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54 Cards in this Set
- Front
- Back
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Transfemoral Considerations
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Cause of Amputation
Chronology Biomechanics: Length/ROM Patient Issues Funding Issues Geographic Location |
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Transfemoral Considerations
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Cause of Amputation
Peripheral Vascular Disease Diabetes Infection Gangrene Trauma Congenital Tumor |
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Transfemoral Considerations
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Chronology
Date of amputation RL Condition Post Op? Intermediate 3-6 mos Definitive ~6mos |
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Transfemoral Considerations
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Biomechanics:
ROM Length - important for leverage? Surface Area RL Condition/Surgical techniques |
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Transfemoral Considerations
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Patient Issues
General Physical Condition Desire, Ability Activities |
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Medicare K-levels 0-1
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K0 - Does not have ability or potential to ambulate safely with or without assistance and a prosthesis does not enhance their quality of life or mobility.
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 ambulator. |
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Medicare K-levels 2-3
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K2 - Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stair or uneven surfaces. Typical of limited community ambulator.
K3 - Has the ability or potential to ambulate with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activities that demands prosthetic utilization beyond simple locomotion. |
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Medicare K-levels 4
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K4 - Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete.
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Prescription Factors
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K-Level mediates knee and foot componentry
Knee Selection Foot Selection Other design criteria: Exoskeletal vs. Endoskeletal (majority) Socket Design Suspension |
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Complete Transfemoral Rx
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Socket design & material
Suspension Knee Foot Rotator/Torque Absorber |
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Quadrilateral socket
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Total contact
Wider in the ML dimension than AP Originally made in just thermo-setting laminates bulge in the front keeps the residual limb so the ischial tube can fit |
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Posterior Wall and Posterior Brim
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Wall
Flat, slants anteriorly to provide initial flexion of 15 degrees Contoured for hamstrings Brim Horizontal parallel to floor Ischial seat |
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Medial Wall and Medial Brim
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Wall
Relief channel located anteriomedial for adductor longus tendon High to prevent adductor roll Prevents medial movement of limb in socket Brim Same height as posterior brim or slightly lower Socket should not press on pubic ramus |
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Anterior Wall
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2.5 inches higher than the medial wall (even higher for shorter limbs)
Provides counter pressure for posterior wall Scarpa’s bulge—maintains ischial tuberosity on the ischial seat by providing counter pressure against posterior wall (Scarpa’s triangle=sartorius, inguinal ligament, adductor longus) |
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Lateral Wall
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Higher than anterior wall
Inclines medially as it goes distally Set in 10 degrees of adduction to put glut med on stretch In summary of wall height: Lateral>Anterior>Posterior>/=Medial wall Lateral angled medially @ distal end, posterior angled anteriorly |
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Icelandic Swedish new York (ISNY) or Scandinavian Flexible Socket (SFS)
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Same design as quadrilateral
Has a flexible socket with a rigid retainer This is NOT a hard socket, is quadrilateral in shape |
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Normal Shape Normal Alignment (NSNA)
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ML diameter is less than the AP
Ischial tuberosity sits within the socket Lateral wall is higher than greater trochanter Lateral wall is set in 10-15 degrees of adduction Usually made with thermosetting laminate hard socket, but may be soft socket with rigid retainer |
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Socket Design –
Normal Shape Normal Alignment (aka ischial containment)
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Also known as ischial containment, CAT CAM (Contoured adducted trochanteric-controlled alignment method), and now Sabolich socket
Some contain both Ischium and ramus therefore creating a “boney lock” with the femur. Closer to anatomical design Requires test sockets and very good understanding of the theory and fitting principles |
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CAT-CAM
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Has a flexible socket with a rigid retainer
the name refers to specialized computer program |
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Sabolich
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“Containment” of the residual limb
High fit for rotational stability and side to side control Flexible material for the socket—comfortable High strength, light weight frame |
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Suspension
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Suction
Partial Suction Worn with a type of auxiliary suspension such as a Silesian band or belt Silesian band or belt A webbing belt used as auxiliary suspension Total Elastic Suspension (TES Belts) Another type of auxiliary suspension Sometimes called a neoprene belt Pelvic Band with Hip Joint |
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Suspension continued
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Pin Suspension (roll-on silicone liner pin suspension –shuttlecock with lanyard )
Roll on “Seal In”liner Roll on liner and Coyote Summit Lock Osseointegration |
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Suction
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Best primary suspension if possible
Provides greatest feedback-no sock is worn Many suction designs Difficult to don Not indicated for individuals with fluctuating volume heart conditions balance problems Pearl: The limb will change volume with repeated donning and doffing so don’t keep doing it! |
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Silesian Belt or Band
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Simple
Made of cotton/Dacron webbing Relatively low profile Controls rotation well Auxiliary suspension Used with partial suction-Patient wears a sock |
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Total Elastic Suspension (TES Belt)
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Very simple to use
Somewhat bulky Moderate rotational control Prosthesis may “telescope” Auxiliary suspension-used with suction, roll on silicone suction, or partial suction |
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Pelvic Band with Hip Joint
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Bulky
Very stable in M/L and Rotational control Indicated for Weak hip abductors Short femur Uncomfortable Some patient’s are just used to it and like it (they’re old) |
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Roll-on Silicone Liner with Pin with shuttlecock and lanyard
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Liners now being used for transfemoral applications. Used with patients who have difficulty donning a traditional suction suspension
Extra guidance needed to get pin in shuttle Lanyard used to solve this problem Hand dexterity is a must Makes socket longer than normal |
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Roll-on Seal In Liner
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Provides a suction socket
Easier to don than traditional true suction Relatively new and have had good results |
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Roll-on Liner with Coyote Summit Suspension
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Relatively new
Prevents rotation in the socket Easy to apply Works like a ski boot lock |
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Osseointegration
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Advantages
Less feeling of weight More control of prosthesis No perspiration, pain from socket Easy don and doff |
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Osseointegration (disadvantages)
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Disadvantages
2 surgeries required First-fixture threaded into skeleton-wound closed and wait for bone to grow into the threads (6 months) Second-re-expose implanted fixture, attach abutment, gradually load limb-another 6 months Long rehab period Deep infection risk If occurs=bone loss, need to re-amputee at higher level |
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Structure Design Criteria (two types)
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Exoskeletal
Traditional “Hard Finish” Fabrication Method Durability / Heavy Duty Use Limited Componentry Non-Adjustable Endoskeletal Vast Componentry Options Post Fabrication Adjustability Light Weight More “Anatomical” / Soft / Cosmetic |
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Knees (primary design selection)
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Primary Design Selection
Axis Single Axis Polycentric (multiple axis - many for flexion and ext to allow more ROM) Swing Resistance Mediated by K-level Constant Friction (adjusted by prosthetist, not PT) Fluid Resistance |
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Other features of knees
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Other Features
Extension Assist (at terminal swing so the heel hits the ground first - it has NOTHING to do with keeping knee straight in standing) Stance Control Computer Controlled ($60K) Rotator (can cross leg) Torque Absorber |
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Advantages of polycentric
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Axis
Polycentric Multiple “centers of rotation” Provides added stability Indicated for anyone especially long limbs example is “total knee” |
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Types of swing resistance
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Swing Resistance
Constant Friction Single speed ambulators (K1 or K2) Adjusted for one speed of walking Fluid Resistance Hydraulic oil or air (pneumatic) Variable speed ambulators (K3 or K4) Resistance against flexion increases as forces increase Increase V increase cadence increase resistance This slows the swing rate which allows the foot to advance more quickly (increased cadence) |
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Types of assist or control
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Extension Assist:
Assists extension at terminal swing - doesn’t help stand Ext hip keeps it locked, or can manually lock Don’t have friction break to stop fall if you land on flexed knee Stance Control: Locked Friction “Brake” Mechanical Hydraulic |
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Details re:
Single Axis Constant Friction Knee With Stance Control (Not a SAFETY Knee) |
Uses a weight-activated friction brake
Restricts more flexion when wt put on in 15 –20 degrees of flexion For K1 or K 2 To 220 lbs. Comes in Child size |
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Total Knee specs
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Polycentric
CF (concentric friction) Mechanical Stance Control: locks in stance To 225lbs Comes in child size See video |
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Ottobock specs
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Polycentric
Hydraulic Swing Phase Control To 225lbs |
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Info re: Henschke-Mauch Stance and Swing Control (SNS)
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Provides increasing resistance to flexion as knee flexes more & more to prevent falling
In swing, as knee is flexed more than 20 degrees, the foot is lifted and the knee extends Know whether the knee is polycentric/single axis, mechanical/hydraulic, mechanical/ computerized |
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Details about Computer-controlled Hydraulic Units
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C-Leg by Otto Bock
Intelligent knee by Endolite Controls resistance to flexion & extension Does not provide active flexion/extension See video It controls knee flexion so pt doesn’t have to descend stairs with ext knee like other prostheses Doesn’t facilitate ascending stairs, need to go one leg at a time |
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Where and what about a Rotator
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Located Proximal to Knee Joint
Allow Pt. To Sit With Leg Crossed |
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Torque Absorber
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May Be Specific Unit on Shank or Integral With Foot
Absorbs Torque and Thereby Decreases Shear at Residuum / Socket Interface |
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Common type of foot used with AKA/TF
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May See Increased Use of Single Axis Foot
Otherwise: TT / TF Utilize Same Feet |
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What does medicare pay for?
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K0 - non ambulator
(No prosthetic coverage) K1 - household ambulator (SACH, Constant Friction Knee) K2 - limited community ambulator (Flexible Keel Foot, Constant Friction Knee) Evidence shows C-Leg can bring to K3 K3 - unlimited community ambulator (Dynamic.Response Foot, Fluid Friction Knee) K4 - high activity (Dynamic Response Foot, Fluid Friction Knee) |
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Why get a Knee Disarticulation?
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everyones doing it?
Advantages End bearing RL Self suspending Long lever arm Less surgically traumatic Disadvantages Component limitations Cosmetic concerns |
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Transfemoral Biomechanics: how is the TF designed to facilitate movement/gait?
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Must provide for ML stability of pelvis during mid-stance on prosthetic side
Lateral wall of socket adducted to give glut medius an advantage to keep pelvis level during gait Provide AP stability of prosthetic knee between heel contact and heel off Socket aligned in flexion approximately 5-10 degrees Knee joint posterior to TKA line |
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TKA line: what about it?
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Socket forward of knee
Knee posterior to trochanter and ankle if drop a plumb line |
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what's the dilly with
HD Endoskeletal Prosthesis (Hip disarticulation)?? |
Patients can walk unassisted but with noticeable deviations
Suspension by socket that encompasses the waist Requires a lot of gait training in order to learn the proper method of hip, knee and ankle control Operates using momentum Can walk very well, doesn’t have to limit activity |
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Who walks with stubbies initially?
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Bilateral Amputees:
Limbs shorter so easier to control Begin training with stubbies Stubbies are basically the socket with suction cups on the bottom - it’s easier to start with this |
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what is it called when your ankle is your knee?
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Rotation Plasty:
(e.g. Van Nes Rotation) - a procedure where the leg is amputated above the knee, the lower portion of the leg is rotated 180° and reattached - the ankle acts like a knee joint, providing extra function; more mobility and better control with a prosthesis. PF extends the knee, DF flexes it. |
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What major components are involved with
Prescription recommendation? |
Socket:
Structural design - Suspension: Knee - Foot - |
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