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Evaluation of an interphalangeal-joint prosthetic hand in trans-radial

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Evaluation of an interphalangeal-joint prosthetic

hand in trans-radial prosthesis users

Natthawan Sutthison, Kazuhiko Sasaki, Gary Guerra, Sirarat

Chaisumritchoke, Wisavaporn Niamsang & Thanatat Charatrungolan

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joint prosthetic hand in trans-radial prosthesis users, Annals of Medicine, 55:1, 447-455, DOI:
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ANNALS OF MEDICINE
2023, VOL. 55, NO. 1, 447–455
https://doi.org/10.1080/07853890.2023.2166979

ORIGINAL ARTICLE

Evaluation of an interphalangeal-joint prosthetic hand in trans-radial

prosthesis users
Natthawan Sutthisona,b, Kazuhiko Sasakia, Gary Guerraa,c, Sirarat Chaisumritchokea,
Wisavaporn Niamsanga and Thanatat Charatrungolana
a
Sirindhorn School of Prosthetics and Orthotics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand;
b
Prosthetic and Orthotic Unit, Sirindhorn National Medical Rehabilitation Institute, Nonthaburi, Thailand; cDepartment of Exercise and
Sport Science, St. Mary’s University, San Antonio, TX, USA

ABSTRACT ARTICLE HISTORY

Background: A body-powered functional and cosmetically appeasing hand with moving inter- Received 30 June 2022
phalangeal joints (IPJ-Hand) was created. Function and satisfaction with the IPJ-Hand, conven- Revised 27 December 2022
tional hand (CH) and functional hook (FH) in trans-radial prosthesis users were evaluated. Accepted 5 January 2023
Methods: Eight participants with trans-radial amputations were provided with three prosthetic
KEYWORDS
hands and performed the Nine Hole Peg Test (NHPT), Brief Activity Measure of Upper Limb Trans-radial; upper limb
Amputees (BAM-ULA) and Quebec User Evaluation of Satisfaction with Assistive Technology prosthesis; nine hole peg
QUEST). test; QUEST; BAM-ULA
Results: The data are shown as the median and interquartile range (IQR) due to skewed data
distribution. Differences across hands were seen in NHPT with CH 57 (13.3), FH 49.5 (26.5), IPJ-H
and 49 (14.8) seconds respectively. BAM-ULA, 10 (1.5), FH 10 (0.7), and IPJ-Hand 10 (1.7). QUEST
scores, FH 28.5 (7.2) with the highest score, IPJ-Hand 26 (6.8), and lastly CH 25.5 (9.2).
Conclusion: Individual participant results varied, with some participants performing better on
the NHPT when using the IPJ-Hand when compared to the CH and FH. No differences between
hands on the BAM-ULA were seen, and although no large differences in QUEST were observed,
users performed best using IPJ-Hand.
KEY MESSAGES

An interphalangeal joint prosthetic hand (IPJ-Hand) offers the similar function of a prosthetic
hook, and the appearance of a conventional hand, but with improved dexterity.

Minimal resources are needed to create the IPJ-Hand for prosthesis wearers.

Introduction powered or externally powered devices. Body-pow-

Upper limb amputation accounts for approximately
8% of all major limb amputations [1] and is typically a
result of trauma [2]. Although upper limb amputations
make up a small percentage of all amputations, by the
year 2050 an estimated 3.6 million individuals will be
living with amputation [1]. Upper limb amputation has
been reported to be as high as 68.6% of trauma-
related injuries [3]. In fact, the incidence of upper limb
amputations has seen a decline as a result of limb sal-
vaging surgeries [4] and possibly a reduction in occu-
pational safety [5].
Fortunately, a number of prosthetic treatments are
available for individuals with upper limb amputation.
Prosthetic restoration is accomplished through body-
ered devices employ the use of a cabling and strap
system tethered to the device which opens and closes
the hand or hook via user body movements [6]. In
contrast, externally powered devices require motors
and batteries relying on either surface electrodes sens-
ing muscle contractions, electroencephalogram (EEG)
or brain-computer interface BCI technologies [7–10].
Both types of prosthesis, body or externally pow-
ered, can offer both function and cosmesis. Yet
because externally powered devices typically leverage
the use of myoelectric hands with interphalangeal
joints and cosmetic gloves, they generally have dis-
tinct advantages over body-powered devices [11]. This
is because for years body-powered terminal device
options have been limited to either the functional

CONTACT Kazuhiko Sasaki kazuhiko.sas@mahidol.edu Sirindhorn School of Prosthetics and Orthotics, Siriraj Hospital, Mahidol University, 14 Arun
Amarin Rd, Arun Amarin, Bangkok Noi, Bangkok, 10700, Thailand
ß 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
448 N. SUTTHISON ET AL.
hook that is well suited for large dexterous tasks or
the functional hook that permits similar function with
great aesthetics but limited fine motor dexterity.
Recently, great emphasis has been placed on the
development of better upper limb prostheses as users
have had high rates of prosthesis rejection [12,13],
and have desired affordable life-like hands [14]. In fact,
rejection can be exacerbated for those with higher-
level amputations exerting greater effort for device
use [15]. There are a number of new externally pow-
ered myoelectric hands which can provide both func-
tion and cosmesis, but these are cost-prohibitive for
the majority of upper limb amputees in the world.
Users residing in resource-limited environments (RLE)
must choose between a functional hook that offers
tactility or a functional hook that provides cosmesis
but with reduced function.
Although upper limb amputations generally make
up a small percentage of the amputee population
[16], several products, such as Otto Bock’s
Michelangelo arm have been developed with compu-
terized interphalangeal prosthetic joints (IPJ) and a
cosmetic glove cover [17]. These technologies have
met user needs for enhanced tactility and cosmesis
but at an out-of-pocket price point of approximately
$40–60,000 USD. However, is the additional cost
worthwhile in terms of user function and satisfaction?
Several studies have looked at both of these import-
ant facets. A recent study evaluated the US
Department of Defense’s advanced prosthesis rehabili-
tation and technology program. When comparing
amputee veterans of the Vietnam conflict to those
from recent conflicts, a shift from the use of body-
powered to externally powered devices was observed
[18]. Another study found users exhibiting great satis-
faction with powered multi-function myoelectric upper
limb prosthesis [19].
Further evidence to support the importance of mar-
rying both function and cosmesis is evident in a
recent study exploring the long-term effects of the
Michelangelo hand on functional and psychosocial
measures. These authors found consistently high
scores in the Box and Block Test (BBT) and Trinity
Amputation and Prosthesis Experience Scales (TAPES)
[17]. However, a recent review of myoelectric and
body-powered prosthesis by Carey et al. noted insuffi-
cient evidence to support one type of device over
another, emphasizing device selection be based on a
patients unique needs [7].
Still, it is clear that a body-powered terminal device
providing both dexterity as well as cosmesis might
serve a purpose for users residing in RLE. As such, we
constructed a body-powered functional and cosmetic-
ally appeasing hand with moving interphalangeal
joints (IPJ-Hand). Our objective was to evaluate func-
tion and satisfaction with the IPJ-Hand, conventional
hand and functional hook in a sample of trans-radial
prosthesis users.
Methods
Participants
This study was approved by the Siriraj Hospital Faculty
of Medicine IRB (COA no. SI 902/2020), and all partici-
pants provided informed consent prior to study par-
ticipation. Eligible participants needed to have either a
unilateral or bilateral trans-radial amputation, experi-
ence using a prosthesis  1 year, no physiological or
musculoskeletal issues, and normal limb ranges of
motion. A convenient sample of eight participants, six
male and two female traumatic trans-radial amputees
49.87 ± 12.72 years of age were recruited for this study
(Table 1).
IPJ-Hand
The design of the IPJ-Hand is simple and perfectly
suited for prosthetists and prosthetic technicians living
in austere settings. The hand is a technical modifica-
tion to an existing voluntary opening (VO) prosthetic
hand, the Otto Bock 8K23 (Otto Bock, Duderstadt,
Germany). Importantly, any voluntary opening hand
may suffice, however, when modifying the hand it is
important to note that modification may void the war-
ranty and original functionality. This hand was chosen
as it is widely available in RLE, with other manufac-
turers offering similar hands at a range of prices. We
estimated materials and modifications to these hands
to be roughly $20. Fabrication begins by cutting off
approximately 1.27 cm of the index and thumb fingers
(Figure 1(A)). These pieces are not to be discarded as
they will now serve as a template for creating six alu-
minum alloy extension pieces (Figure 1(B)). The exact
contours of these extensions should follow that of the
hands remaining fingers. This step is part art and
requires only that the dimensions of each piece be a
length of approximately 21 mm, a width of 10 mm and
a height of 1.5 mm. Next, a series of 0.3 mm holes
must be punched into the extension bars which serve
as a means for attachment back onto the hand. Three
bolts along with nuts are required so that the exten-
sions can be pieced together back onto the hand.
Technicians may trial a variety of bolt sizes and select
appropriately. The dimension of the bolt was chosen
 ANNALS OF MEDICINE 449

Table 1. Participant demographics.

Participant 1 2 3 4 5 6 7 8
Gender Male Male Male Female Female Male Male Male
Age (years) 52 56 39 50 61 69 29 43
Amputation Right Right Right Right Right Left Right Right
Socket NW Conventional NW Munster NW NW Conventional NW
Previous TD None Hook Myoelectric Passive Hand Hook Functional hook Hook
Harnessing Figure 9 Figure 8 Figure 9 Figure 9 Figure 9 Figure 8 Figure 8 Figure 8
Note: Amputation: amputation side; TD: terminal device; NW: Northwestern; Myo: myoelectric.

Figure 1. Images illustrating completed steps of the fabrica-

tion process for the IPJ-Hand.
A voluntary opening prosthetic hand is sourced and fabrication begins by
cutting off at the estimated mechanical interphalangeal joint locations of
approximately 1.27 cm of the index and thumb fingers (Figure 1(A)). These
pieces are not to be discarded as they will now serve as a template for
creating six aluminum alloy extension pieces (Figure 1(B)). The exact con-
tours of these extensions should follow that of the hands remaining fin-
gers. This step is part art and requires only that the dimensions of each
piece be a length of approximately 21 mm, a width of 10 mm and a
height of 1.5 mm. Next, a series of 0.3 mm holes must be punched into Figure 2. Image of a frontal and sagittal view of IPJ-Hand.
the extension bars which serve as a means for attachment back onto the
hand. Three bolts along with nuts are required so that the extensions can
be pieced together back onto the hand. The dimension of the bolt was
chosen so as to permit the hook of the springs to easily catch onto the bolts on each finger and thumb extension and then to
bolts (Figure 1(C)). Orange arrows designate pieces which need to be cut the hand itself. With the springs attached to the
and used to assemble the interphalangeal joint.
extensions, the opposite ends of the springs must
so as to permit the hook of the springs to easily catch then be attached to the proximal hand, this requires
onto the bolts (Figure 1(C)). The final step in fabrica- drilling two additional 0.3 mm holes. Lastly, fingertips,
tion is to attach two stainless steel helical tension made from ethyl vinyl acetate foam (EVA), are glued
springs (Figure 2). to the extensions to aide finger pinch tasks and to
Springs were chosen in order to provide a pinch protect the cosmetic glove. At this point the desired
force between 9 and 15 N, whilst still allowing for an pinch force can be fixed through the use of a pinch
outer glove in order to maintain cosmesis. For the gauge, any such gauge will suffice, however, we rec-
index finger spring, the free length measurement is ommend a hydraulic gauge that allows a wide range
45 mm, the length of the body is 39 mm, the inside of pinch forces (B&L Pinch Gauge, B&L Engineering,
diameter is 0.15 mm, the outside diameter is 3.0 mm Santa Ana, CA, USA). The IPJ-Hand pinch force chosen
and the wire diameter is 0.08 mm. The thumb spring for this study was 12.3 N and is within the average
free length is 35 mm, length of the body is 29 mm pinch force of 9 to 20 N seen in the literature for pros-
with identical wire and inside and outside diameters. thetic hands [20]. Once fully fabricated, this modifica-
These springs were first attached to the most distal tion permits a slight amount of interphalangeal flexion
450 N. SUTTHISON ET AL.

in the proximal finger and thumb, which aides fine

motor movements (Figure 2).

Procedures
Each participant was evaluated by the study prosthet-
ist for a new trans-radial prosthesis. The choice of
prosthetic socket type was largely dependent upon
each patient’s unique residuum, short or long and
conical or cylindrical. Thus, five participants received a
Northwestern-style socket, two participants received a
conventional prosthesis and one participant received a
Muenster-style socket. A figure of 9 suspension was
Figure 3. Image of a participant performing the Nine-Hole
provided to four participants and a figure of 8 suspen- Peg Test with IPJ-Hand.
sion to four participants, see Table 1. Two prostheses
were made per participant because the length of the
hand and hook were different, however, through
adjusting the forearms, prostheses lengths remained
similar. Upon successful fitting, and prior to outcome
measurement, each participant performed a prosthesis
checkout procedure to optimize function and trans-
mission efficiency [21]. Optimized pinch force gauging
for each hand resulted in a mean force of 10 N for CH,
24 N for FH and 12.3 N for IPJ-Hand. These pinch
forces were determined from pilot testing which
allowed users to trial a range of pinch forces which
we later selected based on user feedback.

Outcome measurements
Each user was fit in a randomized order with either
the IPJ-Hand, Conventional Hand (CH) VO Otto Bock
8K23 or Otto Bock Functional Hook (FH) VO Otto Bock
10A60. Participants then performed a pinch force test
via the pinch force gauge and battery of outcome
measurements. The same prosthetic outer glove was
applied to each hand, blinding the participants to the
hand type. Both performance-based and patient-
reported outcome measures were administered.
Outcome measurements were selected because they
challenged the user to perform both large and fine
motor skills and allow for subjective feedback. Practice
time was provided for all performance-based outcome
measures with sufficient time for participants to
accommodate device and outcome measures. Once
participants felt accommodated, a total of three trials
were performed for outcome measures. The Nine-Hole
Peg Test (NHPT) required the participant to sit in a
chair at a table, pick up and place nine wooden pegs
into a series of holes, then remove pegs and return to
a dish. Each participant was provided ninety seconds
to complete this process, and the duration of time to
Figure 4. Image of a participant performing task four of the
Brief Activity Measure for Upper Limb Amputees (BAM-ULA).
complete this task was recorded. Figure 3 illustrates
participants placing wooden dowels into a tray during
testing [22]. The Brief Activity Measure for Upper Limb
Amputees (BAM-ULA) required the participant to com-
plete ten common activities of daily living, see Figure
4 demonstration of removing of wallet task of BAM-
ULA [22]. A score of 0 (inability to complete the task)
or 1 (completion of the task) was given for each of
the ten tasks with scores being summed. Finally, the
Quebec User Evaluation of Satisfaction with Assistive
Technology questionnaire (QUEST) was administered
to participants. The survey asks the participant to con-
sider the weight of the device, safety and security,

durability, ease of use and effectiveness [23]. From
these outcome measurement data, we performed a
descriptive analysis to provide descriptive data of par-
ticipant outcome measurement performances.
Results
Due to the small number of subjects and skewed data
distributions, the whole data was reported at the
median and Interquartile range (IQR). Nine Hole Peg
Test (NHPT) scores across each participant varied with
large differences observed between CH and IPJ-Hand
(Figure 5). Differences between hands were seen in
NHPT with CH 57(13.3), FH 49.5(26.5), IPJ-Hand
49(14.8) seconds respectively (Figure 6). In the BAM-
ULA, no large differences were observed across each
hand with the conventional hand scores being 10(1.5),
FH 10(0.7) and IPJ-Hand 10(1.7). Lastly, QUEST scores
were as follows, FH 28.5(7.2) with the highest score,
IPJ-Hand 26(6.8) and lastly CH 25.5(9.2) (Figure 7).
Discussion
The objective of this study was to enhance upper limb
amputee dexterity whilst maintaining cosmesis
through the development of an interphalangeal pros-
thetic joint. Pinch forces for each of the three hands
were within normal ranges for prosthetic hands [20].
Individual participant results varied, with four partici-
pants performing better on the NHPT when using the
IPJ-Hand when compared to the CH and FH. Although,
comparisons for each type of hand across all trials of
the NHPT indicated no differences between IPJ-Hand
and CH. No differences between hands on the BAM-
ULA were seen, and although no large differences in
QUEST were observed, users performed best using the
IPJ-Hand.
Upper limb prosthesis hand development has seen
marked improvements over the last decade. This is
especially apparent with the advent of additive manu-
facturing technologies which have ushered in a new
method of creating prosthetics [24], and the possible
use of carbon fiber for lightweight durable prosthetics
[25]. Moreover, additive manufacturing is cost-effect-
ive, rapid and can greatly enhance the research devel-
opment and innovation activity of prosthetics. A
plethora of materials can be processed with 3D print-
ing (e.g. polymers, composites, metals, alloys), and
provides freedom when complex models and struc-
tures have to be manufactured.
Creating a prosthesis with intuitive control and an
aesthetic which can help the users overall body image
ANNALS OF MEDICINE 451
is a goal worth striving for in prosthetic treatment
[26]. Projects like the Defense Advanced Research
Project Agency (DARPA) have greatly enhanced the
possibilities for upper limb amputees [27]. Still, as
helpful as these technologies are, for now at least, the
dexterity offered by these devices remains out of
reach for the majority of those with limb loss. These
devices are myoelectrical controlled via electromyog-
raphy (EMG) and although they offer great dexterity
[28,29], these users tend to depend upon visual feed-
back of their device for hand awareness which can
increase cognitive demand on function [30]. In fact,
participants of our study performed better when using
the FH over the CH. This may be because functional
hooks do not interfere with the line of sight of an
amputee as hands sometimes may [7]. However,
whether or not CH users required more visual atten-
tion or cognition was not explored in our study.
In contrast to more recent myoelectrical prosthesis
research, our study participants could not benefit from
EMG. It may very well be that participants employed a
feedforward control system through the formation of
an internal model of their arm comprising of pros-
thesis weight, length and segment masses [31,32].
This internal model may have aided body-powered
prosthesis users through direct hand-to-prosthetic har-
nessing proprioceptive feedback [33]. However, we did
not collect these data, and future research is needed
to determine whether IPJ-Hand users can leverage an
internal model, by enhancing tactility through IP joint
modification. Still, identifying the optimal spring
attachment points for IPJ-Hand required numerous
iterations, however once determined, lead to optimal
pinch forces for all participants. This process is slightly
trial and error, and the clinician or technician will have
to contend with this during fitting.
This study has several limitations that negate gen-
eralizing findings to the broader community. Our sam-
ple size (n ¼ 8) was small and recruited experienced
prosthesis users. The preliminary character of this
study necessitates a more robustly designed trial
before we can recommend the broad use of the IPJ-
Hand. A within-subjects design recruiting a larger
cohort of participants would add greater statistical
power to the study. After performing a post hoc ana-
lysis we determined that a sample of 14 can help
achieve a more suitable power (1  b ¼ 0.83). Another
limitation of our study was the limited duration pro-
vided to use each type of hand before outcome meas-
urement. This is especially important with patient-
reported outcome measures of satisfaction such as the
QUEST which should be evaluated after a longer free-
452 N. SUTTHISON ET AL.

Figure 5. Box and whisker plots for Nine-Hole Peg Test (NHPT) in eight participants wearing prosthetic hands. Note: : P < 0.05:
the result of Paired Wilcoxon signed-rank test with Bonferroni correction after a Friedman’s v2 r-test; IPJ-Hand: interphalangeal
joint hand. Center lines show median and interquartile ranges. A longer duration indicates worse dexterity and a shorter duration
better dexterity.

Figure 6. Box and whisker plots for Nine-Hole Peg Test (NHPT) in three prosthetic hands. Note: IPJ-Hand: interphalangeal joint
hand; CH: Conventional hand. Center lines show median and interquartile ranges. A longer duration indicates worse dexterity and
a shorter duration better dexterity.
Figure 7. Box and whisker plots for QUEST in three prosthetic
hands. Note: QUEST: Quebec User Evaluation of Satisfaction
with Assistive Technology; IPJ-Hand: interphalangeal joint
hand; CH: Conventional hand. Center lines show median and
interquartile ranges. longer duration indicates worse dexterity
and shorter duration better dexterity.
living experience. However, our participants expressed
positive feedback, often requesting to trial the hand in
the home during activities of daily living. Moreover,
because the IPJ-Hand is covered with a hand cover,
they noted increased confidence and a willingness to
use the hand in public settings. Users noted that the
IPJ-Hand combined with a body-powered harness
offered the capability to sense their pinching force
through the harness, even when closing their eyes.
ANNALS OF MEDICINE 453
Still, we recommend others to evaluate the long-term
use of this hand in free-living settings. Moreover,
some research has observed improved prosthesis use
and skill with longer accommodation time for hand
training [34].
Conclusion
The IPJ-Hand adds to the many prosthetic technical
interventions a prosthetist and technician can perform
to enhance user quality of life. Although the IPJ-Hand
was initially intended for those in RLE, users in devel-
oped settings preferring body-powered systems but in
need of additional dexterity may benefit from this
hand. Scholars have surveyed persons with limb loss
and asked them to list their top five design priorities
for a prosthesis. A life-like appearance and enhanced
dexterity were among the top requests [14]. We hope
the IPJ-Hand may someday facilitate dexterity and aes-
thetics for upper limb prosthesis users.
Author contributions
Conception and design; N.S., K.S., G.G., Analysis and inter-
pretation of the data; N.S., K.S., S.C., W.N., T.C., Drafting of
the paper; N.S., K.S., G.G., S.C., W.N., T.C., Revising critically
for intellectual content; K.S., G.G., S.C., W.N., T.C., Final
approval of the version to be published; N.S., K.S., G.G., S.C.,
W.N., T.C., Authors agree to be accountable for all aspects of
the work.
Consent form
Consent to publish these data was provided by all
individuals.
454 N. SUTTHISON ET AL.
Disclosure statement
No potential conflict of interest was reported by the
author(s).
Funding
No funding was received.
Data availability statement
The data that support the findings of this study are available
from the corresponding author, K.S., upon reasonable
request.
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