INTRODUCTIONINTRODUCTIONOrthotics

An orthotic device (commonly just referred to as an orthotic) is an external device applied on the body to limit motion, correct deformity, reduce axial loading, or improve function in a certain segment of the body.

Design characteristics of an orthotic device are crucial to function. Most important features include the following:

Weight of the orthosis Adjustability Functional use Cosmesis Cost Durability Material Ability to fit various sizes of patients Ease of putting on (donning) and taking off (doffing) Access to tracheostomy site, peg tube, or other drains Access to surgical sites for wound care Aeration to avoid skin maceration from moisture

Indications for recommending orthotic devices include the following:

Pain relief Mechanical unloading Scoliosis management Spinal immobilization after surgery Spinal immobilization after traumatic injury Compression fracture management Kinesthetic reminder to avoid certain movements

Duration of orthotic use is determined by the individual situation.

In situations where spinal instability is not an issue, recommend use of an orthosis until the patient can tolerate discomfort without the brace.

When used for stabilization after surgery or acute fractures, allow 6-12 weeks to permit ligaments and bones to heal.

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Use of an orthotic device is associated with several drawbacks, including the following:

Discomfort Local pain Osteopenia Skin breakdown Nerve compression Ingrown facial hair for men Muscle atrophy with prolonged use Decreased pulmonary capacity Increased energy expenditure with ambulation Difficulty donning and doffing orthosis Difficulty with transfers Psychological and physical dependency Increased segmental motion at ends of the orthosis Unsightly appearance Poor patient compliance

Success of the orthosis may lead to any of the following:

Decreased pain Increased strength Improved function Increased proprioception Improved posture Correction of spinal curve deformity Protection against spinal instability Minimized complications Healing of ligaments and bones

Maintenance of orthosis:

Orthosis should be simple and durable as possible.Patient should be taught for:

Cleaning the leather. Oiling the joints. Wash the orthosis if possible.

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Physicians must understand the biomechanics of the spine and each individual orthosis. The cervical spine is the most mobile spinal segment with flexion greater than extension. The occiput and C1 have significant flexion and extension with limited side bending and rotation. The C1-C2 complex accounts for 50% of rotation in the cervical spine. The C5-C6 region has the greatest amount of flexion and extension. The C2-C4 region has the most side bending and rotation.

When compared to the cervical and lumbar spine, the thoracic spine is the least mobile. The thoracic spine has greater flexion than extension. Lateral bending increases in a caudal direction, and axial rotation decreases in a caudal direction.

The lumbar spine has minimal axial rotation. The greatest movement in the lumbar spine is flexion and extension. Immobilization of the spine increases erector spinae muscle activity since normal rotation that occurs with ambulation is limited by the orthosis.

Biomechanichal principles of orthotic design

The biomechanical principles of orthotic design assist in promoting control, correction, stabilization, or dynamic movement.

All orthotic design are based on three relatively principles:

The pressure principle:

the pressure should be equal to the total force per unit area. Force P = ------------------------ Area of Application

It means that the greater the area of a pad or plastic shell of an orthosis, the less force will be placed on the skin.

Therefore, any material that creates a force against the skin should be of dimension to minimize the force on the tissue.

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These principles are:

Pressure equilibrium The lever arm

The equilibrium principle: The sum of the forces and the bending moments created must be

equal to zero. This means that three-point pressure or loading system occurs when

three forces are applied to a segment in such a way that a single primary force is applied between two additional counter forces with the sum of all three forces equalizing zero.

The primary force is of a magnitude and located at a point where movement is either inhibited or facilitated, depending on the functional design of the orthosis

The lever arm principle: The farther the point of force from the joint the greater the moment

arm and the smaller the magnitude of force required to produce a given torque at the joint.

This why most orthosis are designed with long metal bars or plastic shells that are the length of adjacent segment.

The greater the length of the supporting orthotic structure, the greater the moment or torque that can be placed on the joint or unstable segment.

These three principles act dependently on each otherSo when designing or evaluating an orthotic devise we should check that:

1) There is adequate padding covering the greatest area possible for comfort.

2) The total forces acting on the involved segment is equal to zero or there is equal pressure throughout the orthosis and no areas of skin irritation.

3) The length of the orthosis is suitable to provide an adequate force to creat the desired effect and to avoid increased transmission of shear forces against the anatomic tissues.

General othotic considerations: The forces at the interface between the orthotic materials and the

skin. The degrees of freedom of each joint. The number of joint segments. The neuromuscular control of a segment, including strength and

muscle tone. The material selected for orthotic fabrication. The activity level of the client. The goal of orthotic fitting is to meet the functional requirements of

the client with minimal restriction.

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Functional orthotic considerations:1) Alignment:2) Movement: A) Assistance with joint motion. B) Resistance with joint motion.3) Weight bearing:4) Protection

The biomechanical principles in orthotic design include balance of horizontal forces, fluid compression, distraction, construction of a cage around the patient, placement of an irritant to serve as a kinesthetic reminder, and skeletal fixation. Construction of a cage around the patient, like a thoracolumbar brace, increases intraabdominal pressure. Increased intraabdominal pressure converts the soft abdomen into a semirigid cylinder, which helps to relieve part of the vertebral load. In general, structural damage to posterior elements of the spine creates more instability with flexion, whereas damage to anterior elements creates more instability with extension.

Orthotic devices (orthoses) are generally named by the body regions that they span. For example, a CO is a cervical orthosis, while a CTLSO is a cervicothoracolumbosacral orthosis, spanning the entire length of the spine. Many of these devices are also known by eponyms.

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Types of orthosis

Orthoses are named by the joints they encompass

Ankle-foot orthosisKnee-ankle foot orthosis

Hip-Knee-ankle foot orthosisReciprocal Gait orthosis

AFOKAFO

HKAFORGO

Foot orthosisKnee orthosisHip orthosis

LL orthosesFOKOHO

Cervical-Thoracic orthosisCervical-Thoracolumbosacral orthosis

Thoracolumbosacral orthosis

Lumbosacral orthosis

CTOCTLSO

TLSOLSO

Cervical orthosisThoracic orthosis

Sacral orthosisSacroiliac orthosis

Spinal orthosesCOTOSOSIO

Wrist-Hand orthosisElbow-Wrist-Hand orthosisShoulder-Elbow orthosis

Shoulder-Elbow-Wrist-Hand orthosis

WHOEWHOSEO

SEWHO

Hand orthosisWrist orthosisElbow orthosis

Shoulder orthosis

UL orthosesHdOWOEOSO

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Types of orthosis

Upper limb orthosis

Spinalorthosis

Lower limb orthosis

Cervical Orthotics

Several drawbacks to cervical orthotic (CO) use have been noted. The soft tissue structures around the neck (eg, blood vessels, esophagus, trachea) limit application of aggressive external force. The high level of mobility at all segments of the cervical spine makes it difficult to restrict motion. Cervical orthoses offer no control for the head or thorax; therefore, motion restriction is minimal. Cervical orthoses serve as a kinesthetic reminder to limit neck movement.

Observe appropriate precautions associated with orthotic use. Keep in mind that continued long-term use has been associated with decreased muscle function and dependency.

The soft collar is a common orthotic device made of lightweight material, polyurethane foam rubber, with a stockinette cover. It has Velcro closure strap for easy donning and doffing. Patients find the collar comfortable to wear, but it is soiled easily with long-term use.

Soft collar

Indications for use of the soft collar include the following benefits for the patient:

Warmth Psychological comfort Support to the head during acute neck pain Relief with minor muscle spasm associated with spondylolysis Relief in cervical strains

The soft collar provides some limitations of motion for the patient, including the following:

Limits full flexion and extension by 5-15% Limits full lateral bending by 5-10% Limits full rotation by 10-17%

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The hard cervical collars are similar in shape to a soft collar but are made of Plastizote, a rigid polyethylene material shaped like a ring with padding. Height can be adjusted in certain designs to fit patients better. Velcro straps are used for easy donning and doffing. The hard collar is more durable than a soft collar with long-term use.

Malibu collar

Several problems can be alleviated with use of a hard collar. The indications include the following:

Support to the head during acute neck pain Relief of minor muscle spasm associated with spondylosis Psychological comfort Interim stability and protection during halo application

Motion restrictions for the hard collar include the following:

Limits full flexion and extension by 20-25% Less effective in restricting rotation and lateral bending Better than a soft collar in motion restriction

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Head Cervical Orthotics

Head cervical orthotics (HCOs) include the occiput and chin to decrease range of motion (ROM). Supported chin area is a common place for skin breakdown and ingrown hair for men. The clavicle is another area for skin breakdown and discomfort with HCOs. HCOs generally are used in stable spine conditions. Like in the case of cervical orthotics, continued long-term use of HCOs has been associated with decreased muscle function and dependency.

The Philadelphia collar is a semirigid HCO with a 2-piece system of Plastizote foam. Plastic struts on the anterior and posterior sides are used for support. The upper portion of the orthosis supports the lower jaw and occiput, while the lower portion covers the upper thoracic region. The Philadelphia collar comes in various sizes and is comfortable to wear, improving patient compliance. Velcro straps are used for easy donning and doffing. The Philadelphia collar is difficult to clean and becomes soiled very easily. An anterior hole for a tracheostomy is available. A thoracic extension can be added to increase motion restriction and treat C6-T2 injuries.

Philadelphia collar with a thoracic extension

Motion restrictions for the Philadelphia collar include the following:

Limits flexion and extension by 65-70% Limits rotation by 60-65% Limits lateral bending by 30-35%

The goal of the Philadelphia collar is to provide immobilization and is indicated after the following:

Anterior cervical fusion Halo removal

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Dens type I cervical fracture of C2 Anterior diskectomy Suspected cervical trauma in unconscious patients Tear-drop fracture of the vertebral body (Note: Some tear-drop fractures

require anterior decompression and fusion.) Cervical strai

The Miami J collar

is another cervical orthotic device in common use. The Miami J collar has a 2-piece system made of polyethylene and a soft washable lining. The anterior piece has a tracheostomy opening similar to that in the Philadelphia collar. Velcro straps provide easy donning and doffing. The Miami J collar is a semi-rigid HCO. A thoracic extension can be added to increase support and treat C6-T2 injuries. The Miami J collar is available in various sizes and can be heated and molded to a contoured fit.

Miami J collar

Motion restrictions with the Miami J collar include the following:

Limits flexion and extension by 55-75% Limits rotation by 70% Limits lateral bending by 60%

Indications for use of a Miami J collar are the same as the Philadelphia collar.

The Malibu collar is similar to the Philadelphia collar as it is a semi-rigid orthosis designed in a 2-piece system with an anterior opening for a tracheostomy. The Malibu collar comes in only one size, but it is adjustable in multiple planes to ensure proper fit. Anterior chin support height is also adjustable. Straps around the chin, occiput, and lower cervical area provide for tightening. Padding around the chin can be trimmed to ensure proper fit. Thoracic extension can be added to increase support and treat C6-T2 injuries.

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Motion restrictions for the Malibu collar include the following:

Limits flexion and extension by 55-60% Limits rotation by 60% Limits lateral bending by 60%

Indications for use of a Malibu collar are similar to those for the Miami J and Philadelphia collars.

The Aspen Collar has a 2-piece system made of polyethylene with soft foam liner with an anterior opening for a tracheostomy. The Aspen collar is a semi-rigid HCO with Velcro straps for easy donning and doffing.

Motion restrictions mirror those of the Miami J collar and include the following:

Limits flexion and extension by 55-60% Limits rotation by 60% Limits lateral bending by 60%

Indications for use of the Aspen collar include the same as the HCOs discussed above. The Jobst Vertebrace is made of high-density polyethylene with soft polyethylene foam liner. The Jobst Vertebrace is a semi-rigid HCO designed for use in emergent transport situations, and it is similar to the Yale or Philadelphia collar in restricting motion. The Jobst Vertebrace provides full contact along its costal ends to the sternum and cradles the mandible for stability.

Motion restrictions for the Jobst Vertebrace are similar to those of the Yale and Philadelphia collars, including the following:

The Jobst Vertebrace is made of high-density polyethylene with soft polyethylene foam liner. The Jobst Vertebrace is a semi-rigid HCO designed for use in emergent transport situations, and it is similar to the Yale or Philadelphia collar in restricting motion. The Jobst Vertebrace provides full contact along its costal ends to the sternum and cradles the mandible for stability. Motion restrictions for the Jobst Vertebrace are similar to those of the Yale and Philadelphia collars, including the following:

Limits flexion and extension by 55-60% Limits rotation by 60% Limits lateral bending by 60%

Indications for use of the Jobst Vertebrace are similar to those for the Miami J and Philadelphia collars

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Cervical Thoracic Orthotics

Cervical thoracic orthotics (CTOs) provide greater motion restriction in the middle to lower cervical spine from the added pressure on the body. The upper cervical spine has less motion restriction. CTOs are used in minimally unstable fractures.

The Sternal-Occipital-Mandibular-Immobilizer is a rigid three-poster CTO with anterior chest plate that extends to the xiphoid process and has metal or plastic bars that curve over the shoulder. Straps from the metal bars go over the shoulder and cross to the opposite side of the anterior plate for fixation. A removable chin piece attaches to the chest plate with an optional headpiece that can be used when the chin piece is removed for eating. The two-poster CTOs start from the chest plate and attach to the occipital component. The SOMI is ideal for bedridden patients since it has no posterior rods.

Sternooccipital-mandibular immobilization brace

The SOMI is relatively comfortable to wear. Proper adjustment is crucial for motion restriction; in fact, motion restriction may be minimal with incorrect application. The SOMI is less effective compared to other braces in controlling extension, but it is very effective in controlling flexion at the atlantoaxial and C2-C3 segments. The SOMI is better than the cervicothoracic brace in controlling flexion in the C1-C3 segments.

Indications for use of the SOMI include the following:

Immobilization in atlantoaxial instability because of rheumatoid arthritis (Note: Ligamentous disruption in rheumatoid arthritis affects flexion more than extension since extension is held in check by the intact dens.)

Immobilization for neural arch fractures of C2 since flexion causes instability

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Motion restrictions with the SOMI include the following:

Limits cervical flexion and extension by 70%-75% Limits lateral bending by 35% Limits rotation by 60-65%

The Yale orthosis is a modified Philadelphia collar with thoracic extension made of fiberglass extending anteriorly and posteriorly with mid-thoracic straps on the sides connecting the 2 thoracic extensions. The thoracic component helps to treat C6-T2 injuries. The occipital piece extends higher up on the skull posteriorly. Increased contact surface area improves stability of the brace. Patients find the Yale orthosis comfortable to wear. The Yale orthosis is easy to fabricate and costs approximately

Various indications for use of the Yale orthosis include the following:

Immobilization to C1 fractures with intact transverse ligament Immobilization after surgical fixation of Dens Type III fractures Immobilization to Dens type I fractures Immobilization to Hangman fractures (traumatic spondylolisthesis of C2) Immobilization to Jefferson fractures (multiple fractures of C1 ring with

spreading due to axial loading) Provide immobilization to postoperative fixation

Motion restrictions for the Yale orthosis include the following:

Limits flexion and extension by 85% Limits rotation by 70% to 75% Limits lateral bending by 60%

The four-poster brace is a rigid orthosis with anterior and posterior chest pads connected by a leather strap. Molded occipital and mandibular support pieces connect to the chest pads and have adjustable struts. Straps connect the occipital and mandibular support pieces. The mandibular plate can interfere with eating. This brace uses shoulder straps, but it has no underarm support. Open design allows heat loss from the neck. The brace is as effective as the cervicothoracic brace in controlling flexion in the mid-cervical area and is better than the Philadelphia collar. The four-poster design limits lateral bending and rotation better than the two-poster brace.

Motion restrictions provided by the four-poster orthosis include the following:

Limits flexion and extension by 80%

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Limits lateral bending by 55%-80% Limits rotation by 70%

The Guilford brace is a rigid CTO with a two-poster design with anterior chest plate and shoulder straps that connect to the posterior plate. Chin plate and occipital piece connect to the anterior and posterior struts. Underarm straps circle the lower chest wall for stability. The brace has poor control of flexion, extension, rotation, and lateral bending at C1-C2. Motion restrictions afforded by the Guilford brace include limitation of flexion and extension from C3-T2.

Indications for use of the Guilford brace include the following:

Immobilization to minimally unstable fractures from C3-T2 Immobilization after postoperative internal fixation from C3-T2

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Halo device

The halo device is the most common device for treatment of unstable cervical and upper thoracic fractures and dislocations as low as T3. The halo provides maximum motion restriction of all cervical orthotics. The halo ring is made of graphite or metal with pin fixation on the frontal and parietal-occipital areas of the skull. Development of lightweight composite material led to design of radiolucent rings compatible with magnetic resonance imaging (MRI). The halo ring attaches to the vest anteriorly and posteriorly via 4 posters.

Halo device.

The halo vest has shoulder and underarm straps for tightening and usually is made of rigid polyethylene and extends down to the umbilicus. Restriction in cervical motion depends on the fit of the halo vest since improper fit can allow 31% of normal spine motion. The halo vest is the weak link in terms of motion control. Compressive and distractive force can occur with variable fit of the vest.

Multidirectional shear forces can cause increased pinhole size with craterlike enlargement. Pin loosening occurs twice as frequently with a heavier halo vest. Generally, upper cervical spine injuries are treated best with a full-length vest to the iliac crest.

Indications for use of a halo device are for immobilization in the following cases:

Dens type I, II, and III fractures of C2 (Note: Dens type III fractures of C2 are treated more successfully with surgery.)

C1 fractures with rupture of the transverse ligament Atlantoaxial instability from rheumatoid arthritis with ligamentous

disruption and erosion of the dens C2 neural arch fracture and disc disruption between C2 and C3. (Note:

Some patients may need surgery for stabilization.) Bony single column cervical fractures Following cervical arthrodesis Following cervical tumor resection in an unstable spine

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Following debridement and drainage of infection in an unstable spine Following spinal cord injury (SCI)

Contraindications for use of the halo device include the following:

Concomitant skull fracture with cervical injury Damaged or infected skin over pin insertion sites

The relative contraindications for use of the halo device include the following:

Cervical instability with ligamentous disruption Cervical instability with 2 or 3 column injury Cervical instability with rotational injury involving facet joints

The application process for the halo device consists of several steps. Optimal placement for the anterior pins is the anterolateral aspect of the skull 1 cm above the orbital rim on the lateral part of orbit since this prevents penetration into the orbit. Avoid placing pins in the temporalis muscle and through the zygomaticotemporal nerve, which supplies sensation to the temporal area. Pins inserted into the temporalis muscle affect mandibular motion and cause pain. Placement away from the medial one third on the orbital rim preserves the supraorbital and supratrochlear nerves and decreases risk of entering the frontal sinus.

Insertion of posterior pins on the posterolateral aspect of the skull is less crucial. Skin incisions are not necessary prior to pin placement. The halo ring should be 1 cm above the top of the ear. Place all pins perpendicular to the skull, and allow 1-2 cm clearance with the halo ring along the skull perimeter.

In adults, pin insertion requires a torque wrench set at 8 inches per pound since this lowers incidence of pin infection and loosening. In children, set the torque wrench between 2-5 inches per pound since the skull is too weak to sustain heavier forces. Use multiple pin sites in children because of the weaker skull.

Determine the halo vest size by measuring chest circumference at the xiphoid process. Elevate the patient at 30-40° for vest placement. Secure the posterior portion to the halo first, then to the anterior part of the vest. Tighten the bolts on the vest to a torque setting of 28 feet per pound. Tools for the vest sometimes are taped to the anterior part of the vest in case of emergency.

At 24-48 hours after placement, recheck all pins for loosening. Clean the pin sites with saline or soap and water on a sterile swab. Take x-rays immediately after halo placement and after any adjustment to check spinal alignment. Shaking of the cervical spine because of forced movement against the orthosis or changes in pin tightening can cause some segmental motion. Symptoms of dysphagia

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may result from placement of the neck in too much extension. Repositioning of the halo, if possible, can eliminate dysphagia.

Motion restrictions provided by the halo include the following:

Limits flexion and extension by 90-96% Limits lateral bending by 92-96% Limits rotation by 98-99%

Various complications associated with halo placement include the following:

Neck pain or stiffness 80% Pin loosening 60% Pin site infection 22% Scars 30% Pain at pin sites 18% Pressure sores 11% Redislocation 10% Restricted ventilation 8% Dysphagia 2% Nerve injury 2% Dural puncture 1% Neurological deterioration 1% Avascular necrosis of the dens Ring migration Inadequate bony healing Inadequate ligamentous healing

In use of the halo device, keep in mind the following important considerations:

The halo fixation device is used for 3 months to allow adequate time for bone healing.

Use of an HCO after removal of the halo provides some support for the head, as the neck muscles are weak and stiff.

Approximately 40-45% of patients with facet joint dislocations achieve stability with the halo vest, whereas 70% of patients without facet joint dislocations achieve stability.

Nearly 75% of patients without facet joint dislocation achieve good anatomic results.

Surgical stabilization in cases of facet joint dislocation improves outcome.

Patients with facet joint dislocation have higher likelihood of spinal cord injury.

Thorough neurologic examination before and after reduction of facet joint dislocation is important.

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The best orthotic device to control various cervical regions is indicated as follows:

All orthotics tend to control flexion better than extension. The halo is the most effective in controlling flexion and extension at C1-

C3, followed by the four-poster brace, and then the cervicothoracic orthotics.

The cervicothoracic orthotics are best at controlling flexion and extension at C3-T1, while the SOMI brace is best at controlling flexion from C1-C5.

The SOMI is less effective in controlling extension compared to other orthotics.

The halo is the best at controlling rotation and lateral bending from C1-C3. The cervicothoracic brace is second best at controlling rotation and lateral

bending in the cervical spine. The four-poster brace is slightly better at controlling lateral bending

compared to the cervicothoracic brace in the cervical spine.

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Thoracolumber orthotics

Thoracolumbar orthotics (TLOs) are used mainly to treat fractures from T10-L2 since their mobility is not restricted by the ribs, unlike fractures from T2-T9. Immobilization from T10-L2 helps prevent further collapse.

The cruciform anterior spinal hyperextension (CASH) brace features anterior sternal and pubic pads to produce force opposed by the posterior pad and strap around the thoracolumbar region. Sternal and pelvic pads attach to the anterior metal cross-shaped bar, which can be bent to reduce excess pressure on the chest and pelvis. The brace is easy to don and doff, but it is difficult to adjust. Compared to the Jewett brace, it provides greater breast and axillary pressure relief. Two round upper chest pads can be used instead of the sternal pad to decrease discomfort around the breast area. Average cost of a CASH brace is approximately $460.

Indications for the CASH brace include the following:

Flexion immobilization to treat thoracic and lumbar vertebral body fractures

Reduction of kyphosis in patients with osteoporosis

Motion restrictions provided by the CASH brace include the following:

Limits flexion and extension from T6-L1 Ineffective in limiting lateral bending and rotation of the upper lumbar

spine

Contraindications to use of the CASH brace include the following:

Three-column spine fractures involving anterior, middle, and posterior spinal structures

Compression fractures due to osteoporosis

The Jewett hyperextension brace uses a 3-point pressure system with 1 posterior and 2 anterior pads. The anterior pads place pressure over the sternum and pubic symphysis. The posterior pad places opposing pressure in the mid-thoracic region. The posterior pad keeps the spine in an extended position, and it has a lightweight design that is more comfortable than the CASH brace. Pelvic and sternal pads can be adjusted from the lateral axillary bar where they attach. The pads can cause discomfort from pressure applied to small surface area. No abdominal support is provided with this device. When the patient is seated, the sternal pad should be half an inch inferior to the sternal notch, and the pubic pad

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should be half an inch superior to the pubic symphysis. The Jewett brace is not a custom-molded brace.

Jewett® hyperextension brace

Indications for use of the Jewett brace include the following:

Symptomatic relief of compression fractures not due to osteoporosis Immobilization after surgical stabilization of thoracolumbar fractures

Motion restrictions provided by the Jewett brace include the following:

Limits flexion and extension between T6-L1 Ineffective in limiting lateral bending and rotation of the upper lumbar

spine

Contraindications to use the Jewett brace include the following:

Three column spine fractures involving anterior, middle, and posterior spinal structures

Compression fractures above T6 since segmental motion increases above the sternal pad

Compression fractures due to osteoporosis

One important consideration in use of the Jewett brace is that it is more effective than the CASH brace. The Korsain brace is a modification of the Jewett brace with added abdominal support for increased rigidity. The cost of the Korsain brace is similar to that of the Jewett brace.

Indications for the Korsain brace include the following:

Symptomatic relief of compression fractures not due to osteoporosis Immobilization after surgical stabilization of thoracolumbar fractures Flexion immobilization to treat thoracic and lumbar vertebral body

fractures

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Motion restrictions and contraindications of the Korsain brace are similar to the Jewett brace.

The Knight-Taylor brace features a corset type front with lateral and posterior uprights and shoulder straps to help reduce lateral bending, flexion, and extension. Shoulder straps may cause discomfort in some patients. The brace can be prefabricated and made with polyvinyl chloride or aluminum. The posterior portion of the brace has added cross supports below the inferior angle of the scapula and a pelvic band fitted at the sacrococcygeal junction. The anterior corset is made of canvas and provides intracavitary pressure. The anterior corset is laced to the lateral uprights. The brace is indicated to provide flexion immobilization to treat thoracic and lumbar vertebral body fractures.

Cruciform anterior spinal hyperextension brace with round anterior chest pads.

Motion restrictions of the Knight-Taylor brace include the following:

Poor rotation control Limits flexion, extension, and lateral bending

Custom-molded plastic body jacket, or thoracolumbosacral orthosis (TLSO), is fabricated from polypropylene or plastic and offers best control in all planes of motion and increases intracavitary pressure. This orthosis has a lightweight design and is easy to don and doff. The material is easy to clean and comfortable to wear. This brace sometimes is referred to as the clamshell. The TLSO provides efficient force transmission as pressure is distributed over wide surface area, which is ideal for use in patients with neurologic injuries. The brace may have a tendency to ride up on the patient in a supine position. Plastic retains heat, so an undershirt helps to absorb perspiration and protect the skin. Frequent checks to ensure proper fit help prevent pressure ulcers.

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Custom-molded plastic lumbosacral orthosis

Indications for the TLSO include the following:

Immobilization for compression fractures from osteoporosis Immobilization after surgical stabilization for spinal fractures Bracing for idiopathic scoliosis Immobilization for unstable spinal disorders for T3 to L3

Motion restrictions for the TLSO include the following:

Limits sidebending Limits flexion and extension Limits rotation to some extent

Clinical information on the custom-molded TLSO suggests that it is more effective in preventing idiopathic scoliosis curve progression than the Milwaukee and Charleston braces. The mean curve progression with TLSO is less than 2° while the Charleston and Milwaukee braces have a curve progression greater than 6°. Fewer than 18% of patients treated with TLSO brace required surgery for scoliosis compared to 23% for patients treated with a Milwaukee brace

Lumbosacral orthotics

The chairback brace is a rigid short lumbosacral orthotic (LSO) with 2 posterior uprights with thoracic and pelvic bands. The abdominal apron has straps in front for adjustment to increase intracavitary pressure. The thoracic band is located 1 inch below the inferior angle of scapula. The thoracic band extends laterally to the mid-axillary line, and the pelvic band extends laterally to the mid-trochanteric line. Place the pelvic band as low as possible without interfering with sitting

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comfort. Position the posterior uprights over the paraspinal muscles. Uprights can be made from metal or plastic. The brace uses a 3-point pressure system and can be custom molded to improve the fit for each individual patient.

Chairback brace from side view

Indications for use of the chairback brace include the following:

Unloading of the intervertebral discs and transmit pressure to soft tissue areas

Relief for low back pain (LBP) Immobilization after lumbar laminectomy Kinesthetic reminder to patient following surgery

Motion restrictions of the chairback brace include the following:

Limits flexion and extension at the L1-L4 level Limits rotation minimally Limits lateral bending by 45% in the thoracolumbar spine

The chairback Ortho-Mold brace is similar to the chairback brace, but it has a rigid plastic back piece custom molded to the patient. The plastic back can be inserted into the canvas and elastic corset. The chairback Ortho-Mold brace costs approximately $500-600.

Indications for use of the chairback Ortho-Mold brace and its motion restrictions are the same as the chairback brace noted above..

The Williams brace is a short LSO with an anterior elastic apron to allow for forward flexion. Lateral uprights attach to the thoracic band, and oblique bars are used to connect the pelvic band to the lateral uprights. The abdominal apron is laced to the lateral uprights. The brace limits extension and lateral trunk movement but allows forward flexion. The brace is indicated to provide motion restriction during extension to treat spondylolysis and spondylolisthesis. The device is contraindicated in spinal compression fractures.

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Motion restrictions of the Williams brace include the following:

Limits extension Limits side bending at terminal ends only

The MacAusland brace is an LSO that limits only flexion and extension. This brace has 2 posterior uprights but no lateral uprights. The 3 anteriorly directed straps connect with the abdominal apron to provide increased support.

Indications for use of the MacAusland brace are similar to the chairback brace. Motion restrictions include limitation of flexion and extension in the L1 to L4 level.

The Standard LSO corset has metal bars within the cloth material posteriorly that can be removed and adjusted to fit the patient. The anterior abdominal apron has pull-up laces from the back to tighten. The abdominal apron can come with Velcro closure for easy donning and doffing. The Standard LSO corset has a lightweight design and is comfortable to wear. The corset increases intracavitary pressure. Anteriorly, the brace covers the area between the xiphoid process and pubic symphysis. Posteriorly, the brace covers the area between the lower scapula and gluteal fold.

Indications for the Standard LSO corset include the following:

Treatment of LBP Immobilization after lumbar laminectomy

Motion restrictions of the Standard LSO corset include limitation of flexion and extension.

The rigid LSO is a custom-made orthosis molded over the iliac crest for improved fit. Plastic anterior and posterior shells overlap for a tight fit. Velcro closure in the front is designed for easy donning and doffing. Multiple holes can be made for aeration to help decrease moisture and limit skin maceration. The rigid LSO can be trimmed easily to make adjustments for patient comfort and may be used in the shower if needed.

Indications for use of the rigid LSO brace include the following:

Post-surgical lumbar immobilization Treatment of lumbar compression fractures

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Motion restrictions provided by the rigid LSO brace include the following:

Limits flexion and extension Limits some rotation and side bending

Rigid LSO with hip spica uses a thigh piece on the symptomatic side and extends to 5 cm above the patella. The hip is held in 20° of flexion to allow sitting and walking. Some patients require a cane for ambulation after application. Indications for the rigid LSO with hip spica use include the following:

Immobilization to treat lumbar instability from L3-S1 Immobilization after lumbosacral fusion with anchoring to the sacrum

Motion restrictions of the rigid LSO with hip spica include the following:

Limits flexion and extension Limits some rotation and side bending

New brace designs for LSO have strapping systems designed to pull the brace inward and up to improve hydrostatic affect to relieve pressure on the lumbar spine. The better fit helps limit migration. Some low-profile designs take pressure off the hip and rib area, which, in turn, improves patient compliance. Low-profile braces allow easier fitting under clothes. These braces can treat areas from L3-S1.

Some spinal braces come with an interchangeable back with an open center or flat back design for postoperative patients. The same brace can be interchanged with a back that has an indentation to fit the lordotic curvature of the lumbar spine for pain management purposes. Braces with interchangeable parts allow a LSO to be converted into a TLSO with a large back support and an attachment for a sternal extension to prevent unwanted flexion. The sternal extension has straps that attach to the LSO.

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BRACING FOR SCOLIOSIS Bracing for scoliosis

The main goal of a brace in scoliosis is to prevent further deformity and prevent or delay need for surgery. If surgery is needed, delaying the procedure as long as possible helps optimize spinal height and avoid stunting of truncal growth.

Assessing the degree of skeletal maturity in a child with scoliosis is important because with more advanced skeletal maturity, you expect less further skeletal growth and thus less progression of the scoliosis. This has obvious implications when forming a treatment plan.

Risser classification of ossification of the iliac epiphysis is used to evaluate skeletal immaturity. Ossification of the iliac crest occurs from the anterior superior iliac spine (ASIS) to the posterior superior iliac spine (PSIS). When ossification is complete, fusion of the epiphysis occurs to the iliac crest. Risser staging is based on using radiographs to determine what percent of the excursion (along the length of the iliac epiphysis) has ossified. Risser score of 0-I with a curve of 20-30° indicates nearly 70% chance of progression.

Risser stages are defined as follows:

Stage 0 = 0% excursion Stage I = 25% excursion Stage II = 50% excursion Stage III = 75% excursion Stage IV = 100% excursion and correlates with end of spinal growth Stage V = fusion to ilium, indicating cessation of vertical height growth

The clinician must take into account several bits of clinical information about use of braces in scoliosis including the following:

Patients with pre-brace curves of 20-29° require surgery in only 3% of cases, whereas 28% of patients with pre-brace curves of 40-49° require surgery.

Patients aged younger than 13 years with curves of 30-39° require surgery 25% of the time, whereas only 14% of patients older than 14 years with curves 30-39° require surgery.

The most common time to lose control of idiopathic curves is at puberty. Boys tend to show less curve progression than girls, and tend to have later onset of curve progression between 15-18 years.

Younger patients show greater initial in-brace correction. Curve correction with bracing greater than 50% is expected to have final net correction, whereas curve correction less than 50% is expected to have limited progression.

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Generally, curves between T8-L2 have the best correction. Young patients with large curves usually fail treatment with a brace.

Patients successfully completing treatment for idiopathic scoliosis using a TLSO with initial curves measuring 20-45° can anticipate their scoliosis to remain stable until adulthood. The correction of the curvature can be lost over time, to its initial magnitude. Therefore, obtaining a spinal radiograph in the third or fourth decade of life to check progression is reasonable.

The Milwaukee brace is a CTLSO originally designed by Blount and Schmidt to help maintain postoperative correction in patients with scoliosis secondary to polio. The brace is designed to stimulate corrective forces from the patient. When the patient has been fitted properly with a brace, the trunk muscles are in constant use; therefore, disuse atrophy does not occur. The brace has an open design with constant force provided by the plastic pelvic mold. The pelvic portion helps reduce lordosis, derotates the spine, and corrects frontal deformity.

Uprights have localized pads to apply transverse force, which is effective for small curves. The main corrective force is the thoracic pad, which attaches to the 2 posterior uprights and 1 anterior upright. Discomfort from the thoracic pad creates a righting response to an upright posture. The lumbar pads play a passive role compared to the thoracic pads.

The uprights are perpendicular to the pelvic section, so any leg-length discrepancy should be corrected to level the pelvis. The neck ring is another corrective force and is designed to give longitudinal traction. Jaw deformity is a potential complication of the neck ring. The throat mold, instead of a mandibular mold, allows use of distractive force without jaw deformity.

During the child's growth, brace length can be adjusted. Pads also can be changed to compensate for spinal growth. The brace needs to be changed if pelvic size increases. Average cost of this brace is approximately $2100-2300.

Indications for use of the Milwaukee brace include the following:

Patients with Risser score of I-II and curves greater than 20-30° that progress by 5° over 1 year need application of brace.

Curves between 30-40° need bracing, but not curves less than 20°. Curves of 20-30°, with no year-over-year progression, require observation

every 4-6 months. The Milwaukee brace is used for curves with apex above T7.

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Duration of the Milwaukee brace use is determined by the following criteria:

Daily use ranges from 16-23 hours per day. Treatment should continue until the patient is at Risser stage IV or V. If curve is greater than 30°, consider continued use for 1-2 years after

maturity since patients with curves of this magnitude are at risk for progression.

Side effects of the Milwaukee brace include the following:

Jaw deformity Pain Skin breakdown Unsightly appearance Difficulty with mobility Difficulty with transfers Increased energy expenditure with ambulation

Failure to correct deformity can be caused by any of the following:

Poor patient compliance Improper fit Curves below T7

Keep in mind clinical information regarding use of the Milwaukee brace, including the following:

Only 40% of patients with curves of

20-29° progressed with a Milwaukee brace, compared to 68% by natural history without bracing.

When comparing the Milwaukee and Boston braces, note that curve progression beyond 45° occurred in 31% of patients with the Boston brace and in 62% with the Milwaukee brace.

X-rays to evaluate scoliosis in the Milwaukee brace are performed with the patient in a standing position.

Successful outcomes with brace treatment show an in-brace curve reduction greater than 50%.

The Milwaukee brace and a custom-made TLSO can be used to treat Scheuermann kyphosis in children with pain, or pain with kyphosis greater than 60°.

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The Boston brace is a prefabricated symmetric thoracolumbar-pelvic mold with built-in lumbar flexion that can be worn under clothes. Lumbar flexion is achieved through posterior flattening of the brace and extending of the mold distally to the buttock. Braces with superstructures have a curve apex above T7. Curves with an apex at or below T7 do not require superstructures to immobilize cervical spine movement. This brace, unlike the Milwaukee brace, cannot be adjusted if the patient grows in height. Both braces need to be changed if pelvic size increases. Average cost of the Boston brace is approximately $2000.

Indications for use of the Boston brace include the following:

Curves 20-25° with 10° progression over 1 year Curves 25-30° with 5° progression over 1 year Skeletally immature patients with curves 30° or greater

Side effects associated with use of the Boston brace include the following:

Local discomfort Hip flexion contracture Trunk weakness Increased abdominal pressure Skin breakdown Accentuation of hypokyphosis above brace in the thoracic spine

Certain preventive measures can reduce difficulties associated with use of the Boston brace, including the following:

Regimen of hip stretches decreases contractures at the hip. Exercise to promote active correction in the brace is suggested.

Presence of thoracic hypokyphosis is a relative contraindication for use of the Boston brace.

Failure of the Boston brace to correct deformity can occur because of several factors, including the following:

Curve above T7 Improper fit Poor patient compliance

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Duration of Boston brace use is determined by several factors, including the following:

Daily use ranges from 16-23 hours per day. Treatment should continue until the patient is at Risser stage IV or V. If the curve is greater than 30°, consider continued use for 1-2 years after

maturity since these curves are at risk for progression. The Boston brace with and without superstructure is equally effective in

treating curves below T7.

Clinical information relevant to use of the Boston brace includes the following:

The Boston brace is more effective than the Charleston brace in preventing curve progression and avoiding surgery.

Nearly 43% of patients using the Boston brace progressed more than 5°, compared to 83% with the Charleston brace.

The use of a Charleston brace is only indicated with lumbar or small thoracolumbar curves; avoid use in thoracic curves.

X-rays to evaluate scoliosis in the Boston brace are performed with the patient in a standing position.

Successful outcomes with brace treatment show an in-brace curve reduction greater than 50%.

The Charleston bending brace is a rigid custom-made orthosis designed to correct scoliosis at nighttime to improve patient compliance. This brace holds the patient in maximum side-bending correction. The Charleston bending brace costs approximately $2000.

Indications for use of this particular brace include the following:

Curves 20-25° with 10° progression over 1 year Curves 25-30° with 5° progression over 1 year Skeletally immature patients with curves 30° or greater

Clinical information regarding use of the Charleston bending brace includes the following:

The Charleston brace, compared to the Boston brace, is significantly less effective in treating double major curves and single thoracic curves in patients with Risser stage 0 to 1.

Over 50% of patients with a single thoracic curve treated with a Charleston brace required surgery compared to 24% with the Boston brace.

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As a result, the Charleston brace is not recommended for use in thoracic curves.

The Charleston brace is less effective at treating single thoracolumbar or lumbar curves, but the figures are not statistically significant compared to those for the Boston brace.

X-rays to evaluate scoliosis with the Charleston bending brace are performed in a supine position since the patient wears it at night sleeping supine.

Successful outcomes with brace treatment show an in-brace curve reduction greater than 50%.

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lower limb orthosis

A lower limb orthosis is an external device applied or attached to a lower body segment to improve function by controlling motion, providing support through stabilizing gait, reducing pain through transferring load to another area, correcting flexible deformities, and preventing progression of fixed deformities.

Terminology

Orthosis (or orthotic device) is the medical term for what most people would refer to as a brace or splint. Orthoses generally are named by the body regions that they involve, as demonstrated by the following abbreviations:

AFO is an ankle-foot orthosis. KAFO is a knee-ankle-foot orthosis. HKAFO is a hip-knee-ankle-foot orthosis. THKAFO is a trunk-hip-knee-ankle-foot orthosis.

Locomotion and gait

The total mass of the body can be considered concentrated at one point, called the center of gravity. The center of mass is located in the midline, just anterior to the second sacral vertebra while the individual is standing and walking. The center of mass changes with the configuration and function of the body.

The line of gravity is a line passing through the center of gravity to the center of the earth. This line (1) arises from the supporting surface between the ball and heel of the foot, then (2) passes in front of the ankle and knee joints and slightly behind the hip joint to the center of gravity, then (3) passes through the lumbosacral junction and behind the lumbar vertebral bodies to intersect the spine at the thoracolumbar junction, then (4) continues in front of the thoracic vertebral bodies and through the cervicothoracic junction, and, lastly, (5) travels behind the cervical vertebral bodies to the occipitocervical junction. When the center of gravity does not fall through the area of support, it is unstable at that moment.

Gait cycle is defined as the activity that occurs between the initial contact of one extremity and the subsequent initial contact of the same extremity. During a single gait cycle, each extremity passes through one stance phase and one swing phase. Stance phase occupies over 60% of the gait cycle during walking at average velocity. Stance phase includes initial contact, loading response, midstance, terminal stance, and preswing. Swing phase includes initial swing, mid swing, and terminal swing.

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The average total displacement of the center of gravity in both the vertical and lateral directions is less than 2 inches in normal gait. The increase in displacement of the center of gravity increases the amount of energy for walking.

The purpose of using an orthosis is to enhance normal movement and to decrease abnormal posture and tone. Lower extremity orthoses can be used to correct abnormal gait patterns and to increase the efficiency of walking.

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Lower extremity orthotics

An orthosis is classified as a static or dynamic device. A static orthosis is rigid and is used to support the weakened or paralyzed body parts in a particular position. A dynamic orthosis is used to facilitate body motion to allow optimal function. In all orthotic devices, 3 points of pressure are needed for proper control of a joint.

Principles

A lower limb orthosis should be used only for specific management of a selected disorder. The orthotic joints should be aligned at the approximate anatomic joints. Most orthoses use a 3-point system to ensure proper positioning of the lower limb inside the orthosis.

The orthosis selected should be simple, lightweight, strong, durable, and cosmetically acceptable. Considerations for orthotic prescription should include the 3-point pressure control system, static or dynamic stabilization, flexible material, and tissue tolerance to compression and shear force.

MATERIALS

An orthosis can be constructed from metal, plastic, leather, synthetic fabrics, or any combination. Plastic materials, such as thermosetting and thermoplastics, are the materials most commonly used in the orthotic industry.

Plastics o Thermosetting materials can be molded into permanent shape after

heating. They do not return to their original consistency even after being reheated. Thermoplastic materials soften when heated and harden when cooled.

o Low-temperature thermoplastics can be fabricated easily and rapidly with hot water or hot air and scissors, but they are used mainly in low stress activities.

o High-temperature (polypropylene) thermoplastics require higher temperature (150°C) to mold, but they are ideal for high stress activities.

Leather, such as cattle hide, is used for shoe construction because it conducts heat and absorbs water well.

Rubber o Rubber has tough resiliency and shock-absorbing qualities. o Rubber is used for padding in body jackets and limb orthoses.

Metal o Metals, such as stainless steel and aluminum alloys, are

adjustable, but they are heavy and not cosmetically pleasing.

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o Metals can be used for joint components, metal uprights, sprints, and bearings.

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SHOES AND FOOT ORTHOTICSShoes

Shoes are the important foundation of the lower limb orthosis. Shoes are used to protect and warm the feet, transfer body weight while walking, and reduce pressure or pain through redistributing weight. Shoes should be comfortable and properly fitted. They should be at least 1 cm longer than the longest toe and correspond to the shape of the feet.

The shoe can be divided into lower and upper parts. The lower parts consist of the sole, shank, ball, toe spring, and heel. The upper parts include the quarter, heel counter, vamp, toe box, tongue, and throat.

Parts of the shoe

Sole o Outer and inner soles are separated by compressible filler. Both of

them are made preferably of leather for breathability. o The ball is the widest part of the sole and corresponds to the area

of the metatarsal heads. o The shank area is from the anterior border of the heel to the ball. A

steel piece may be used to reinforce the shank area. o The toe spring is the space between the anterior sole and the floor.

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Heel o Leather with rubber on the plantar surface commonly is used for the

heel. o A spring heel is one-eighth inch high. o An Oxford heel is three quarters to one inch high. o A military heel is one and one quarter inches high. o A Cuban heel is one and a half inches high. o The heel counter is the posterior portion of the upper part between

the quarters. This structure is used to reinforce the quarters and support the calcaneus. The heel counter can increase the posterior stability of the shoe.

Upper o The upper is the portion of the shoe above the sole. o The vamp is the anterior section. o The quarters are the posterior section. o The throat is the base of the tongue. o The tongue is a piece attached to the vamp. o The toe box is the reinforcement of the vamp to protect the shoe

from trauma.

Rocker shoe.

:  Blucher style orthopedic shoe (top); diabetic shoe (bottom)

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Shoe modifications

A properly fitted shoe should have adequate room for the foot to expand while the patient is bearing weight. The shoe should be at least 1 cm longer than the longest toe, and the widest part also should correspond to the widest part of the foot. Shoes can be modified to reduce pressure on sensitive areas by redistributing weight toward pain-free areas.

External shoe modifications

Heel modifications o A cushioned heel: A wedge of compressible rubber is inserted into

the heel to absorb impact at heel strike. This cushion often is used with a rigid ankle to reduce the knee flexion moment by allowing for more rapid ankle plantar flexion.

o A heel flare: A medial flare is used to resist inversion, and a lateral flare is used to resist eversion. Both flares are used to provide heel stability.

o A heel wedge: A medial wedge is used to promote inversion, and a lateral wedge is used to promote eversion. The heel counter should be strong enough to prevent the hindfoot from sliding down the incline created by the wedge.

o Extended heel: The Thomas heel projects anteriorly on the medial side to provide support to the medial longitudinal arch. The reverse Thomas heel projects anteriorly on the lateral side to provide stability to the lateral longitudinal arch.

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o Heel elevation: A shoe lift is used to compensate for fixed equinus deformity or for any leg-length discrepancy of more than one quarter of an inch.

Sole modifications

o A rocker bar is a convex structure placed posterior to the metatarsal head. The rocker bar is used to shift the rollover point from metatarsal head to metatarsal shaft to avoid irritation of ulcers along the metatarsal head in patients with diabetes mellitus (DM).

o A metatarsal bar is a bar with a flat surface placed posterior to the metatarsal head. The metatarsal bar is used to relieve the pressure from the metatarsal heads.

o A sole wedge: A medial wedge is used to promote supination, and a lateral wedge is used to provide pronation.

o A sole flare: A medial flare is used to resist inversion, and a lateral flare is used to resist eversion. Both flares promote great stability.

o A steel bar: The steel bar is placed between the inner sole and outer sole. This bar is used to reduce forefoot motion to reduce the stress from phalanges and metatarsals.

Combination of sole and heel modifications: If heel elevation is more than one half an inch, a sole elevation should be added to avoid equinus posture.

Internal shoe modifications

Heel modifications o Heel cushion relief: This soft pad with excavation is placed under

the painful point of the heel.

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o Heel wedges: A medial heel wedge can rotate the hindfoot into inversion. A lateral heel wedge can evert the hindfoot to avoid pressure on the cuboid.

Sole modifications o Metatarsal pad: This domed pad is designed to reduce the stress

from metatarsal heads by transferring the load to metatarsal shafts in metatarsalgia.

o Inner sole excavation: A soft pad filled with compressible material is placed under one or more metatarsal heads.

o Scaphoid pad: This type of pad extends from one half inch posterior to the first metatarsal head to the anterior tubercle of the calcaneus. The apex of the scaphoid pad is between the talonavicular joint and the navicular tuberosity. The scaphoid pad is used for medial arch support.

o Toe crest: A crescent-shaped pad is placed behind the second through fourth phalanges. The toe crest fills the void under the proximal phalanges and reduces the stress.

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Foot orthosis

The foot orthosis extends from the posterior border of the foot to a point just posterior to the metatarsal heads. This device is used to accommodate the abnormal foot to help restore more normalized lower limb biomechanics.

UCBL (University of California at Berkeley Laboratory) insert: This insert is made of rigid plastic fabricated over a cast of the foot held in maximal manual correction. The UCBL encompasses the heel and midfoot, and it has rigid medial, lateral, and posterior walls.

Heel cup: The heel cup is a rigid plastic insert that covers the plantar surface of the heel and extends posteriorly, medially, and laterally up the side of the heel. The heel cup is used to prevent lateral calcaneal shift in the flexible flat foot.

Sesamoid insert: This addition to an orthosis is an insert amounting to three quarters of an inch with an extension under the hallux to transfer pressure off the short first metatarsal head and onto its shaft.

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ANKLE-FOOT ORTHOTICS An AFO is commonly prescribed for weakness or paralysis of ankle dorsiflexion, plantar flexion, inversion, and eversion. AFOs are used to prevent or correct deformities and reduce weight bearing. The position of the ankle indirectly affects the stability of the knee with ankle plantar flexion providing a knee extension force and ankle dorsiflexion providing a knee flexion force. An AFO has been shown to reduce the energy cost of ambulation in a wide variety of conditions, such as spastic diplegia due to cerebral palsy, lower motor neuron weakness of poliomyelitis, and spastic hemiplegia in cerebral infarction.

Thermoplastic molded ankle-foot orthosis (posterior leaf spring, minimal resistance, moderate resistance, maximal resistance/solid ankle-foot orthosis).

Thermoplastic AFOs: These devices are plastic molded AFOs, consisting of the following 3 parts: (1) a shoe insert, (2) a calf shell, and (3) a calf strap attached proximally. The rigidity depends on the thickness and composition of the plastic, as well as the trim line and shape. Thermoplastic AFOs are contraindicated in cases of fluctuating edema and insensation.

1. Posterior leaf spring (PLS): The PLS is the most common form of AFO with a narrow calf shell and a narrow ankle trim line behind the malleoli. The PLS is used for compensating for weak ankle dorsiflexors by resisting ankle plantar flexion at heel strike and during swing phase with no mediolateral control.

2. Spiral AFO: This AFO consists of a shoe insert, a spiral that starts medially, passes around the leg posteriorly, then passes anteriorly to terminate at the medial tibial flare where a calf band is attached. The spiral AFO allows for rotation in the transverse plane while

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controlling ankle dorsiflexion and plantar flexion, as well as eversion and inversion.

3. Hemispiral AFO: This AFO consists of a shoe insert with a spiral starting on the lateral side of the shoe insert, passing up the posterior leg, and terminating at the medial tibial flare where the calf band is attached. This design is used for achieving better control of equinovarus than the spiral AFO can.

4. Solid AFO: The solid AFO has a wider calf shell with trim line anterior to the malleoli. This AFO prevents ankle dorsiflexion and plantar flexion, as well as varus and valgus deviation.

5. AFO with flange: This AFO has an extension (flange) that projects from the calf shell medially for maximum valgus control and laterally for maximum varus control.

6. Hinged AFO: The adjustable ankle hinges can be set to the desired range of ankle dorsiflexion or plantar flexion.

7. Tone-reducing AFO (TRAFO): The broad footplate is used to provide support around most of the foot, extending distally under the toes and up over the foot medially and laterally to maintain the subtalar joint in normal alignment. The TRAFO is indicated for patients with spastic hemiplegia.

Metal and metal-plastic AFOs

This type of AFO consists of a shoe or foot attachment, ankle joint, 2 metal uprights (medial and lateral), with a calf band (application of force) connected proximally. The stirrup anchors the uprights to the shoes between the sole and the heel. The caliper is a round tube placed in the heel of the shoe, which connects to the uprights and also allows for easy detachability of the uprights. A molded shoe insert is another alternative to fit the stirrup into the shoe, which also allows maximum control of the foot and aligns the anatomic and mechanical ankles.

Ankle joints: The mechanical ankle joints can control or assist ankle dorsiflexion or plantar flexion by means of stops (pins) or assists (springs). The mechanical ankle joint also controls mediolateral stability. Knee extension moment is promoted by ankle plantar flexion, and knee flexion moment is promoted by ankle dorsiflexion.

1. Free motion ankle joint: The stirrup has a completely circular top, which allows free ankle motion and provides only mediolateral stability.

2. Plantar flexion ankle joint stop: This ankle joint stop is produced by a pin inserted in the posterior channel of the ankle joint or by flattening the posterior lip of the stirrup's circular stop. The plantar flexion stop has a posterior angulation at the top of the stirrup that restricts plantar flexion but allows unlimited dorsiflexion and promotes knee flexion moment. This design is used in patients with

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weakness of dorsiflexion during swing phase and flexible pes equinus.

3. Dorsiflexion ankle joint stop: The stirrup has a pin inserted in the anterior channel of the ankle joint or by flattening the anterior lip of the stirrup's circular stop. The dorsiflexion stop has an anterior angulation at the top of the stirrup that restricts dorsiflexion but allows unlimited plantar flexion and promotes a knee extension moment in the meantime. This design is used in patients with weakness of plantar flexion during late stance.

4. Limited motion ankle joint stop: This ankle joint stop has anterior and posterior angulations at the top of the stirrup with restricted dorsiflexion and plantar flexion ankle motion. The limited motion ankle joint stop has a pin in the anterior and the posterior channel, and it is used in ankle weakness affecting all muscle groups.

5. Dorsiflexion assist spring joint: This joint has a coil spring in the posterior channel and helps to aid dorsiflexion during swing phase.

6. Varus or valgus correction straps (T-straps): A T-strap attached medially and circling the ankle until buckling on the outside of the lateral upright is used for valgus correction. A T-strap attached laterally and buckling around the medial upright is used for varus correction.

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KNEE-ANKLE-FOOT ORTHOTICS AND KNEE ORTHOTICS

KAFOs consist of an AFO with metal uprights, a mechanical knee joint, and 2 thigh bands. KAFO can be used in quadriceps paralysis or weakness to maintain knee stability and control flexible genu valgum or varum. KAFO also is used to limit the weight bearing of the thigh, leg, and foot with quadrilateral or ischial containment brim. A KAFO is more difficult to don and doff than an AFO, so it is not recommended for patients who have moderate-to-severe cognitive dysfunction.

KAFO: This orthosis can be made of metal-leather and metal-plastic or plastic and plastic-metal. The metal design includes double upright metal KAFO (most common), single upright metal KAFO (lateral upright only), and Scott-Craig metal KAFO. The plastic designs are indicated for closer fit and maximum control of the foot, including supracondylar plastic KAFO, supracondylar plastic-metal KAFO, and plastic shells with metal uprights KAFO.

1. A double upright metal KAFO: This is an AFO with 2 metal uprights extending proximally to the thigh to control knee motion and alignment. This orthosis consists of a mechanical knee joint and 2 thigh bands between 2 uprights.

2. A Scott-Craig orthosis consists of a cushioned heel with a T-shaped foot plate for mediolateral stability, ankle joint with anterior and posterior adjustable stops, double uprights, a pretibial band, a posterior thigh band, and knee joint with pawl locks and bail control. Hyperextension of the hip allows the center of gravity falling behind the hip joint and in front of the locked knee and ankle joint. With 10° of ankle dorsiflexion alignment, it allows a swing-to or swing-through gait with crutches. This orthosis is used for standing and ambulation in patients with paraplegia due to spinal cord injury (SCI).

3. The supracondylar plastic orthosis uses immobilized ankle in slight plantar flexion to produce a knee extension moment in stance to help eliminate the need for a mechanical knee lock. This orthosis also resists genu recurvatum and provides mediolateral knee stability.

4. A plastic shell and metal upright orthosis consists of a posterior leaf spring AFO with double metal uprights extending up to a plastic shell in the thigh with an intervening knee joint.

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Knee joints: The mechanical knee joint can be polycentric or single axis. Polycentric is used for significant knee motion, and a single axis is more common and is used for knee stabilization. Single axis knee joints include the following:

1. Free motion knee joint: This joint has unrestricted knee flexion and extension with a stop to prevent hyperextension. The free motion knee joint is used for patients with recurvatum but good strength of the quadriceps to control knee motion.

2. Offset knee joint: The hinge is located posterior to the knee joint and ground reaction force; thus, it extends the knee and provides great stability during early stance phase of the gait cycle. This joint flexes the knee freely during swing phase and is contraindicated with knee or hip flexion contracture and ankle plantar flexion stop.

3. Drop ring lock knee joint: The drop ring lock is the most commonly used knee lock to control knee flexion. The rings drop to unlock over the knee joint while the knee is in extension by gravity or manual assistance. This type of joint is stable, but gait is stiff without knee motion. A ball bearing on a spring can be added just above the drop lock to keep it from slipping up as the patient ambulates. Patients over 120 pounds usually feel more secure with both medial and lateral drop locks.

4. Pawl lock with bail release knee joint: The semicircular bail attaches to the knee joint posteriorly, and it can unlock both joints easily by pulling up the bail or backing up to sit down in a chair. A major drawback is the accidental unlocking while the patient is pulling his or her pants up or bumping into a chair.

5. Adjustable knee lock joint (dial lock): The serrated adjustable knee joint allows knee locking at different degrees of flexion. This type of knee joint is used in patients with knee flexion contractures that are improving gradually with stretching.

6. Ischial weight bearing: Most individuals in a KAFO sit partially on the upper thigh band unless the cuff is brought up above the ischium.

Knee cap and strap: The knee cap can be placed in front of the knee in the orthosis to prevent flexion of the knee. A medial strap is used for genu valgum and a lateral strap is used for genu varum. These buckles wrap around the upright in the same way as ankle straps.

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Knee orthoses

A knee orthosis (KO) only provides support or control of the knee but not of the foot and ankle. The knee joint is centered over the medial femoral condyle. If the patient does not have adequate gastrocnemius delineation so that there is a shelf for the distal end of the orthosis to rest on, the brace may slide down the leg with wear. In that case, the brace needs to extend to the sole of the foot.

Knee orthoses for patellofemoral disorder: These orthoses are used to supply mediolateral knee stability and to control tracking of the patella during knee flexion and extension. This type of orthosis includes an infrapatellar strap KO and Palumbo KO.

Knee orthoses for knee control in the sagittal plane: These orthoses are used to control genu recurvatum with minimal mediolateral stability. This type of KO includes a Swedish knee cage and a 3-way knee stabilizer.

Knee orthoses for knee control in the frontal plane: These orthoses consist of thigh and calf cuffs joined by sidebars with mechanical knee joints. The knee joint usually is polycentric and closely mimics the anatomic joint motion. This type of KO includes traditional metal-leather KO, Miami KO, Canadian Arthritis and Rheumatism Society-University of British Columbia KO, and supracondylar KO.

Knee orthoses for axial rotation control: These orthoses can provide angular control of flexion-extension and mediolateral planes, in addition to controlling axial rotation. This orthosis is used mostly in management of sports injuries of the knee. This type of KO includes Lenox-Hill derotation orthosis and Lerman multiligamentous knee control orthosis.

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HIP-KNEE-ANKLE-FOOT ORTHOTICS An HKAFO consists of a hip joint and pelvic band in addition to a KAFO. The orthotic hip joint is positioned with the patient sitting upright at 90°, while the orthotic knee joint is centered over the medial femoral condyle. Pelvic bands complicate dressing after toileting unless the orthosis is worn under all clothing. Pelvic bands increase the energy demands for ambulation.

Pelvic bands 1. Bilateral pelvic band: This band is used more commonly with its

posterior metal ends located anterior to the lateral midline of the pelvis and is interconnected by a flexible belt.

2. Unilateral pelvic band: This band rarely is used because most conditions requiring a HKAFO have bilateral involvement.

3. Pelvic girdle: The pelvic girdle is made of molded thermoplastic materials, providing a maximum degree of control in patients with bilateral involvement.

4. Silesian belt: This belt has no metal or rigid band and offers mild resistance to abduction and rotation of the hip. The Silesian belt attaches to the lateral upright and encircles the pelvis.

Hip joints and locks: The hip joint can prevent abduction and adduction as well as hip rotation.

1. Single axis hip joint with lock: This joint is the most common hip joint with flexion and extension. The single axis hip joint with lock may include an adjustable stop to control hyperextension.

2. Two-position lock hip joint: This hip joint can be locked at full extension and 90° of flexion and is used for hip spasticity control in a patient who has difficulty maintaining a seated position.

3. Double axis hip joint: This hip joint has a flexion-extension axis and abduction-adduction axis to control these motions.

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TRUNK-HIP-KNEE-ANKLE-FOOT ORTHOTICSA THKAFO consists of a spinal orthosis in addition to a HKAFO for control of trunk motion and spinal alignment. A THKAFO is indicated in patients with paraplegia and is very difficult to don and doff.

1. Reciprocating gait orthosis (RGO): An RGO consists of bilateral KAFOs with posteriorly offset locking knee joints, hip joints, and a custom-molded pelvic girdle with a thoracic extension. The hip joints are coupled with cables preventing bilateral hip flexion simultaneously. The hip extension on one side coupling hip flexion on the other side through the cables produces reciprocal walking gait pattern. The RGO combined with functional electronic stimulation (FES) can be used for 2-point or 4-point gait patterns in ambulatory paraplegic or tetraplegic (C8) patients. Using the RGO with FES can double the patient's optimum gait speed, lower blood pressure and heart rate, and increase oxygen uptake as compared to ambulating with the RGO without FES.

2. Para walker: This device is a hip guidance orthosis, which consists of bilateral KAFOs with a ball bearing hip joint and a body brace. Ambulation is performed through trunk motion transmitted to the lower extremities with hip flexion and extension via the brace. Hip flexion is restricted by a stop, and hip extension may be free or limited by a stop. The para walker is developed for patients with SCI. A study of 5 paraplegic patients found an average reduction in oxygen consumption of 27%, with 33% faster ambulatory rate compared to the RGO.

3. Parapodium: This device is developed for pediatric myelodysplastic patients to allow them to stand without crutches for functional activities with their upper limbs free. The parapodium consists of a shoe clamp, aluminum uprights, a foam knee block, and back and chest panels. Hip and knee may be locked for standing and unlocked for sitting. A torque converter under the base allows side-to-side rocking to be translated into forward propulsion.

4. Standing frame: This allows standing but does not permit hip and knee flexion. The standing frame is used for children to learn standing balance and achieve a swing-through gait.

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SPECIAL PURPOSE LOWER LIMB ORTHOTICS Weight-bearing orthoses: This orthosis is designed to eliminate weight bearing through the lower extremities. Weight-bearing orthoses consist of patellar-tendon–bearing orthosis (PTBO), ischial weight-bearing orthosis, and patten bottom with uprights terminated in a floor pad or patten distal to the shoe.

1. Fracture orthoses: This orthosis stabilizes the fracture site and promotes callus formation, while allowing weight bearing and joint movement after initial subsiding pain and edema. The bony motion at the fracture site is prevented through circumferential compression of the soft tissue. Fracture orthoses include the tibial fracture orthosis and femoral fracture orthosis.

2. Angular and deformity orthoses: This orthosis is used in the pediatric population. The Denis Brown splint is for clubfoot. A frame orthosis applies corrective forces to proximal rotational deformities. A torsion shaft orthosis is used in mild scissoring gait of spastic diplegia.

3. Congenital hip dislocation orthoses, such as Pavlik harness, Ilfeld splint, and VonRosen splint are used to maintain the hip in flexion and abduction position to hold the femoral head within the acetabulum.

4. The Scottish Rite, Toronto, and non–skeletal-bearing trilateral orthoses are used in Legg-Calve-Perthes disease to maintain the hip in abduction and keep the femoral head in the acetabulum.

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:  Rocker shoe.

:  Blucher style orthopedic shoe (top); diabetic shoe (bottom)

Thermoplastic molded ankle-foot orthosis (posterior leaf spring, minimal resistance, moderate resistance, maximal resistance/solid ankle-foot orthosis).

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Modular ankle-foot orthosis with double adjustable hinged joint ankle-foot orthosis.

Flesh colored plastic Gelett joint with dorsiflexion assist ankle-foot orthosis.

:  Double upright metal ankle-foot orthosis.

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Carbon plastic ankle-foot orthosis with footplate.

Double upright metal knee-ankle-foot orthosis.

:  Plastic shell and metal uprights molded knee-ankle-foot orthosis with drop lock joints.

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Offset knee joint knee-ankle-foot orthosis.

Drop ring lock knee joint knee-ankle-foot orthosis.

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Limb Prostheses

General Background:

External prosthetic appliances are devices used to replace the function of a missing body part and are often referred to as prosthetic devices, or prostheses. Lower limb prostheses are used to replace the function of a lower extremity. In the elderly population, amputation (loss) of the lower extremity most often results from complications of disease processes, such as diabetes, peripheral vascular disease, thromboembolism and vasculitis. The second most common cause of lower limb amputation is trauma to the limb, which is frequently seen in a younger population. Amputation may also result from treatment for a malignancy or various other medical conditions. Several prosthetic devices are available to replace the function of lower limbs. For amputees with above-knee limb loss, devices have traditionally consisted of single-axis knees and/or hydraulic or pneumatic fluid-controlled therapy devices. These devices provide optimum gait control at usual speed but require additional compensation when walking slower or faster and also require increased concentration and effort of the amputee. Although a device of this type does produce a limp, the greatest stability is offered with the use of a manual locked knee which locks the prosthesis straight for walking. The manual locked-knee device has a release lever or cable that can be pulled to unlock the joint and allows bending. Prosthetic devices consisting of an ankle and/or foot device are also utilized for below-the-knee amputees.

Definition:

A limb prosthesis is an artificial replacement for any or all parts of the lower extremity or upper extremity.

An artificial limb is a type of prosthesis that replaces a missing extremity, such as arms and legs.

Purpose:

A prosthesis is used to provide an individual who has an amputated limb with the opportunity to perform functional tasks, particularly ambulation (walking), which may not be possible without the limb.

Amputation surgery most often is performed due to complications of peripheral vascular disease or neuropathy; trauma is the second leading cause of amputation. Industrial, vehicular, and war related accidents are the leading cause

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of amputations, disease is the leading cause of amputations.[1] Cancer, infection and circulatory disease are the leading diseases that may lead to amputation. Amputations performed because of tumor or congenital limb deficiency are less common. A congenital defect can create the need for an artificial limb when a person is born with a missing or damaged limb.

The type of prosthesis (artificial limb) used is determined largely by the extent of an amputation or loss and location of the missing extremity.

Recovery Stages: The American Academy of Orthotists and Prosthetists (AAOP) formed the Clinical Standards of Practice (CSOP) on Post-operative Management of the Lower Extremity (2004). The committee defined stages of care extending from the preoperative period to the late stage postoperative rehabilitation. Typically, the postoperative recovery period (including activity recovery, reintegration, prosthetic management and training) lasts from 12–18 months. However, healing of a residual limb is a continuous process and prosthetic readiness is an individualized transition point. The following stages of care were defined:

• Preoperative stage: This stage begins with the decision to amputate.

• Acute hospital postoperative stage: This stage includes the time in the hospital after amputation surgery, generally 5–14 days.

• Immediate postacute hospital stage: This stage begins with the hospital discharge and may extend up to eight weeks after surgery. Endpoints of this stage are characterized by wound healing and readiness for a prosthetic fitting.

• Intermediate recovery stage: This stage begins with wound healing and extends 4–6 months from the healing date and involves the use of a preparatory prosthesis or first prosthesis. Often, the most rapid limb volume changes occur during this period as a result of ambulation and prosthetic use. This stage typically ends with stabilization of residual limb size, as defined by consistency of prosthetic fit for several months.

• Transition to stable stage: A period of relative limb stabilization after the immediate recovery stage. This stage was historically marked as a transition from the preparatory prosthesis to the definitive prosthesis, although more recently it has been characterized by a change from a rapidly changing limb to a slower maturation of the limb. While limb volume changes are not as drastic in this stage, the limb may continue to change for 12–18 months after initial healing. Modular systems are frequently encouraged during this stage.

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Postoperative rehabilitation should begin as soon as possible. Fitting for the prosthesis may begin once the suture line has completely healed, and swelling is minimized, although in some rare cases (e.g., young patients with traumatic amputations), a temporary prosthesis may be fitted in surgery. Immediate postoperative prosthetic limb fitting has not gained wide acceptance due to unacceptable rates of wound complications (Pinzur, 2003). Residual limb shrinkage and swelling are often controlled in the postoperative recovery phase with the use of various types of dressings. Ace wraps prevent swelling and encourage shrinkage and may be used prior to complete healing of the limb. A rigid dressing, such as a cast, may be used when temporary prosthetic devices are recommended. Other methods to assist in shrinkage and reduction of swelling include the use of compression stockings and stump shrinkers (elastic stockings). The initial shrinkage and shaping of the limb takes approximately six weeks to three months, depending on response and condition (Sherman and Jones, 1995). Care of the residual limb is a lifelong process, and changes in residual stump size may be the result of weight gain, weight loss or swelling.

Prosthetic devices for children are often staged based on the child’s developmental readiness. The prosthesis must accommodate growth and other physiological changes. According to AAOP (Cummings and Kapp, 1992), methods that allow for growth and that may increase the lifespan of the prosthesis include the following:

• modification of socket liners

• flexible sockets

• removable sockets (slip or triple wall sockets)

• adding or decreasing sock thickness

• distal pads

• the use of modular systems

• growth oriented suspension systems and modifications

Furthermore, although the prosthetic treatment plan is highly individualized, children require frequent follow-up for growth and typically require new devices every 12–18 months on average, although the actual lifespan of the device depends on the child’s rate of skeletal growth.

Types of Prosthetic Devices:

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Prosthetic devices may be preparatory or permanent. A preparatory device (more common for lower limb amputees) is a prosthesis made soon after an amputation (approximately four weeks) as a temporary method of retraining a person to walk and balance while shrinking the residual limb. Preparatory devices often use transparent diagnostic test sockets and special fitting techniques to accurately fit the prosthesis so problems can be eliminated before it is copied for the permanent prosthesis. The average use of these devices may last for 3–6 months in some cases or until the residual limb has reached its final shape and size. Stabilization of the residual limb is difficult to define; however, AAOP CSOP (2004) suggests that a permanent prosthesis be recommended when a patient has used a prosthetic device full time for a period of six months and when the limb volume has stabilized to a point where the socket fit remains relatively consistent for 2–3 weeks. Once fitted, the permanent prosthesis, also referred to as a definitive prosthesis, is classified as a device that meets accepted clinical standards for comfort, fit, function, appearance and durability. In some circumstances, a patient may be fitted only for a permanent device, and fitting should be delayed until the residual limb is fully mature (usually 3–4 months) or until stabilization occurs in the patient’s weight and stump circumference (Bodeau, 2002). When an initial below-knee prosthesis (Health Care Financing Administration [HCFA] Common Procedural Coding System [HCPCS] code L5500) or a preparatory below-knee prosthesis (HCPCS codes L5510–L5530, L5540) is provided, prosthetic substitutions and/or additions of procedures and components may be medically necessary in accordance with the functional level assessment, except for HCPCS codes L5629, L5638, L5639, L5646, L5647, L5704, L5785, L5962 and L5980; the latter are not considered medically necessary. When a below-knee preparatory, prefabricated prosthesis (HCPCS code L5535) is provided, prosthetic substitutions and/or additions of procedures may be medically necessary in accordance with the functional level assessment, except for HCPCS codes L5620, L5629, L5645, L5646, L5670, L5676, L5704 and L5962; the latter codes are not considered medically necessary. When an above-knee initial prosthesis (HCPCS code L5505) or an above-knee preparatory (HCPCS codes L5560–L5580, L5590–L5600) prosthesis is provided, prosthetic substitution and/or additions of procedures and components may be medically necessary in accordance with the functional level assessment, except for HCPCS codes L5610, L5631, L5640, L5642, L5644, L5648, L5705, L5706, L5964, L5980, L5710–L5780 and L5790–L5795; the latter codes are not considered medically necessary. When an above-knee preparatory, prefabricated prosthesis (HCPCS code L5585) is provided, prosthetic substitution and/or additions of procedures and components may be medically necessary in accordance with the functional level assessment, except for HCPCS codes L5624, L5631, L5648, L5651, L5652, L5705, L5706, L5964 and L5966; the latter codes are not considered medically necessary. Functional Classifications

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Prior to being fitted with a prosthetic device, the patient must demonstrate specific functional levels. A functional level is defined as a measurement of the capacity and potential of the patient to accomplish his/her expected post-rehabilitation daily function. The Centers for Medicare and Medicaid Services (CMS) have defined the following functional levels: Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and prosthesis does not enhance his/her quality of life or mobility. Level 1: Has the ability or potential to use prosthesis for transfers or ambulating on level surfaces at fixed cadence; typical of the limited and unlimited household ambulator. Level 2: Has the ability or potential for ambulating with the ability to traverse environmental barriers such as curbs, stairs or uneven surfaces; typical of the limited community ambulator. Level 3: Has the ability or potential for ambulating with variable cadence; typical of the community ambulator who has the ability to traverse most environmental barriers and may have

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vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. Level 4: Has the ability or potential for prosthetic ambulating that exceeds basic ambulating skills, exhibiting high impact, stress, or energy levels; typical of the prosthetic demands of the child, active adult, or athlete. Potential functional ability is based on reasonable expectations of the prosthetist and the treating physician that are based on factors including but not limited to:

• the patient’s past history (including prior prosthetic use, if applicable)

• the patient’s current condition (including status of the residual limb and the nature of other medical problems)

• the patient’s desire to ambulate

A patient whose functional level is zero (0) is not a candidate for a prosthetic device; the device is considered not medically necessary. A basic (i.e., conventional) lower limb prosthetic device consists of the following:

• a socket (connection between the residual limb and prosthesis)

• a suspension mechanism (how the socket is attached to the prosthesis)

• a knee joint (provides support during stance, smooth control during swing phase and unrestricted motion for sitting and kneeling)

• a pylon (a tube or shell that attaches the socket to the terminal device) that is either exoskeleton or endoskeleton

• a terminal device (foot)

Components and/or additions to the prosthesis may be medically necessary; the determination of medical necessity is based on the patient’s functional ability and expected functional potential as defined by the prosthetist and the ordering physician. Additional documentation supporting medical necessity must accompany claims submitted for prosthetic components and/or additions. Customizing prosthetic devices with enhanced features is not medically necessary if activities of daily living can be met with standard devices. Accessories that are necessary for the effective use of the prosthetic device, such as stump socks and harnesses, may be considered medically necessary devices. Accessories that are not necessary for the effective use of the device are considered not medically necessary.

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The following items are typically included in the reimbursement for a prosthetic device:

• evaluation of the residual limb and gait

• fitting of the prosthesis

• cost of base component parts and labor contained in HCPCS base codes

• repairs due to normal wear and tear during the 90 days following delivery

• adjustments of the prosthesis or the prosthetic component made when fitting the prosthesis or component and for 90 days from the date of delivery when the adjustments are not necessitated by changes in the residual limb or the patient’s functional ability

Description

There are several levels of lower limb amputation, including partial foot, ankle disarticulation, transtibial (below the knee), knee disarticulation, transfemoral (above the knee), and hip disarticulation. The most common are transtibial (mid-calf) and transfemoral (mid-thigh). The basic components of these lower limb prostheses are the foot-ankle assembly, shank, socket, and suspension syste

The basic components of a lower extremity prosthesis include:

the socket, a sock or gel liner, a suspension system, a knee joint (articulating joint), the shank (a pylon), and a foot (terminal device)

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(Fig. 1).

Figure 1: Lower extremity prosthesis components.

Foot-ankle assembly

The foot-ankle assembly is designed to provide a base of support during standing and walking, in addition to providing shock absorption and push-off during walking on even and uneven terrain. Four general categories of foot-ankle assemblies are non-articulated, articulated, elastic keel, and dynamic-response. One of the most widely prescribed foot is the solid-ankle-cushion-heel (SACH) foot, due to its simplicity, low cost, and durability. It may be inappropriate, however, for active community ambulators and sports participants. Articulated

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assemblies allow motion at the level of the human ankle; this motion may occur in one or more planes, depending on whether it is a single-axis or multi-axis foot. These assemblies offer more mobility at the cost of less stability and increased weight. The elastic keel foot is designed to mimic the human foot without the use of mechanical joints; the dynamic-response foot is designed to meet the demands of running and jumping in athletic us

Figure 3: Variety of Foot or Terminal Devices

Shank

The shank corresponds to the anatomical lower leg, and is used to connect the socket to the ankle-foot assembly. In an endoskeletal shank, a central pylon, which is a narrow vertical support, rests inside a foam cosmetic cover. Endoskeletal systems allow for adjustment and realignment of prosthetic components. In an exoskeletal shank, the strength of the shank is provided by a hard outer shell that is either hollow or filled with lightweight material. Exoskeletal systems are more durable than endoskeletal systems; however, they may be heavier and have a fixed alignment, making adjustments difficult.

Suspension

Suspension devices should keep the prosthesis firmly in place during use and allow comfortable sitting. Several types of suspension exist, both for the transtibial and transfemoral amputation. Common transtibial suspensions include sleeve, supracondylar, cuff, belt and strap, thigh-lacer, and suction styles. Sleeves are made of neoprene, urethane, or latex and are used over the shank, socket and thigh. Supracondylar and cuff suspensions are used to capture the femoral condyles and hold the prosthesis on the residual limb. The belt and strap method uses a waist belt with an anterior elastic strap to suspend the prosthesis, while the thigh-lacer method uses a snug-fitting corset around the thigh. The suction method consists of a silicone sleeve with a short pin at the end. The sleeve fits over the residual limb and the pin locks into the socket. With a

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transfemoral prosthesis, suction and several types of belt suspension also are available.

Transfemoral amputations also provide the additional challenge of incorporating a prosthetic knee unit. The knee unit must be able to bend and straighten smoothly during ambulation, in addition to providing stability during weightbearing on that limb. Knees are available as single-axis, polycentric, weight-activated, manual-locking, hydraulic, and pneumatic units. Technology using microprocessors in knee units is becoming a reality, although costs can be prohibitive.

The socket

The socket enables the prosthesis to connect and fit to the stump (residual limb). This is the most important prosthetic component. A good fit is critical. A socket that is uncomfortable is a common reason why a prosthesis is rejected. Contoured sockets fit closer to the remaining bones, muscles, and soft tissues providing better support, and provide relief where it's needed for comfort. 8 Examples of contoured sockets include the Hanger ComfortFlex™ Socket System, Quadrilateral Socket, CAT/CAM Socket, ML socket, Acrylic socket, Total Contact Socket, Pump It Up system, the Otto Bock Air Cushion Socket system and more. Liners are sometimes used inside the socket to obtain a better fit and for comfort. A gel liner helps in pressure distribution, comfort, and skin smoothing.

Operation

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Use of an actual prosthesis usually follows a period of postoperative management that includes addressing issues of pain, swelling, and proper positioning. In addition, physical therapy for range of motion, strength, bed mobility, transfers, and single limb ambulation often takes place during the initial rehabilitation period. In some cases, an individual may be fitted with an immediate post-operative prosthesis to allow for early double-limb ambulation. Many individuals will be fitted with a temporary prosthesis when the wound has healed. A temporary prosthesis allows for ambulation and continued shrinkage of the residual limb until a definitive prosthesis is fit.

When evaluating a prosthesis before use, the prosthetist and physical therapist should ensure that the inside of the socket is smooth and that all joints move freely. The socket should fit securely on the residual limb, and the overall prosthesis length should match the length of the intact leg. The patient must learn how to properly put on the residual limb sock and the prosthesis itself. A variety of techniques are used, depending on the type of socket and suspension system.

Maintenance

The user should be aware of how to properly care for and maintain the prosthesis, liner, and socks. Most plastic sockets and liners can be wiped with a damp cloth and dried. Socks should be washed and changed daily. Due to the wide variety of componentry and materials used in the fabrication of prostheses, the prosthetist should be the source for instructions regarding proper care and maintenance for each individual. In general, the patient should return to the prosthetist for any repairs, adjustments or realignments.

Health care team roles

The patient's primary care physician, surgeon, neurologist, prosthetist, physical and occupational therapists, nurses, and social worker are all important players in the multidisciplinary health care team. Surveys of patients with amputations have shown that the physical therapist, along with the physician and prosthetist, plays one of the most valued roles in providing information and help both at the time of amputation and following amputation. The entire team's input, along with the patient's input, is vital in determining whether a prosthesis should be fit and the specific prescription for the prosthesis. Input should be provided regarding the patient's medical history, premorbid level of function, present level of function, body build, range of motion, strength, motivation, and availability of familial and social support.

The physical therapist usually plays a major role in training an individual to walk with a prosthesis, and also is the health care professional who can evaluate prosthetic function immediately and over time. The physical therapist is trained in

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gait assessment and should watch for compensations and gait deviations that may indicate a problem with the prosthesis.

Training

The main goal of prosthetic training usually is smooth, energy-efficient gait. This includes the ability of the individual to accept weight on either leg, balance on one foot, advance each leg forward and adjust to different types of terrain or environmental conditions. Principles of motor learning often are used in training, progressing from simple to complex tasks. Individuals begin with learning to keep their bodies stable in a closed environment with no manipulation or variability. An example may be practicing standing balance on one or both legs. Mobility, environmental changes, and task variability are added slowly to further challenge the individual as tasks are mastered. In the end, an example of a more complex task practiced may be the ability walk in a crowded hallway while carrying an object in one hand. In addition to ambulation training, the patient also should be taught how to transfer to and from surfaces, assume a variety of positions such as kneeling or squatting, and manage falls. Depending upon the individual's previous and present level of function, use of a traditional cane, quad cane, or crutches may be indicated. Patient motivation, comorbidity, level of amputation and level of function are all factors in determining the outcome of rehabilitation.

Current Technology/Manufacturing

In recent years there have been significant advancements in artificial limbs. New plastics and other materials, such as carbon fiber, have allowed artificial limbs to be stronger and lighter, limiting the amount of extra energy necessary to operate the limb. This is especially important for transfemoral amputees. Additional materials have allowed artificial limbs to look much more realistic, which is important to transradial and transhumeral amputees because they are more likely to have the artificial limb exposed.[4]

In addition to new materials, the use of electronics has become very common in artificial limbs. Myoelectric limbs, which control the limbs by converting muscle movements to electrical signals, have become much more common than cable operated limbs. Myoelectric limbs allow the amputees to more directly control the artificial limb. Computers are also used extensively in the manufacturing of limbs. Computer Aided Design and Computer Aided Manufacturing are often used to assist in the design and manufacture of artificial limbs.[4]

Most modern artificial limbs are attached to the stump of the amputee by belts and cuffs or by suction. The stump usually fits into a socket on the prosthetic. The socket is custom made to create a better fit between the leg and the artificial limb, which helps reduce wear on the stump. The custom socket is created by taking a plaster cast of the stump and then making a mold from the plaster cast.

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Newer methods include laser guided measuring which can be input directly to a computer allowing for a more sophisticated design.

One of the biggest problems with the stump and socket attachment is that there is a large amount of rubbing between the stump and socket. This can be painful and can cause breakdown of tissue.

Artificial limbs are typically manufactured using the following steps:

1. Measurement of the stump 2. Measurement of the body to determine the size required for the

artificial limb 3. Creation of a model of the stump 4. Formation of thermoplastic sheet around the model of the stump –

This is then used to test the fit of the prosthetic 5. Formation of permanent socket 6. Formation of plastic parts of the artificial limb – Different methods

are used, including vacuum forming and injection molding 7. Creation of metal parts of the artificial limb using die casting 8. Assembly of entire limb.

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Types of Prosthesis

Prosthetic Shoes:

Prosthetic shoes (HCPCS code L3250) may be medically necessary if they are an integral part of the prosthesis for a patient with a partial foot amputation. These types of devices are used when all or most of the forefoot is missing and are considered terminal prosthetic devices. The function of a prosthetic shoe is different from that of an orthopedic shoe and supportive foot device, which are used by individuals whose feet, although impaired, are essentially intact. Claims for prosthetic shoes for other conditions are considered not medically necessary.

Foot Prostheses:

The basic lower-extremity foot prosthesis consists of the solid-ankle/cushioned-heel (SACH) foot. Other prosthetic feet may be considered medically necessary, based upon functional classification, ability and individual need. The SACH simulates plantar flexion at heel strike by compressing an elastic heel wedge and provides forefoot dorsiflexion by way of a flexible toe section. The device has no moving parts and is frequently indicated for amputees defined as functional level 1, but may be used in level 2 or level 3 amputees. It may also be selected as a preparatory prosthesis. A single-axis foot provides fore-aft movement about an ankle axis limited and cushioned by plantar flexion and dorsiflexion bumpers. It is often used in amputees of functional level 3 and is frequently preferred for above-the-knee amputees because of the increase in knee stability during early stance phase. Multiaxial devices provide inversion-eversion and some degree of transverse rotation in addition to dorsiflexion and plantar flexion. These types of devices are particularly suited for ambulating on uneven terrain and for bilateral amputees. A flexible keel provides dynamic assist at toe-off, helping to propel the leg into swing phase. The flexible keel is often used with a dynamic response

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that allows the amputee to ambulate at variable cadence. The device deforms during weight-bearing, storing energy and then releasing it during late stance phase, allowing forward movement. The flexible keel is also known as a SAFE (solid-ankle-flexible-endoskeletal) foot. Foot covers are included in the codes for the prosthetic foot component. Medical necessity for a prosthetic foot is based on the following functional levels:

• An external-keel SACH foot (HCPCS code L5970) or single-axis ankle/foot (HCPCS code L5974) may be medically necessary for a patient whose functional level is 1 or above.

• A flexible-keel foot (HCPCS code L5972) or multiaxial ankle/foot (HCPCS code L5978) may be medically necessary for a patient whose functional level is 2 or above.

• A flex foot system (HCPCS code L5980), energy-storing foot (HCPCS code L5976), multiaxial ankle/foot with dynamic response (HCPCS code L5979), a flex-walk system or equal (HCPCS code L5981), or shank system with vertical loading pylon (HCPCS L5987) may be medically necessary for a patient whose functional level is 3 or above.

Knee Prostheses:

The basic lower-extremity prosthesis includes a single-axis, constant friction knee. This device is a basic knee that acts as a door-and-hinge device, is free-swinging and does not allow stance control. It allows one-speed ambulation and is often used in children. Other prosthetic knees may be medically necessary based upon functional classification, ability and individual need. A hydraulic unit that includes piston cylinders and contains either air (i.e., pneumatic) or fluid (i.e., hydraulic) may be added to the knee device to allow swing control as the amputee speeds up or slows down. Swing control may allow the amputee to walk at variable speeds. It is often used in more active amputees. The polycentric knee, a device with multiple rotational axes, is sometimes referred to as the “four bar” knee. It has four points of rotation connected by a linkage bar. The device is asserted to be very stable in early stance and easy to flex in swing phase.

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Medical necessity for a prosthetic knee device is based on the following functional levels:

• A high activity knee control frame (L5930) may be medically necessary for patients whose functional level is 4.

• Fluid, pneumatic or electronic knees (HCPCS codes L5610, L5613, L5614, L5722–L5780, L5822–L5840, L5848, L5856, L5857, and L5858) may be medically necessary for patients whose functional level is 3 or above.

• Other knee systems (HCPCS codes L5611, L5616, L5710–L5718, and L5810–L5818) may be medically necessary for patients whose functional level is 1 or above.

Ankle Prostheses:

Axial rotation units (HCPCS codes L5982–L5986) may be medically necessary for patients whose functional level is 2 or above.

Sockets: The socket is the part of the prosthesis that fits around the residual limb and fits around the liner or socket insert. Test sockets are used prior to permanent sockets to determine correct fitting. Test sockets (e.g., Page 6 of 18 Coverage Position Number: 0194

Socket replacements may be medically necessary if there is a functional or physiological need, including but not limited to changes in the residual limb, changes in functional need, irreparable damag

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Transtibial Prosthesis :

A transtibial prosthesis is an artificial limb that replaces a leg missing below the knee. Transtibial amputees are usually able to regain normal movement more readily than someone with a transfemoral amputation, due in large part to retaining the knee, which allows for easier movement.

Transfemoral Prosthesis

A transfemoral prosthesis is an artificial limb that replaces a leg missing above the knee. Transfemoral amputees can have a very difficult time regaining normal movement. In general, a transfemoral amputee must use approximately 80% more energy to walk than a person with two whole legs.[5] This is due to the complexities in movement associated with the knee.

Transradial Prosthesis

A transradial prosthesis is an artificial limb that replaces an arm missing below the elbow. Two main types of prosthetics are available. Cable operated limbs work by attaching a harness and cable around the opposite shoulder of the damaged arm. The other form of prosthetics available are myoelectric arms. These work by sensing, via electrodes, when the muscles in the upper arm moves, causing an artificial hand to open or close.

Transhumeral Prosthesis

A transhumeral prosthesis is an artificial limb that replaces an arm missing above the elbow. Transhumeral amputees experience some of the same problems as transfemoral amputees, due to the similar complexities associated with the movement of the elbow. This makes mimicking the correct motion with an artificial limb very difficult.

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LOWER EXTREMITY PROSTHETICS

There are seven basic prosthetic options to consider for the person with a lower extremity amputation:

Partial Foot Prosthetics

Complete Prosthetic Feet

Shock Absorbers and Rotators

Prosthetic Knees for Artificial Limbs

Prosthetic Interface Materials

Prosthetic Socket Design and Suspension

Cosmetic Covers

Partial Foot Prosthetics

Partial foot amputations are fit with prosthetic devices ranging from simple toe-fillers in shoes for toe amputations, to custom-molded silicone prosthetics that incorporate contoured arch supports and carbon fiber keels. A comfortable fit, control of weight-bearing forces and adaptation to the needs of each individual are the most important features of this type of prosthesis. In some instances it may be necessary to purchase slightly larger or extra-depth shoes to accommodate the arch support or prosthesis required.

For persons with Diabetes, a comfortable and supportive pair of shoes with a soft sole and uppers is important to safeguard feet against any further injury.

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Complete Prosthetic Feet

Prosthetic foot design and construction has progressed tremendously in the past few decades and now commonly incorporates carbon fiber structures to reduce weight and improve energy return. Some feet have terrain adapting and shock absorbing features, while others are more suitable for special purposes such as swimming. Most high-end feet can be ‘tuned’ to suit each individual by adjusting or exchanging internal elastomer bumpers or wedges, and are custom ordered from the manufacturer to specifications for each client. Prosthetic feet are selected by considering each individual’s activity level and the type of terrain that they will be traversing. We encourage our clients to become familiar with the different types of prosthetic feet available, to assist in the selection of the most appropriate type for them.

Prosthetic feet, like knees, hips, and other components incorporated into a prosthesis, can be grouped according to a recognized functional level classification system:

1 .Low Impact Level:

Daily activities involving limited and steady walking with the use of a walking aid.

Example: Ambulation at home, limited in community.

2 .Moderate Impact Level:

Daily activities involving normal walking, with the ability to demonstrate varied cadence.

Example: Community ambulation with confidence.

3 .High Impact Level:

Daily activities involving fast walking, jogging and climbing stairs.

Example: Light manual labor, recreational sports.

4 .Extreme Impact Level:Daily activities involving rigorous walking, running and heavy lifting.

Example: Heavy manual labor including lifting, track and field sports.

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SACH, Solid Ankle Cushioned Heel (Low Impact Level)

This foot has a wedge-shaped cushion in the heel that compresses with each step and a simple internal supportive structure embedded in a foam cosmetic shape. These feet can be quite light and are also suitable for prostheses intended for use around water.

Sach Foot

Single Axis (Low Impact Level)

A hinged ankle joint is incorporated into the prosthetic foot. Rubber bumpers within the ankle structure absorb ankle motion induced by body weight.

Dycor Foot

Multi Axis (Moderate Impact Level)

Rubber bumpers in the ankle mechanism permit a rocking motion of the foot from heel to toe as well as from side to side. This can be useful for walking on uneven terrain. Generally these feet do not have much stored energy return and they have a softer feeling underfoot than the SACH feet.

Endolite Foot

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Stored Energy (Moderate to High Impact Level)

These feet have an internal structure that acts like a spring. This spring will store energy and return this energy to the amputee, propelling them forward, as the toes of the prosthetic foot leave the ground. Some of the designs are virtually maintenance-free, while others incorporating internal bushings and bumpers require regular servicing to maintain optimal performance. Most of these feet have terrain-adapting features that absorb irregularities in the ground and improve performance on inclined surfaces. Some of the photos show the prosthetic feet without their accompanying cosmetic covers.

College Park Foot Genesis II Foot

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Talux FootLuxon Foot

Luxon DP Foot Modular III Foot

Advanced Features Stored Energy (Moderate to High to Extreme Impact Level)

These feet incorporate multiple features such as energy storage and return, shock absorption and rotation, and terrain adaptation. Suitable for prolonged walking, running and jumping they can be used both in daily ambulation and in sports.

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Ceterus Foot Pathfinder Foot

Reflex VSP Foot

Shock Absorbers and Rotators

Rotators, with or without accompanying shock absorbers, are good additions to most lower extremity prosthetic devices. While they do add weight to a prosthesis, they reduce torsional stress on tissue. A rotation unit is definitely an asset to playing golf, and some units can be ‘tuned’ to suit the preferences of each individual.

4R85 Torsion AdapterDelta Twist Shock Absorber

Prosthetic Knees for Artificial Limbs

Like prosthetic feet, the type of prosthetic knee selected for each individual is determined based on their intended activity level and the type of terrain that they will be traversing. These knee units can be similarly grouped into categories associated with the four main Impact Levels.

Children, Youth and Adults have access to many of the same classifications of knee units, built to suit their weight range and activity levels. Contact us at

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Custom Prosthetic Services Ltd. to inquire about various prosthetic knee options.

Single Axis Constant Friction Knees (Impact Level Low)

This is a basic knee where the friction is set for each patient’s walking speed. The knee will feel stiff if the person is walking slower than the setting and not stiff enough if walking faster.

Safety Knees (Impact Level Low)

This is a single axis knee as described above, but includes a locking mechanism that will engage when the person places weight on the prosthesis, preventing the knee from buckling. This lock is released when the toe of the prosthetic foot is in contact with the ground and weight is transferred off of the prosthesis.

Manual Locking Knees (Impact Level Low)

A Manual Lock feature can be added to many knee designs and would usually be used by very low impact level individuals, who need to ambulate with no possibility of the knee bending, unless the lock is manually released.

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4 Bar Knees (Impact Level Low to Moderate unless it is combined with pneumatic or hydraulic control for High)

This type of knee is designed to have more than one center of rotation throughout the bending cycle and in this way mimics the human anatomical knee joint. This design creates a stabile more easily controlled knee at the heel contact moment of the gait cycle and has a smooth action from mid-stance until the toe leaves the floor at the beginning of the swing phase portion of the gait cycle. Each knee is designed or can be adjusted to increase or decrease the initial centre of rotation and this influences knee safety. This type of knee also has less length in swing phase to improve toe clearance and is particularly suited for persons with a long trans femoral or knee disarticulation amputation.

These knees can have a constant friction brake and an adjustable knee extension assist to adjust to the gait speed of each person, or they can include either pneumatic or hydraulic swing phase control units. These features will determine performance levels of the knees.

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5 to 7 Bar Knees (Impact Level Low to Moderate unless it is combined with pneumatic or hydraulic control for High)

These knees are designed for additional safety and even smoother function than the 4 Bar Knees. Again, these can include pneumatic or hydraulic swing phase controls for greater function.

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Pneumatic Swing Control Knees (Impact Level High)

A pneumatic cylinder is installed in the knee that uses principles of fluid mechanics to vary the resistance of the knee as the user changes their walking speed. This allows the individual to walk at different cadences and have the prosthetic knee keep pace to ensure the prosthesis is always in the correct position for safety when placing weight onto the prosthesis at heel contact. Pneumatic knee units are usually lighter in weight and less heavy duty than hydraulic knees.

Hydraulic Swing Control Knees (Impact Level High)

A hydraulic fluid cylinder is installed in the knee that uses principles of fluid mechanics to vary the resistance of the knee as the user changes their walking speed. This allows the individual to walk at different cadences and have the prosthetic knee keep pace to ensure the prosthesis is always in the correct position for safety when placing weight onto the prosthesis at heel contact. Hydraulic knee units are usually heavier duty than pneumatic knees.

Hydraulic Swing and Stance Control Knees (Functional Level III)

These Hydraulic knees can be set to different modes such as free swinging for bicycle riding, or slow resistance for descending steps foot over foot. It is also and excellent safety feature for stumble recovery.

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High Technology Knees (Impact Level Moderate to High to Extreme)The Otto Bock 3C100 C-Leg System

The C-Leg Micro processor knee system provides optimal stability during the gait cycle. Multiple sensors in the C-Leg records information more than 50 times per second resulting in reproducing the closest possible natural gait for the amputee.

This new dimension provides stability and security whilst walking down stairs, ramps and all uneven terrain.

We are pleased to discuss the benefits of this system with our clients.

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Stance Flexion Feature:

This feature allows the knee to bend slightly at heel contact without the knee buckling on flexion. This feature acts as a shock absorber, the same as the human anatomical knee.

Prosthetic Interface Materials

A prosthetic interface is that material located closest to the wearer’s skin, whether it be the traditional fine nylon sheaths and stump socks or the newer urethane, polymer gel and silicone liners with or without integral suspension pins. At Custom Prosthetic Services Ltd. we strive to match each individual with the most appropriate interface and prosthetic suspension system. Each type of system requires routine cleaning to maintain good hygiene and healthy skin. We also carry a number of skin care lotions and ointments to be used separately from or together with the various types of gel liners. Considerable relief from pressure and friction-related skin problems and effective management of persistent scar tissue can be obtained through the use of a carefully shaped and supportive prosthetic socket coupled with the correct interface material.

Roll-On Gel Liners:

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Prosthetic Socket Design and Suspension

Custom Prosthetic Services Ltd. provides state-of-the-art prosthetic socket design and components. Comfort begins with a properly designed socket. We use careful hand-casting techniques and build prostheses that both support weight bearing and relieve pressure regions. We use flexible inner socket liners to allow the limb musculature to expand and contract throughout the gait cycle. In our above-knee prosthetic designs this flexible liner is supported by a lightweight rigid frame, which attaches to the prosthetic knee of choice. Many types of prosthetic suspension systems, including suction fitting and locking pin mechanisms are used. We use all of the advanced technology feet that will enhance the function of each prosthesis.

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Harmony VASS (Vacuum Assisted Socket System)Total Environment Control and Suction Suspension System

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The Harmony VASS system is a recent significant advance in the technology of prosthetic suspension and volume control. Used correctly, the system offers many benefits over conventional prostheses including: unrestricted vascular flow (healthier for the tissues); control of swelling and edema; volume management; and enhanced linkage of the prosthesis to the residual limb. An excellent choice for active individuals with below or above knee amputations.

The VASS self-contained suction pump is linked to the interior of the prosthetic socket and it maintains a low pressure environment therein, while a flexible sealing sleeve prevents air entry at the socket brim. A urethane gel liner is worn directly over the skin of the residual limb to absorb shear and impact forces. The extra weight of this system is not a significant problem due to the feeling of being 'linked' solidly to the prosthesis. The VASS system can be retrofit to many existing prostheses or incorporated directly into the PATHFINDER foot.

Cosmetic CoversCustom Prosthetic Services Ltd. can provide very realistic looking cosmetic covers over below knee and above knee prostheses using custom colored latex and silicone skins. Inquire for more details.

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Upper Limb ProstheticsProsthesis and orthosis

A prosthesis is a device that is designed to replace, as much as possible, the function or appearance of a missing limb or body part. An orthosis is a device that is designed to support, supplement, or augment the function of an existing limb or body part.

Characteristics of a successful prosthesis

Ideally, a prosthesis must be comfortable to wear, easy to put on and remove, lightweight, 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.

Considerations when choosing a prosthesis

Amputation level Contour of the residual limb Expected function of the prosthesis Cognitive function of the patient Vocation of the patient (eg, desk job vs manual labor) Avocational interests of the patient (ie, hobbies) Cosmetic importance of the prosthesis Financial resources of the patient

Most common reasons for an upper extremity amputation

Reasons for amputation vary but can be correlated by age range. Correction of a congenital deformity or tumor is commonly seen in individuals aged 0-15 years. Trauma is the most common reason for amputation in patients aged 15-45 years, with tumors being a distant second. Upper extremity amputations tend to be rare in patients who are older than 60 years, but they may be required secondary to tumor or medical disease.

Amputation levels

Transphalangeal amputation - Resection of the thumb or fingers at distal interphalangeal (DIP), proximal interphalangeal (PIP), or metacarpophalangeal (MCP) levels or at any level in between

Transmetacarpal amputation - Resection through the metacarpals Transcarpal amputation - Resection through the carpal bones

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o Transmetacarpal and transcarpal amputations are less advised because, except for select circumstances, they provide for decreased functional outcomes.

Wrist disarticulation - Transection between the carpals and radius/ulna

Transradial amputation - Below-elbow amputation (May be classified as long, medium, or short.)

Elbow disarticulation - Transection through the elbow joint Transhumeral amputation - Above-elbow (Standard length is 50-

90% of humeral length.) Shoulder disarticulation - Transection through the shoulder joint Interscapulothoracic disarticulation (forequarter) - Amputation

removing the entire shoulder girdle (scapula and all or part of the clavicle) (Some surgeons choose to leave part of the medial clavicle.)

Definitions of relevant terminology

Residual limb - The preferred term for the remaining portion of the amputated limb

Relief - A concavity within the socket that is designed for areas that are sensitive to high pressure (bony prominences)

Buildup - A convexity that is designed for areas that are tolerant to high pressure (such as a bulge)

Terminal device - The most distal part of a prosthesis that substitutes for the hand; it may be a prosthetic hand, a hook, or another device.

Myodesis - Direct suturing of residual muscle or tendon to bone/periosteum

Myoplasty - Suturing of agonist-antagonist muscles pairs to each other

Prehensile - Grasp

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DIFFERENT TYPES OF 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 often are more difficult to keep clean, can be expensive, and usually sacrifice some function for increased cosmetic appearance.

Functional prostheses generally can be divided into the following 2 categories:

Body-powered prostheses - Cable controlled Externally powered prostheses - Electrically powered .

o Myoelectric prostheses o Switch-controlled prostheses

Body-powered prostheses

Body-powered prostheses (cables) usually are of moderate cost and weight. They are the most durable prostheses and have higher sensory feedback. However, a body-powered 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 two 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.

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 (for example,

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flexion and extension). The patient uses muscle contractions of different strengths to differentiate between flexion and extension. For instance, 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. This 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.

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Table 1. Various Upper Limb Prostheses1

Type Pros Cons

CosmeticMost lightweightBest cosmesisLess harnessing

High cost if custom-madeLeast functionLow-cost glove stains easily

Body powered

Moderate costModerately lightweightMost durableHighest sensory feedbackVariety of prehensors available for various activities

Most body movement needed to operateMost harnessingLeast satisfactory appearanceIncreased energy expenditure

Battery powered(myoelectric and/or switch controlled)

Moderate or no harnessingLeast body movement needed to operateModerate cosmesisMore function-proximal areasStronger grasp in some cases

HeaviestMost expensiveMost maintenanceLimited sensory feedbackExtended therapy time for training

Hybrid (cable to elbow or TD* and battery powered)

If excursion to elbow and battery-powered TD

If excursion to TD and battery-powered elbow

All-cable excursion to elbow or TD

All-cable excursion to elbowIncreased TD pinch

All-cable excursion to TDLow effort to position TDLow-maintenance TD

Battery-powered TD weights forearm (harder to lift but good for elbow disarticulation or long THA†)

Lower pinch for TD and least cosmetic

*TD=terminal device

†THA=transhumeral amputation

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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 single–control-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.

Suspension

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

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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 harness provides minimal suspension and requires a self-suspending 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 pin-locking 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.

cable's necessary attachment point and counterforce. Although the figure-9

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Table 2. Suspension Options

Suspension Indications Advantages Disadvantages

Harness Figure-8

TransradialTranshumeralLight to normal activities

Simple, durable, adjustable

Axillary pressure produces discomfort

Shoulder saddle and chest strap

TransradialTranshumeralHeavy lifting

Greater lifting ability, more comfortable than figure-8 harness

Reduced control compared with figure-8 harness, difficult to adjust in women because straps cross breasts

Self-suspending

Muenster Northwestern Supracondylar

Wrist disarticulationElbow disarticulationShort transradial Myoelectric transradial

Ease of use

Limited lifting capacity compared with harness systems, compromised cosmesis, reduced elbow flexion

Suction Suction socket with air valve

Transhumeral with good soft tissue cover

Secure suspension, elimination of suspension straps

Requires stable residual volume, harder to put on than other suspension systems

Gel sleeve with locking pin

TransradialTranshumeral Compromised limbs with scarring or impaired skin integrity

Accommodate limb volume change with socks,reduced skin shear

Greater cleaning and hygiene requirements,can be uncomfortable in hot climates

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Control-cable mechanisms

Body-powered prosthetic limbs use cables to link movements of 1 part of the body to the prosthesis in order to control a prosthetic function. This usually is 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 two separate cable Body movements that are captured for prosthetic control

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. 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 terminal-device control without biscapular abduction (mutual protraction) for prosthetic control. 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 system. This 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 similhousings known as a fair lead cable system.are types of systems are sometimes invaluable, offering cable-control options for more complex cases where many control functions are needed.

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TERMINAL DEVICE

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 (i.e., pincher grip) - The pad of the thumb and index finger are in opposition to pick up or pinch a small object (e.g., a small bead, pencil, grain of rice).

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

Lateral grip (i.e., 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).

Terminal devices generally are broken down into 2 categories: passive and active.

Passive terminal devices

Passive terminal devices fall into two 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 usually are less functional and more expensive than active terminal devices.

Active terminal devices

Active terminal devices usually are 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 terminal devices (hooks or hands) can be of a voluntary opening design (most commonly used) or a voluntary closing design. Voluntary opening mechanism - With a voluntary

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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

Voluntary closing mechanism - 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 usually is 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.

A prosthetic hand usually is bulkier and heavier than a hook, but it is more cosmetically pleasing. A prosthetic hand can be powered by a cable or utilize external power. 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, while active hands provide a 3-point chuck action. Many different options are available for terminal devices that address occupations, hobbies, and sports.

Many specialized terminal-device designs are available or are custom fabricated by prosthetists to meet the unique functional requirements of individual amputees. Most of the commercially available specialized terminal devices are designed for various recreational and hobby activities. 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).

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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.

Quick-disconnect wrist unit

This style is configured to allow easy swapping of terminal devices that have specialized functions.

Locking wrist unit

Wrist units with a locking capacity prevent rotation during grasping and lifting.

Wrist flexion unit

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 flexion wrist unit usually is employed on only one side, most often the longer of the two 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 elbow hinge

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

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triceps pad or cuff helps distribute suspension forces and is needed to anchor the control cable.

Rigid elbow hinge

With short transradial amputations, a patient has no residual, active forearm pronation and supination but does have adequate native elbow flexion. Rigid elbow hinges provide additional stability. Hinges are available in single-axis or polycentric versions. Rigid 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 2º of motion for every 1º of actual residual limb and elbow motion. Since movement of the limb and the prosthesis are not directly connected, the proprioceptive feedback is compromised.

Internal elbow

The standard elbow component for a transhumeral prosthesis is an internal locking elbow joint. This allows for 135º 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 elbowjointsmay 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

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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.

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PROCESS/TIMELINE FOR AN AMPUTATION/PROSTHESIS FITTING

Pre-amputation

Ideally, a patient who needs an upper extremity amputation should be seen by the rehabilitation team prior to the surgery. This allows a chance to evaluate postoperative needs and desires, to discuss prosthetic restoration, and to begin any needed range-of-motion (ROM) exercises, strengthening, and training in activities of daily living (ADLs). Peer support by another successful amputee at the proposed level has a positive benefit for all amputees and may reduce anxiety for the elective amputee patient. However, since most upper extremity amputations are traumatic in nature, this is not always possible.

Surgical procedure

During the amputation surgery, several actions can be taken to maximize the function of the residual limb. These actions include the following:

Bevel the bone end. This can help to minimize soft-tissue trauma from sharp or irregular bone edges.

When severing a nerve, place gentle traction on it, sharply transect it, and allow the nerve to retract into proximal soft tissue. A severed nerve forms a neuroma (scar tissue) at the distal end. When the neuroma forms in soft tissue, there is less likelihood of postsurgical pain.

Perform a myoplasty (in which agonist-antagonist muscle pairs are sutured to each other) or a myodesis (in which residual muscle is stitched to bone) to secure the muscles of the residual limb. These procedures stabilize the bone and soft tissues in the residual limb, minimizing bone movement within the soft-tissue envelop of the residual limb and therefore enhancing prosthetic function. Maintaining muscle tension also facilitates the potential for future myoelectric control, if desired.

During skin closure, position the wound edges to avoid bony prominences at the distal end of the residual limb. This prevents future pressure on the incision from the underlying bone when the patient wears the prosthesis.

Ensure proper length so that specific prosthetic components may be used that result in cosmesis and functional goals.

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Acute postsurgery

The major physical issues in this phase are adequate wound healing, pain management, instruction in the performance of ADLs, mobility, ROM, and strength. During this phase, a program to prepare the residual limb for the prosthesis should be initiated. A skin desensitization program consists of the following:

Gentle tapping on the distal portion of the residual limb to mature the site

Massage to prevent excessive scar formation, with adherence of the skin and soft tissues to underlying bone

Edema control with ace wraps, a rigid removable dressing, or a residual limb (stump) shrinker

Application of pressure to the distal end of the residual limb to prepare for anticipated contact on the residual limb following prosthetic fitting

Psychology should be involved at this phase if possible (ie, elective procedure) or immediately postoperatively. Adjustment and grief reaction are common for new amputees. The patient may struggle with self-image and cosmetic concerns early, as well as later, in the prosthetic restoration process.  A simple and organized psychological framework proposed by Van Dorsten delineates the process well.3 The stages address survival, recovery and reintegration. The amputee will have many questions and concerns during each stage. As previously mentioned, peer support visits by another successful amputee can provide a tremendous benefit for the new amputee. Initially, the team should suggest and remind the patient of available peer support, but it is important to allow the patient to indicate when he or she is ready for such a visit.  

The frequency of psychological visits depends on many factors, such as premorbid coping skills, family support, pain intensity, and medical-surgical complications. The patient will need to be followed throughout the course of immediate postamputation, prosthetic training, and functional reintegration back into his or her societal routine.

Prosthesis fitting and testing

A temporary prosthesis can be fitted during surgery; in this way, when the patient awakens, he or she can visualize a limb in place. This is called an immediate postoperative prosthesis (IPOP). IPOPs are usually fitted in healthy young patients with traumatic amputations. In such cases, rehabilitation physicians work integrally with surgical specialists and prosthetists. Alternatively, in older patients

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or in those with vascular disease, a prosthesis is not fitted until the suture line has completely healed. The prosthesis must be individually fitted to the patient, since 1 size does not fit all. Fitting an upper extremity amputee with a body-powered preparatory prosthesis within 7-30 days after amputation is advisable. This is referred to by Malone as the "golden period."4 Prosthetic fitting during this time correlates with a higher acceptance and success rate of prosthetic use.

Prostheses are either preparatory (nonpermanent) or definitive (permanent). The advantage to using a preparatory prosthesis is that it is fitted while the residual limb is still maturing. A preparatory prosthesis allows the patient to train with the prosthesis several months earlier in the process. Use of a preparatory prosthesis often results in a better fit for the final prosthesis, since the preparatory socket can be used to mold the residual limb into the desired shape. During this period, the patient “test drives” the prosthesis and learns what it can and cannot do.

Sometimes a preparatory prosthesis is not feasible because of financial considerations. In this case, a patient can only be fitted for the definitive (final) prosthesis. If a patient is being fitted for a final prosthesis without ever having had a preparatory prosthesis, fitting for the socket should be delayed until the residual limb is fully mature (a process that sometimes can take several months).

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PHANTOM LIMB SENSATION AND PAIN

In addition to the usual postoperative pain, most individuals who have undergone an amputation experience phantom sensation. Phantom sensation is the perceived sense that the amputated limb, or at least a part of it, is still present. Phantom sensation is not painful, and the patient usually just needs to be reassured that this sensation is common and that he or she is not suffering from mental instability. The phenomenon of telescoping can accompany phantom sensation. Telescoping is the sensation that the amputated limb has shrunk (eg, the toes are at the ankle, the foot is at the knee). Telescoping is normal and usually fades without sequelae.

Phantom pain is the sensation of pain originating in the amputated part. Phantom pain may or may not be dermatomal in nature. Individuals may describe a burning, stinging, or cramping pain, or they may describe a feeling that the missing body part is "positioned awkwardly or painfully." The pain usually develops in the first month after amputation and is most likely to develop in individuals who had a lot of pain before amputation. Phantom pain is constant and is most intense right after the amputation. The pain becomes more intermittent and resolves with time, although some patients can still experience phantom pain years after the amputation. Patients who have undergone amputation commonly report intermittent phantom pain symptoms, but they are able to ignore them and require no medication for treatment. Phantom pain is usually worse at night, after the extremity has been in a dependent position, and can be worsened by anxiety and stress.

Unlike postsurgical pain, which responds well to opioids, such as Percocet or Lortab, phantom pain is best treated with low doses of tricyclic antidepressants (ie, nortriptyline or amitriptyline 10-25 mg PO qhs) that aim to improve sleep.  Phantom pain may respond well to medications such as carbamazepine (Tegretol), amitriptyline (Elavil), pregabalin (Lyrica) and gabapentin (Neurontin; titrate to at least 300 mg tid; serum gabapentin levels can be monitored), which serve to stabilize the nerve's ability to depolarize and which decrease dysesthetic symptoms.

Transcutaneous electrical nerve stimulation, topical anesthetics (ie, capsaicin cream), and anxiolytics may be useful. Decreasing residual limb edema is helpful, and the use of a prosthesis results in lower reports of phantom limb pain.

Theories exist as to why patients experience phantom limb pain and phantom sensation. One theory is that the remaining nerves continue to generate impulses spontaneously or as a result of irritation. A second theory is that the spinal cord nerves begin excessive, spontaneous firing in the absence of expected sensory input from the limb. A third theory is that altered signal transmission and

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modulation occur within the somatosensory cortex. Other possible causes include abnormal sympathetic function and psychologic factors.

1. Esquenazi A, Leonard JA Jr, Meier RH 3rd, et al. Prosthetics, orthotics, and assistive devices. 3. Prosthetics. Arch Phys Med Rehabil. May 1989;70(5-S):S206-9. 

2. Gitter A, Bosker G. Upper and lower extremity prosthetics. In: DeLisa JA, ed. Rehabilitation Medicine: Principles and Practice. 4th. Philadelphia, Pa: Lippincott Williams & Wilkins; 2005:1325-54.

3. Van Dorsten B. Integrating psychological and medical care: practice recommendations for amputation. In: Meier RH, Atkins DJ. Functional Restoration of Adults and Children with Upper Extremity Amputation. New York, NY: Demos Med Pub; 2004:73-88.

4. Malone JM, Fleming LL, Roberson J. Immediate, early, and late postsurgical management of upper-limb amputation. J Rehabil Res Dev. May 1984;21(1):33-41. 

5. Flor H. Phantom-limb pain: characteristics, causes, and treatment. Lancet Neurol. Jul 2002;1(3):182-9. 

6. Fryer CM, Stark GE, Michael JW. Body powered components. In: Smith DG, Michael JW, Bowker JH, ed. Atlas of Amputations and Limb Deficiencies. 3rd ed. Rosemont, Ill: Am Acad Orthop Surg; 2004:117-30.

7. Fryer CM, Michael JW. Harnessing and controls for body-powered devices. In: Smith DG, Michael JW, Bowker JH, eds. Atlas of Amputations and Limb Deficiencies. 3rd ed. Rosemont, Ill: Am Acad Orthop Surg; 2004:131-44.

8. Meier RH, Atkins DJ. Functional Restoration of Adults and Children with Upper Extremity Amputation. New York, NY: Demos Med Pub; 2004.

9. Glennon TP, Smith BS. Amputations. In: Garrison SJ, ed. Handbook of Physical Medicine and Rehabilitation Basics. Philadelphia, Pa: JB Lippincott; 1995:34-60.

10.Heckathorne CW. Components for electric-powered systems. In: Smith DG, Michael JW, Bowker JH, eds. Atlas of Amputations and Limb Deficiencies. 3rd ed. Rosemont, Ill: Am Acad Orthop Surg; 2004:145-72.

11.Malone JM, Leal JM, Underwood J, et al. Brachial plexus injury management through upper extremity amputation with immediate postoperative prostheses. Arch Phys Med Rehabil. Feb 1982;63(2):89-91.  McIntyre KE Jr, Bailey SA, Malone JM, et al. Guillotine amputation in the treatment of nonsalvageable lower-extremity infections. Arch Surg. Apr 1984;119(4):450-3. 

12.Ashok Muzumdar, ed. Powered Upper Limb Prostheses. New York, NY: Springer; 2004.

13.Spires MC, Miner L. Upper extremity amputation and prosthetic rehabilitation. In: Grabois M, ed. Physical Medicine and Rehabilitation: The Complete Approach. Malden, Mass: Blackwell Sci; 2000:549-82.

14.Tan JC. Prostheses. In: Practical Manual of Physical Medicine and Rehabilitation. St Louis, Mo: Mosby; 1998:229-59.

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COSMETICFUNCTIONAL

CABLE-ACTIVATEDTERMINAL DEVICES

MYOELECTRICALLYCONTROLLED

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