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Lower extremity artificial limbs deals with the prosthetic fitting of lower limb amputations.
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It is well accepted that any fluid-control mechanism (hydraulic or pneumatic) results in a smoother gait. Motion studies conducted at Northwestern University have confirmed that a more normal gait for the hip dis-articulation/transpelvic amputee is also produced. Gait analysis has demonstrated that utilization of a hydraulic knee in a hip disarticulation prosthesis results in a significantly more normal range of motion at the hip joint during the walking cycle than is possible with conventional knees. In addition, a more rapid cadence was also possible.
A third type that has proved advantageous for this level of amputation is the polycentric (four-bar) knee. Although slightly heavier than the previous two types, this component offers maximum stance-phase stability. Because the stability is inherent in the multilinkage design, it does not erode as the knee mechanism wears during use. In addition, all polycentric mechanisms tend to "shorten" during swing phase, thus adding slightly to the toe clearance at that time. Many of the endoskeletal designs feature a readily adjustable knee extension stop. This permits significant changes to the biomechanical stability of the prosthesis, even in the definitive limb. Because of the powerful stability, good durability, and realignment capabilities of the endoskeletal polycentric mechanisms, they are particularly well suited for the bilateral amputee. Patients with all levels of amputation, up to and including translumbar (hemicorporectomy), have successfully ambulated with these components.
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Prosthetic fitting is typically limited to motivated and physiologically vigorous individuals; still, a significant number do not become long-term wearers. To investigate this further, the senior author (T.v.d.W) studied a group of 20 male and female hip disarticulation and transpelvic amputees who were representative of the age and diagnoses typically encountered. Only 15% had been full-time users of their initial prostheses; many complained of how cumbersome or uncomfortable their rigid sockets seemed.
One of the inherent limitations of the Canadian design is that the prosthesis must be significantly short (1 cm+) to avoid forcing the amputee to vault for toe clearance. Fig 21B-3. and Fig 21B-4. illustrate why this is so. At toe-off, the heel rises up during knee flexion and pulls the hip joint firmly against its posterior (extension) stop. The thigh segment remains vertical until the knee has reversed its direction of motion and contacted the knee stop. Only then does the thigh segment rotate anteriorly and cause the hip joint to flex. In essence, the prosthesis is at its full length during midswing. Since the patient has no voluntary control over any of the passive mechanical joints, the prosthetist is forced to shorten the limb for ground clearance.
Evaluation of Robotic Prosthesis Control during Ambulation
For many years, the use of fluid-controlled knee mechanisms for high-level amputees was considered unwarranted since these individuals obviously walked at only one (slow) cadence. The development of hip flexion bias mechanisms and more propulsive foot designs have challenged this assumption. Furthermore, a more sophisticated understanding of the details of prosthetic locomotion has revealed an additional advantage of fluid control for the hip-level amputee.
In general, a softer forefoot requires special care during dynamic alignment to ensure that knee buckle does not occur inadvertently. However, when used in concert with a polycentric knee, the reverse occurs: the prosthesis actually becomes more stable during late stance phase. The polycentric knee mechanism strongly resists a bending moment, which leads to its powerful stability at heel strike. It flexes during swing phase only if the forefoot remains firmly planted on the floor as the body "rides" the prosthesis over it. This creates a shearing force that disrupts the linkage and permits easy flexion of the knee. Because the softer flexible keel delays this shearing moment, the polycentric knee is actually more stable in late stance than with a more rigid foot.
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Certainly one of the more effective adjuncts to the treatment program is extensive use of the prosthesis
Hip Disarticulation Prosthesis at Award Prosthetics
Prosthesis - Wikipedia
TKA Prosthesis Design - Recon - Orthobullets
We prefer to have the amputee simulate weight bearing during the plaster impression technique to create as precise a mold as possible. However, in contrast to the technique advocated by Otto Bock, we believe that careful attention to shaping the medial wall in the ischial region is important to improve control of the prosthesis for both walking and sitting.
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Many materials are suitable for socket fabrication. As is the case with other levels of lower-limb amputation, the most commonly utilized socket material is a rigid thermosetting resin: polyester or acrylic. An increasing trend toward more flexible thermoplastic materials is evident, as in other aspects of prosthetic practice. One of the authors (J.W.M.) has fitted more than two dozen polypropylene/polyethylene copolymer sockets for hip-level amputation over the past decade with good long-term results in durability, comfort, and patient acceptance (Fig 21B-14.).
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The most important part of any prosthesis is the socket, which provides the man-machine interface. During the initial assessment of the amputee, examination of postoperative radiographs and careful palpation of the pelvis are recommended. Some amputees present as "hip disarticulation" when they have a short femoral segment remaining or as "transpelvic" when part of the ilium, sacrum, or ischium remains. Unanticipated bony remnants can become a puzzling source of discomfort. On the other hand, they may sometimes be utilized to assist suspension or rotary control or to provide partial weight-bearing surfaces. Due to the success of ischial containment transfemoral sockets, the importance of precise contours at the ischium and ascending ramus is now more widely recognized. The same principles can readily be applied to hip disarticulation sockets to increase both comfort and control (Fig 21B-11.).
THA Prosthesis Design - Recon - Orthobullets
Torque-absorbing devices are often added to hip dis-articulation/transpelvic prostheses to reduce the shear forces transmitted to the patient and components. Ideally, they are located just beneath the knee mechanism (Fig 21B-9.). This increases durability by placing the torque unit away from the sagittal stresses of the ankle while avoiding the risk of introducing swing-phase whips (which can occur if it is placed proximal to the knee axis). The major justification for such a component is that the high-level amputee has lost all physiologic joints and, hence, has no way to compensate for the normal rotation of ambulation.
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