Lower limb prosthesis (hip, knee)

Well explained slides about lower limb prosthesis of knee and hip after transfemoral ans transtibial amputation. Hip disarticulation and bilateral amputation not discussed

1. Lower limb prosthesis (hip / knee ) By DR VIPIN DEV M GUIDE – DR SANJAY MULLAY

2. PROSTHESIS Device to replace part of the limb or complete limb “substitute ” Prosthetist : Health care professional who designs, fabricates and fits limb prosthesis

3. Aim of prosthesis To substitute for a lost part To restore lost function Comfortable ambulation Minimal/reduce of expenditure of energy Minimizing the shift of the center of gravity of the body during gait

4. GOOD STUMP Proper length Proper shape Complete skin coverage Healthy scar Good muscle power Good range of motion for joints No neuroma No phantom pain or sensation

5. PREPROSTHETIC TRAINING Training in Active rom exercise Proper positioning of stump Muscle strengthening Skin care Crutch training Wheel chair training Self care Patient and family education

6. PROSTHETIC TRAINING Prosthetic fitting – alignment check , pressure point relief , color check Donning and doffing caring Skin care training Gait training Maintenance of prosthesis

7. IMMEDIATE POST OPERATIVE PROSTHESIS Described by Berlemont On conclusion of amputation temporary prosthesis given Most common – rigid plaster cast molded like PTB to which pylon and foot attached Physio started in 24-48 hours

8. Advantage Reduce edema and pain Prevent muscle contracture and atrophy Reduce chance of phantom pain and speeds up rehabilitation Disadvantages Increased chance of wound gaping Delayed wound healing Infection

9. TRANSTIBIAL / TRANSFEMORAL AMPUTATION

10. TRANSTIBIAL AMPUTATION . Ideal length- five inches from tibial tubercle Minimum length – two inches from tibial tubercle Types Ultra short (below tibial tubercle) Short(upper 1/3 rd tibia) Standard (junction of upper and middle 1/3 rd ) Long( jun of lower and middle 1/3rd) Wound healing inversely related to length of stump

11. TRANSTIBIAL PROSTHESIS Parts Socket Suspension Shin Ankle joint Foot

12. SOCKET Encloses the stump Forms connection b/w stump and artificial limb Protects the stump and transmits forces PLUG FIT SOCKETS – open ended and stump fits in like a plug fits in drain

13. TYPES Conventional Below Knee Socket Patellar Tendon Bearing Socket Patellar Tendon Bearing Supracondylar Suprapatellar Socket Bent Knee Socket Slip Socket

14. Conventional Below Knee Socket Used in elderly patients with unstable knee Person with quardriceps weakening Fabricated like no pressure over distal tibia , fibula head and tibial crest Requires external knee joint and thigh corset Disadvantages Skin irritation from friction Stump chocking by edema by constriction from superior portion socket

15. PATELLAR TENDON BEARING SOCKET T o load the weight in pressure tolerant areas like patellar tendon and medial tibial flare. Commonly used Total contact socket 60 % weight – patellar tendon 40% - medial tibial flare

16. Name – because of BAR that is built in to patella tendon ( midway b/w patella and tibial tubercle) Socket aligned at 5° of knee flexion lateral and posterior brim – level of adducter tubercle Posterior brim – proximal to patella bar to provide stability and to prevent the limb from sliding too far to socket

17. TOTAL SURFACE BEARING SOCKET To distribute weight over entire surface of limb Strategic allotment of weight by molding the contours according to type of tissue and anticipated loading.

18. PATELLAR TENDON BEARING SUPRAPATELLAR SUPRACONDYLAR SOCKET Anterior trim line – suprapatellar Medial and lateral – supracondylar Gives good suspension Forms quadriceps bar In patients with short stump and genu recurvatum

19. SLIP SOCKET Two layers External – wooden or plastic socket Internal – fine leather Uses Short stump Painful scars

20. BENT KNEE SOCKET Indication – patients having FFD of stump Up to 20 ° can be accommodated

21. INTERFACE MATERIALS Separate limb from socket Mimic soft tissue to provide extra cushioning Advantage Provide shock absorption Protect from shear forces Wicks away moisture Types Socks and sheaths Inner gel foams Flexible inner socket

22. SUSPENSION The method of connecting a prosthesis to residual limb Suspension designed according to activity level, comfort and safety If suspension not adequate – motion occur between socket and limb – called pistoning

23. SUSPENSION - TYPES SUPRACODYLAR CUFF In cooperates prosthesis to supracondylar region Most common Closed by velcro or buckle closure With PTB called PTB SC

24. Waist belt

25. Cuff strap

26. EXTERNAL KNEE JOINT WITH THIGH CORSET Corset must fit above femoral condyles Indications In patients with unstable knee Obese patients Aged ones with short stump Advantage Weight bearing through corset Disadvantage Quadriceps wasting Non cosmetic

27. Shuttle lock Suspension

28. Vacuum Suspension

29. Magnetic Prosthetic Suspension system Lanyard distally mounted strap

30. Osseous Integration :- Direct structural and functional connection between living bone and a prosthetic device. Eliminates the need for a traditional socket-type prosthesis Surgically implant a rod in the bone that can connect to any prosthesis through an external connection.

31. SHIN PIECE Substitute for the human leg Transmit body weight from the socket of the prosthesis to the prosthetic foot . Types Exoskeltal Moulded Hard plastic shell Disadvantage – fixed alignment after finishing.

32. Endoskeletal Modular in type Has pylon (shape of skeleton) Cosmetic foam in shape of leg. Adv – lighter , cosmetic, alignment after finishing , parts can be changed

33. ANKLE FOOT ASSEMBLY Designed to provide support during standing/walking and shock absorption as well Types SOLID ANKLE CUSHION HEEL (SACH ) SINGLE AXIS FOOT MULTI AXIS FOOT SOLID ANKLE FLEXIBLE KEEL FOOT ENERGY STORING FOOT

34. SOLID ANKLE CUSHION HEEL (SACH) Commonest one No ankle joint Solid heel made of wood or metal Cushion heel – rubber heel edge or alternating hard and soft rubber layers Cushion heel compresses during heel strike –stimulate plantar flexion Light weight , durable and little maintenance Modifications - MADRAS FOOT/ JAIPUR FOOT

35. MADRAS FOOT Modification of SACH Space between heel and ground filled with sponge rubber Toes shaped like normal Tendo achilles like shape made Rubber sole for bare foot walking

36. JAIPUR FOOT Solid ankle joint Made of galvinized rubber with shaping of toes

37. SINGLE AXIS FOOT Have bumpers made of hard rubber When heel strikes plantar flexion and then foot flat

38. MULTI AXIS FOOT All movements possible Good shock absorption Good for walking in uneven surface and even in scarred stump

39. SOLID ANKLE FLEXIBLE KEEL FOOT Similar to SACH Use flexible keel Good shock absorption In obese ones

40. ENERGY STORING FOOT Dynamic response foot Shock absorbing leaf spring or carbon steel used Absorb energy on heel contact R elease in terminal stance providing propultion

41. TRANSFEMORAL PROSTHESIS

42. KNEE DISARTICULATION VS TARNSFEMORAL AMPUTATION KNEE DISARTICULATION TRANSFEMORAL RESIDUAL STUMP LONG AND BULBOUS SHORT AND CONICAL DONNING DIFFICULT EASY SUSPENSION ENHANCE – DUE TO SHAPE CHALLENGING PROSTHETIC KNEE CONTROL EASY DIFFICULT ENERGY COST FOR AMBULATION ( inv to length) LESS MORE

43. KNEE DISARTICULATION VS TARNSFEMORAL AMPUTATION

44. TRANSFEMORAL AMPUTATION - PRINCIPLES Amputation between femoral condyles and greater trochanter Preserve as much as length as possible Countering abduction force of G. MED and G.MIN – suturing adductors to femur

45. PROSTHEIS - PARTS Socket Knee Rotator Pylon Foot

46. SOCKET Quadrilateral Socket By UNIVERSITY OF CALIFORNIA Have four distinct walls Flat posterior Ischial seat – major weight bearing area To give weight during stance phase

47. Anterior wall contoured to direct force posteriorly to Scarpa’s triangle –to keep ischium in position A-P dimension narrowed than M-L dimension

48. ISCHIAL CONTAINMENT SOCKET Different types – depends on structures contained A-P dimension more than M-L dimension to prevent abduction CAT – CAM- contoured anterior trochanteric controlled alignment method- to maintain femur in adducted position and to control socket rotation by containing ischial tuberocity

49. QUARDRILATRAL SOCKET ISCHIAL CONTAINMENT SOCKET Ischial seat for weight bearing No ischial seat Weight bearing area less More weight bearing area Lateromedial dimension more Lateromedial dimension less A-P dimesion less A-P dimension more Poor pelvic control and rotational stability Good pelvic control and rotational stability Less energy efficient more energy efficient In standard stumps In short stumps and gluteus medius weakness

50. MARLO ANATOMICAL SOCKET Provide skeletal support along medial ischio ramal complex Encapsulate ischial tuberocity and ramus Low posterior and gluteal trim line. Allow to sit on gluteus maximus

51. ELEVATED VACCUM SOCKET Low trim lines( subischial ) Good comfort and rom 2-4 inches below ischial tuberosity

52. SUSPENSION Traditional pull in suction suspension Roll on suspension liners Shuttle lock systems Cushion liner with air expulsion valve Silesian belt Total elastic suspension belt Pelvic belt

53. KNEE JOINT PROSTHESIS difficult to replicate Modified hinge joint

54. KNEE JOINT PROSTHESIS- TYPES SINGLE AXIS KNEE UNITS Simple hinge Fixed center of rotation Cadence responsive minimal Allow flexion and extension No mechanical stability Give support during stance not during swing Light weight , durable and low maintanace Not good for ones having short stump For patients with primary residual limb who can voluntary stabilize the knee through active hip extension against posterior wall of prosthesis

55. POLYCENTRIC KNEE JOINT Moving center of rotation Rotates in more than one axis During swing phase, it leads to shortening of distal prosthesis enhancing toe clearance Good for long residual limb or knee disarticulation patients Good stance phase stability – so in short stump ones and hip extensor weakness patients Less durable than single axis

56. WEIGHT ACTIVATED STANCE CONTROL KNEE UNITS Braking mechanism when weight applied To prevent unwanted knee flexion while standing Can be adjusted according to individual pattern If initial contact made when knee not completely extended (in uneven surface) provides additional stability and prevent buckling Acts like single unit in swing phase For recently amputated ones , short residual limbs and extensor weakness

57. MANUAL LOCKING KNEE UNITS For ones who rely on stability during stance Single axis knee with a locking mechanism Locks when knee fully extended Compromise toe clearance in swing So less height than contralateral leg Usually walk with knee locked in extension

58. HYDRAULIC KNEES Cadence responsive good Provides frictional resistance by the flow of hydraulic fluid Provides variable resistance – provides almost a normal gait High cost , higher maintenance needed , weight and difficulty during cold time SNS system – swing and stance control system – weight bearing stance control and swing phase controll

59. PNEUMAIC KNEE PROSTHESIS LIKE HYDRAULIC Less weight , maintainance cost less Less cadence control than hydraulic

60. INTELLIGENT PROSTHESIS PLUS Microprocessor swing phase control knee Sensors monitor knee position during swing and pressure s ensors detecting ground related forces during stance

61. TRANSVERSE ROTATORS To sit crossed leg. External button pushed to unlock it gets locked automatically when knee back to neutral

62. COMPLICATIONS General Issues • Choke syndrome • caused by obstructed venous outflow due to a socketthat is too snug • acute phase Red indurated skin with orange-peel appearance chronic phase hemosiderin deposits and venous stasis ulcers

63. Skin problems Contact dermatitis most commonly caused by liner, socks, and suspension mechanism treatment remove the offending item with symptomatic treatment Cysts and excess sweating

64. Painful residual limb possible causes include bony prominences, poorly fitting prostheses, neuroma formation, and insufficient soft tissue coverage

65. THANK YOU…