KD Prosthetic Alignment

Introduction
• This session we will try to explain, how we
maintain our balance when standing and
walking using lower limb prosthesis.
• To start we will look at the basics behind
posture and walking as well how this is
affected by prosthetic alignment
 Basic definitions
• Gravity
• Center of gravity (CG) 
• Line of gravity (LG) 
• Base of support (BOS) 
• Balance 
• Alignment 
 Gravity
• is a natural phenomenon by which all things
are brought towards one another.

• In our case we need to remember that our

bodies are constantly being drawn towards
the earth.
 Center of gravity (CG) 
• Is the average location of the weight of an
object.
• In our case, when we are standing still this
point is in front of our spine just below (S2)
the belly button
 Line of gravity (LG) 

• Is a vertical line passing through the center of

gravity
 Base of support (BOS) 

• Is quite simply the area beneath a person that

includes every point in contact with the
ground
 Base of support
• The picture demonstrates
the base of support (BOS)
depicted in green.
• It is shown that the size of
this green area changes
with different postures and
walking aids. It is visible
that straddled legs and
walking aids enlarge the
BOS and help us remain
stable. 
• When the line of gravity is
within the BOS, a person is
said to be stable.
 Stable and Unstable BoS

• The picture
demonstrates a stable
and an unstable body
position. 
• The unstable person’s
line of gravity (LG) falls
outside of his base of
support (BOS).
 Balance 
• Is the ability to maintain the line of gravity
through the center of gravity within the base
of support.
• To do this we have to use lots of different
muscles to maintain a vertical position.
 BOS During walking
• When walking, our base
of support (BOS) and
center of gravity (CG)
are constantly changing. 
• To accommodate for this
and remain balanced, our
body is continuously work
ing to keep its line of
gravity (LG)
within the base of
support. 
 Alignment
• Is the relative position of different parts to
each other. This can be between different
body parts or between different components
of a prosthesis.
• Naturally our bodies have their own individual
alignment that is unique to each of us.
• This position allows us to stand and walk using
the least amount of effort and without losing
balance
 Prosthetic alignment
• When prosthesis is involved, it must maintain the
body’s natural alignment.
• If the prosthesis is not correctly aligned, the body
has to accommodate for this abnormal position.
• This can put unnecessary stress on muscles and
joints, making it harder to walk and can lead to
complications
• Failure to provide a satisfactory alignment may result
in problems for the amputee, such as difficulty in
walking, stump pain, or tissue breakdown
 The Alignment Process

• Stump position 
• Bench alignment 
• Static alignment and 
• Dynamic alignment
 Stump position
• The photo demonstrates
an example of a standing
frame used to find the
individual alignment
reference line.
• It is visible that the rings
supporting the check
socket can freely rotate,
allowing the stump to
find its natural position.
• A visible red laser is used
as a landmark to draw a
reference line on the
socket
 Bench alignment
• Defined  as the position
and orientation of the
socket, knee joint and
foot relative to each
other
• With reference lines
marked on the socket,
the lower limb
prosthesis can be
assembled
 Static alignment
• Now that we have an
assembled prosthesis
with its initial alignment,
it is time to make sure the
user can stand and
balance on it.
• This photo also depicts a
pretty common situation
when a rigid contracture
of the hip joint was not
taken into account during
bench alignment
 Static alignment

• The photo
demonstrates the same
amputee with a
prosthesis that takes
into account the bodies
individual alignment
• it accommodates for his
hip contracture
 Dynamic alignment
• The photo demonstrates
walking with the
prosthesis, the final phase
of dynamic alignment.
• During this phase the
amputee imitates
different walking
situations in a controlled
real-life environment. 
• Prosthetist will observe
how the amputee walk
and corrects the
alignment if required
 Summary
• Alignment is a crucial process in prosthetic
management.
• As we mentioned before, our body has to
work to stay balanced when we stand and
walk.
• Prosthetic alignment directly and dramatically
affects on the amputees ability to balance and
maintain an energy efficient gait
 Prosthetic alignment – The Socket
• The picture
shows a reference line
drawn on
the check socket.
• The prosthetic socket
connects to the rest of
the prosthesis by means
of a socket adapter. 
• In general, the positioning
of this adapter should
coincide with the point
where the frontal and
sagital planes intersect on
the bottom of the socket
 Socket adaptor position
• If the socket adapter is
located in the correct
position, the amputee
should be able to stand
and maintain balance
naturally without
excessive effort.
 Socket adaptor position
• The picture shows
an appropriate individual
position of the socket adapter
in frontal plane with
the socket in equilibrium. 
• The point support (where
the socket adapter should be
placed) is depicted in the
shape of a red triangle. 
• A red dot is used to
indicate where two
planes (frontal and
sagittal) intersect on the
bottom of the socket
 Socket adaptor position
• The picture shows
a situation where the
socket adaptor is
positioned too far
medially in the frontal
plane.
• The socket is not in
equilibrium and tends
to tilt laterally due to
rotating forces
 Socket adaptor position
• The picture shows the
position of the socket
adapter found without
taking into account a
contracture of the hip
joint in the sagittal plane. 
• In this case, the amputee
has to strain their back
(depicted by red arrow)
to maintain a vertical
position
 Prosthetic Knee alignment
• The picture demonstrates a
prosthetic knee joint
bending
• Prosthetic knee units are
designed to imitate the
movement and functions of
the natural knee
• If it is aligned properly, it
will have its own stability in
a straight position
 Prosthetic Knee alignment
• If this line passes too far behind the knee’s
reference point, it will want to bend making it
unstable and risk buckling when under load.
• If this line is too far in-front of the reference
point, it will become overly stable and will be
difficult to bend when sitting down and
walking.
• If the alignment line is in an appropriate
position, the knee will be stable in stance and
require minimal effort to initiate swing
 Prosthetic Knee alignment
• The picture shows a side
on view (sagittal plane)
with three different
positions of the
alignment line in
relation to the knee
joints reference point.
• Note that each model of
knee has its own point
in which the alignment
line should pass
 Antero-posterior alignment
• "Alignment stability" is
a key element in
prosthetic fitting.
• By reference to "TKA,“
a vertical line in the
sagittal plane through
the trochanter, knee,
and ankle
Prosthetic Knee centre (Left to Right) Anterior,
Through and Posterior to the Lateral reference
(TKA ) line
 Prosthetic Foot alignment
• All prosthetic feet have a
manufacturer’s
recommended alignment
reference point.
• The photo shows the
reference point on a
prosthetic foot as a red dot.
• The vertical alignment lines
found from the prosthetic
socket and knee are shown
to pass through this point
 Prosthetic Foot alignment
• The picture above
demonstrates three
different linear
translation positions of
the foot in the sagittal
plane (side on view).
• Figure 1 Alignment too far
forward
• Figure 2 Correct alignment
• Figure 3 alignment too far
behind
 KD external side bars alignment
(Sagittla plane)
TKA line
• TKA line should fall
5mm anterior knee
joint axis for stance
phase stability
• If patient has weak hip
extensors, distance can
be increased for more
stability
• 1/3 along the foot
 KD external side bars alignment
(Forontal plane)
• Mid way between
medial tibial plateau (if
comparing to sound
limb)

• Approximately 1.5 ­2.5

cm above medial tibial
plateau (MTP)
 KD external side bars alignment
(Transverse plane)
Knee joint rotation

• External rotation 5
degrees in reference to
line of progression

Foot rotation

• External rotation 5
degrees in relation to
line of progression
 KD with Polycentric knee
alignment
• In extension, the IC

instantaneous centre
(IC) of rotation is
located above the
pyramid adapter and
behind the alignment
reference line, thus
providing knee stability
in the stance phase
 KD with Polycentric knee
alignment
• The optimal residual limb position must be
anticipated when positioning the socket
connector.
• Plumb lines in the frontal and sagittal planes
(drawn from the hip joint’s centre of rotation
and marked during plaster cast taking and trial
fitting of the test socket) will facilitate correct
positioning of the lamination anchor or socket
adapter
 KD with Polycentric knee
alignment
• Position the middle of
the foot 30 mm anterior
to the alignment
reference line
• For bench alignment,
the alignment reference
line should run 0 mm in
front of the upper
anterior axis
 KD with Polycentric knee
•
alignment
Mark the centre of the socket
proximally and distally on the
lateral side.
• Draw a line through both marks
from socket brim to the distal
end of the socket.
• Now position the socket such
that the alignment reference line
passes through the proximal
centre mark of the socket
• Set the socket flexion to
somewhere between 5° and 7°;
however, the individual situation
(e.g. hip joint contractures) must
be taken into account
 KD-Stability Heel contact

• As opposed to a
monocentric knee joint,
the polycentric hinge
construction is safe
(stance phase safety) in
this phase because the
vector (red arrow) is in
front of the center of
rotation (intersection of
black axes) and provides
a knee extension torque
 Mid stance
• Also during the mid
stance, the polycentric
knee joint is in a save
condition because the
load line passes the
center of rotation in
front .
• Compared to the
monocentric the
polycentric is more
reliable during standing.
 Toe off
• After the toe-off the user
has to provide a strong hip
flexion moment in order to
flex the knee
• Basically, the polycentric
knee constructions have
higher safety from initial
contact to mid stance.
• When taking the terminal
stance into consideration,
the polycentric knee joint
has less dynamic
characteristics than mono-
centric knee joints.