BYDR.MAJIDPG IN ORTHOPAEDICSGANDHI HOSPITAL

MODERATOR:DR.RAMESHASSOCIATE.PROFGANDHI HOSPITAL

OrthosisExternally applied mechanical devices support weakened injured, paralyzed, diseased part

“ supplimentation

Prosthesis Device to replace part of the limb or missing limb “substitute”

Prosthetist a person skilled in prosthetics and its application.

Prosthetics: a rehabilitation science includes theory and practice of design, production of prosthesis and application

Aim of prosthesis fitting

• to substitute for a lost part and to restore lost function.

• In the lower extremity prosthesis must permit comfortable ambulation minimal expenditure of energy.

• Reduction of energy requirement

depends on minimizing the shift of the center of gravity of the body during gait

by a well-fitted socket and proper alignment.

But for upper limb:It is difficult to get the function as it

is not possible to replace the “Normal Hand”

center of gravity of the body during gait wheel does not deviate from straight line-hence extreme efficient

Normal human locomotion >2”deviation of CG both horizontally and vertically hence also efficient

Power source of prosthesis

Body powered amputation stump & other limbs .

Externally powered

electric or battery

More distal the amputation more the functional ability ( more natural limb control the prosthesis).

used in the upper limb prosthesis more.

Level of amputation and prosthesis

Toe disarticulation: toe filling rubber,foam,wool as spacer to prevent hyperextension of boot at toe break.

Transmetatarsal amputation: boot with long steel shank, metatarsal pad and stiff insole.

Lisfranc's amputation: boot filled with stiff insoleChopart's amputation: 1.syme's model

prosthesis 2. high collar shoe with toe filler

Syme's amputation: syme's prosthesisSyme's prosthesis should have end bearing pad for

shock absorption. Types1.full end bearing i.e. Conventional prosthesis: Has leather socket and wooden foot piece Most pts are unable tom bear long time standing

and distance walking2.CANADIAN SYME'S PROSTHESIS: more distal end

bearing and less proximal PTB weight bearing Medial window is given to pull bulbous end to the

socket. Also provides suspension over malleoli

SYME'S PROSTHESIS

3. closed expandable syme's prosthesis: more PTB bearing and less end bearing

Prescribed for modified syme's amputation where the lower end is less bulbous and there is no need for any window

Advantages: better cosmesis and better suspension

-Socket

-Suspension system

-Extension joints (knee assembly)

-Shank/pylon

-Terminal device (usually includes foot and Ankle )

Suction& Mechl close fitting

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

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

suspension system -for attaching socket to body.

can be done bya)belt ,straps or cuff

b)others– by suction

prosthesis – by Mechanical

close fitting or silicon sock helps to maintain airtight seal

Silesian bandage

Hip joint,pelvicband waist belt

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

• 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

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

1. Axis system2. Friction mechanism3. stabilizers-

• Axis systemSingle 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

• Friction mechanismConstant 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) frictionAir (pneumatic)frictionAllows best gait pattern –best for active patients-expensive

Medium friction

(hydraulic) friction

Constant friction

“ 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

• Stabilizers

Manual locking knee

left locked in extension,

unlocked whole sitting to permit flexion

Used in weak ,unstable patients primarily

StabilizersManual locking

1. Endoskeleton

“Modular prosthesis”

2,Exo skeleton:

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.

• 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.

articulated

Non articulated

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 keel-energy stored and released

Articulated

SINGLE AXIS

MULTI AXIS

SACH Foot (solid Ankle cushion Heal)Some movementt in all directionsUseful when not used for heavy dutyWomen/childrenNot suitable for indian amputies barefoot/squating cannot

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

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

strike

Commonly used varieties of prosthesis

AK prosthesispreferred design quadrilateral

socket –pelvic belt – Suction prosthesis

BK prosthesisPatellar tendon bearingMechanical Fit or with bar suspension system

Commonly used varieties of prosthesis

AK prosthesisquadrilateral socket

–medwall high,latwall flat10 deg adduction med inclination

pelvic belt Suction prosthesis

BK prosthesisPatellar tendan

bearing60%pt 40% condyles,post wallMed flare oftibiaalso wt bearing

Mechanical Fit or with bar suspension system

Slide the CROW into position, ensuring that the heel is fully seated within the CROW

The heel needs to be back all the way and in contact with the bottom of the footplate.

Check by looking along the sides and the back where it is separated above the heel.

Apply the front section of the device,

making sure it's sides overlap the back section

Apply the instep strap on the front of the ankle

Fasten all remaining straps

Skin should be checked for redness that does not go away after approximately 15 minutes.

Slight redness is common over the instep and under the ball of the foot.