1 What is an Ideal prostheses

Characteristics of a successful prosthesis

Ideally, a prosthesis must be comfortable to wear, easy to put on and remove, light
weight, durable, and cosmetically pleasing. Furthermore, a prosthesis must function well
mechanically and require only reasonable maintenance. Finally, prosthetic use largely
depends on the motivation of the individual, as none of the above characteristics matter
if the patient will not wear the prosthesis.
2 Mention components of Lower-extremity prosthesis
The major components of a lower-extremity prosthesis are the socket (with or without a
socket liner), a suspension system, interposed joint components (as needed), a shank
(pylon), and a prosthetic foot. The prosthetic foot is typically a component that functions
and looks like a foot but that may take other forms or functions for water or other sports
activities.
The socket

The socket serves as the interface between the residual limb and the prosthesis. It must
not only protect the residual limb, but it must also appropriately transmit the forces
associated with standing and ambulation. The preparatory (temporary) socket will likely
need to be adjusted several times as the volume of the residual limb stabilizes. The
preparatory socket can be created by using a plaster mold of the residual limb as a

template. Some prosthetic manufacturing facilities use computer-assisted technology to

map the residual limb, manufacturing a socket directly from that data.
The most common socket used in a transtibial amputation is a patellar tendonbearing
(PTB) socket. This socket emphasizes increased contact or weight bearing in the area
of the patellar tendon, inferior to the patella, but that is not to say that there is not
significant contact or weight bearing elsewhere on the residual limb

.
The concept of total contact is important, because before the advent of the total-contact
PTB socket, transtibial sockets often had an open-ended, plug-fit design, which lead to
numerous skin problems, chronic choke syndrome, ulceration, and other complications.
Total-surfacebearing (TSB) transtibial socket designs are moving away for the concept
of emphasizing patellar tendon weight bearing, but even these require selective loading
and selective relief over certain areas of the residual limb with the PTB design, weight is
distributed over many different areas, such as the anterior and posterior compartments
and the medial tibial flair.

"Total contact socket," which denotes the PTB design. The PTB socket has variations,
including the PTB-supracondylar (PTB-SC) socket and PTB-suprapatellarsupracondylar (PTB-SCSP) socket.
A PTB-SC has high medial and lateral sidewalls that extend above and over the
femoral condyles, providing enhanced mediolateral stability and self-suspension for the
prosthesis.
The PTB-SCSP socket furthers the PTB-SC concept by also extending the anterior
aspect so that the patella is enclosed within the socket. The PTB-SCSP socket gives
additional stiffness to the mediolateral walls and applies force proximal to the patella
during stance, in this way providing sensory feedback to limit genu recurvatum. The
PTB-SC and PTB-SCSP sockets are used primarily for amputees with short residual
limbs in order to improve varus/valgus control and to provide greater surface area for
weight distribution.

An alternative option is a joint-and-corset system, which is especially good for heavyduty use .This system may be used to increase the weight-bearing surface area onto
the thigh or to off-load the transtibial residual limb, transferring the weight to the thigh.
The joint-and-corset system is also used when there is a need to provide great
mediolateral stability for the knee of a transtibial amputee. Another option is a rigid
frame with a flexible liner; the outer rigid frame has windows that provide additional
pressure relief.
An alternative socket design for transtibial amputees is the TSB socket that is used with
an elastomeric liner system. The TSB socket is made from a cast of the residual limb
that has minimal modifications. When used with gel liners (see the images below), the

TSB socket is believed to distribute pressures more uniformly within the socket. It
should be kept in mind, however, that the gel liners themselves have their own set of
problems, including increased motion and, particularly, rotatory instability that leads to
skin irritation and breakdown.
The relative advantages and disadvantages of the TSB socket versus PTB socket are
unique to each individual. When a comfortable fit with one socket style cannot be
achieved, empirically switching to the other may be successful.
The most commonly fabricated socket for transfemoral amputations is the ischial
containment socket. There are a number of subtle variations in this socket design. The
socket has a wide anteroposterior dimension and a narrow mediolateral dimension. This
design replaced the quadrilateral socket design, which had a wide mediolateral
dimension and a narrower anteroposterior dimension
The ischial containment socket was initially designed to provide compression of soft
tissues and limited abduction of the femur within the socket during the stance phase. It
has been subsequently been demonstrated that resecuring the transected adductor
muscles distally is more important and effective in controlling the lateral movement of
the femur in the socket, resulting in improved prosthetic ambulation.

Explain the suspension mechanism of lower limb prostheses?

Every prosthesis requires some type of suspension system to keep it from falling off the
residual limb. Suspension can be achieved by a variety methods, including the
following:

Self-suspension of the socket: This makes use of the anatomic shape of the
residual limb (Syme or knee disarticulation).

Suction suspension: Methods of creating suction suspension include the use of

an appropriate suction socket design and of a gel suspension liner

Suspension device or harness: Such equipment includes belts, cuffs, wedges,

straps, and sleeves

A combination of these techniques also can be used

Suction suspension
Standard suction is a common suspension choice for transfemoral prostheses; it
employs a total-contact, form-fitting, rigid or semirigid socket with a 1-way air valve in
the distal end that allows air to be expelled after the socket is donned (see the following
image). The socket's intimate fit creates a seal between the skin of the residual limb and
the socket. When air is driven out of the end of the socket, a small negative pressure
strong enough to suspend the socket on the residual limbdevelops inside the socket.
This form of suspension allows excellent proprioceptive feedback and is lightweight.
One disadvantage of the suction socket is its inability to tolerate much weight or volume
fluctuation up or down before it requires replacement.\.

Total elastic suspension and Silesian belt

A total elastic suspension (TES) belt and a Silesian belt are used for auxiliary aboveknee suspension or as the sole means of suspension, especially in the pediatric patient
The Silesian belt fastens to the socket laterally, above the greater trochanter, and wraps
around the opposite iliac crest. Because it does not control rotation very well, people
using this type of suspension belt often have difficulty with internal rotation, especially if
the residual limb is fleshy. The TES belt is made from the same neoprene material that
is used for transtibial suspension sleeves. It slips over the outside of the prosthetic
socket and surrounds the waist above the iliac crest to provide suspension.
The TES belt is more commonly used today than is the Silesian belt and aids in
rotational control. Disadvantages include some inevitable pistoning of the prosthesis,
reduced comfort because of bandage pressure, heat intolerance, and the possibility that
the belt will cause dermatitis and chafing. A single-axis hip joint is integrated into the
lateral socket wall and pelvic band to control rotation and is used for weak hip adductors
or short residual limbs (see the following image).

What is gel liner suction system?

Patients with a transfemoral or transtibial amputation may utilize the gel liner suction
system, which uses a gel elastomeric liner. The liner rolls onto the residual limb and is
then inserted and locked into the socket. A pin may or may not be used. This
suspension system can provide improved cosmesis, cushions the residual limb, can
reduce shear between the residual limb and the socket, and minimizes pistoning of the
residual limb in the socket. Heat buildup, skin problems, and decreased proprioception
can be drawbacks to this suspension system.
The supracondylar cuff is a long-standing suspension design for a transtibial prosthesis.
It consists of an adjustable strap encircling the distal thigh above the femoral condyles
and is good for heavy laborers who may have difficulty with heat buildup from some of
the more enclosing suspension systems. Suspension sleeves made of neoprene,
rubber, latex, or other elastic materials may be used as the primary suspension system
or in combination with another suspension system as an auxiliary mechanism. The
sleeve fits snugly over the outside of the proximal prosthesis and extends up onto the
thigh, over the prosthetic sock

Add a note on vacuum assisted Suction suspension?

Another transtibial suspension option is suction. As with standard transfemoral suction
suspension, it uses an airtight sleeve and a 1-way air valve located in the bottom of the
socket to create a partial vacuum within the socket. This vacuum helps suspend the
prosthesis during swing phase. The vacuum needed to hold the residual limb can be
generated when air is expelled from the socket through the valve during stance, with a
resultant negative pressure inside the socket during swing. The vacuum can also be
generated through the use of a small vacuum pump built into the prosthesis. This
vacuum-assisted suspension system (VASS) works by use of a vertical shock pylon that
acts as a vacuum pump and continually withdraws air from the sealed socket during
ambulation.

Describe the prosthetic knee joint and its variations?

Knee joint
The prosthetic knee must fill the following 3 functions:

Provide support during the stance phase of ambulation

Produce smooth control during the swing phase

Maintain unrestricted motion for sitting and kneeling

The prosthetic knee can have a single axis with a simple hinge and a single pivot point,
or it may have a polycentric axis with multiple centers of rotation.
The following are some features of prosthetic knees:

The 4-bar linkage design and shifting center of rotation provide knee stability;
cosmesis is excellent, especially during sittingtherefore, this design is used for knee
disarticulations and short residual limbs

Polycentric knees are heavy, costly, and require high maintenance

The weight-activated, or safety knee cannot be flexed during weight bearing,

which provides stability during stance phase; the safety knee can accommodate up to
20 of knee flexion, produces friction, and prevents buckling; it allows ambulation on
uneven surfaces; a delay in swing phase is noted, because complete unloading of the
knee must occur for knee flexion to transpire; the safety knee is a common initial
prosthetic knee for geriatric patients, persons with extreme debility, and patients with
poor hip control; it is contraindicated in patients with bilateral transfemoral amputations

The hydraulic knee (pneumatic or oil) allows for cadence variance; the design
uses a piston in a fluid-filled cylinder that accommodates the swing phase of the
patient's gait; the knee is heavy, costly, and requires high maintenance

The manual-locking knee provides the most stability, but the gait is awkward and
energy consuming; however, it is ideal for a hemiparetic residual limb

Add a note on hydraulic based C leg and Magnetorheologic fluis based Rheo knee?
The hydraulic-based Otto Bock C-Leg (Otto Bock Health Care) provides several
benefits over purely mechanical knee systems. These microprocessor-controlled knees

improve upon the timing of the hydraulic and pneumatic knees. The patient can
ambulate at greater speeds with optimal, biomechanically correct symmetry while
expending less energy. Most importantly, the user can safely walk step-over-step up and
down stairs. The built-in battery lasts anywhere from 25-40 hours, which means that it
can support a full day of activity. The recharge can be performed overnight or while
traveling in a car (via a cigarette lighter adapter).
The magnetorheologic-fluidbased Rheo Knee (Ossur; Ossur North America) is capable
of "learning" how the patient walks. Electronic sensors on the artificial joint measure the
joint's angle and the loads it is bearing 1000 times per second while a computer chip
controls the viscosity of magnetic fluid inside the knee. Tiny metal particles suspended
in the fluid form small chains when the magnetic field is turned on, causing the fluid to
become thicker. That, in turn, affects the stiffness of the joint, which is modified
constantly while the knee is in use, allowing for a smooth swing of the leg. However, the
cost of technologically advanced knees is prohibitory for most amputees.

Summary of the types of prosthetic knees, their advantages/disadvantages, and their

potential uses.
Types of Prosthetic Knees and Usage
Type of Knee

Advantages

Single-axis,

Simple

constant

Durable

friction

Disadvantages
Only constant
swing phase control

Excellent for
pediatric patients

No stance

Lowmaintenance

Possible Uses

control

Useful for
patients who have

Single cadence single cadence but

Polycentric
without fluid

(less adjustable to

good voluntary control

variation in cadence

of swing and stance

speed)

phase

Has varying

Increased

stability through stance weight and bulk

control (also

Shortens shank

disarticulations

Complex

known as

during swing for better mechanism

pneumatic)

toe clearance
Natural and

Knee
Long
transfemoral (for

Single cadence appearance)

Short

(less adjustable to

better cosmetic

variation in cadence

transfemoral (for knee

appearance while

speed)

stability)

sitting

Weak hip
extensors

Weight-

Benefits

Requires

activated

patients who do not

stance control

have adequate control

Not very

to manage a bending

responsive for active

knee or good enough

walker

hip control to stabilize

Braking

regular maintenance

Geriatric
patients
Short residual
limb
General debility

Gait modified
to unload knee

Uneven
surfaces

mechanism if weight

Single

applied with knee

cadence(less

flexed 0-20

adjustable to variation

Helpful to

in cadence speed)

slower candidates
Manual lock

Total stability in
stance phase

No swing

Patient

phase flexion,

requires mechanical

resulting in stiff knee

stability in stance

gait

Last resort
Awkward in

sitting
Fluid Control Units
Single-axis,
pneumatic

Responds to

Higher cost

changing gait speeds

control

May need
more maintenance

From pediatric
patients to adults with
good control

Heavy, but
lighter than hydraulic
units
Gases are
compressible and
may not provide
adequate resistance
during vigorous
activities
Allow less
precision in cadence
control than do
hydraulic units
Single-axis,
hydraulic

Swing responds
to changing gait

May need
more maintenance

From pediatric
patients to adults with

control

speeds
In addition to
cadence variation,

Heavier
Hydraulic

good control
Excellent

performance affected reliability

some units can provide by extreme cold

hydraulic stance
weather

Good for the

more active amputee

stability to resist knee

flexion during weight
bearing
Polycentric
and multiaxis,

Varying stability
through stance

fluid control

Higher cost
May need

Shortens shank more maintenance

during swing for better

Heavier

toe clearance

Knee
disarticulations
Long
transfemoral (for
appearance)

Smoothest gait

Short
transfemoral (for knee

Can unlock with

stability)

some activities (biking)

For patients

Natural and
better cosmetic

who vary cadence

appearance while

frequency

sitting
Variable
cadence
Microprocessor Control
Single axis or
multiaxis

Onboard

Highest cost

microprocessor,

Heavy

hydraulics,

Unproven track

For active
patients
For patients

pneumatics, and

record for

who vary cadence

servomotors to adjust

dependability

frequency

knee for variable gait

cycles

Allows more
natural movement

Energy saving

during stair descent

Some
computerized knees
use a computerregulated valve to
adjust the swingphase resistance of a
pneumatic cylinder
Some use the
computer to control
swing-phase function
and stance phase
stability
Some systems
use multiple sensors
to send messages
about changes in the
patient's walk to the
microchip 50 times
per second

Describe the Pylon and the ankle components of lower limb prostheses?

The pylon and ankle

The pylon is a simple tube or shell that attaches the socket to the terminal device.
Pylons have progressed from simple, static shells to dynamic devices that allow axial
rotation and that absorb, store, and release energy. The pylon can be an exoskeleton
(soft foam contoured to match the other limb and covered with a hard, laminated shell)
or an endoskeleton (an internal, metal frame with cosmetic soft covering).
The ankle function is usually incorporated into the terminal device. A separate ankle
joint can be beneficial in heavy-duty industrial work or in sports such as mountain
climbing, swimming, and rowing. However, the additional weight of a separate joint
requires more energy expenditure and greater limb strength to control the additional
motion.

Prosthetic feet
The 5 basic functions of the prosthetic foot are as follows:

Provide a stable, weight-bearing surface

Absorb shock

Replace lost muscle function

Replicate the anatomic joint

Restore cosmetic appearance

Prosthetic feet are broadly classified as energy-returning feet or nonenergy-returning

feet.
Nonenergy-returning feet include the solid-ankle, cushioned-heel (SACH) foot and the
single-axis foot The SACH foot mimics ankle plantar flexion, which allows for a smooth
gait. The prosthetic is a low-cost, low-maintenance foot for a sedentary patient who has
had a below-knee amputation (BKA) or an above-knee amputation (AKA). The rigid
forefoot provides an anterior lever arm and proprioception. The single-axis foot adds
passive plantar flexion and dorsiflexion, which increase stability during the stance
phase. They are most commonly used for patients with a transfemoral amputation if
knee stability is desired.
Energy-returning feet are probably improperly named because, in fact, they do not
return energy. They do, however, assist the body's natural biomechanics and allow for
greater cadence or less oxygen consumption. The multiaxis foot and the dynamicresponse foot are members of this family.
The multiaxis foot adds inversion, eversion, and rotation to plantar flexion and
dorsiflexion; it handles uneven terrain well and is a good choice for the individual with a
minimal to moderate activity level. The dynamic-response foot is the top-of-the-line foot
and is commonly used by young, active persons and by athletic individuals. The forefoot
acts like a spring, compressing in the stance phase and rebounding at toe-off. Geriatric
patients benefit from the light weight of these feet.

Types of Prosthetic Feet and Usage,

Type of Foot Unit

Advantages

Disadvantages

Possible Uses

Rigid Keel
SACH

Inexpensive

Energy

General use

Light (lightest

consuming

foot available)
Durable
(solid ankle,

Reliable

Children (the

Rigid

prosthetics are

Best used

durable)

on a flat surface

cushioned heel)

If ambulation
needs are limited

(composed of a
wooden keel and a
compressible heel)

Single-Axis Foot
Movement in 1 plane
(dorsiflexion and

Adds stability to
prosthetic knees

plantarflexion)

Greater

To enhance

weight (70%

knee stability

heaver than

(For a

SACH)
Greater
cost

patient with an AKA

who needs greater
knee stability:

Greater
maintenance

quickly goes to flat

foot before the knee
buckles; the knee
returns to extension
[stability is provided
in early stance])

Multiaxis Foot
Allows dorsiflexion,
plantarflexion,
inversion, eversion,
and rotation

Multidirectional
motion

Relatively
bulky

Permits some
rotation
Accommodates
uneven surfaces

Ambulation
on uneven surfaces

Heavy

Absorbs

Expensive some of the

Increased
maintenance

torsional forces
produced during

Relieves stress
Products:

on skin and prosthesis

Material in the

College Park
prostheses

Blatchford/En
dolite Multiflex foot

Otto Bock
Greissinger foot

Available with

Greater
latitude of
movement may

ambulation
The foots
deflection and

keel of these feet are

make patents with return provides a

required to deflect

decreased

response to users

under load and return

coordination

that lessens their

to their original shape.

unstable

energy expenditure
with ambulation.

This return, while being

unloaded, is what
propels the limb
forward.

materials that are

termed energystoring, and this
subclass is called
multiaxial dynamic
response

College Park
Trustep
Flexible Keel
SAFE (stationary

Flexible keel

Heavy

ankle, flexible

Multidirectional

Greater

endoskeleton)

motion

cost
Moisture and grit

resistant

Not
cosmetic

Accommodates
uneven surfaces
Absorbs rotary
torques

Does not
offer
inversion/eversion
Greater

Ambulation
on uneven surfaces

Smooth rollover maintenance

Otto Bock dynamic

Elastic keel

foot

Conforms to
uneven ground

STEN (stored

Elastic keel

energy)

Moderate cost

Similar to

Similar to

SAFE's

SAFE's possible

disadvantages

use

Moderate
to heavy weight

When
smooth rollover is
needed

Accommodates
many shoe styles
Mediolateral
stability similar to that
of SACH

Types of Prosthetic Feet and Usage

Foot Unit

Advantages

Disadvantages

Possible Uses

High cost

Jogging,

Energy-Storing Foot/ Dynamic Response

Model & Instrument Works
Seattle Foot

Energy
storing

No SACH
Smooth

rollover

heel, making it

sports

difficult to change

Conservin

compressibility of
(composed of a plastic, Cor U-shaped, cantilevered
keel that functions like a
compressed spring

general

heel

g the patient's
energy

Ohio Willow Wood Carbon

Light

High cost

Copy 2 Foot (composed of a weight

rigid, solid-ankle, posterior
bolt block made of
combined with 2 flexible

Not as much general sports

Energy

storing

reinforced nylon/Kevlar;

Jogging,
Conservin

spring as the

Seattle Foot or Flex- g the patient's

Smooth

Foot has

energy

rollover

deflection plates)

Very
stable
mediolaterally
Highest
solid-ankle foot

Hosmer Dorrance Quantum

Foot

Lightweig

High cost

ht

Similar to
those of the
Carbon Copy 2

Energy

Foot

storing
(lightweight, nonarticulated,
energy-storing foot; includes
2 deflection plates, situated
anteriorly and posteriorly)

Ossur Flex-Foot

Very light
Greatest
energy storing
capability

(pylon and foot incorporated

Most

Very high
cost

Running,
jumping, vigorous

Alignment
can be cumbersome

sports
Conservin
g the patient's

into a single unit; the Flex-

stable

Foot keel extends to the

mediolaterally

bottom of the transtibial

Lowest

socket [or, in patients with

energy

inertia

an AKA, to the level of the

knee unit])

Flex-Walk

(a shorter version of the

Flex-Foot; it attaches to at
ankle level to the shank)

Add anote on Jaipur foot,sach foot and madrs foot?

Jaipur foot came into existence depending on socio economic and cultural needs of
squatting, cross leg sitting and bare foot walking. It consists of three structural blocks
almost simulating normal foot and ankle. Fore foot and heel are made up of sponge
rubber and middle ankle portion is made up of light wood. Three components are bound
together and enclosed in a rubber shell and vulcanized in a dye to provide cosmetic
appearance of real foot. Its very cost effective, does not require any shoe .Patient can
walk bare foot on prostheses. Patient can walk on uneven surface since it provides
enough dorsiflexion. It is made up off water proof materials making patients walking on
muddy and watery fields.

For the floor tread rubber compound is used rest of the foot is filled with cushion rubber
which is lighter and more resilient. Rubber is reinforced with rayon cord dripped in
rubber gum. Metatarsal block is filled with single piece of sponge rubber placed in the
metatarsal region. It provides stability and shape to the fore foot. The length of the
metatarsal block corresponds to the lenghth of the metatarsal from the base to just
before the head of metatarsal. It is higher medially and posterior and tapers down
gradually lateral and anterior. The anterior end of block has a curve simulating the
normal metatarsal arch. The sponge rubber block extends from heel to posterior part of
the metatarsal block. Pieces of sponge rubber sole are stacked one above the other
with glue to required height. The stump mold is placed over the top layer and outline is
carved so that lowest portion of mold layer snuggly fits the sponge rubber.
SACH FOOT-Solid Ankle Cushion Heel was designed by Eberhart and Radcliff in 1958.
It is made up of wooden keel which acts as a solid ankle as well as portion of heel.It has
a flat arch portion,a rounded lower front end portion, a flat top and curved instep portion.
A re enforcing member comprising of highly resilient synthetic resin strip is placed in
the rear end to the above mentioned flat arch portion.Its front end extends to said toe
portion to give predetermined flexibility.The keel is made to contribute to some portion of
the heel.Its density and toe flexibility are controlled by compostion gauge ,length and
number of synthetic resin strips. The resin bonds the keel with reinforcing member
used. SACH foot is made up of
1 Inelastic keel made up of wood without any ankle joint.
2 A molded polymer of rubber completely covering the core except the portion
where it completely comes in contact with the artificial limb.
3 Either a flexible steel spring as a band of belting material bonds with the core and
extends to the front end towards toe section.
4 Cushion heel of micro cellular rubber.
Adhesive bonds are used to strengthen core, rubber and belting. Reinforcing material is
a plurality of strips or single strip of nylon with thickness of 3mm to 6mm. Nylon gives
good bonding and resilience with foams such as PU.

SACH foot requires various degrees of flexibility in the toes and the density in the heel
in order to provide different height weight characteristics.

Madras Foot
It is mainly used in southern parts of India mainly in Tamil nadu and kerala. It is
handicraft foot made in the work shop of government institute of rehabilitative
medicine(GIRM). It is the first customized artificial foot made in India suiting the
functional need. It is composed of Wooden keel,canvas rubber,hard rubber,soft rubber
and swade leather. The wooden keel extends from rare to front end up till the middle
part of the foot. Anteriorly it is composed of alternate layers of hard and soft rubbers
which is incorporated to keel with adhesive glue. The alternative hard and soft layers
of rubber are given to the heel to provide diminished ankle. Anterior and posterior
portion of madras foot are made up of hard and soft rubber which are separated by
5mm thick canvas rubber sheet. The wood used is Red cedar wood. It has the
advantage of bare foot walking,durability and cultural modifications like Toe
ring( separated first and second toe.)

1.

Appearance
SACH Foot doesnt look like a
It looks like a Normal Foot.

2.

Normal Foot.
SACH Foot requires a closed

No such need or requirement with Jaipur

shoe to protect as well as hide it. Foot. But in case someone wants to wear a
shoe, he can do it comfortably with a flat

3.

heel shoe.
Movements & Activities of Daily Living
Wooden Keel is long enough to Metallic keel (carriage bolt) is confined to
restrict/limit movements in all

ankle only. So no restriction of movement

direction and what so ever

and all the movements take place at natural

movements take place they occur sites.

4.

at unnatural sites.
Squatting is not possible with

Squatting is easily achieved; as a sufficient

SACH foot as it requires dorsi

range of dorsiflexion is attainable

flexion at ankle joint, which due to comfortably.

5.

its rigid keel is not possible.

No cross- leg sitting is possible

Cross- legged sitting is possible because

because it requires adduction at sufficient forefoot adduction & transverse

forefoot & transverse rotation of
6.

rotation of foot in relation to shank is

foot in relation to shank.

available.
As there is almost no movement As there is adequate inversion & eversion
at sub-tarsal joint inversion or

at subtarsal level, so walking on uneven

eversion is not possible; so

ground and rough terrain is very

SACH Foot is suitable only for

comfortable.

walking on level ground walking

on uneven grounds & rough
7.
8.

terrain is very uncomfartable.

Bare-Foot walking is not possible. Bare-Foot walking is possible.
As no transverse rotation of the
As transverse rotation of foot in relation to
foot in relation to leg is possible, leg is possible, no complaint of discomfort
the amplified uneven ground

while walking on uneven ground.

reaction while walking on uneven

ground & rough terrain is
transmitted over the stump, so
great discomfort is complained by
amputees.
9.

Availability of Material & Cost

Stern training & skills are
Requires very little training to fabricate.

required to fabricate SACH Foot.

10. Raw Material for fabrications is Raw Material for fabrication is locally
not locally available. ( in many
parts of world)
11. It is costly and unavailability of
the material further adds to the

available.
It is very economical.

cost.
Financial Advantage
12. 8000 U.S. Dollar

35 U.S. Dollar
Fitment Time

13. 3 Months

1 Hours

SACH FOOT

Add a note on energy consumption in lower limb prostheses?

Energy consumption in lower-extremity prostheses

The increased energy requirements of prosthetic ambulation can limit the use of a
prosthesis. An individual who has a lower-extremity amputation and requires a walker or
crutches to ambulate (with or without a prosthesis) uses 65% more energy than does
someone with a normal gait. Energy consumption (percentage above normal, according
to amputation level) for ambulation with a prosthesis is as follows

Below-knee, unilateral amputation: 10-20%

Below-knee, bilateral amputation: 20-40%

Above-knee, unilateral amputation: 60-70%

Above-knee, bilateral amputation: >200%

BKA actually requires less energy consumption than does ambulation with crutches.
However, ambulating with an AKA requires more energy than ambulating with crutches
does, which makes the cardiopulmonary status of the patient more significant.
As noted earlier, lower limb prosthetics are devices designed to replace the function or
appearance of the missing lower limb as much as possible. The reasons for,
terminology, and types of lower-extremity amputations; myoplasty and myodesis; and
determinants of a successful outcome with prosthetic use are reviewed in this section.
What is the difference between myodesis and myoplasty?
Myoplasty and myodesis
There are 2 approaches to managing the muscle in the limb during amputation:
myodesis and myoplasty.
With a myodesis, the muscles and fasciae are sutured directly to the distal residual
bone through drill holes. The objective of this technique is to provide a structurally
stable residual limb, with the insertions of the residual muscles securely attached to
maintain their function; this ultimately results in better prosthetic control and function.
Myodesis is not always performed, because when attempted by even the most
experienced surgical hands, it often fails. Myodesis is contraindicated in patients with
severe peripheral vascular disease, because the blood supply to the muscle may be
compromised.
Myoplasty requires the surgeon to suture the opposing muscles in the residual limb to
each other and to the periosteum or to the distal end of the cut bone. Sufficient muscle
stretch must be provided to maintain active muscle control of the residual limb following
amputation, but without producing so much muscle tension that the blood supply is
compromised. A well-performed myoplasty can provide some distal soft-tissue padding
over the residual bone and result in a stable, functional residual limb. On occasion,
some myoplasties will not securely anchor to the distal residual limb, resulting in a
movable soft-tissue sling, with a bursa developing between the soft tissues and the
underlying bone. Some of these bursa can become symptomatic and painful.

Describe briefly End-bearing (weight-bearing) amputations?

Amputations that provide an end-bearing residual limb are advantageous for prosthetic
restoration. These amputations theoretically permit the weight-bearing forces within the
prosthesis to be concentrated in a circumscribed area of the residual limb, or
specifically, the residual limb's weight-tolerant, distal end. This can simplify prosthetic
socket fitting considerations and minimize many of the prosthetic fitting complications,
most of which are related to residual limb socket interface issues. Because of their
shape and length, some end-bearing residual limbs limit the prosthetic options that are
available for prosthetic restoration.
End-bearing lower-extremity amputations include the following:

Partial foot amputations: These are more weight bearing than end bearing
(transmetatarsal amputation, Lisfranc amputation, Chopart amputation)

Syme amputation

Ertl transtibial osteomyoplasty amputation procedure: An osteoperiosteal tube

joins the ends of the bones, which ossify to form a sturdy, weight-bearing bone bridge;
shrinkers for limb shaping are not advisable after this procedure, because they will
compress the fusion site; preparatory prosthetic fitting is delayed until the bony bridge
has completed fusion

Mention the differences between transtibial and transfemoral amputee gait?

Transtibial Amputee Gait.

Gait Cycle

Observed Gait

Phase

Abnormality

Initial contact to

Possible Cause

Modifications

Abrupt heel

loading

contact, rapid knee

response

flexion

Suggested

Excessive heel
lever*

Realign
prosthetic foot,

Inadequate heel change heel stiffness

Prolonged heel lever or worn-out heel

contact, knee remains

fully extended
Jerky knee
motion

Increase heel

Improper socket stiffness

Realign

flexion
Learned gait

prosthesis
Gait training,

pattern
Quadriceps

gait strengthening

weakness
Loose socket,
poor alignment
Inadequate
suspension
Midstance

Medial or
lateral socket thrust
Lateral trunk
shift over prosthesis

Foot too far

outset or inset

Realign
prosthesis

Loose socket
Prosthesis too

Replace
socket

Pelvis drops or short/too long

Adjust socks

elevates

Adjust length
of prosthesis

Midstance to

Early knee

terminal stance flexion or "drop off"

Inadequate toe
lever

Realign
prosthesis, replace
foot

Terminal stance

Heel-off too

Excessive toe
lever

early
Heel-off
excessively delayed

Realign
prosthesis

Too much
socket extension
Inadequate toe
lever
Too much
socket flexion

Swing phase

Prosthetic foot
drags

Prosthesis too

Shorten limb

long

Modify
Inadequate

suspension

suspension
Successive
double support

Uneven step
length

Hip flexion
contracture, gait

Physical
therapy

insecurity
Uncomfortable
socket

Adjust socket
fit

. Transfemoral Amputee Gait

Gait Cycle

Observed Gait

Possible Cause

Abnormality
Initial contact to
loading

Modifications

Foot rotation at
heel strike

Suggested

Poor socket
fit/rotation

response

Adjust socket
fit, add belt for
rotation control

Knee buckling

Heel too firm

Excessive heel

Reduce heel
stiffness
Realign limb,

lever*
Incorrect

reduce heel stiffness

Change

prosthetic knee
alignment, weak hip

trochanter-knee-

extensors

ankle alignment
Employ gait
training and
strengthening

Mid stance

Lateral trunk
bend or shift over
prosthesis

Prosthetic limb
abducted

Realign
prosthesis

Too much
socket abduction, foot

Adjust length
of prosthesis

too far outset

Prosthesis too
long/too short
Short residual

Adjust socket
fit
Gait training
and strengthening

limb

Accept,
Medial groin

possibly add hip joint

pain
Poor mediallateral prosthetic
control
Poor socket fit
Weak hip
abductors
Initial swing

Uneven heel
rise

Knee friction too

tight or loose knee

Adjust knee
friction or damping

extension
Swing phase

Circumduction
or prosthetic limb

Inadequate
knee flexion, knee too
stiff

Adjust knee
friction or damping
Adjust length

Prosthesis too
long, inadequate
suspension

of prosthesis
Physical
therapy

Poor gait
pattern
Whips

Improper knee
rotational alignment
Excessive

Realign
prosthesis Adjust
socket fit

socket rotation
Successive
double support length

Uneven step

Hip flexion
contracture
Insufficient
socket flexion

Physical
therapy
Realign
prosthesis

Mention different types of upper limb prostheses?

The continuum of prostheses ranges from mostly passive or cosmetic types on one end
to primarily functional types on the other .The purpose of most prostheses falls
somewhere in the middle. Cosmetic prostheses can look extremely natural, but they are
often more difficult to keep clean, can be expensive, and usually sacrifice some function
for increased cosmetic appearance.
Various Upper Limb Prostheses
Type

Pros

Cons

Cosmetic

Most lightweight

High cost if custommade

Best cosmesis
Least function

Less harnessing
Low-cost glove stains
easily

Body powered

Moderate cost

Most body movement

needed to operate

Moderately lightweight
Most harnessing

Most durable
Least satisfactory
appearance
Highest sensory feedback
Increased energy
expenditure
Variety of prehensors
available for various
activities

Battery powered (myoelectric

Moderate or no harnessing

Heaviest

Least body movement

Most expensive

and/or switch controlled)

needed to operate

Most maintenance
Moderate cosmesis

Limited sensory
More function-proximal areas feedback

Stronger grasp in some

Extended therapy time

cases

for training

Hybrid (cable to elbow or TD

All-cable excursion to elbow

Battery-powered TD

and battery powered)

or TD

weights forearm

Lower pinch for TD and

If excursion to elbow and

All-cable excursion to elbow

battery-powered TD

Increased TD pinch
If excursion to TD and batterypowered elbow
All-cable excursion to TD

Low effort to position TD

Low-maintenance TD

least cosmetic

TD-Terminal devise

What are functional prostheses of upper limb?

Functional prostheses generally can be divided into the body-powered prostheses

(cable controlled) and externally powered prostheses (electrically powered) (myoelectric
prostheses, switch-controlled prostheses)
Body-powered prostheses
Body-powered prostheses (cables) are usually of moderate cost and weight. They are
the most durable prostheses and have higher sensory feedback. However, a bodypowered prosthesis is more often less cosmetically pleasing than a myoelectrically
controlled type is, and it requires more gross limb movement.
Externally powered prostheses
Prostheses powered by electric motors may provide more proximal function and greater
grip strength, along with improved cosmesis, but they can be heavy and expensive.
Patient-controlled batteries and motors are used to operate these prostheses. Currently
available designs generally have less sensory feedback and require more maintenance
than do body-powered prostheses. Externally powered prostheses require a control
system. The 2 types of commonly available control systems are myoelectric and switch
control.
A myoelectrically controlled prosthesis uses muscle contractions as a signal to activate
the prosthesis. It functions by detecting electrical activity from select residual limb
muscles, with surface electrodes used to control electric motors. Different types of
myoelectric control systems exist, including the following:

The 2-site/2-function (dual-site) system has separate electrodes for paired

prosthetic activity, such as flexion/extension or pronation/supination; this is more
physiologic and easier to control

When limited control sites (muscles) in a residual limb are available to control all
of the desired features of the prosthesis, a 1-site/2-function (single-site) device may be
used; this system uses 1 electrode to control both functions of a paired activity (eg,
flexion and extension); the patient uses muscle contractions of different strengths to
differentiate between flexion and extension (eg, a strong contraction opens the device,
and a weak contraction closes it)

When multiple powered components on a single prosthesis must be controlled,

sequential or multistate controllers can be used, allowing the same electrode pair to
control several functions (eg, terminal device, elbow activation); this type of controller
requires the control function of the electrodes to be switched from one function to the
other, which is accomplished by a brief co-contraction of the muscle or by a switch
used to cycle between control-mode functions
Switch-controlled, externally powered prostheses utilize small switches, rather than
muscle signals, to operate the electric motors. Typically, these switches are enclosed
inside the socket or incorporated into the suspension harness of the prosthesis. A switch
can be activated by the movement of a remnant digit or part of a bony prominence
against the switch or by a pull on a suspension harness (similar to a movement a
patient might make when operating a body-powered prosthesis). This can be a good
option to provide control for external power when myoelectric control sites are not
available or when the patient cannot master myoelectric control.
Many contemporary myoelectric control systems allow for the use of proportional control
so that the speed of the component or terminal device activation varies with the intensity
of the muscle contraction.
What are typical components of an upper extremity, body-powered prosthesis?
A typical example of a transradial (below-elbow) prosthesis includes a voluntary opening
split hook; a friction wrist; a double-walled, plastic-laminate socket; a flexible elbow
hinge; a singlecontrol-cable system; a triceps cuff; and a figure-8 harness. A

transhumeral (above-elbow) prosthesis is similar but includes an internal-locking elbow

with a turntable for the missing anatomic elbow, uses a dual-control cable system
instead of a single-control cable, and does not require a triceps cuff.
All conventional body-powered, upper extremity prostheses have the following
components:

Socket

Suspension

Control-cable system

Terminal device

Components for any interposing joints as needed according to the level of

amputation
Socket
The socket of an upper extremity prosthesis typically has a dual-wall design fabricated
from lightweight plastic or graphite composite materials. In this design, a rigid inner
socket is fabricated to fit the patient's residual limb, and the second, outer wall is added,
designed to be the same length and contour as the opposite, sound limb. Comfort and
function are directly tied to the fit of the inner socket.
An alternative approach parallels the rigid frame, flexible liner approach sometimes
used in lower extremity socket fabrication. The inner socket is fabricated from flexible
plastic materials to provide appropriate contact and fit. Surrounding the flexible liner, a
rigid frame is utilized for structural support and for attaching the necessary cables and
joints as needed. The windows in the outer socket allow movement, permit relief over
bony prominences, and enhance comfort.

Mention the types of Suspension for upper limb prostheses?

The suspension system must hold the prosthesis securely to the residual limb, as well
as accommodate and distribute the forces associated with the weight of the prosthesis
and any superimposed lifting loads. Suspension systems can be classified as follows

Harnessed-based systems

Self-suspending sockets

Suction sockets
Suspension Options
Suspension
Harness

Figure-8

Indications

Advantages

Transradial

Simple, durable, Axillary pressure

adjustable

Transhumeral

Disadvantages

produces discomfort

Light to normal
activities

Shoulder

Transradial

Greater lifting

Reduced control

saddle and

ability, more

compared with

chest strap

comfortable

figure-8 harness;

than figure-8

difficult to adjust in

harness

women, because

Transhumeral

straps cross breasts

Heavy lifting

Self-

Munster

Wrist

suspending

Northwestern

disarticulation

Supracondylar

Ease of use

Limited lifting
capacity compared
with harness
systems,
compromised

Elbow

cosmesis, reduced

disarticulation

elbow flexion

Short transradial
Myoelectric
transradial

Suction

Suction socket Transhumeral

Secure

Requires stable

with air valve

with good soft-

suspension,

residual volume,

tissue cover

elimination of

harder to put on

suspension

than other

straps

suspension systems

Gel sleeve with Transradial

Accommodate

Greater cleaning

locking pin

limb volume

and hygiene

change with

requirements,

socks,
Transhumeral
Compromised
limbs with

can be

scarring or

reduced skin

uncomfortable in

impaired skin

shear

hot climates

integrity

What are harnessed based system?

Harnessed-based systems and their variants are the most commonly used systems. For
the figure-8 strap, a harness loops around the axilla on the sound side. This anchors the
harness and provides the counterforce for suspension and control-cable forces. On the
prosthetic side, the anterior (superior) strap carries the major suspending forces to the
prosthesis by attaching directly to the socket in a transhumeral prosthesis or indirectly to

a transradial socket through an intermediate Y-strap and triceps cuff. The posterior
(inferior) strap on the prosthetic side attaches to the control cable.
For heavier lifting or as an alternative to the figure-8 harness, a shoulder saddle with a
chest-strap suspension can be used with a transradial prosthesis. A chest strap alone is
sometimes used to suspend a transhumeral prosthesis. The figure-9 harness is an
alternative for a patient with a long transradial amputation or a wrist disarticulation, in
order to provide the control cable's necessary attachment point and counterforce.
Although the figure-9 harness provides minimal suspension and requires a selfsuspending socket, it is more comfortable than a figure-8 harness
Self-suspending and suction sockets are capable of providing adequate prosthetic
suspension without the use of a harness. However, either design can also be used with
a harness suspension to provide for a more secure suspension of the prosthesis.
Self-suspending sockets are largely limited to wrist or elbow disarticulations and to
transradial amputations. This socket design is most commonly utilized with an externally
powered, myoelectrically controlled transradial prosthesis. An example of this type is the
Munster socket. Proper fit of this socket precludes full elbow extension.
Suction suspension is similar to lower extremity options. These sockets use an external,
elastic suspension sleeve; a one-way air valve; or roll-on gel suspension liner with a pinlocking mechanism. Upper limb suction sockets (unlike nonsuction sockets) require a
total contact socket design and ideally a residual limb with no skin invagination,
scarring, and stable volume to avoid skin problems, such as a choke syndrome. Suction
socket designs are most commonly used for the patient with a transhumeral amputation.
Explain about Control-cable mechanisms?
Body-powered prosthetic limbs use cables to link movements of one part of the body to
the prosthesis in order to control a prosthetic function. This is usually a movement of the
humerus, shoulder, or chest, which is transferred via a Bowden cable (a single cable
passing through a single housing) to activate the terminal device of the prosthesis. A
control cable used to activate a single prosthetic component or function is called a
single-control cable, or Bowden cable system. A dual-control cable system uses the

same cable to control 2 prosthetic functions (such as flexion of the elbow and, when the
elbow is locked, activation of the terminal device). This latter control cable setup is
accomplished with a single cable passing through 2 separate cable housings known as
a fair lead cable system.
Body movements that are captured for prosthetic control include the following:

Glenohumeral forward flexion: A natural movement that provides excellent power

and reach and that can activate the terminal device or flex an elbow joint; it is good for
activities away from midline

Biscapular abduction (chest expansion), mutual protraction: A movement that can

activate the terminal device; however, the device must stay relatively stationary and
the force generated is weak; this movement is easy for the amputee to do, and it is
good for fine motor activities that are performed near the midline or close to the trunk
of the body; shoulder protraction can occur on just the ipsilateral side for terminaldevice control without biscapular abduction (mutual protraction) for prosthetic control,
and chest expansion results in biscapular abduction without actual protraction

Glenohumeral depression/elevation, extension, abduction: Other body

movements that the amputee can utilize to control prosthetic components/function;
these movements are most frequently used simultaneously, in a maneuver to lock or
unlock an elbow for a patient with a transhumeral amputation, via a separate, anterior
cable in a dual-cable systemthis maneuver can be difficult to master; the use of a
waist belt or groin loop allows the amputee to employ scapular elevation as an
alternative motion, one that operates a prosthetic function by utilizing a cable that has
been run through a pulley

Nudge control: Less cosmetic-appearing action; however, nudge-control devices

and similar types of systems are sometimes invaluable, offering cable-control options
for more complex cases where many control functions are needed

What are major function of hand that a prostheses tries to replicate?

The major function of the hand that a prosthesis tries to replicate is grip (prehension).
The 5 different types of grips are as follows:

Precision grip (ie, pincher grip): The pad of the thumb and index finger are in
opposition to pick up or pinch a small object (eg, a small bead, pencil, grain of rice)

Tripod grip (ie, palmar grip, 3-jaw chuck pinch): The pad of the thumb is against
the pads of the index and middle finger

Lateral grip (ie, key pinch): The pad of the thumb is in opposition to the lateral
aspect of the index finger to manipulate a small object (such as turning a key in a lock)

Hook power grip: The distal interphalangeal joint and proximal interphalangeal
joint are flexed with the thumb extended (as when carrying a briefcase by the handle)

Spherical grip: Tips of the fingers and thumb are flexed (when, for example,
screwing in a light bulb or opening a doorknob)

What are the types of terminal devices ?

Terminal devices generally are broken down into 2 categories: passive and active.
Passive terminal devices
Passive terminal devices fall into 2 classes, those designed primarily for function and
those to provide cosmesis. Examples of the functional passive terminal devices include
the child mitt frequently used on an infant's first prosthesis to facilitate crawling or the
ball-handling terminal devices used by older children and adults for ball sports.
The main advantage of most passive terminal devices is their cosmetic appearance.
With newer advances in materials and design, some passive hands are virtually
indistinguishable from the native hand. However, most of these cosmetic passive

terminal devices are usually less functional and more expensive than active terminal
devices.

Active terminal devices

Active terminal devices are usually more functional than cosmetic; however, in the near
future, active devices that are equally cosmetic and functional may be available. Active
devices can be broken down into 2 main categories: hook (and similarly specialized
function) terminal devices and prosthetic hands. There are designs of both of these
terminal device groups available to operate with cable or externally powered
prostheses.
Cable-operated active terminal devices (hooks or hands) can be of a voluntary opening
design (most commonly used) or a voluntary closing design. With a voluntary opening
mechanism, the terminal device is closed at rest. The patient uses the control-cable
motion to open the terminal device against the resistive force of rubber bands (hook) or
internal springs or cables (hand). Relaxation of the proximal muscles allows the terminal
device to close around the desired object. The number of rubber bands determines the
amount of prehensile force that is generated. One rubber band provides about 1 pound
of pinch force (typical nonamputee pinch force is 15-20 lb). Up to 10 rubber bands can
be used

With a voluntary closing mechanism, the terminal device is open at rest. The patient
uses the control-cable motion to close the terminal device, grasping the desired object.
This type of mechanism is usually heavier and less durable than a voluntary opening
mechanism. It offers better control of closing pressure (up to 20-25 lb) and is more
physiologic, but active effort may be needed to maintain closure for some terminal
devices to prevent dropping items. Because of the need to maintain an active muscle
contraction for terminal device closure, the amputee can get some sensory feedback
with this type of terminal device.
. With a myoelectrically controlled device, it is possible for the patient to initiate palmar
tip grasp by contracting residual forearm flexors and to release by contracting residual
extensors.
Most hook-style terminal devices provide the equivalent of active lateral pinch grip,
whereas active hands provide a 3-point chuck action. Many different options are
available for terminal devices that address occupations, hobbies, and sports.
Multiarticulating prosthetic hands terminal devices are electrically powered and have
significantly more potential functionality than other terminal device types. Grip,
prehension, and positioning patterns are programmed into the hand, limited only by the
number of control sites available. Grip force is varied by increasing the electric signal to
the hand. Multiarticulating hands are more fragile and should not be used for heavy-duty
activities. Many individuals with limb loss use a multiarticulating hand for everyday tasks
and a myoelectric hook or body-powered prosthesis with a hook for heavy-duty tasks.
There are terminal devices available for specific activities, such as golfing, bowling,
swimming, tennis, weight lifting, fishing, skiing, shooting pool, rock climbing, baseball,
hunting (bow and rifle), photography, and the playing of musical instruments (guitars
and drums).

briefly discuss the wrist, elbow, shoulder, and forequarter units.?

Wrist units
The wrist unit provides orientation of the terminal device in space. It can be positioned
manually, by cable operation, or with external power (whether myoelectrically or by
switch). Once positioned, the wrist unit is held in place by a friction lock or a mechanical
lock. Several different unit designs are available, including a quick-disconnect unit, a
locking unit, and a flexion unit. Friction-control wrist units are easy to position but can
slip easily when carrying heavier loads.
The quick-disconnect wrist unit is configured to allow easy swapping of terminal devices
that have specialized functions.
The locking wrist unit style consists of wrist units with a locking capacity to prevent
rotation during grasping and lifting.

A wrist flexion unit can provide an amputee (especially a bilateral upper extremity
amputee) with improved function for midline activities, such as shaving, manipulating
buttons, or performing perineal care. A wrist flexion unit is usually employed on only 1
side, most often the longer of the 2 residual limbs but, ultimately, it should be placed on
the side that the amputee prefers. Multifunction wrist units have become available.
Elbow units
Elbow units are chosen based on the level of the amputation and the amount of residual
function. It is helpful to remember that supination and pronation of the forearm decrease
as the site of amputation becomes more proximal. Flexible and rigid elbow hinges are
available, as are internal locking elbow joints.
Flexible elbow hinges are utilized for medium and long transradial amputations and
wrist disarticulations. When the patient has sufficient voluntary pronation and
supination, as well as elbow flexion and extension, flexible elbow hinges help translate
any residual active pronation and supination to the terminal device. A triceps pad or cuff
helps distribute suspension forces and is needed to anchor the control cable.
Rigid elbow hinges provide additional stability in cases with short transradial
amputations, in which a patient has no residual, active forearm pronation and supination
but does have adequate native elbow flexion. Rigid elbow hinges are available in singleaxis or polycentric versions. These hinges are important in amputees with short
transradial limbs. In patients with very short transradial, residual limbs or limited active
elbow flexion, the use of step-up elbow hinges can improve prosthetic function by
increasing functional, active elbow motion. This system uses special elbow joints
together with a split-socket design permitting the prosthetic forearm and attached
terminal device to move 2 of motion for every 1 of actual residual limb and elbow
motion. Because movement of the limb and the prosthesis are not directly connected,
the proprioceptive feedback is compromised.
The standard elbow component for a transhumeral prosthesis is an internal locking
elbow joint. This allows for 135 of flexion and can be locked into a number of preset
flexed positions. The standard internal elbow joint incorporates a turntable that allows

passive internal or external humeral rotation. Elbow spring-lift assists are available and
are used to counterbalance the weight of the forearm, making elbow flexion easier.
The standard elbow unit requires a length of 8-10 cm to be adequately installed in a
transhumeral prosthesis. If the level of amputation is less than 8-10 cm proximal to the
distal end of the humerus, then an internal locking elbow unit cannot provide symmetric
elbow centers (prosthesis and sound upper extremity). Even if an asymmetric elbow
position (compared with the sound side) is acceptable, functional problems will result
with the prosthesis from this alignment.
Unless the forearm section of the prosthesis is lengthened to accommodate the
lengthened arm section, the amputee will not be able to reach the midline or mouth, with
the prosthesis compromising function. However, lengthening the forearm to
accommodate the added arm length will result in difficulties when the patient tries to
perform bimanual activities, and it usually will not be cosmetically acceptable to the
patient. For long transhumeral amputations or elbow disarticulations, locking external
elbow joints may be used, but they are not cosmetic or as durable as internal elbow
joints.
Shoulder and forequarter units
When an amputation is required at the shoulder or forequarter level, function is very
difficult to restore. This is due to a combination of the weight of the prosthetic
components and the diminished overall function when combining multiple prosthetic
joints, as well as the increased energy expenditure necessary to operate the prosthesis.
For this reason, some individuals with a unilateral amputation at this level choose a
purely cosmetic prosthesis to improve body image and the fit of their clothes or decide
to go without a prosthesis.