadian
 Removable posterior

wall
 Permits rear entry of

stump
C. Veterans Admin. Prosthetic Center
(VAPC) prosthesis
 Medial window

– for strength
 Transtibial (Below Knee)
Amputation Prostheses
 Components:
A. Foot–ankle
assembly
B. Shank
C. Socket
D. Suspension
element
 IV. Transfemoral (Above-knee)
amputation prosthesis
 Components:
1. Foot ankle assembly
2. Shank
3. Knee assembly
4. Thigh piece
5. Socket
6. Suspension device
 Foot-Ankle assembly for
Transfemoral prosthesis
• Similar to BKA (SACH – most
common)
• Differences:
a. needs increased knee stability
b. low level of activities
c. more single axis, less energy storing
d. more compressible heel cushions
 Knee assembly for AKA

a. Wooden or plastic knee block

b. Axis – allows flexion
c. Friction device – swing phase control
d. Extension stop – prevents recurvatum
 V. Knee disarticulation
prosthesis
Characteristics:
1. long thigh segment/ knee more distal:
• gait asymmetry
• when sitting: knee protrudes, foot
doesn’t reach the floor
2. weight bearing capacity
3. bulbous distal contour
4. suspension on swing phase
 VI. Hip disarticulation
prosthesis
A. Canadian Hip Disarticulation Type
 Most common

 Accomodates irregular

body forms
 Comfortable, functional

 Socket contains the stump

and encircle pelvis

 Bilateral Amputation Prosthesis

A. Bilateral Above knee

 No anatomic knee
 Non-articulated “STUBBY”
 Total contact quadrilateral

sockets attached to rocker

bottoms
 Prosthesis 12 inches lower

than preoperative height

 Bilateral Amputation Prosthesis

B. Above knee / Below Knee

• Depends on condition of the stumps
• Shanks 2 inches shorter for stability
• AKA prosthesis ½ inch shorter than the
BKA prosthesis to facilitate toe
clearance
• Use limb with intact knee to raise and
lower body
 Bilateral Amputation Prosthesis

C. Bilateral below knee

• Use PTB prostheses
• 2 inches shorter
• SACH feet with stiffer heels
 Summary

Amputation Prosthesis
1. Lisfranc, Chopart,
Toe disarticulation shoe filler
2. Syme’s Syme’s prosthesis
3. Transtibial PTB socket
Supracondylar cuff
suspension
SACH foot
 Summary

Amputation Prosthesis
4. Transfemoral Total contact Ischial
weight bearing socket
Constant friction knee
SACH foot
5. Hip disarticulation Canadian hip
disarticulation
prosthesis,SACH foot
THANK YOU!!!