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PRINCIPLES OF PROSTHETIC INTERFACE DESIGN
Jason T. Kahle, MSMS, CPO, LPO, FAAOP M. Jason Highsmith, PhD, PT, DPT, CP, FAAOP
University of South Florida College of Medicine School of Physical Therapy & Rehabilitation Sciences !
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THREE BASIC ELEMENTS OF A PROSTHESIS
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1. Components
•Foot
•Knee
•Pylon
•Rotators
THREE BASIC ELEMENTS OF A PROSTHESIS
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THREE BASIC ELEMENTS OF A PROSTHESIS
1. Components
2. Suspension
•Pin
•Suspension Sleeve
•Straps
•Vacuum
•Lanyard
!
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THREE BASIC ELEMENTS OF A PROSTHESIS
1. Components
2. Suspension - Swing
3. Interface design - Stance
•Weight Bearing Characteristics
!
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EVOLUTION OF THE RESIDUAL LIMB
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•Mechanical principles used in designing the interface !
•Weight Bearing Characteristics: The forces applied to the residual limb to support the weight of the amputee during stance phase
MORE ON DIABETES & FOOT ULCER
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WEIGHT-BEARING CHARACTERISTICS
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WEIGHT-BEARING CHARACTERISTICS
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Pressure= F/A
•Force /Area
•Smaller the RL (area) = the greater the force
RESIDUAL LIMB LENGTH
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THREE CATEGORIES OF INTERFACE DESIGN
•Specific Weight Bearing
•Total Surface Bearing
•Hydrostatic
!
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SPECIFIC WEIGHT BEARING
Mechanical principles provide the support for the residual limb similar to a bridge.
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SPECIFIC WEIGHT BEARING
•Use of soft tissue areas to achieve weight bearing
•Create reliefs over boney prominences
•Opposing horizontal forces support vertical weight bearing forces
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SPECIFIC WEIGHT BEARING
Most common materials used
•Pelite(soft foam interface)
•Lamination or Polypropylene (hard frame)
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ADVANTAGES OF SPECIFIC WEIGHT BEARING
•Time tested -oldest of the 3 designs
•Proven success
•Prosthetists can easily make adjustments •Accommodate residual limb changes •Preparatory prosthesis •Wear of the soft interface
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DISADVANTAGES OF SPECIFIC WEIGHT BEARING
•Does not take advantage of newer materials and design
•Applies the most pressure to the smallest areas
•High trim line in the back to achieve oppositional forces
• limits knee flexion ROM • NO DISTAL connection
suspension systems
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WHO SHOULD GET SPECIFIC WEIGHT BEARING?
•Short to medium residual limbs
•Patients who require stabile interface interaction
• Firm resilient materials • Knee stability/supracondylar • High tight coronal trim lines
•Preparatory prosthesis
•Bony limbs
•Past users
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WHO SHOULD GET SPECIFIC WEIGHT BEARING?
•Suspension Options •Suspension sleeves •Supracondylar •Strap
- Cuff - Fork
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TOTAL SURFACE BEARINGMechanical principles provide the support for the residual limb similar to a Tempur-Pedic mattress
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TOTAL SURFACE BEARING
•Circumferential pressure provides the bearing characteristics
•Most common materials used are gels
•Pressure from the leg encourages the gel to flow from the areas of greater pressure to the areas of lesser pressure
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•Even distribution of pressure
•Comfortable
•Infinite liner selection •Thickness •Shore durometer •Covered or not
•Liners are easy to replace when they wear out because of generic sizing
•Custom availabe
ADVANTAGES OF TOTAL SURFACE BEARING
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•The fit is sensitive to volume changes •Sock management is best to accommodate
•Traps fluids
•Hygiene plays an important role in the success
•Liners are expensive •Some insurance companies will not reimburse for
more than 1 •Liners can wear out fast if the RL changes
DISADVANTAGES OF TOTAL SURFACE BEARING
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•All lengths •All tissue consistencies •All activity levels •Patients with abnormalities
•scar tissue •adherent tissue •invaginations •chronic breakdown
•Suspension inclusion •pin system •lanyards •seal-in
WHO SHOULD GET TOTAL SURFACE BEARING?
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HYDROSTATICMechanical principles provide the support for the residual limb by containing the body fluids
•Similar to a hydraulic cylinder
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HYDROSTATIC
•Proximal seal of condyles contain the soft tissue (fluids)
•Soft tissue is drawn distally •Provides distal padding •Solidifies soft tissue
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HYDROSTATIC•Always uses a gel liner
•Always a distal attachment
•Usually uses a pressure chamber for casting
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ADVANTAGES OF HYDROSTATIC
•Sound mechanical principles of design
•Solidifies the soft tissue by containing it
•Total surface bearing due to use of pressure chamber
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ADVANTAGES OF HYDROSTATIC
•Sound principles of design that are amputee friendly
•Provides a natural distal (bottom) padding because of the tissue elongation
•Lower trim line in back, which allows ease in bending
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DISADVANTAGES OF HYDROSTATIC
•Sometimes encourages rapid volume loss
•Difficult to adjust
•Difficult to cast
•Sometimes creates pulling sensation on the bottom of the leg
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WHO SHOULD GET HYDROSTATIC?
•Fleshy medium length residual limbs
•Short-not enough soft tissue
•Long-difficult to fitdistal attachment
•Active patients
•Suspension inclusion •pin system •lanyards •seal-in
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THE ERTL PROSTHESIS
•Bone Bridge Procedure •Attaches tibia to fibula •Creates blunt end •Can end bear for weight •Accommodates
volume changes
•Reduces the reliance on weight bearing considerations
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•3 styles of TT interface design to distribute weight off the distal end.
•Maximizing the anatomy of the residual limb will enhance performance.
•Many options that can be utilized for different patient types
TT INTERFACE CONCLUSION
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TRANSFEMORAL INTERFACE DESIGN
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TRANSFEMORAL INTERFACE DESIGN
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Pressure= F/A
•Force /Area
•Smaller the RL (area) = the greater the force
RESIDUAL LIMB LENGTH
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TRANSFEMORAL INTERFACE DESIGN
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TRANSFEMORAL AMPUTATION LEVEL
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•Major muscle groups are intact
• Sagittal Insertion • Iliopsoas • Gluteus maximus • Gluteus minimus
ANATOMY OF AMPUTATION
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•Major adductor muscle groups are NOT intact
•Coronal insertions • Adductor magnus • Semimembranosus • Sartorius • Gracilus • Semitendinosus
ANATOMY OF AMPUTATION
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• Loss of control • muscles • bone
• Increases rehab time • cut bone • myodesis /myoplasty • difficulty controlling prosthesis
• Ischial containment
TRANSFEMORAL AMPUTATION
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•Biomechanically sound connection to the ground • Femoral adduction •Knee alignment •Foot alignment •5-10 cm base of support
NORMAL HUMAN LOCOMOTION
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•5-10 cm Base of Support •Femoral Adduction •Knee Alignment •Foot Alignment •Connection to the Ground
•Pelvic Movement •Tilt •Rotation •Spine Control
NORMAL HUMAN LOCOMOTION
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•Biomechanically sound Transfemoral Gait= •Spinal Control •Pelvic Stabilization •Femur control
- Control pistoning - Maintain adduction angle
TRANSFEMORAL BASICS
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•Lose connection to the ground
•Stability •IRC + lateral wall •Pelvic + femoral = Spinal
TRANSFEMORAL BASICS
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Lose Connection to the Ground •Femur is Floating •Loss of proprioception •Stability •Control •Implications to spine
TRANSFEMORAL BASICS
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Femur stabilization? •Quad •IRC
Suspension-Plays a role in Femoral Stabilization?
•Suction •Pin •Lanyard
TRANSFEMORAL BASICS
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Femur stabilization - How? •Quad •IRC
Problems with standard of care •Cast/ modify/ fabricate/ fit •Discomfort/ unsanitary
TRANSFEMORAL BASICS
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ISCHIAL RAMUS CONTAINMENT IRC
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•Ischial tuberosity does not escape medial capture
•Prevent lateralinterface shift
•IRC Brim assists maintaining femurol alignment
•Adduction angle= 9 degrees
IRC PROXIMAL TRIM LINE FUNCTION
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QUADRILATERAL VS. IRC
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QUADRILATERAL VS. IRC
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QUADRILATERAL VS. IRC
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QUADRILATERAL VS. IRC
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TRANSFEMORAL BASICS
•Suspension Options- current standard of care •Suction •Pin •Lanyard •Silesian Belt
•Suspension Problems •Pistoning •Clearance •Volume fluctuation
•What if we could use VAS?
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VACUUM ASSISTED SUSPENSION
•History
•Transtibial Only •Proximal Seal-requires suspension sleeve •Liner choices, more TT- TT here before TF •Pump Clearance •TT VAS problems= bad fit , but not catastrophic •TF VAS problems= unreliable and problems lead to catastrophic failure
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•NHL
•Suspension •Dynamic •Forces Increased Area under Vacuum
•Control •Rotation •Pistoning
•Surface Bearing •Weight Distribution •Proprioception
VAS- BETTER MECHANICS?
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VAS Vacuum Assisted Suspension
Technology Allows Application of Alternative Interface Design
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BRIMLESS TRANSFEMORAL
•No current standard of care in TF VAS principles because of Sealing Design
•Seal is INSIDE interface • Protects Seal • Rotational Control • Proximal or Distal Seal Options
•Silicone • Various durometers -100 -60 % • Padded distal end • Flow Characteristics • Distal Pad Option
Transfemoral Interface Design
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•Assists in controlling rotation
•Allows for maximum use of the surface area
•Solid liner connection to the residual Limb
AdvantagesVAS BRIMLESS
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VAS BRIMLESS
•Liners require care and handling and hygiene
•More expensive than traditional systems
•Not for everyone •Open mind •Eureka moment
Disadvantages
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VAS BRIMLESS
•Desire to try something new
•Past VAS user
•Desire to remove brim •Difficult to fit traditional IRC in conjunction
w/ VAS
•Proper Length •at least 11-18cm •Depending on size
Indications
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VAS BRIMLESS
Some patients are...
•Not mechanically inclined
•Used to traditional methods
•Mental Aptitude
•Too Short (currently)
Contraindications
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VAS BRIMLESS
•Simple volume matching
•Can use CAD
•Can use fiber cast instead of plaster
•“Contain” IRC
•Alignment lines
•Measurements from the model
Casting Procedure
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VACUUM ASSISTED SUSPENSION
Randomized Control Trials are needed to prove…
•Better Mechanics?
•Better Total Surface Bearing?
•Volume Fluctuation?
•What Materials are best?
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Must be something to it bc of manufacturing •No current standard of care in TF VAS principles because of
Sealing Design
What’s out there? •Otto Bock
• Urethane • P2, P3, E Pulse
•OWW • Electronic Pump
•Evolution • Aura • Electronic pump • Hand Pump
VACUUM ASSISTED SUSPENSION
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•RCTs are needed
•Could be very beneficial because of Better Mechanics •Dynamic Suspension •Body Weight Support-by Better Total Surface Bearing •Proprioception-by Better Total Surface Bearing •Volume Fluctuation-by Eliminating pistoning •Dermatological Health-Materials that flow work best for VAS
VACUUM ASSISTED SUSPENSION
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•History
•Transtibial Only •Proximal seal-requires suspension sleeve •Liner choices are primarily for TT-
- Evolution of TF - Application of TF
•Pump - Reliability - Clearance
TF + VACUUM ASSISTED SUSPENSION
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TF + VACUUM ASSISTED SUSPENSION
•Double wall •Pump clearance •Difficult to fabricate •Unreliable
•Minimal area exposed to vacuum
•Connection to liner + interface
•TF VAS problems= unreliable and problems lead to catastrophic failure
•TT VAS problems= bad fit , but not catastrophic
TF Current Options
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•History has been Transtibial only •Proximal seal-requires suspension sleeve •Liner choices +Pump clearance
- more TT choices- TT here before TF •TT VAS problems= bad fit , but not catastrophic •TF VAS problems= unreliable and problems lead to catastrophic failure
VACUUM ASSISTED SUSPENSION
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Clinical Trials are needed…
VAS could be beneficial because of better mechanical principles?
•Dynamic suspension
•Sub-atmospheric?
•Total surface bearing? • Body weight support • Proprioception • Dermatological health
•Volume fluctuation? How?
VACUUM ASSISTED SUSPENSION
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Control?
•IRC + Femur
•Thigh =
•Pelvic control =
•Spinal control
TRANSFEMORAL + VAS
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TRANSFEMORAL INTERFACE/ ALIGNMENT
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BRIMLESS VERSUS ISCHIAL RAMUS CONTAINMENT VACUUM ASSISTED
SUSPENSION TRANSFEMORAL INTERFACES
Jason T. Kahle, CPO, LPO, FAAOP M. Jason Highsmith, PT, DPT, CP, FAAOP
University of South Florida College of Medicine School of Physical Therapy & Rehabilitation Sciences !
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RANDOMIZED CLINICAL TRIAL
•12 Transfemoral Amputees, 10 males 2 females
•2 dropped out due to unrelated medical reasons
•1 could not tolerate IRC •Included in this analysis
!
!
Funded by Southern Bone & Joint
USF SPTRS RCT, 2011. n = 10
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•Averaged Age= 42.9 years (+14.7, 21-70)
•Average RL length was 60.25% (+18.7%,) of the sound side.
•Subjects’ average time as an amputee was 8.3 years (+10.1, 0.8-26 years)
•Average AMP score was 40 (+6.4, 27-45).
•All subjects had medium or firm tissue consistency.
•Alignments were duplicated
•All subjects were fit with a Symmetry IRC and Brimless interface + given 2 days to accommodate prior to testing each interface in random order.
DEMOGRAPHICS - HIGHLIGHTS
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•Skeletal kinematics using X-Ray/Fluoroscope • Femur add/ abduction angle
•Internal interface pressure • Techscan, F-socket
•Agility / Balance • 4 square step test • Biodex SD
•Temporal spatial • Gaitrite gait matt
•PEQ
OUTCOME MEASURES
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IRC VS. BRIMLESS +0.7cm vs-3.5cm
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X-RAY =WEIGHT BEARING
IRC BRIMLESS
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X-RAY “PROSTHETIC SWING”
IRC BRIMLESS
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X-RAY “PROSTHETIC STANCE”
IRC BRIMLESS
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FLUOROSCOPE VIDEOS
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Medial
IRC
IR
Lateral Wall
Rectus
Femur
Adductor Relief
Posterior
Anterior
X-RAY “PROSTHETIC STANCE”
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FLUOROSCOPE VIDEOS
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FLUOROSCOPE VIDEOS
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•Biomechanical ~ Equivalence •Skeletal kinematics •Internal interface pressure
•Agility / Balance Equivalence •4 square step test •Biodex SD
•Temporal spatial ~ Equivalence •Gaitrite gait matt
•PEQ Favored Brimless
~ BRIM VS. BRIMLESS CONCLUSIONS
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•3 styles of TF interface design to distribute weight off the distal end + assist in control of the pelvis/spine.
•Proximal brim of the TF interface determines weight bearing characteristics, alignment, and gait.
•Maximizing the anatomy of the residual limb will enhance performance.
CONCLUSION
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THERE ARE NO PROSTHETIC PANACEAS