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Prosthetics - Dr Anil Jain

Prosthetics
PMR Refresher Course

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Prosthetics - Dr Anil Jain

  1. 1. ProstheticsProsthetics
  2. 2. Dr. Anil Kumar JainDr. Anil Kumar Jain M.D. DNB MNAMSM.D. DNB MNAMS Physical Medicine & RehabilitationPhysical Medicine & Rehabilitation Dr. P.K. Sethi Rehabilitation CentreDr. P.K. Sethi Rehabilitation Centre Santokba Durlabhji Hospital, JaipurSantokba Durlabhji Hospital, Jaipur First private hospital in the country to have prosthetics and orthotics center
  3. 3. Dr. P.K. Sethi Rehabilitation Centre
  4. 4. (Dr. P.K. Sethi Rehabilitation Centre, Santokba Durlabhji Memorial(Dr. P.K. Sethi Rehabilitation Centre, Santokba Durlabhji Memorial Hospital, Jaipur ) Started in 1985 by Late Dr. P.K. Sethi.Hospital, Jaipur ) Started in 1985 by Late Dr. P.K. Sethi. INNOVATOR OF JAIPUR FOOT Dr. Pramod Karan Sethi (28-11-1927 - 06-01-2008 )
  5. 5. Transfemoral socketTransfemoral socket Quadrilateral socketQuadrilateral socket - Introduced in 1940’s. Still in use.Introduced in 1940’s. Still in use. - Has comfort and stability problem.Has comfort and stability problem. - Ischial seat at horizontal brim serves as seat forIschial seat at horizontal brim serves as seat for ischial tuberosity and the user’s weight isischial tuberosity and the user’s weight is transferred to the quadrilateral socket through it.transferred to the quadrilateral socket through it.
  6. 6. - The narrow AP dimension pushes the ischialThe narrow AP dimension pushes the ischial tuberosity on ischial seat.tuberosity on ischial seat. - Large mediolateral dimension cannot preventLarge mediolateral dimension cannot prevent the excessive abduction of femur.the excessive abduction of femur. - Distal end of femur is left unsupported inDistal end of femur is left unsupported in socket, becomes painful and discomfort issocket, becomes painful and discomfort is also felt at proximal medial part of thigh.also felt at proximal medial part of thigh.
  7. 7. - The gluteus medias pulls the femur in to abduction,The gluteus medias pulls the femur in to abduction, pelvis slides medially and ischial tuberosity shiftspelvis slides medially and ischial tuberosity shifts along ischial seat of quadrilateral socket.along ischial seat of quadrilateral socket. - To reduce the pain and discomfort patient leans toTo reduce the pain and discomfort patient leans to position the torso over the abducted distal end ofposition the torso over the abducted distal end of femur.femur. - This deficiency was corrected in new design ischialThis deficiency was corrected in new design ischial containment socket introduced in 1980.containment socket introduced in 1980.
  8. 8. Abducted distal end of Femur in quadrilateral socket Ischial containment socket
  9. 9. - The above deficiency of quadrilateral socket canThe above deficiency of quadrilateral socket can be corrected by a new socket design which hasbe corrected by a new socket design which has narrow ML dimension and wider AP dimensionnarrow ML dimension and wider AP dimension chosen in such a way that ischial tuberosity andchosen in such a way that ischial tuberosity and a portion of the ramus of the ischium is containeda portion of the ramus of the ischium is contained within the socket.within the socket. - This narrow ML socket configuration also hasThis narrow ML socket configuration also has high lateral wall which provides mediallyhigh lateral wall which provides medially directed reactive force to the greater trochanter.directed reactive force to the greater trochanter.
  10. 10. - In this the abduction angle of the femur in theIn this the abduction angle of the femur in the stump more closely resembles the femur in thestump more closely resembles the femur in the sound extremity in all phases of the user’s gaitsound extremity in all phases of the user’s gait thus greatly reducing the characteristic limp.thus greatly reducing the characteristic limp. - This design is called N.S. N.A. socket (NormalThis design is called N.S. N.A. socket (Normal shape Normal alignment or a CAT-CAMshape Normal alignment or a CAT-CAM (contoured, adducted trochanteric, controlled(contoured, adducted trochanteric, controlled aligned method) socket.aligned method) socket.
  11. 11. Suction socketSuction socket - Germans first used the concept of creatingGermans first used the concept of creating relative vacuum inside the socket to berelative vacuum inside the socket to be effective for suspension.effective for suspension. - Skin must be pliable and free of scarring.Skin must be pliable and free of scarring. - Positive mould rectification to ensure skinPositive mould rectification to ensure skin remains in contact with socket withoutremains in contact with socket without constricting the blood vessels.constricting the blood vessels.
  12. 12. - Valve is installed in socket and is opened andValve is installed in socket and is opened and closed every time donning and doffing theclosed every time donning and doffing the prosthesis.prosthesis. - Concentration of vacuum in particular areaConcentration of vacuum in particular area will damage in skin.will damage in skin. - Skin problems and volume fluctuations has toSkin problems and volume fluctuations has to be kept in mind.be kept in mind.
  13. 13. - Has to be donned in standing position soHas to be donned in standing position so bilateral cases are difficult.bilateral cases are difficult. - Balancing problems in old age and upper limbBalancing problems in old age and upper limb dysfunction are contraindication.dysfunction are contraindication.
  14. 14. ICEROSSICEROSS - Icelandic roll-on suction socket.Icelandic roll-on suction socket. - Pliable liner of silicone rubber rolled on to stump andPliable liner of silicone rubber rolled on to stump and attached to cord at distal tip of liner and draw the liner-attached to cord at distal tip of liner and draw the liner- limb combination in to the socket.limb combination in to the socket. - Can be done in sitting so bilateral cases can be taken up.Can be done in sitting so bilateral cases can be taken up. - Better than suction socket as volume changes can beBetter than suction socket as volume changes can be handled.handled.
  15. 15. Prosthetic kneeProsthetic knee 1.1. Most complex among all prostheticMost complex among all prosthetic components due to various needscomponents due to various needs - To support body weight.- To support body weight. - To facilitate smooth motion during walking.- To facilitate smooth motion during walking. - Accommodate large range of motion- Accommodate large range of motion
  16. 16. 2. Simple mechanical to computer control2. Simple mechanical to computer control - Single axis knee joint.- Single axis knee joint. - Hydraulic or Pneumatic knee joint.- Hydraulic or Pneumatic knee joint. - Polycentric knee joint.- Polycentric knee joint. - Microprocessor controlled knee.- Microprocessor controlled knee.
  17. 17. 3. Single axis3. Single axis - Most simple, least expensive and most- Most simple, least expensive and most maintainence free.maintainence free. - For low activity patients.- For low activity patients. -Allows comfortable walking at one gait speed.-Allows comfortable walking at one gait speed. - Major biomechanical deficiency that it has no- Major biomechanical deficiency that it has no inherent stability.inherent stability.
  18. 18. On standing, muscle power of the amputee hasOn standing, muscle power of the amputee has to be used to maintain knee in extension.to be used to maintain knee in extension. - For this reason it is not a good option in elderlyFor this reason it is not a good option in elderly amputees with medical problems.amputees with medical problems. - Manual lock may be there to prevent- Manual lock may be there to prevent buckling during standing.buckling during standing.
  19. 19. Stance control kneeStance control knee - Most commonly used prosthetic knee worldwideMost commonly used prosthetic knee worldwide it has a weight activated friction brake.it has a weight activated friction brake. - As the limb is loaded in early stance, the brake isAs the limb is loaded in early stance, the brake is engaged and resulting friction holds the kneeengaged and resulting friction holds the knee securely.securely.
  20. 20. - When unloaded, brake is released and knee isWhen unloaded, brake is released and knee is allowed to flex.allowed to flex. - Good to use for fresh amputees and for thoseGood to use for fresh amputees and for those with limited walking due to medical reasons.with limited walking due to medical reasons. - For bilateral cases it is very useful.For bilateral cases it is very useful. - Not good for high speed walking.Not good for high speed walking.
  21. 21. Hydraulic or fluid controlled kneesHydraulic or fluid controlled knees - Prosthetic knee which incorporates hydraulicProsthetic knee which incorporates hydraulic unit to control knee motion.unit to control knee motion. - It provides a smoother more normal swingIt provides a smoother more normal swing phase movement.phase movement. - Hydraulic knees are smaller, lighter andHydraulic knees are smaller, lighter and costly as compared to pneumatic knees.costly as compared to pneumatic knees. - They require periodic servicing.They require periodic servicing.
  22. 22. - This is indicated when amputee is capable ofThis is indicated when amputee is capable of walking at variable speeds.walking at variable speeds. - In very cold climate, thickening of hydraulicIn very cold climate, thickening of hydraulic fluid may reduce its efficiency. It is not so influid may reduce its efficiency. It is not so in pneumatic knees.pneumatic knees. - Mauch knee is purely hydraulic and composed ofMauch knee is purely hydraulic and composed of aluminium, weighting 1140 grams and flexionaluminium, weighting 1140 grams and flexion range isrange is 1150 ..
  23. 23. Pneumatic kneePneumatic knee - They are similar to hydraulic knees except thatThey are similar to hydraulic knees except that air is used as control medium. Their function isair is used as control medium. Their function is not effected by very cold climate so usednot effected by very cold climate so used commonly in such areas.commonly in such areas. - The primary limitation to pneumatic knees isThe primary limitation to pneumatic knees is that they may not provide sufficient resistancethat they may not provide sufficient resistance for very vigorous activities because gases suchfor very vigorous activities because gases such as air are compressible.as air are compressible.
  24. 24. Hybrid kneeHybrid knee - These types of knees provide features ofThese types of knees provide features of hydraulic as well as pneumatic design.hydraulic as well as pneumatic design.
  25. 25. Polycentric knee jointPolycentric knee joint - Multiple articulations they contain with 4 axis- Multiple articulations they contain with 4 axis points which are connected by 4 linkage bars.points which are connected by 4 linkage bars. - For high levels of activities, more stable andFor high levels of activities, more stable and better suited for uneven terrain.better suited for uneven terrain. - Four bar linkage allows variable resistanceFour bar linkage allows variable resistance through out the gait cycle to more closelythrough out the gait cycle to more closely mimic normal waling.mimic normal waling. - A key distinction is that the functional centerA key distinction is that the functional center of rotation is generally located out side theof rotation is generally located out side the knee joint .knee joint .
  26. 26. - The ICOR (Instantaneous Center of Rotation)The ICOR (Instantaneous Center of Rotation) is located posteriorly and proximally to theis located posteriorly and proximally to the mechanical knee axis. This posterior positionmechanical knee axis. This posterior position makes the knee inherently stable because themakes the knee inherently stable because the GRF (ground reaction force) is located farGRF (ground reaction force) is located far anteriorly thus generating a strong extensionanteriorly thus generating a strong extension moment .moment . - As the amputees starts flexing the knee, theAs the amputees starts flexing the knee, the ICOR changes, typically it moves moreICOR changes, typically it moves more anteriorly and distally with each additionalanteriorly and distally with each additional degree of knee flexion.degree of knee flexion.
  27. 27. - Polycentric knees offer yet another mechanicalPolycentric knees offer yet another mechanical advantage that is additional toe clearance at midswingadvantage that is additional toe clearance at midswing reducing the risk of tripping on environmentalreducing the risk of tripping on environmental obstacles.obstacles. - Polycentric knees also works very well in bilateralPolycentric knees also works very well in bilateral patients.patients. - Newly designed polycentric knees are now available toNewly designed polycentric knees are now available to minimize the protrusion beyond the socket in flexion.minimize the protrusion beyond the socket in flexion. This design is ideal for knee disarticulation and veryThis design is ideal for knee disarticulation and very long above knee stumps.long above knee stumps.
  28. 28. DisadvantagesDisadvantages - Increased cost, high weight and need forIncreased cost, high weight and need for servicing.servicing. - Flexion range decreased so patient can’t crouchFlexion range decreased so patient can’t crouch or squat.or squat. - Remotion knee 80 US $ made up of polymersRemotion knee 80 US $ made up of polymers and stainless steel, weight 400 gms and 165and stainless steel, weight 400 gms and 1650 knee flexion allows to squat or crouch.knee flexion allows to squat or crouch.
  29. 29. Microprocessor kneeMicroprocessor knee - New and most advanced. It has a- New and most advanced. It has a - Sensor microprocessor,Sensor microprocessor, - Software,Software, - Resistance systemResistance system - Battery.Battery. The knees internal computer (theThe knees internal computer (the microprocessor) controls an internal fluid whichmicroprocessor) controls an internal fluid which may be hydraulic or pneumatic microprocessor,may be hydraulic or pneumatic microprocessor, monitors each phase of gait cycle using a seriesmonitors each phase of gait cycle using a series of sensors.of sensors.
  30. 30. Continuous monitoring and control of fluidContinuous monitoring and control of fluid allows the processor to make adjustments inallows the processor to make adjustments in resistance so one can walk at various speedsresistance so one can walk at various speeds and walk more safely up and down.and walk more safely up and down.
  31. 31. Different prosthetic componentsDifferent prosthetic components Shock absorbing pylon – Telescoping springShock absorbing pylon – Telescoping spring loaded pylon to act as shock absorber whileloaded pylon to act as shock absorber while descending stairsdescending stairs
  32. 32. Positional RotatorPositional Rotator –– It is locking turntable that allows amputees toIt is locking turntable that allows amputees to passively rotate the lower leg while sitting,passively rotate the lower leg while sitting, dressing and doing other ADL.dressing and doing other ADL. Torque absorberTorque absorber –– It permits controlled transverse rotation toIt permits controlled transverse rotation to absorb stresses before it reaches the stump.absorb stresses before it reaches the stump. - More useful in bilateral amputees to provideMore useful in bilateral amputees to provide rotary motion thus facilitating reciprocal gait.rotary motion thus facilitating reciprocal gait.
  33. 33. Below knee socketBelow knee socket 1. Open ended1. Open ended - Problem of distal edema- Problem of distal edema - Proprioceptive input is less- Proprioceptive input is less - We often use aluminium as- We often use aluminium as socket material which issocket material which is time tested, durable, cheaptime tested, durable, cheap and rapid fit limb.and rapid fit limb. - Very successful design since- Very successful design since last 40 years.last 40 years.
  34. 34. Total contact PTB/PTS socket Areas requiring pressure relief in PTB socket Anterior Lateral Posterior
  35. 35. Total contact PTB/PTS socket A- Anterior B-Lateral view C- Posterior view Pressure-tolerant areas in a PTB socket
  36. 36. Total contact socketTotal contact socket 1.1.More surface area in contactMore surface area in contact 2. Better proprioceptive input2. Better proprioceptive input 3. Better tolerated by diabetic3. Better tolerated by diabetic amputeesamputees
  37. 37. Silicone linerSilicone liner - It is protective cover made up of flexibleIt is protective cover made up of flexible cushioning material to reduce movement andcushioning material to reduce movement and chafing between the skin and the socket.chafing between the skin and the socket. - For stumps with grafted skin and very skinnyFor stumps with grafted skin and very skinny stumps with prominent bony landmarks.stumps with prominent bony landmarks. - Very soft, delicate and costly material.Very soft, delicate and costly material. - Uncertain durability.Uncertain durability.
  38. 38. Prosthetic foot pieceProsthetic foot piece
  39. 39. CROSS SECTIONCROSS SECTION SACH FOOTSACH FOOT Wooden keel extending up to metatarsal region
  40. 40. It has a rigid keelIt has a rigid keel 1.1.Which does not allow freedom ofWhich does not allow freedom of movement needed for squatting.movement needed for squatting. 2.2.sitting cross legged.sitting cross legged. 3. walking on uneven terrain.3. walking on uneven terrain.
  41. 41. Inversion and eversionInversion and eversion Permitted in a very limited range inPermitted in a very limited range in SACH foot by compression of theSACH foot by compression of the heel pad.heel pad.
  42. 42. Jaipur footJaipur foot Culture specific Innovation and simpleCulture specific Innovation and simple solution to a very complex problemsolution to a very complex problem
  43. 43. 1.1. FlexibilityFlexibility Permit squattingPermit squatting Cross legged sittingCross legged sitting Walking on uneven terrainWalking on uneven terrain
  44. 44. 2. Water proof exterior allows working in2. Water proof exterior allows working in fields for farmers.fields for farmers.
  45. 45. 3. Can be worn without shoes (bare foot3. Can be worn without shoes (bare foot walking) so allows one to enter places ofwalking) so allows one to enter places of worship (Temple, Mosque, Gurudwara)worship (Temple, Mosque, Gurudwara) and kitchen.and kitchen. Can be worn with shoes with equal easeCan be worn with shoes with equal ease..
  46. 46. 4.4. It is made up of locally availableIt is made up of locally available rubbers, wood and metals sorubbers, wood and metals so uninterrupted supply can be ensured.uninterrupted supply can be ensured. 5. Can be attached to any type of shank.5. Can be attached to any type of shank.
  47. 47. DurabilityDurability 6. W6. We expect it to last for at least 3 years whene expect it to last for at least 3 years when used by moderately active person.used by moderately active person. Shelf lifeShelf life 7. Since it is made up of materials which7. Since it is made up of materials which doesn't deteriorate with time when kept indoesn't deteriorate with time when kept in normal environment so shelf life is good andnormal environment so shelf life is good and can be stored.can be stored.
  48. 48. CostCost Cheapest prosthetic foot piece available. It isCheapest prosthetic foot piece available. It is approximately Rs.600/- (US $10)approximately Rs.600/- (US $10)
  49. 49. Shortcomings in Jaipur footShortcomings in Jaipur foot
  50. 50. 1. Weight 850 grams1. Weight 850 grams 2. Lack of material standardization.2. Lack of material standardization. 3. Labor intensive fabrication (non3. Labor intensive fabrication (non standardized).standardized). 4. Available only in one colour.4. Available only in one colour. 5. Quality control in such a situation is not5. Quality control in such a situation is not possible.possible.
  51. 51. Break pointsBreak points The common break points and areas of wear andThe common break points and areas of wear and tear aretear are 1. Carriage bolt1. Carriage bolt 2. Universal joint2. Universal joint 3. Proximal part of heel3. Proximal part of heel 4. MTP joint area4. MTP joint area 5. Discoloration5. Discoloration of outer cover.of outer cover.
  52. 52. GoalsGoals 1.1.Weight reduction.Weight reduction. 2.2.Material characterization.Material characterization. 3.3.Minimizing manufacturing steps withMinimizing manufacturing steps with standardization.standardization. Keeping affordability in mind.Keeping affordability in mind.
  53. 53. ModificationModification what we have tried?what we have tried?
  54. 54. 1. Polyurethane1. Polyurethane In a research project funded by Department ofIn a research project funded by Department of Science and Technology, Government ofScience and Technology, Government of IndiaIndia Collaborating institutionsCollaborating institutions 1. Indian Institute of Technology, Mumbai.1. Indian Institute of Technology, Mumbai. 2. National chemical Laboratories, Pune.2. National chemical Laboratories, Pune.
  55. 55. Results were not encouraging as foot piecesResults were not encouraging as foot pieces were breaking in three to six months timewere breaking in three to six months time and were very slippery.and were very slippery.
  56. 56. 2.2. Carriage BoltCarriage Bolt Iron carriage bolt now replacedIron carriage bolt now replaced stainless steel.stainless steel.
  57. 57. It has not been recognized in the developedIt has not been recognized in the developed world because of absence of biomechanicalworld because of absence of biomechanical evaluation.evaluation.
  58. 58. In the year 2011 and 2012 we work withIn the year 2011 and 2012 we work with Michigan Technological University, USA toMichigan Technological University, USA to replace microcellular rubber with EVA (ethylenereplace microcellular rubber with EVA (ethylene vinyl acetate).vinyl acetate).
  59. 59. MCR heel and forefoot blocks wereMCR heel and forefoot blocks were replaced by EVA (Ethylene Vinylreplaced by EVA (Ethylene Vinyl Acetate)Acetate) 35 shore A EVA 65 shore A EVA 45 shore A EVA
  60. 60. Due to vulcanization problem the durability ofDue to vulcanization problem the durability of the foot piece got compromised.the foot piece got compromised. Following this nylon 6 foam was tried which alsoFollowing this nylon 6 foam was tried which also did not work.did not work.
  61. 61. In the year 2014, National Science Foundation,In the year 2014, National Science Foundation, USA sanctioned a research project to us forUSA sanctioned a research project to us for improvisation of Jaipur foot in association withimprovisation of Jaipur foot in association with Ohio State University, USA and MalviyaOhio State University, USA and Malviya National Institute of Technology, Jaipur.National Institute of Technology, Jaipur. This work will continue up to 2017.This work will continue up to 2017.
  62. 62. Seattle foot Introduced in 1985 - Economic - Efficient - Less maintainence - Resembles real foot.
  63. 63. It has a delrin keel which is a spring to improveimprove running. It is the first foot to have effective energy absorbing system.
  64. 64. The prosthetics using the simple energy- absorption were only effective for slow walking. The Seattle Foot became the first device that genuinely attempted to replicate the natural movement of the foot during various human gaits.
  65. 65. Dynamic response footDynamic response foot Characterized by spring like keel that extendsCharacterized by spring like keel that extends from the toe region to the calf region. It isfrom the toe region to the calf region. It is made up of carbon fiber composites.made up of carbon fiber composites. - Deflects under load.Deflects under load. - Stores potential energy.Stores potential energy.
  66. 66. -Releases in the later part of the stance phase. -Needed for recreational and sports activities.
  67. 67. Flexible keel footFlexible keel foot Innovative design made from solid rubber keelInnovative design made from solid rubber keel extending beyond the metatarsal region in to theextending beyond the metatarsal region in to the toe area of foot. This makes the forefoot verytoe area of foot. This makes the forefoot very flexible and facilitates rollover and amputees canflexible and facilitates rollover and amputees can walk easily.walk easily.
  68. 68. Multiaxial ankle - footMultiaxial ankle - foot It contains a mechanism that offers a limitedIt contains a mechanism that offers a limited range of coronal plane inversion and eversion asrange of coronal plane inversion and eversion as well as sagittal plane plantar flexion andwell as sagittal plane plantar flexion and dorsiflexion. It is helpful in negotiating unevendorsiflexion. It is helpful in negotiating uneven terrain. This contributes to socket comfort byterrain. This contributes to socket comfort by absorbing some of the impacts of walking.absorbing some of the impacts of walking.
  69. 69. Flex-Foot Cheetah Blades Cost of each side approx. US$ 18000 (INR 11,70,000/-) Carbon Copy
  70. 70. Oscar Pistorius with running bladesOscar Pistorius with running blades
  71. 71. - These blades are transtibial prosthesis which areThese blades are transtibial prosthesis which are designed to store kinetic energy, like spring,designed to store kinetic energy, like spring, allowing the wearer to jump and run effectively.allowing the wearer to jump and run effectively. - These are made up of carbon-fiber-reinforcedThese are made up of carbon-fiber-reinforced polymer which is strong and light material.polymer which is strong and light material. - Blades are bolted to carbon fiber socket.Blades are bolted to carbon fiber socket. - Custom made spike pads are attached on theCustom made spike pads are attached on the blade.blade. - Because of the curved design the blades have toBecause of the curved design the blades have to be slightly longer than the runners biological legbe slightly longer than the runners biological leg and foot would be.and foot would be.
  72. 72. OsseointegrationOsseointegration Yet to begin in India.Yet to begin in India. The metal implant is inserted in to the medullaryThe metal implant is inserted in to the medullary cavity of residual long bone and a tubular component,cavity of residual long bone and a tubular component, with a surface self-tapping screw thread that engageswith a surface self-tapping screw thread that engages the inner aspect of the cortex. The connectingthe inner aspect of the cortex. The connecting component called abutment, is attached to lower endcomponent called abutment, is attached to lower end of implant.of implant. Abutment projects out side the skin to be attached toAbutment projects out side the skin to be attached to the prosthetic component.the prosthetic component.
  73. 73. ThanksThanks

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