Ch10 - Prescription TF

Polytechnic of Health Sciences Jakarta I
Ministry of Health of Republic of Indonesia

Department of Prosthetics & Orthotics
Transfemoral Prosthetics
Course Handout 2022
1
Chapter 10
Prescription Principles
2 TFProsth/Ch.10/2022/Intake 13
Learning Outcome
At the end of the session, students should be

able to:
– Identifying type and functions of e
ach components in TFP
– Comparing which prescription is match
with patient needs
– Using this knowledge to provide optimal outc
ome services
Contents
1. Introduction
6. Alignment devices
2. Suspension
7. Feet
3. Sockets
8. Cosmesis
4. Knees
9. Other equipment
5. Shanks
Customer Satisfaction
• The prescribed prosthesis should satisfy the needs

of the patient
• In prescribing a prosthesis, we must first start with
what is available
• If the patient needs a component which is not
available, we should try our best to get it
• If this is not possible, then we must use what we
have
Patient's Needs
 The patient's stump condition and general health will
influence the choice of socket materials and design
 The patient's job and living conditions will influence
the type of limb system chosen
Prescription tables
 The following table is to help you make decisions on

components
 However, remember that not all of these choices may

be available where you are
 These are guidelines and some opinions
Prescription Tables Describing
A-D-I-C
 Socket designs  Stance phase controls

 Socket materials  Swing phase controls
 Suspensions  Shank components
 Knee joints  Foot and ankle components
Socket Design Advantages Disadvantages Indications Contraindications
Quadrilateral Commonly Amputee with Vascular
– the ischium used in long muscular amputee,
sits on a many stump are Bilateral
shelf countries successful
posteriorly Quad. wearers amputee ?
(There are no
absolute
contraindications to
any design)
Contra-
Socket Design Advantages Disadvantages Indications
indications
Ischial Ramal Improved gait Difficult Vascular Amputee, If clinic staff
Containment - and ML technique to High activity do not have
the ischium is stability, does learn 2 people experience
amputee, Bilateral
contained in not restrict
required for amputee, Clinic staff with IC
the socket circulation
casting have knowledge /
experience of
IC
Socket Dis- Contra-
Advantages Indications
Material advantages indications
Polypropylene Allow total Has to be Suitable For very heavy
contact, imported for vast patients
Relatively majority
inexpensive, of
Easy to patients
manufacture
Dis- Contra-
Socket Material Advantages Indications
advantages indications
GRP Allows Increased If If patient has
(Glass total time in patient allergy to
Reinforced contact, manufacture, is GRP
plastic) Can be made Some heavy,
lightweight, chemicals If using
Areas of may cause particular
socket can allergy (in components
be manuf.)
reinforced
Socket Dis- Contra-
Flexible Allows total Expensive, For patients

materials contact, Needs to with poor
muscle tone,
High level of be imported
bony
comfort
residual
limbs
Socket Dis- Contra-
Aluminum Locally Does not allow If other If any other
available, total contact materials are material is
Cooler not available available
Suspension Dis- Contra-
Type advantages indications
Self No Sweating – no Young Elderly, poor

suspension- additional socks worn, active muscle tone,
suction straps Increased amputee Poor hand
needed, time needed with good function,
Good to ensure muscle tone Excessive
cosmesis good fit, stable limb sweating,
Difficult to volume Very short
don/ doff, residual
Even with limbs
good fit can
lose suction,
Embarassing
noises
Silicone Very secure Expensive, User who Poor upper

suction suspension, Donning and requires limb
suspension Good doffing is excellent function,
cosmesis, difficult suspension , Excessive
Silicone also Needs to be e.g sports sweating
protects skin imported, activities,
hot – sweaty Patient with
excessive
scarring on
residual limb
Suspension Contra-
Advantages Disadvantages Indications
Type indications
Silesian belt Secure, Reduced cosm- Majority of If user is
– soft belt comfortable esis compared to amputees. especially
made of fabric suspension; Does suction. If not Requiring good concerned
or leather not restrict correctly suspension and about
movement; positioned will some stability. cosmesis.
Simple to cause rotation.
fit and repair.
Locally
available
materials;
ML stability and
rotational control
Rigid Pelvic Very good Uncosmetic, Elderly Young

band- a ML stability bulky, heavy patients with active
metal band and May be un- poor muscle amputee
covered with rotational comfortable control with good
leather and control. in sitting. needing muscle
single axis Can be made secure strength.
hip joint form local suspension
materials.
Dis- Contra-
Knee Joint Advantages Indications
Single axis Inexpensive, Lack of Suitable for Long

simple mechanical most residual limb
design, low stability amputees Inability to
maintenance with average control knee
stump length with muscle
and good action.
muscle
strength.
Dis- Contra-
Knee Joint Advantages Indications
Polycentric Mechanical (Historically KD Person who

stability in – increased Long TF is not able to
gait cycle. weight and residual attend for
Easier toe bulk) limb. repairs often
clearance in Now Cost Short TF
swing, due residual
to shortened limb.
shank. Weak hip
Improved extensors
cosmesis for
long stumps.
Stance phase
Dis- Contra-
control of Advantages Indications
knee
No Patient No For young, Short
stabilizing maintains additional fit amputee residual limb
mechanism use of stability if with good Weak
muscles in needed length of Muscles.
controlling residual limb Flexion
prosthesis and muscle Contracture.
strength
Stance
phase Dis- Contra-
control of advantages indications
knee
Manual Very stable Poor gait - Elderly Young fit
knee lock – need to amputee , amputee
the knee circumduct, poor muscle with good
remains vault to strength, residual
locked allow flexion limb able to
throughout clearance in contracture control knee
stance and swing phase. with
swing muscular
contraction
Stance
phase Dis- Contra-
knee
Weight Provides Increased If user is Indoor
activated stability weight, walking on walker, low
stance when limb is Some rough, activity
control in flexion maintenance uneven
required ground.
compared to If user
MKL requires
some added
stability
(medium
activity)
Stance
phase Dis- Contra-
knee
Hydraulic Allows easy Heavy, High activity Low
stance knee flexion Requires walker, activity,
control in swing , maintenance, runner poor muscle
yet high Cost strength
resistance to
flexion in
stance.
Variety of
functional
options.
Swing
phase Contra-
control of indications
knee
Friction Low weight, Can be Good for High activity
control Simple adjusted but children due patients
design, only for one to durability, using more
Low walking For users who than one
maintenance. speed. live very far walking
Any from clinic. speed
variation in Patients who
speed causes do not change
uneven walking speed.
timing.
Swing phase
Contra-
control of Advantages Disadvantages Indications
indications
knee
Extension Cheap, Not durable, For patients Active
assist Easily fitted, Uncosmetic who need patient, with
external: Reduced help to good muscle
elastic strap effort from extend knee. strength
Provides amputee
extension at
end of swing
Swing phase
Contra-
indications
knee
Internal Simple Increased For patients Active
spring assist design, weight who need patient, with
: a spring Durable, help to good muscle
inside the knee Does not extend knee strength
mechanism is affect
compressed cosmesis
during flexion Reduced
and provides effort from
extension amputee
assist.
Swing phase
Contra-
indications
knee
Pneumatic Provides control Heavy, Expensive,Patient who Low activity Poor
of swing phase Requires walks at different muscle strength
at different Maintenance, speeds
walking speeds Range of walking
(simpler, lighter, speeds is limited
less expensive
compared to
hydraulic unit)
Swing phase
Contra-
indications
knee
Hydraulic Provides Heavy, Patient who Low activity
cylinder control of Expensive, walks at Poor muscle
swing phase Requires different strength
over a wide maintenance speeds,
range of Heavy user
walking high activity
speeds Teen adult
male
Shank Contra-
components indications
Exoskeletal Strong, Cannot For heavy Patient

durable, change patient, requiring
May be alignment or Patients regular
water proof socket after working in changes of
Inexpensive limb is fitted wet/ dirty alignment or
Locally Heavy environment socket
available Patient doing
heavy work
Shank Contra-
Components indications
Endo- Lightweight Usually Children, Heavy

skeletal Allows expensive, users patients,
 ICRC change of Weight requiring Patients
 Otto Bock socket and limits, regular working in
 Endolite alignment Has to be change of dirty/ wet
after imported, socket and environment
delivery Requires height.
maintenance
Foot and ankle Dis- Contra-
components advantages indications
Peg Leg Light weight Poor gait, no Farmer All users not
No anterior working in working as
maintenance support , muddy farmers
lack of conditions
cosmesis
Foot and ankle Contra-
SACH foot Lightweight Heel cushion Children, High activity

Little may corrode low or users.
maintenance over time, medium People
Inexpensive Soft heel activity walking on
cushion users uneven
required for terrain.
TF
Single axis Ability to Maintenance Patients High activity

foot change required, with users,
stiffness of Increased limited Users
plantarflexion weight muscle unable to
Improved compared to strength attend for
knee control, and regular
SACH,
lack of knee maintenance
Works well Reduced
control.
on slopes cosmesis
Multiaxial Allows Increased For medium Low activity

foot movement maintenance or high patients,
AP and ML Expensive activity Indoor
planes and users, walkers,
rotation; Patients Users unable
Ability to walking on to attend for
change rough regular
resistance to ground maintenance
plantar flexion,
Allows
different
heel height,
Energy If foot is Reduced Very high Children,

storing foot unloaded stability, activity Low,
quickly it Increased users, medium
releases weight, Athletic activity
energy when High cost patients patients
walking engaged in
sports
Practice
• Socket :
o ICS + silicone (GRP/thermoset)
• Suspension :
o Suction
• Knee joint :
o Single axis, WA, hydraulic, polycentric
• Prosthetic foot :
o Single axis, SACH, SAFE, multi axis
• Other considerations?
o Rotation adapter, torsion adapter
Reimbursement
• Self payment => BPJS Kes 2017: coverage Duration

No problem LL/UL prostheses IDR 2,500,000 /5 yrs
• Insurance => Corset IDR 350,000 /2 yrs

Neck collar IDR 150,000 /2 yrs
Good
Walker IDR 350,000 /5 yrs
• Previously
Disadvantaged
Individuals
(PDI) => ???
Foreshortened prostheses
Stubbies Who can benefit?

• Short prostheses which are: • Bilateral leg amputees
– Custom fitted (especially short RL)
– Usually made up of standard • The elderly, physically unfit,
sockets diabetic
– No articulated knee • Those affected by vascular
joints/shank • Cardiorespiratory conditions
– With modified rocker • Children?
bottoms/SACH feet turned
backward
• Used during and sometimes after
initial ambulatory rehabilitation
Foreshortened prostheses
Fact:
• Reduced heart rate and
oxygen use by 7 to 23%
• Increased walking speed by
up to 25%
(amputee-coalition.org)
Make a good prescription!
The prescribed prosthesis should satisfy

the needs of the patient.

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Polytechnic of Health Sciences Jakarta I

Ministry of Health of Republic of Indonesia

At the end of the session, students should be

• The prescribed prosthesis should satisfy the needs

 The patient's stump condition and general health will

influence the choice of socket materials and design

 The patient's job and living conditions will influence

the type of limb system chosen

 The following table is to help you make decisions on

 However, remember that not all of these choices may

 These are guidelines and some opinions

 Socket designs  Stance phase controls

Flexible Allows total Expensive, For patients

Self No Sweating – no Young Elderly, poor

Silicone Very secure Expensive, User who Poor upper

Rigid Pelvic Very good Uncosmetic, Elderly Young

Single axis Inexpensive, Lack of Suitable for Long

Polycentric Mechanical (Historically KD Person who

Exoskeletal Strong, Cannot For heavy Patient

Endo- Lightweight Usually Children, Heavy

SACH foot Lightweight Heel cushion Children, High activity

Single axis Ability to Maintenance Patients High activity

Multiaxial Allows Increased For medium Low activity

Energy If foot is Reduced Very high Children,

• Self payment => BPJS Kes 2017: coverage Duration

• Insurance => Corset IDR 350,000 /2 yrs

Stubbies Who can benefit?

The prescribed prosthesis should satisfy

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