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Special Topics

Prosthetics

QuestionAnswer
Prosthetics -Replacement of all or part of an extremity
Prosthetist -Health professional who: designs, fabricates, fits, modifies a limb prostheses
Types of prostheses -Foot -Syme's -Transtibial -Transfemoral -Knee & hip disarticulation
Partial foot prosthesis -Plastic socket attached to rigid plate -Cosmetic toe filler pictured
Standard components -Suspension -Liners/socks -Socket -Shank/pylon -Foot/ankle assembly
Foot/ankle assembly -Purpose to stimulate muscle and joint activity -3 purposes of the foot and ankle: ?
Foot/ankle assembly: 2 major categories -Non-articulated vs articulated- related to motion -Non- dynamic vs dynamic response-related to stored energy
Foot/ankle assembly: Non-articulated -No axis between foot and rest of prosthesis= no motion -Lighter, more durable, more attractive -High-heel versions
Foot/ankle assembly: Articulated -Separate foot and lower shank section joined by bolt or cable= motion -Ankle and foot motion controlled by rubber bumpers -May loosen/ make noise
Foot/ankle assembly: Non-dynamic -NO storing of energy -NO give between parts
Foot/ankle assembly: Dynamic -Store & release energy giving some spring or recoil to a step: -used for active people -respond to more time spent on the forefoot -allows for running and jumping
Types of foot/ankle assembly -Solid Ankle Cushion Heel (SACH) -Stationary Attachment Flexible Endoskeleton (SAFE) -FlexFoot & Springlite -Single Axis -Multi-axis -Personal bionics
SACH -Wooden/metal center covered with rubber -Soft heel simulates PF -Non-articulated and non-dynamic
SAFE -Variation of SACH -Good with uneven terrain: Mobile rearfoot in med/lat directions Limited DF/PF bumpers More flexible foot -Heavier/More expensive -Non-articulated but dynamic
Flex-foot and Spring-lite -Long curved carbon fiber band -Non-articulated but more dynamic
Single axis -Most common articulated foot -Limited DF/PF: Bumpers, Toe action, No IV/EV -Commonly used with trans-femoral/-tibial -Non-dynamic
Multi-axis -Moves slightly in all planes with bumpers -Heavier and less durable -Dynamic and non-dynamic versions
Personal bionics: Biom -Mimics muscle function therefore dynamic -Benefits: -Normalize gait speed and energy use -Alleviate comorbidities i.e. LBP/OA -Improve ground adaptation -Patient profile: -190-250 lbs -BKA or AKA -Bluetooth capability settings
Shank -Substitute for human leg -Transmits body weight from the socket to the foot -Not present in Syme's prosthesis
Shank: Exoskeletal -Hollow wood/ plastic -Non-changeable
Shank: Endoskeletal -Without cosmetic cover -Central pylon -Foam rubber cover
Sockets -Plastic receptacle for RL -Vary with: Level of amputation/ Configuration of the limb -Designed for: -Weight-bearing -Assisting circulation -Providing feedback
Movement within the socket may cause... -Skin problems -Abnormal gait -Decreased limb security (i.e. falls)
Pressure relief area -Internal socket concavity
Pressure tolerant area -Internal socket convexity -Not the bottom of the RL
BKA -Fibular head -Anterior tibia: tibial crest/ tibial condyles -Hamstring tendons
AKA tendons -Anteromedial: Adductor longus tendon -Posteromedial: Hamstrings tendon/ Sciatic n -Posterolateral: permit glute max m. function -Anterolateral: rectus femoris tendon
AKA: femoral triangle -Anterior wall over femoral triangle: femoral n, femoral vv, lymphatic vv
Common pressure tolerant areas -BKA: -Patellar tendon and tibial tubercle -Proximal medial tibia and shaft (NOT condyle) -Fibular shaft -Gastrocnemius muscle bulk -AKA: -Ischial tuberosity -Quads/hamstrings muscle bulk (not tendons)
Greater surface area tends to be more... -Pressure tolerant -i.e. large/ flat bony landmarks and muscle bellies
Smaller surface area tends to be more... -Pressure relief -i.e. small/ pointed bony landmarks and thin tendons
Socket skin reactions -Transient redness with pressure tolerant areas -No reddness with pressure relief areas
Syme's Socket -Distal loading -Cut out for bulbous RL -No shank
Transtibial Socket: PTB -Patellar tendon bearing (PTB) -Aligned on shank in slight flexion to: -Increase patellar tendon loading -Prevent genu recurvatum (hyperext) -Prevent RL inferior sliding
Transtibial socket: PTB cont... -Also aligned in slight lateral tilt (genu valgus) to decrease fibular head load
Knee Disarticulation Sockets -Terminantes below ischial tuberosity
Transfemoral sockets -Quadrilateral-most common -Ischial containment
Transfemoral Sockets (Quadrilateral) -Posterior shelf for ischial tuberosity and glutes plus medial dege at same level -Higher anterior wall to push ischial tuberosity onto posterior shelf -Lateral wall same height as anterior for stabilization
Transfemoral socket (Ischial containment) -Coverage for greater stabilization: -Ischial tuberosity -Pubic ramus -Greater trochanter -Mediolateral width narrower yo: …↑ frontal plane stability … minimize bulk between legs -Anterior wall lower
Transfemoral sockets: slight flexion to... -Facilitate hip extensors -Decrease lumbar lordosis -Increase available hip extension ROM for equal step length
Hip disarticulation/ hemipelvectomy sockets -Molded plastic -Weight-bearing on ischial tuberosities and gluteals instead of torso
Liners -Provides protection between skin and socket -Liners: Gel or foam, rolled on/ off, lock or seal into socket
Socks -Cotton, wool, or synthetic fabric -Add more as RL shrinks due to… -Decreased swelling -Atrophy
Suspension methods -Cuff/straps- grip above boney prominences -Thigh Corset -Brim (edge) Variants -Sleeves -Suction
Transtibial Cuff -Supracondylar cuff: -Leather strap anchoring on femoral epicondyles -May have waist belt attachment -Good for short RL, heavy thighs, and active patients -Easy adjustment except with visual or hand dysfunctions
AKA straps -Grip above iliac crest
Thigh corset -Lace up thigh w/ hinge to knee socket -Advantage: -Used on person w/ very sensitive skin -Increases the weight bearing and contact area -Disadvantage: -Heavier and may foster pistoning & pressure atrophy of the thigh -More difficult to don
Transtibial Brim Variant -Supracondylar suspension: -Grips onto femoral epicondyles -May be above patella also -↑s medial/lateral stability -Good for shorter RL
Sleeves -Grips soft tissue -Made of rubber silicon -Advantages: -Used for AKA/BKA -Grip is distributed over a greater area -Disadvantages: patient needs two strong hands and firm thigh musculature
Suction -Works by pressure differences inside and outside of the socket -Internal pressure < less than external pressure -Atmospheric pressure causes the socket to remain on the thigh -One way air release valve on bottom of the socket
3 types of suction -Total -Partial -No
Total suction -Very snug -Max control without auxiliary suspension -Most difficult donning/doffing
Partial suction -Mod snugness -Sock needed -Additional suspension device needed
No suction -Least snug -Multiple socks needed -Additional suspension device needed -No valve but a hole -Easy donning/doffing but control is sacrificed -Decreases sitting comfort
AKAs may also have... -Knee unit and possibly... -Hip unit components
Knee unit: 4 possible components -Axis system -Friction mechanism -Extension aid -Stabilizers -Personal bionics
2 axis systems -Single axis -Multiple axes
Friction mechanisms -Changes speed of knee motion during various parts of swing phase according to walking speed -Controls knee motions and provides resistance to pendular motion
Friction mechanisms: 4 types -Constant -Variable -Hydraulic/pneumatic -Microprocessor control
Constant friction -Most popular -Same friction throughout motion -Easily adjusted -Usually prescribed for older adults
Variable friction -Friction changes during swing phase -Early swing: high friction used to slow heel rise -Mid-swing: friction reduces to permit more natural swing -Late swing: friction increases to prevent impactful extension
Hydraulic or Pneumatic friction -Oil/air medium -Adjusts resistance dynamically per walking speed -Prescribed for younger more active people -Heavier, more complicated, more expensive and more maintenance is required
Microprocessor control -Can prevent stumbling -Computerized control -Beneficial when resistance is needed to change more frequently -Blue tooth capability settings -Computer Knee
Extension aid -Assists knee extension during the later part of swing phase Keeps a constant rate of extension: -External -Simplest -Elastic webbing in front of the knee axis provides recoil -Internal: elastic strap or coiled spring inside the axis
Stabilizer -Uncommon: most use hip motion or posterior alignment for stabilization -2 types: manual lock, friction brake
Stabilizer: Manual lock -Simplest -Drop down loop over the hinge -Pin lodges on receptacle
Stabilizer: friction brake -Brakes and slows knee flexion when weight bearing occurs with the knee in 0-20 degrees flexion
Personal bionics -Power knee
Hip unit -Provides flexion motions and extension aid to bias prosthesis toward neutral -Set below normal hip: -Relatively shorter thigh segment and longer leg segment -Won’t protrude when seated -Set anterior to normal hip to engage hip extensors
General maintenance: Foot and ankle assemblies -Bumpers shoulder be replaced as needed -Keep dry -Keep sand and debris out of articulation
General maintenance: Socket & suspension -Clean with damp cloth and mild soap, dry completely -Keep suction valve clear -Leather straps and corsets need saddle soap and conditioning
General maintenance: Knee and hip units -Oil and tighten as needed to maintain alignment -Pneumatic and hydraulic units should be clear of debris, store upright with knee extended to remove air in the cylinder -Keep sand out
General maintenance: Exterior skeletons -Clean, check for slitting -Avoid direct heat like radiators, heat vents, etc
Donning -Show appropriate reference points and landmarks between the socket and RL -The pt needs to learn the correct feel of the prosthesis -The firmer the contact the more difficult it is to don (i.e. suction)
Donning sequence: 1) Liner/Socks -Should not be wrinkled or rotated -Seam parallel to scar but not over it -Used to control volume...never more than 15 ply (layers) -Socks worn over a suction suspension or gel liner
Donning sequence: 2) Insert RL into socket -Roll liner up before donning -Use powder or stockinet prn to pull RL into socket -May have to pump a suction socket
Donning sequence 3) -Apply the suspension prn
Doffing -Usually just a reversal of the donning sequence as the suction interface is usually peeled off after the socket is removed from the pin
Getting stuck -Some patients may get stuck Slide his hand between the liner and the skin Break the suction and get out of the prosthesis
Created by: alovedaytn