Prosthetics-P101 Prosthetic Objectives • Amputee perspective Prosthetic process – Existing amputee v. New amputee • Component selection criteria – – – – – Suspension Materials Alignment Pr(x) Feet Pr(x) Knees Amputee perspective Prosthetic process • Existing Amputee • New Amputee – Ill fitting – Repair cost will outweigh new socket/prosthesis – Begin Prosthetic process Soft Removable Dressing – Order/Call to see new amputee for a protective dressing, shrinker and or consultation – F/u patient to Surgeon removal of sutures/staples – Begin Prosthetic process Amputee perspective Prosthetic process (cont’d) • Amputee – – – – Begin Prosthetic process Begin Therapy process Initial Evaluation Functional Testing AmpnoPro & AmpPro – PM&R Pre-prosthetic Evaluation – Component Selection Lower Extremity Prosthetic Evaluation • • • • • • • Name, age, Hgt, Wgt, Sex Amputation Level, side Other amputations Ortho, neuro copathologies Existing User Living Status Living Environment – Uneven terrain, carpet, hard surfaces • • • • • • Health comorbidities Medications/Treatments Ambulatory Aids Vocational Needs Pre-amputation activities Patient Feedback of current device • Upper Extremity ROM, MMT, dexterity Lower Extremity Prosthetic Evaluation • • • • Residual Limb Features Amputation Level Skin health Boney, invaginated areas • ROM, MMT • Contractures • Functional Testing – AmpnoPro/AmpPro • Limb Length • Contralateral limb Features • Diabetic • Callused • Wounds • Toe, Foot, T.T, T.F, HD Lower Extremity Functional Testing Outcome Measures in Lower Limb Prosthetics K-Levels K-Levels: K-levels are defined by Medicare based on an individual's ability or potential to ambulate and navigate their environment. Once it is determined in which K-level an individual resides, it can be determined which prosthetic components are covered by Medicare. Bilaterals Gait characteristics of persons with bilateral transtibial amputations, Po-Fu Su, MS Steven A. Gard, PhD, Robert Lipschutz, CP, Todd A Kuiken, MD, PhD AmpNoPro AmpPro K-level Description Foot/Ankle Assemblies Knee Units 0-8 n/a K0 Patient does NOT have the ability or potential to ambulate or transfer w/o assistance & prosthesis does not enhance their quality of life or mobility Not Eligible Not Eligible 9-20 15-26 K1 Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulatory. External keel, SACH feet or single axis/feet Single-axis, constant friction knee 21-28 27-36 K2 Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. Flexible-keel feet & multi-axial ankle/foot Polycentric, constant friction knee 29-36 37-42 K3 Has the ability or potential for ambulation with variable cadence. Flex foot, and flex-walk systems, energy Fluid & Pneumatic Control knee Typical of the community ambulator who has the ability to transverse storing feet, multi-axial ankle/feet, or most environmental barriers and may have vocational, therapeutic or dynamic response feet exercise activity that demands prosthetic utilization beyond simple locomotion. 37-43 43-47 K4 Has the ability or potential for prosthetic ambulation that exceeds the basic ambulation skills, exhibiting high impact, stress, or energy levels, typical of the prosthetic demands of the child, active adult, or athlete Any ankle foot system appropriate Any knee system appropriate Examples BK Socket/Suspension selection • Socket Style – Patella Tendon Bearing(PTB) – Total Surface Bearing(TSB) • Suspension • Liners/Sleeves • Research – Öderberg, JPO 2003 PTB Socket Style TSB Socket Style Suspension/Liner Selection • • • • Cushion Locking Distal Locking Suction Fitting process 1. Check Socket 2. Temporary Socket 1. Check 3. Definitive 2. Temporary 3. Definitive Foot Selection Criteria Foot/Ankle Assemblies K0 Not eligible for prosthesis K1 External keel, SACH feet or single axis ankle/feet K2 Flexible-keel feet and multi-axial ankle/feet K3 Flex foot and flex-walk systems, energy storing feet, multi-axial ankle/feet, or dynamic response feet K4 **Any ankle foot system appropriate • • • • • Patient Wgt. Activity Level Carrying Loads Foot size Foot Build Hgt. Effect of wrong category of feet • Premature failure • Delayed/Absent Energy Return • Bumpers require more maintenance • Gait Deviations • Skin Breakdown The AmputeeOT K1-Level Foot Selection • K1-ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence K2-Level Foot Selection • K2-Flexible-keel feet and multi-axial ankle/feet K3-Level Foot Selection • K3-energy storing feet, multi-axial ankle/feet, or dynamic response feet K4-Level Foot Selection • K4-exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels Alignment • Bench/Static/Dynamic • Proper Standing Balance • Easier use of foot functions • Increased socket comfort • Increase Energy return Efficacy of D.R.F AK Socket Selection • Socket Design – Quadrilateral – Ischial/ Ramal containment • More Anatomical Ischial Containment Quadrilateral Prosthetic Knee Selection • Manual Locking (K1) • Polycentric (K2) • Weight Activated Stance Control (K1-K2) • Single Axis Constant Friction • Outside Hinges K1 Single AxisLocking Polycentric Knee Knee Features • Locking Mechanism • Wgt. Activated Stance Control • Geometric Lock • Stance Phase Flexion • Stumble Recovery=Stance Phase Control • Stance Extension Assist • Stance Flexion Resist • Microprocessor Control – C-Leg, Rheo, Plie, Orion References 1. 2. 3. 4. 5. https://med.noridianmedicare.com/web/jddme/education/eventmaterials/op-claim-qa Po-Fu Su, MS, Gard, S., PhD, Lipschutz, R., CP, Kuiken T., MD, PhD, 2007. Gait characteristics of persons with bilateral transtibial amputations. JRRD Vol 44 Num 4, 491-502 Öderberg, B., 2003. Roentgen Stereophotogrammetric Analysis of Motion between Bone and the Socket in a Transtibial Amputation Prosthesis: A Case Study. JPO Vol 15 Num 3, 95-101 Atlas of Limb Prosthetics Sinitski, E.H., et al., 2011. Biomechanics of the ankle-foot system during stair ambulation: Implications for design of advances ankle-foot prosthesis. Journal of Biomechanics DOI:10.1016/j.jbiomech.2011.11.007