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54 Cards in this Set

  • Front
  • Back
Transfemoral Considerations
Cause of Amputation
Chronology
Biomechanics: Length/ROM
Patient Issues
Funding Issues
Geographic Location
Transfemoral Considerations
Cause of Amputation
Peripheral Vascular Disease
Diabetes
Infection
Gangrene
Trauma
Congenital
Tumor
Transfemoral Considerations
Chronology
Date of amputation
RL Condition
Post Op?
Intermediate 3-6 mos
Definitive ~6mos
Transfemoral Considerations
Biomechanics:
ROM
Length - important for leverage?
Surface Area
RL Condition/Surgical techniques
Transfemoral Considerations
Patient Issues
General Physical Condition
Desire, Ability
Activities
Medicare K-levels 0-1
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.
Medicare K-levels 2-3
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.
Medicare K-levels 4
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.
Prescription Factors
K-Level mediates knee and foot componentry
Knee Selection
Foot Selection
Other design criteria:
Exoskeletal vs. Endoskeletal (majority)
Socket Design
Suspension
Complete Transfemoral Rx
Socket design & material
Suspension
Knee
Foot
Rotator/Torque Absorber
Quadrilateral socket
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Originally made in just thermo-setting laminates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
Posterior Wall and Posterior Brim
Wall
Flat, slants anteriorly to provide initial flexion of 15 degrees
Contoured for hamstrings
Brim
Horizontal parallel to floor
Ischial seat
Medial Wall and Medial Brim
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
Anterior Wall
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)
Lateral Wall
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
Icelandic Swedish new York (ISNY) or Scandinavian Flexible Socket (SFS)
Same design as quadrilateral
Has a flexible socket with a rigid retainer
This is NOT a hard socket, is quadrilateral in shape
Normal Shape Normal Alignment (NSNA)
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
Socket Design – 
Normal Shape Normal Alignment (aka ischial containment)
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
CAT-CAM
Has a flexible socket with a rigid retainer

the name refers to specialized computer program
Sabolich
“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
Suspension
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
Suspension continued
Pin Suspension (roll-on silicone liner pin suspension –shuttlecock with lanyard )
Roll on “Seal In”liner
Roll on liner and Coyote Summit Lock
Osseointegration
Suction
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!
Silesian Belt or Band
Simple
Made of cotton/Dacron webbing
Relatively low profile
Controls rotation well
Auxiliary suspension
Used with partial suction-Patient wears a sock
Total Elastic Suspension (TES Belt)
Very simple to use
Somewhat bulky
Moderate rotational control
Prosthesis may “telescope”
Auxiliary suspension-used with suction, roll on silicone suction, or partial suction
Pelvic Band with Hip Joint
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)
Roll-on Silicone Liner with Pin with shuttlecock and lanyard
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
Roll-on Seal In Liner
Provides a suction socket
Easier to don than traditional true suction
Relatively new and have had good results
Roll-on Liner with Coyote Summit Suspension
Relatively new
Prevents rotation in the socket
Easy to apply
Works like a ski boot lock
Osseointegration
Advantages
Less feeling of weight
More control of prosthesis
No perspiration, pain from socket
Easy don and doff
Osseointegration (disadvantages)
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
Structure Design Criteria (two types)
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
Knees (primary design selection)
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
Other features of knees
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
Advantages of polycentric
Axis
Polycentric
Multiple “centers of rotation”
Provides added stability
Indicated for anyone especially long limbs
example is “total knee”
Types of swing resistance
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)
Types of assist or control
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
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
Total Knee specs
Polycentric
CF (concentric friction)
Mechanical Stance Control: locks in stance
To 225lbs
Comes in child size
See video
Ottobock specs
Polycentric
Hydraulic
Swing Phase Control
To 225lbs
Info re: Henschke-Mauch Stance and Swing Control (SNS)
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
Details about Computer-controlled Hydraulic Units
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
Where and what about a Rotator
Located Proximal to Knee Joint

Allow Pt. To Sit With Leg Crossed
Torque Absorber
May Be Specific Unit on Shank or Integral With Foot
Absorbs Torque and Thereby Decreases Shear at Residuum / Socket Interface
Common type of foot used with AKA/TF
May See Increased Use of Single Axis Foot

Otherwise: TT / TF Utilize Same Feet
What does medicare pay for?
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)
Why get a Knee Disarticulation?
everyones doing it?

Advantages
End bearing RL
Self suspending
Long lever arm
Less surgically traumatic
Disadvantages
Component limitations
Cosmetic concerns
Transfemoral Biomechanics: how is the TF designed to facilitate movement/gait?
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
TKA line: what about it?
Socket forward of knee
Knee posterior to trochanter and ankle if drop a plumb line
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
Who walks with stubbies initially?
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
what is it called when your ankle is your knee?
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.

What major components are involved with
Prescription recommendation?
Socket:
Structural design -
Suspension:
Knee -
Foot -
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