Prosthetic management of symes and partial foot amputation

prosthetic management of partial foot and syme's amputation is a very challenging task. Now a days the availability of advanced technology some how fulfilling the need of the amputee but not the fully.

1. PROSTHETIC MANAGEMENT OF PARTIAL
FOOT AND SYME’S AMPUTATION
BY:- MISS SMITA NAYAK
(MPO), PDUNIPPD, DEMO(P&O)
1

2. INTRODUCTION
Foot is a finely tune module having complex
structure & function. It is the base of support,
shock absorber & weight bearing structure for
entire body.
If the foot get amputed due to some
unavoidable causes it disturb alignment,
support, load bearing structure, cosmesis &
affect the symmetry of the gait.
2

3. BONES OF FOOT
3

4. X-RAY VIEW...
4

5. Causes of Amputation
 Infection with tissue necrosis in diabetic patients
 Sensory neuropathy
 Gangrene
 Ischemia due to Peripheral Vascular Disease (PVD) ,Micro
emboli arteritis, Frostbite
 Trauma
-moving machinery
-crush injuries, with or
without fractures
-RTA
- Thermal injuries
 Congenital abnormality
5

6. PARTIAL FOOT AMPUTATION
Partial foot amputations of the foot includes:
 
I.TOES AMPUTATION
II. RAY AMPUTATIONS
III. TRANSMETATARSAL AMPUTATION
IV. TARSOMETATARSAL (LISFRANC)
DISARTICULATION
V. MIDTARSAL (CHOPART) DISARTICULATION
6

7. I. TOE DISARTICULATIONS
A.Interphalangeal (IP) Joint of the Great Toe
B.Toe Metatarsal Phalangeal (MTP) Joint of the
Great
C.Disarticulation of 2nd Toe MTP Joint
D.MTP Joint of Toes 3 or 4
E.All Five Toes
7

8. Interphalangeal (IP) Joint of the Great
Toe
8

9. Toe Metatarsal Phalangeal (MTP) Joint of
the Great
9

10. Disarticulation of 2nd Toe MTP Joint
10

11. MTP Joint of Toe 4
11

12. All Five Toes
12

13. FUNCTIONAL REQUIREMENT

PROSTHETIC GOAL
To prevent Hyperextension of
Metatarsophalangeal joint.
Comfortable shoe fitment
Management
Cosmetic silicone Toes

13

14. II. RAY AMPUTATIONS
A. First Ray
B. Single Amputations of Rays 2, 3 or 4
C. 5th Ray Amputation
D. Multiple Ray Amputations
14

15. First ray amputation
15

16. 2
nd
ray amputation
16

17. 4
th
Ray Amputation
17

18. 5
th
Ray Amputation
18

19. Multiple Ray Amputation
19

20. Complications

Lateral Ray Amputation:-
Hallux valgus deformity
Bunion Deformity
 1
ST
& 5
th
Ray Amputation:-
ML Instability
Pressure problem in push off phase
Prosthetic goal:-
 To Redistribute the pressure
 To Avoid problem of shoe fitting
 To prevent deformity
 For cosmetic Restoration

20

21. MANAGEMENT:-

Cosmetic silicone Rays
Custom made insole with filler
Shoe with filler.
21

22. III. TRANSMETATARSAL AMPUTATION
22

23. FUNCTIONAL CONSIDERATIONS AFTER
TRANSMETATARSAL AMPUTATION
Barefoot walking after
transmetatarsal amputation is
impaired because of loss of the
weight-bearing metatarsal heads
and
 Elimination of forefoot pronation
and supination during gait.
 A rigid rocker bottom (RRB) shoe
may help reduce distal pressure
and shear from a flexible-soled
shoe wrapping around the end of
the residual foot.
23

24. PROSTHETIC GOAL
- To provide maximum
Flexibility to simulate
pronation & Supination
- To prevent shoe hyper
extension during push off
- Cosmetic Restoration
MANAGEMENT:-
Shoe with fillar
AFO with fillar
SCM Foot
Insole with fillar
Modified SMO
24

25. IV. TARSOMETATARSAL (LISFRANC)
DISARTICULATION
This procedure, first described by Lisfranc in
1815.
Removal of metatarsal bone from the tarso-
metatarsal joint.
25

26. A portion of the fifth metatarsal base is also retained to
preserve the insertion of the peroneus brevis tendon. To
help maintain a balanced residual foot, in addition to the
peroneus brevis, the insertions of the peroneus longus
and anterior tibial tendons are preserved.
26

27. 27

28. V. MIDTARSAL (CHOPART)
DISARTICULATION
This disarticulation occurs through the talo
navicular and calcaneo cuboid joints.
28

29. 29

30. Complications
Ulceration or skin breakdown
 Equinus contracture
30

31. PROSTHETIC GOAL
 Prevent deformity
 Provide ant. Support
 To prevent DF motion during Loading
Cosmetic Restoration.
31

32. :-


MANAGEMENT:-
AFO with Filler
Modified SMO
32

33. Carbon fiber foot Plates
33

34. CHOPART PLATE BY
ENDOLITE
Selected by category according to the weight and impact
of the user, this 100% carbon keel is designed to be a
flexible and durable solution for the longest amputation
levels and partial foot prostheses.
Includes a 10mm heel height for compatibility with
standard Flex-Foot® shells and low-heel shoes.
Recommended for Chopart but also recommended for
Lisfranc, Pirogoff, Boyd, and partial foot prostheses
34

35. CHOPART PLATE BY
OTTOBOCK
Available heel heights are 0” (0 mm), 3/8” (10
mm) and ¾” (20 mm)
Available in sizes 22 – 30 cm
Shipped with complete kit of materials and
instructions to perform urethane bonding of plate
to socket
Use in lieu of toe filler for dynamic response,
increased stability and flexibility
35

36. Specifically designed for amputees with Symes,
Chopart or partial foot amputations.
Recommended for amputees who meet Mobility
Grade 3 and 4* of the Otto Bock MOBIS®
Mobility System.
The Chopart foot plate foot shell is available in
two colors – beige and light brown. Delivery
does not include the foot shell, which has to be
ordered separately.
36

37. SCM & Silicone foot By ENDOLITE IND
LTD.
HDSF(High density silicone foot)
HDSF-ER(High density silicone foot
with extra reinforced
37

38. Description and applications
High definition silicone cosmetic foot cover, fine
handprints, veins and optional: With or without zipper
(metal or plastic zipper)
HDSF-ER: High definition silicone foot cover with
integrated carbon fiber footplate
Size chart is required to order the foot
38

39. Custom made Silicone Foot
39

40. Clinical Assessment
Measurement
Alginate casting
Wax Modeling
Stone plaster Modeling
Mould Modification
Alignment
Dye preparation
Selection of swatches
Color matching
Dye pouring
Silicone Foot Preparation
Procedure for Preparation of
silicone foot
40

41. Wax model and Die preparation
41

42. 42

43. 43

44. Other management
AFO With Rocker
Articulated AFO
FRO with Foot plate
44

45. Force required to resist DF
Moment
w
45

46. SYME’S AMPUTATION
Syme’s amputation is an ankle disarticulation (The removal of the
foot through the joint) with removal of the malleoli (The two rounded
protrusions on either side of the ankle) then forward rotation of the
heel pad over the end of the residual tibia
46

47. MANAGEMENT OF
SYME’S AMPUTATION
Clinical challenges:
Height Adjustment
End Bulbous Stump
Donning Doffing
problem
Lack of cosmesis
47

48. PROSTHETIC GOAL
Provision for Donning
Distribution & absorption of stress
Rotational Stability
Relief for the scar
Proper suspension
Absorption of shock
Cosmetic restoration
48

49. SOCKET DESIGN…
49

50. CANADIAN (POSTERIOR OPENING)
SOCKET DESIGN
50

51. VAPC (MEDIAL OPENING) SOCKET
DESIGN
51

52. BIVALVE DESIGN
52

53. SLEEVE SUSPENSION
DESIGN
53

54. FOOT OPTIONS FOR SYME’S
54

55. FLEX SYME’S by Ossur
Extremely low build height with active heel and
alignment options.
The Flex-Syme’s foot design is based on the
well known Flex-Foot concept - a carbon foot
module connected to an actively deflecting
carbon heel. The improved alignment adapter
now offers angulations and adjustments in ML /
AP planes.
55

56. FLEX SYME’S
56

57. LP SYME’S By RSL Steeper
The Low profile Syme’s accommodates the
build height requirements of patients with
Syme’s amputations.
The carbon fiber design delivers energy storage-
and-return, smooth and natural rollover, and
durability in a remarkably lightweight design.
The prosthetic foot incorporates a direct
lamination cup, which keeps the distal mass of
the prosthesis as light as possible, reducing
amputee energy expenditure during the gait
cycle. 2” gap required for fitting.
57

58. LP Syme’s Technical Specifications
Sizes: 22-30cm (31cm special order)
User Weight Rating: 365 lbs. (166kg)
Stiffness Categories: 1-9
Build Height (average): 1.9 inches
Product Weight (average): 295g
Connector: Direct lamination cup
Heel Height: 3/8"
Warranty: 36 months
58

59. LP Syme’s
59

60. Genesis II Low Profile Foot Ankle
Systems
With clearances less than two inches, the Genesis Low
Pro Foot and Ankle System provides the only multi-axial
prosthetic foot suitable for long BK and Syme’s level
amputees.
The Genesis Low Pro combines the Genesis System
multi-axial technologies with advanced strength carbons
and composites to create a system of optimum comfort
and durability. This system offers the most natural range
of motion at a minimal height.
60

61. Genesis II Low Profile
61

62. Ability to adjust the foot position during trial fitting as
well as after completion of the prosthesis
Part Weight= 18 oz (520 gm)
Clearance= (43 mm)
 The key innovation in this foot is a unique spherical
sliding block that allows you to correct alignment
during trial fitting and even after the prosthesis has
been completed.
1C20 Pro Syme’s
of Ottobock health Care Ltd.
62

63. Positioning of the Foot 1C20 Pro Syme’s
Easy adjustment of the foot in relation to the socket is
possible with the new spherical alignment solution.
A setting aid facilitates the alignment and determines the
direction of the maximum adjustment range in the
anterior/posterior direction.
This provides an infinitely variable setting range
beginning with 12° and accommodates different heel
heights.
A sliding block in the lamination anchor provides
additional movement and allows for the abduction (+6°),
adduction (-6°) and rotation (+/- 30°) of the socket.
63

64. 1C20 Pro Syme’s
64

65. Dynamic foot for Symes amputees
Removeable pyramid adapter for even lower structural
height
Lightweight
Dynamic energy return
Recommended for Otto Bock Mobility Grades 3 and 4*
Part weight = 9.3 oz (265 g)
Clearance = 1 1/8" (29 mm )
1E57 Lo Rider
Ottobock
65

66. 1E57 Lo Rider
66

67. KINGSLY SYME’S OF ENDOLITE
67

68. BIO-MECHANICAL ANALYSIS OF STUMP-SOCKET FORCES DURING THE
STANCE PHASE IN SYME’S PROSTHESIS
68

69. Analysis of the distribution of contact pressures
between stump and socket at various times
during the stance phase is useful in the design
of a socket that will be comfortable for the
amputee.
Since pressure distribution varies during each
of the three sub phases-shock absorption, roll-
over, and push-off-each must be analyzed
separately.
ANALYSIS OF STUMP-SOCKET FORCES
DURING THE STANCE PHASE
69

70. Shock Absorption
If it be assumed that body weight is supported
at the distal end of the stump, it can be seen
that during the shock-absorption sub phase
the major functional forces between stump
and socket occur in the antero distal and
postero-proximal areas.
70

71. During roll-over, the need for postero-proximal
pressure decreases, and the contact pressure at
the end of the stump shifts toward the center of
that area. If the force system is to be in
equilibrium, the paths of the forces P, D and F
must intersect at M and their vectors must form
a closed polygon.
Use of this principle makes it possible to
estimate the relative magnitudes of the three
force
71

72. Push-Off
The force system that develops as the Syme’s
amputee rolls over the ball of the foot in the
push-off sub phase.
At the instant shown, the hip joint is being used
to help flex the knee against the force acting
upward on the ball of the foot.
Again, the principle of force equilibrium can be
applied to estimate the magnitude of the forces.
A postero-distal and an antero-proximal contact
force between stump and socket are seen to be
necessary to resist the floor reaction against the
ball of the foot.
72

73. Cont..
It is essential that the antero-proximal force
against the tibia be kept at as high a level as
possible.
Shortening of the distance a results in
increased inclination of the line of the postero-
distal contact force and in a transfer of the
force away from areas surgically prepared for
end-bearing.
73

74. REFERENCE
AAOA Atlas of amputation & limb deficiency
,Third edition.
Orthotic & Prosthetic in rehabilitation by
Michelle M.Lusardi.
www.endoliteindia.in
www.ottobock.in
Website of ossur, kingsley symes,RSL stepper.
American journal of prosthetic & orthotic.
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