overview of orthotics and prosthetics , its biomechanics, uses, various types. for physiotherapy, mbbs n othopaedics

1. Orthotics &prosthetics
Dr. Guru Prasad
DNB orthopaedics

2. Orthosis

3. • Definition
• Nomenclature
• Ideal characteristics
• Function
• Biomechanics
• Materials
• Complications
• Common orthotics

4. Definition
• An orthosis is a device that is externally
applied to a body segment and that facilitates
or improves function by supporting ,correcting
or compensating for skeletal deformity or
weakness

5. 3500BC An Indianpoem, Rig-Veda,is the first recorded document about
a prosthesis. Thepoem tells the tragic story of QueenVishpla, a warrior, who lost
herleg in battle. After the battle, she had aniron prosthesis made, and she was able to
go back to battle. The
Roman general named Marcus Sergius guided his troops against Carthage in the Second Punic War and suffered
over 20 injuries, including the loss of his right arm. An iron hand was created so that he could fight for the rest of
the war.
1st C BC Archeologists discovered bronze peg prosthetic. Although it was rusted, it is the oldest usable artifact of a
prosthetic.
1508 The German knight Götz von Berlichingen (1480-1562) . He had to have his right arm amputated after the
Battle of Landshut. Gotz had two prosthetic iron hands to replace his right arm.
1529 Ambroise Pare introduced amputation to the medical community. He is considered the father of
prosthetics. In1536,he made anartificial limb for the arm and elbow and created other limbs later.
1696 Pieter Andriannszoon Verduyn, a Dutch Surgeon, developed the first non-locking prosthesis for below the
knee. Thisis the basis for the current joint and corset prosthesis.
1843 Sir James Syme described his method for ankle amputation. Before this procedure, the technique used
amputated at the thigh. By amputating at the ankle, the patient could have the possibility to walk again. The
longer leg length allowed an artificial foot to bear a typical weight
[2],[3],[4],[5].

8. nomenclature
• Traditionally
part of body place person
• Knee brace milwakee brace dennis brown
splint

9. • AAOS nomenclature
1st joint or region it encompasses
2nd biomechanical analysis of its function

10. Joint or region it encompasses
• FO = foot orthosis
• KAFO = Knee- ankle-foot orthosis

11. Biomechanical analysis of its function
F Free motion allowed
A Assist
R Resist
S Stop
H Hold
L lock

12. Ideal characteristics of orthotics
• Biomechanically effective
• Light weight
• Durable
• Cosmetically pleasing
• Easy to put on(DON) and put off (DOFF)
• Inexpensive
• Washable
• Adjustable
• Comfortable
• Free from pressure areas

13. Functional characteristics of orthotics
• Provision of support
• Limitation of motion
• Correction of deformity
• Assistance in motion
• Miscellaneous
• Combination of all

14. • Provision of support
- prevent weak muscles or ligaments
being stretched
- support joints

15. • Limitation of motion
- KO prevents hyper extension

16. • Correction of deformity
- dennis brown splint

17. • Assistance in motion
• - HKAFO to aid walking in
myelomeningocele

18. Miscellaneous
- warmth ,placebo

19. • Combination
• - KAFO for polio leg gives support
,limits motion help correct varus ankle, assist
ankle dorsiflexion

20. classification
• Static
- has no moving part
- to immobilize
• Dynamic
- has moving part
- movement controlled by energy store
eg rubber band
- prevents muscle stiffness, muscle wasting
- hastens repair of bone, tendons , ligaments

21. Basic biomechanical concept
• Three point principle – by Sir John Charnley
• Newtons third law
• Ground reaction force (GRF)
• Forces and moments
• Total contact.
• Partial weight relieving.

22. Three point pressure
• "The sum of the forces and the bending
moments created is equal to zero.“
• A single force is placed at the area of deformity;
two additional counter forces act in the opposing
direction.
• During "quiet" standing, line of gravity (weight
line) passes through:
– posterior to hip joint
– anterior to knee joint and
– anterior to ankle joint

23. Partial weight relieving
• “The farther the point of force from the
joint, the greater the moment arm and
the smaller the magnitude of force
required to produce a given torque at
the joint.”
• The greater the length of the supporting
orthotic structure, the greater the
moment or torque that can be placed on
the joint or unstable segment.

24. Total contact
• “Pressure is equal to the total force per unit area. “
• The greater the area of a pad of an orthosis, the less
force will be placed on the skin.
• P = force
Area of application

25. Biomechanics
• Direct
- Control of > moments
> translation forces
> axial forces
• Indirect
- control of > line of action of GRF

29. Materials
• Traditionally
• - rubber, leather, metal, POP
• Now-in-use
• > Thermosetting plastics
• > Thermoforming plastics
• > self generating polyurethane foam

30. Common orthoses

31. Foot orthoses
• Insoles
• Shoes

32. • Insoles
> simple
> total contact insoles
> functional /biomechanical

33. shoes
External
modifications
Heel sole
Internal
modifications
Heel Sole
Cushioned
Flared
Wedged
Extended
elevated
Rocker bars
Metatarsal bars
Wedges
flares
Cushion relief
Cups
Ucbl inserts
Metatarsal pads
Innersole excavations
Arch supports

39. Ankle – foot orthoses
• Plastic AFO
• Posterior leaf AFO
• Solid AFO
• Hinged AFO
• Ground reaction AFO
• Dynamic AFO
• Metal plastic AFO

40. AFO
• Ankle-foot orthosis is a brace, usually
plastic, worn on the lower leg and foot
to support the ankle, hold the foot and
ankle in the correct position, and
correct foot drop.
• Purpose:
– To control alignment and motion of the
joints of foot and ankle.
– For patients affected with muscular
dystrophy, cerebral palsy, etc.
• Construction:
– Consists of a shoe attachment, ankle
control, uprights and a proximal leg
band.

41. • Parts:
– Calf bands
– Metal uprights
– Ankle joint
– Shoe attachments
– Stirrup
Calf band
Metal upright
Ankle joint
Shoe
attachments
Stirrup

42. Floor Reaction Orthosis

43. Posterior leaf AFO Dynamic AFO

44. Hinged AFO
Metal plastic

45. Knee – ankle – foot orthoses

46. Knee Ankle Foot Orthosis (KAFO)
• A KAFO is a long-leg orthosis that spans
the knee, the ankle, and the foot in an
effort to stabilize the joints and assist
the muscles of the leg.
• Material for fabrication: metals, plastics,
fabrics, and leather.
• Used in quadriceps paralysis, maintain
knee stability, control flexible varum
/valgum

47. Parts
Hip joints and locks
• Controls for abduction, adduction and
rotation.
• Controls for hip flexion when locked.
• 2 position hip locks are also available.
• Pelvic band
• To stabilize the hip joint.
• There are two types unilateral pelvic band
and bilateral pelvic band.
• It adds weight and increases overall energy
expenditure during ambulation.

48. Types of knee orthosis
• Dynamic patellar orthosis:
• It consist of an elastic sleeve with patellar cutout.
• Its purpose is to prevent the dislocation of
patella.
• Traditional knee orthosis
• It consists of leather thigh, calf cuffs and metal
side bars.
• Pressure pad may be applied to generate medial
or lateral forces.
• Swedish knee cage
• It used in the management of knee
hyperextension.
• Two anterior pads and adjustable posterior
pressure pad at the attachment to the upright .

49. Types of knee joints
• Free motion knee joint:
allows unrestricted flexion & extension.
• Off-set knee joint:
the hinge is located posterior to the knee
joint stabilize knee during stance.

50. Hip Knee Ankle Foot Orthosis (HKAFO)
• Hip joint and pelvic band attached to the lateral
upright of a KAFO converts it to a HKAFO.
• Purpose:
– Hip flexion/extension instability
– Hip adduction/abduction weakness
– Hip internal rotation/external rotation
instability

52. • Parts:
– Sole plate extending to the metatarsal
heads with a crossbar added to the
metatarsal heads area for mediolateral
stabilization.
– Ankle joint set at 10° of dorsiflexion
– Anterior rigid tibial band (patellar tendon
strap)
– Offset knee joint with bail lock
– Proximal posterior thigh band

53. Types of HKAFO
• Reciprocal Gait Orthosis (RGO)
• It is used for upper lumbar paralysis in
which active hip flexion is preserved.
• RGO consists of bilateral HKAFO with
offset knee joints, knee drop locks,
posterior plastic AFO, thigh pieces,
custom molded pelvic girdle, hip joints,
and a thoracic extension with Velcro®
straps, in addition to the control
mechanism

54. Hip orthosis
• Purpose:
– To resist femoral adduction.
– Mostly in elderly patients who have had total
hip joint replacement.
• Parts:
– Two position lock which permits full extension
and 95 degree of hip flexion and adjustable
adduction stop.

55. Trunk – hip – knee – ankle – foot
orthoses
• THKAFO

56. MISCELLANEOUS
• Weight bearing orthoses
• Fracture orthoses
• Angular and deformity orthoses
• Hip orthoses for paediatrics disorders

57. complications
• Compression phenomenon
• Heat and water retention
• Patient orthoses interfacial affects

58. Prosthesis

59. Definition
• Prosthesis is a device or artificial substitute
designed to replace, as much as possible , the
function or appearance of a missing limb or
body part

60. Aim
• To achieve maximum functional independence
with prosthesis
• Not the same as amputee rehabilitation
• Eg wheelchair mobility who are unable to walk

61. Classification
• Level of amputation
- eg transfemoral , transradial
• Structure
- exoskeleton , endoskeleton
• Function
- cosmetic , functional

62. Exoskeletal
Endoskeletal

63. Parts
• Socket /interface
• Suspension mechanism
- standard suction
- elastometric
• Struts/tubes(pylons)
• Articulating joints
• Terminal device

64. -Socket
-Suspension system
-Extension joints
(knee assembly)
-Shank/pylon
-Terminal device
(usually includes
foot and Ankle )

67. Suction&
Mechl close fitting

70. 1. End bearing
– End of the stump bears the weight
2. Total Contact socket
– load is distributed to entire stump
– supports all the distal tissues within the closed system
– As there is total contact proprioception will be good.
– give good sensory feed back.
– good control of stump
– acts as a circulatory pump
– . During stance phase , positive pressure encourages venous
return;
– during swing phase ,negative pressure encourages distal
blood flow.
Socket WT bearing – 2 types

71. Total Contact socket
– Used for most older patients
– Offers “partial suction”
– Suspended by pelvic belt and hip joint that is
attached to socket
– A selsian bandage suspension preferred over pelvic
belt as the latter often interferes with sitting

72. Suction socket prosthesis
• Indicated for
amputees for
smooth residual limb
contours
• Volume fluctuants
such as weight gain
and fluid retention
– contraindications
Disadvantages
• Difficulty in
obtaining press fit
• Ocassional lossof
suction in sitting
position
• No medium for
absorbing
perspiration
• Requirement of
volume and weight
stability

74. suspension system-Soft belts
• Used as primary or auxiliary suspention
• Traditional form is silesian belt
– Simple
– disadvantage
• hygiene if it is non removable
•Discomfort due to constrictive effect
• Total elastic suspension (TES)
– New ,made ofelasticneoprene lined with smooth Nylon
– Belt fits around proximal 8” of prosthesis
• Hip joint with pelvic band or belt
– Provides rotational stability
– significant mediolateral pelvic stability
– Essential when abductors are week
and amputees are obese
Silesian bandage
Hip joint,pelvicband waist
belt

75. • held on by suction and close
anatomical fit
• most suitable for above
knee.
• eliminates the hip joint and
pelvis belt or shoulder
harness;
• permits free rotator motion
about the hip
• and eliminates piston action
of the stump in the socket ,
permitting greater toe
clearance and smoother gait.
• No stump sock needed.
• closely fitted
• create negative pressure
during the swing phase
• and positive pressure that
expels air through a flap
valve during the stance
phase.
• The tight fit is applied at
the upper two and half or
three inches
and along the anterior wall
of the socket, the reminder
stump hangs free.
• A groove in the anteromedial
wall accommodates the
adductor tendons.
Suction socket prosthesis

78. 1. Axis system
2. Friction mechanism
3. stabilizers-

79. • Axis system
Single axis ….
– Axis of prosthetic knee is same as that of weighty
bearing axis
– Flexion easier, But stance phase control difficult
Posterior off set axis…
– Axis of prosthetic knee is posterior
– Flexion difficult, stance phase control easier
Polycentric….
– variable center of rotation –advantage in both
phases

80. • Friction mechanism
Constant friction
– Hinge to dampen knee swing
– Allows single speed walking
– Most used in children
– Not used for older or weaker
Variable friction-cadence control
– Staggerd friction pads
– More friction at extreme ranges,
– Less friction at mid swing
– Allows walkig at more speed ,but not durale
Medium friction
Oil (hydraulic) friction
Air (pneumatic)friction
Allows best gait pattern –best for active patients-expensive
Medium
friction
(hydraulic)
friction
Constant friction

81. “ Intelligent prosthesis (IP)”
Programmed to each individual
user during walking to achieve
the smoothest, most energy-
saving pattern.
Reacts to speed changes
Intelligence does not extend to
understanding environmental
considerations
Ex. stairs, ramps or uneven
terrain.
•utilizes electronic
sensors
•detect rate and range
of shank
•Provides instant
friction adjustments
to changes in gait
pattern
‘C-LEG’
Friction mechanism

82. • Stabilizers
Manual locking knee
left locked in extension,
unlocked whole sitting to permit flexion
Used in weak ,unstable patients primarily
Stabilizers
Manual locking

83. 1. Endoskeleton
“Modular prosthesis”
2,Exo skeleton:

84. Endoskeleton:
“centrally located tubular
structure
• made of prefabricated.
Made of carbon fibers
• the load bearing structure
• The socket used over it
• Adjustments can be easily
made
• These are called “Modular
prosthesis”
• Exo skeleton:
-conventional artificial
limbs outer visible “skin”
like
-Inner hollow structures.
-made of aluminum ,plastic
-adjustments are difficult
-accurate measurement
should be there in the
beginning it self.

85. Exoskeletal
Endoskeletal

86. • Providing contact between to
the ground the foot provides
shock absorption and stability
during stance
• influences gait biomechanics
by its shape and stiffness.
This is because the
trajectory of the centre of
pressure (COP) and the angle
of the ground reaction forces
is determined by the shape
and stiffness of the foot and
needs to match the subjects
build in order to produce a
normal gait pattern.
• The main problem
found in current
feet is durability,
endurance ranging
from 16–32 months [
• These results are
for adults and will
probably be worse
for children due to
higher activity levels
and scale effects.

87. articulated
Non articulated
Non articulated
Articulated

88. Non articulated
Ex:1)sach Foot
(solid Ankle cushion Heal)
2)Madras foot
-modified sach
–Post TA like look
-sponge between heel&ground
3)Jaipur foot
4) dynamic
-new
-spring in kee
l-energy stored and released
Articulated
SINGLE AXIS
MULTI AXIS

90. • Designed in 1958 by Eberhart and Radcliffe
• One of the most widely prescribed foot is the solid-
ankle-cushion-heel (SACH) foot, due to its simplicity,
low cost, and durability and light weight.
• It has a cushioned heel that compresses during heel
strike,simulating plantar flexion, and a rigid anterior
keel to roll over during the stance phase.
• It is prescribed for juvenile and geriatric amputees
but may be inappropriate for active community
ambulators and sports participants.
SACH foot

91. SACH Foot
(solid Ankle cushion Heal)
Some movementt in all directions
Useful when not used for heavy duty
Women/children
Not suitable for indian amputies
barefoot/squating cannot

92. SACH foot

93. Jaipur foot
• Mcr&vulcanised rubber
• Looks natural
• Bare foot
walking/squating
possible/crossleg/rough
use
• 3level movmt
• Inv/eversion possible –
hence can walk on
uneven area
• Cheap-durable-water
resistant

96. • Madras foot is mainly used in the southern part
of India
• It is composed of :-
• Wooden keel
• Canvas rubber
• Hard rubber
• Soft rubber
• Swade lather.
Has the Advantage of bare foot walking,
durability and cultural modifications like toe rings
etc.

97. Single axis ankle and wood foot
• Heavy duty activities, rapid plantar flexion at heal
strike

98. Multi axis

99. Trans tibial prosthesis
Patellar tendon bearing prosthesis

102. Trans-femoral prosthesis

104. Spot the difference..

107. Disarticulation prosthesis

110. Complications
• Dermatological problems
• Phantom sensation
• Phantom pain
• Choke syndrome
• Increase in energy consumption

111. Bionic arm

116. Thank You