Lower Limb Prostheses

There are several levels of lower limb amputation, including:

1) Partial foot, 2) Ankle disarticulation,

3) Transtibial (below the knee),

4) Knee disarticulation,

5) Transfemoral (above the knee),

6) Hip disarticulation.

The most common are transtibial (mid-calf) and transfemoral (mid-thigh).

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 Lower Limb Prostheses
Description

There are several levels of lower limb amputation, including partial foot, ankle
disarticulation, transtibial (below the knee), knee disarticulation, transfemoral
(above the knee), and hip disarticulation. The most common are transtibial
(mid-calf) and transfemoral (mid-thigh). The basic components of these lower
limb prostheses are the foot-ankle assembly, shank, socket, and suspension
syste

The basic components of a lower extremity prosthesis include:

the socket, a sock or gel liner, a suspension system, a knee joint (articulating
joint), the shank (a pylon), and a foot (terminal device)

(Fig. 1).

Figure 1: Lower extremity prosthesis components.

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Foot-ankle assembly

The foot-ankle assembly is designed to provide a base of support during

standing and walking, in addition to providing shock absorption and push-off
during walking on even and uneven terrain. Four general categories of foot-
ankle assemblies are non-articulated, articulated, elastic keel, and dynamic-
response. One of the most widely prescribed foot is the solid-ankle-cushion-
heel (SACH) foot, due to its simplicity, low cost, and durability. It may be
inappropriate, however, for active community ambulators and sports
participants. Articulated assemblies allow motion at the level of the human
ankle; this motion may occur in one or more planes, depending on whether it is
a single-axis or multi-axis foot. These assemblies offer more mobility at the
cost of less stability and increased weight. The elastic keel foot is designed to
mimic the human foot without the use of mechanical joints; the dynamic-
response foot is designed to meet the demands of running and jumping in
athletic us

Figure 3: Variety of Foot or Terminal Devices

Shank

The shank corresponds to the anatomical lower leg, and is used to connect the
socket to the ankle-foot assembly. In an endoskeletal shank, a central pylon,
which is a narrow vertical support, rests inside a foam cosmetic cover.
Endoskeletal systems allow for adjustment and realignment of prosthetic
components. In an exoskeletal shank, the strength of the shank is provided by a
hard outer shell that is either hollow or filled with lightweight material.
Exoskeletal systems are more durable than endoskeletal systems; however, they
may be heavier and have a fixed alignment, making adjustments difficult.

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Suspension

Suspension devices should keep the prosthesis firmly in place during use and
allow comfortable sitting. Several types of suspension exist, both for the
transtibial and transfemoral amputation. Common transtibial suspensions
include sleeve, supracondylar, cuff, belt and strap, thigh-lacer, and suction
styles. Sleeves are made of neoprene, urethane, or latex and are used over the
shank, socket and thigh. Supracondylar and cuff suspensions are used to
capture the femoral condyles and hold the prosthesis on the residual limb. The
belt and strap method uses a waist belt with an anterior elastic strap to suspend
the prosthesis, while the thigh-lacer method uses a snug-fitting corset around
the thigh. The suction method consists of a silicone sleeve with a short pin at
the end. The sleeve fits over the residual limb and the pin locks into the socket.
With a transfemoral prosthesis, suction and several types of belt suspension
also are available.

Transfemoral amputations also provide the additional challenge of

incorporating a prosthetic knee unit. The knee unit must be able to bend and
straighten smoothly during ambulation, in addition to providing stability during
weightbearing on that limb. Knees are available as single-axis, polycentric,
weight-activated, manual-locking, hydraulic, and pneumatic units. Technology
using microprocessors in knee units is becoming a reality, although costs can
be prohibitive.

The socket

The socket enables the prosthesis to connect and fit to the stump (residual
limb). This is the most important prosthetic component. A good fit is critical. A
socket that is uncomfortable is a common reason why a prosthesis is rejected.
Contoured sockets fit closer to the remaining bones, muscles, and soft tissues
providing better support, and provide relief where it's needed for comfort. 8
Examples of contoured sockets include the Hanger ComfortFlex™ Socket
System, Quadrilateral Socket, CAT/CAM Socket, ML socket, Acrylic socket,
Total Contact Socket, Pump It Up system, the Otto Bock Air Cushion Socket
system and more. Liners are sometimes used inside the socket to obtain a better
fit and for comfort. A gel liner helps in pressure distribution, comfort, and skin
smoothing.

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Operation

Use of an actual prosthesis usually follows a period of postoperative

management that includes addressing issues of pain, swelling, and proper
positioning. In addition, physical therapy for range of motion, strength, bed
mobility, transfers, and single limb ambulation often takes place during the
initial rehabilitation period. In some cases, an individual may be fitted with an
immediate post-operative prosthesis to allow for early double-limb ambulation.
Many individuals will be fitted with a temporary prosthesis when the wound
has healed. A temporary prosthesis allows for ambulation and continued
shrinkage of the residual limb until a definitive prosthesis is fit.When
evaluating a prosthesis before use, the prosthetist and physical therapist should
ensure that the inside of the socket is smooth and that all joints move freely.
The socket should fit securely on the residual limb, and the overall prosthesis
length should match the length of the intact leg. The patient must learn how to
properly put on the residual limb sock and the prosthesis itself. A variety of
techniques are used, depending on the type of socket and suspension system.

Maintenance

The user should be aware of how to properly care for and maintain the
prosthesis, liner, and socks. Most plastic sockets and liners can be wiped with a
damp cloth and dried. Socks should be washed and changed daily. Due to the
wide variety of componentry and materials used in the fabrication of
prostheses, the prosthetist should be the source for instructions regarding
proper care and maintenance for each individual. In general, the patient should
return to the prosthetist for any repairs, adjustments or realignments.

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Health care team roles

The patient's primary care physician, surgeon, neurologist, prosthetist, physical

and occupational therapists, nurses, and social worker are all important players
in the multidisciplinary health care team. Surveys of patients with amputations
have shown that the physical therapist, along with the physician and prosthetist,
plays one of the most valued roles in providing information and help both at the
time of amputation and following amputation. The entire team's input, along
with the patient's input, is vital in determining whether a prosthesis should be
fit and the specific prescription for the prosthesis. Input should be provided
regarding the patient's medical history, premorbid level of function, present
level of function, body build, range of motion, strength, motivation, and
availability of familial and social support.

The physical therapist usually plays a major role in training an individual to

walk with a prosthesis, and also is the health care professional who can
evaluate prosthetic function immediately and over time. The physical therapist
is trained in gait assessment and should watch for compensations and gait
deviations that may indicate a problem with the prosthesis.

Training

The main goal of prosthetic training usually is smooth, energy-efficient gait.

This includes the ability of the individual to accept weight on either leg,
balance on one foot, advance each leg forward and adjust to different types of
terrain or environmental conditions. Principles of motor learning often are used
in training, progressing from simple to complex tasks. Individuals begin with
learning to keep their bodies stable in a closed environment with no
manipulation or variability. An example may be practicing standing balance on
one or both legs. Mobility, environmental changes, and task variability are
added slowly to further challenge the individual as tasks are mastered. In the
end, an example of a more complex task practiced may be the ability walk in a
crowded hallway while carrying an object in one hand. In addition to
ambulation training, the patient also should be taught how to transfer to and
from surfaces, assume a variety of positions such as kneeling or squatting, and
manage falls. Depending upon the individual's previous and present level of
function, use of a traditional cane, quad cane, or crutches may be indicated.
Patient motivation, comorbidity, level of amputation and level of function are
all factors in determining the outcome of rehabilitation

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 Types of Prosthesis

PROSTHETICS
LOWER EXTREMITY

KNEE HIP
BELOW KNEE DISARTICULATION ABOVE KNEE DISARTICULATION

Transtibial Prosthesis

A transtibial prosthesis is an artificial limb that replaces a leg missing below the knee.
Transtibial amputees are usually able to regain normal movement more readily than
someone with a transfemoral amputation, due in large part to retaining the knee,
which allows for easier movement.

Transfemoral Prosthesis

A transfemoral prosthesis is an artificial limb that replaces a leg missing above the
knee. Transfemoral amputees can have a very difficult time regaining normal
movement. In general, a transfemoral amputee must use approximately 80% more
energy to walk than a person with two whole legs.[5] This is due to the complexities in
movement associated with the knee.

Current Technology/Manufacturing
In recent years there have been significant advancements in artificial limbs.
New plastics and other materials, such as carbon fiber, have allowed artificial
limbs to be stronger and lighter, limiting the amount of extra energy necessary
to operate the limb. This is especially important for transfemoral amputees.
Additional materials have allowed artificial limbs to look much more realistic,
which is important to transradial and transhumeral amputees because they are
more likely to have the artificial limb exposed.[4]

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In addition to new materials, the use of electronics has become very common in
artificial limbs. Myoelectric limbs, which control the limbs by converting
muscle movements to electrical signals, have become much more common than
cable operated limbs. Myoelectric limbs allow the amputees to more directly
control the artificial limb. Computers are also used extensively in the
manufacturing of limbs. Computer Aided Design and Computer Aided
Manufacturing are often used to assist in the design and manufacture of
artificial limbs.[4]

Most modern artificial limbs are attached to the stump of the amputee by belts
and cuffs or by suction. The stump usually fits into a socket on the prosthetic.
The socket is custom made to create a better fit between the leg and the
artificial limb, which helps reduce wear on the stump. The custom socket is
created by taking a plaster cast of the stump and then making a mold from the
plaster cast. Newer methods include laser guided measuring which can be input
directly to a computer allowing for a more sophisticated design.

One of the biggest problems with the stump and socket attachment is that there
is a large amount of rubbing between the stump and socket. This can be painful
and can cause breakdown of tissue.

Artificial limbs are typically manufactured using the following steps:

1. Measurement of the stump.

2. Measurement of the body to determine the size required for the
artificial limb.
3. Creation of a model of the stump.
4. Formation of thermoplastic sheet around the model of the stump
– This is then used to test the fit of the prosthetic.
5. Formation of permanent socket.
6. Formation of plastic parts of the artificial limb – Different
methods are used, including vacuum forming and injection
molding.
7. Creation of metal parts of the artificial limb using die casting.
8. Assembly of entire limb.

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Partial Foot Prosthetics

Partial foot amputations are fit with prosthetic devices ranging from simple toe-
fillers in shoes for toe amputations, to custom-molded silicone prosthetics that
incorporate contoured arch supports and carbon fiber keels. A comfortable fit,
control of weight-bearing forces and adaptation to the needs of each individual
are the most important features of this type of prosthesis. In some instances it
may be necessary to purchase slightly larger or extra-depth shoes to
accommodate the arch support or prosthesis required.

For persons with Diabetes, a comfortable and supportive pair of shoes with a
soft sole and uppers is important to safeguard feet against any further injury.

Complete Prosthetic Feet

Prosthetic foot design and construction has progressed tremendously in the past
few decades and now commonly incorporates carbon fiber structures to reduce
weight and improve energy return. Some feet have terrain adapting and shock
absorbing features, while others are more suitable for special purposes such as
swimming. Most high-end feet can be ‘tuned’ to suit each individual by
adjusting or exchanging internal elastomer bumpers or wedges, and are custom
ordered from the manufacturer to specifications for each client. Prosthetic feet
are selected by considering each individual’s activity level and the type of
terrain that they will be traversing. We encourage our clients to become
familiar with the different types of prosthetic feet available, to assist in the
.selection of the most appropriate type for them
Prosthetic feet, like knees, hips, and other components incorporated into a
prosthesis, can be grouped according to a recognized functional level
:classification system

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:Low Impact Level .1

Daily activities involving limited and steady walking with the use of a walking
.aid

.Example: Ambulation at home, limited in community

:Moderate Impact Level .2

Daily activities involving normal walking, with the ability to demonstrate

.varied cadence

.Example: Community ambulation with confidence

:High Impact Level .3

.Daily activities involving fast walking, jogging and climbing stairs

.Example: Light manual labor, recreational sports

:Extreme Impact Level .4

.Daily activities involving rigorous walking, running and heavy lifting

.Example: Heavy manual labor including lifting, track and field sports

SACH, Solid Ankle Cushioned Heel (Low Impact Level)

This foot has a wedge-shaped cushion in the heel that compresses with each
step and a simple internal supportive structure embedded in a foam cosmetic
shape. These feet can be quite light and are also suitable for prostheses
intended for use around water.

Sach Foot

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Single Axis (Low Impact Level)

A hinged ankle joint is incorporated into the prosthetic foot. Rubber bumpers
.within the ankle structure absorb ankle motion induced by body weight

Dycor Foot

Multi Axis (Moderate Impact Level)

Rubber bumpers in the ankle mechanism permit a rocking motion of the foot
from heel to toe as well as from side to side. This can be useful for walking on
uneven terrain. Generally these feet do not have much stored energy return and
.they have a softer feeling underfoot than the SACH feet

Endolite Foot

Stored Energy (Moderate to High Impact Level)

These feet have an internal structure that acts like a spring. This spring will
store energy and return this energy to the amputee, propelling them forward, as
the toes of the prosthetic foot leave the ground. Some of the designs are
virtually maintenance-free, while others incorporating internal bushings and
bumpers require regular servicing to maintain optimal performance. Most of
these feet have terrain-adapting features that absorb irregularities in the ground
and improve performance on inclined surfaces. Some of the photos show the
prosthetic feet without their accompanying cosmetic covers.

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