Lower limb prosthesis (hip, knee)

Lower limb prosthesis (hip, knee)

• 1.
  Lower limb prosthesis(hip / knee) BY DR VIPIN DEV M GUIDE – DR SANJAY MULLAY
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  PROSTHESIS  Device toreplace part of the limb or complete limb  “substitute”  Prosthetist: Health care professional who designs, fabricates and fits limb prosthesis
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  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
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  GOOD STUMP  Properlength  Proper shape  Complete skin coverage  Healthy scar  Good muscle power  Good range of motion for joints  No neuroma  No phantom pain or sensation
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  PREPROSTHETIC TRAINING  Trainingin  Active rom exercise  Proper positioning of stump  Muscle strengthening  Skin care  Crutch training  Wheel chair training  Self care  Patient and family education
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  PROSTHETIC TRAINING  Prostheticfitting – alignment check , pressure point relief , color check  Donning and doffing caring  Skin care training  Gait training  Maintenance of prosthesis
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  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
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   Advantage  Reduceedema 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
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  TRANSTIBIAL / TRANSFEMORAL AMPUTATION
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  TRANSTIBIAL AMPUTATION . Ideal length- five inches from tibial tubercle  Minimum length – two inches from tibial tubercle  Types  Ultra short (below tibial tubercle)  Short(upper 1/3rd tibia)  Standard (junction of upper and middle 1/3rd )  Long(jun of lower and middle 1/3rd)  Wound healing inversely related to length of stump
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  TRANSTIBIAL PROSTHESIS  Parts Socket  Suspension  Shin  Ankle joint  Foot
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  SOCKET  Encloses thestump  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
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  TYPES  Conventional BelowKnee Socket  Patellar Tendon Bearing Socket  Patellar Tendon Bearing Supracondylar Suprapatellar Socket  Bent Knee Socket  Slip Socket
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  Conventional Below KneeSocket  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
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  PATELLAR TENDON BEARINGSOCKET  To 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
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   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
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  TOTAL SURFACE BEARINGSOCKET  To distribute weight over entire surface of limb  Strategic allotment of weight by molding the contours according to type of tissue and anticipated loading.
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  PATELLAR TENDON BEARINGSUPRAPATELLAR SUPRACONDYLAR SOCKET  Anterior trim line – suprapatellar  Medial and lateral – supracondylar  Gives good suspension  Forms quadriceps bar  In patients with short stump and genu recurvatum
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  SLIP SOCKET  Twolayers  External – wooden or plastic socket  Internal – fine leather  Uses  Short stump  Painful scars
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  BENT KNEE SOCKET Indication – patients having FFD of stump  Up to 20 ° can be accommodated
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  INTERFACE MATERIALS  Separatelimb 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
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  SUSPENSION  The methodof 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
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  SUSPENSION - TYPES SUPRACODYLAR CUFF  In cooperates prosthesis to supracondylar region  Most common  Closed by velcro or buckle closure  With PTB called PTB SC
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   Waist belt
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   Cuff strap
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   EXTERNAL KNEEJOINT 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
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   Shuttle lockSuspension
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   Vacuum Suspension
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   Magnetic ProstheticSuspension system  Lanyard distally mounted strap
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   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.
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  SHIN PIECE  Substitutefor 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.
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   Endoskeletal  Modularin type  Has pylon (shape of skeleton)  Cosmetic foam in shape of leg.  Adv – lighter , cosmetic, alignment after finishing , parts can be changed
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  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
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  SOLID ANKLE CUSHIONHEEL (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
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  MADRAS FOOT  Modificationof 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
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  JAIPUR FOOT  Solidankle joint  Made of galvinized rubber with shaping of toes
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  SINGLE AXIS FOOT Have bumpers made of hard rubber  When heel strikes plantar flexion and then foot flat
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  MULTI AXIS FOOT All movements possible  Good shock absorption  Good for walking in uneven surface and even in scarred stump
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  SOLID ANKLE FLEXIBLEKEEL FOOT  Similar to SACH  Use flexible keel  Good shock absorption  In obese ones
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  ENERGY STORING FOOT Dynamic response foot  Shock absorbing leaf spring or carbon steel used  Absorb energy on heel contact  Release in terminal stance providing propultion
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  TRANSFEMORAL PROSTHESIS
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  KNEE DISARTICULATION VS TARNSFEMORALAMPUTATION 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
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  KNEE DISARTICULATION VS TARNSFEMORALAMPUTATION
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  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
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  PROSTHEIS - PARTS Socket  Knee  Rotator  Pylon  Foot
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  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
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   Anterior wallcontoured to direct force posteriorly to Scarpa’s triangle –to keep ischium in position  A-P dimension narrowed than M-L dimension
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  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
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  QUARDRILATRAL SOCKET ISCHIALCONTAINMENT 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 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
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  ELEVATED VACCUM SOCKET Low trim lines(subischial)  Good comfort and rom  2-4 inches below ischial tuberosity
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  SUSPENSION  Traditional pullin suction suspension  Roll on suspension liners  Shuttle lock systems  Cushion liner with air expulsion valve  Silesian belt  Total elastic suspension belt  Pelvic belt
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  KNEE JOINT PROSTHESIS difficult to replicate  Modified hinge joint
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  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
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  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
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  WEIGHT ACTIVATED STANCECONTROL 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
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  MANUAL LOCKING KNEEUNITS  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
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  HYDRAULIC KNEES  Cadenceresponsive 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
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  PNEUMAIC KNEE PROSTHESIS LIKE HYDRAULIC  Less weight , maintainance cost less  Less cadence control than hydraulic
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  INTELLIGENT PROSTHESIS PLUS Microprocessor swing phase control knee  Sensors monitor knee position during swing and pressure sensors detecting ground related forces during stance
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  TRANSVERSE ROTATORS  Tosit crossed leg.  External button pushed to unlock it  gets locked automatically when knee back to neutral
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  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
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   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
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   Painful residuallimb  possible causes include bony prominences, poorly  fitting prostheses, neuroma formation, and insufficient  soft tissue coverage
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  THANK YOU…