PROSTHESIS IN BELOW KNEE AMPUTATION AND GAIT TRAINING

Project Work Submitted As Per Partial Fulfillment Towards Bachelor Of Physiotherapy Programme Project Course Code 26454

By SONAL KHERA Annual IV year

INSTITUTE OF REHABILITATION MEDICINE AND ALLIED SCIENCES

(AFFILIATED WITH G.G.S.I.P. UNIVERSITY)

NEW DELHI 110017

ACADEMIC YEAR 2011-2012

INSTITUTE OF REHABILITATION MEDICINE AND ALLIED SCIENCES (AFFILIATED WITH G.G.S.I.P. UNIVERSITY)

Project Code: PT-26454

This is certify that this project is the bonafide record of work done by Sonal Khera 0391382608 For BACHELOR OF PHYSIOTHERAPY ANNUAL TERM - lV Academic year 2011-2012 And Submitted to G.G.S.I.P. University

EXAMINER/S

PROJECT GUIDE

DIRECTOR

Acknowledgement

On the completion of my project work, I take the opportunity to express my gratitude & heartfelt thanks & indebtedness of all those who have directly or indirectly helped me in completing my project work successfully. I would like to express my gratitude to my project guide Dr. Monica sultan, MPT neurology lecturer IRMAS (H.O.D, physiotherapy, IRMAS) for her excellent guidance, precious time, valuable suggestions without which I could not have completed my work. I would also like to thanks Dr. D. Malhotra (DPMR, DNB), director IRMAS who has been supportive throughout. No words acknowledge the love, sacrifice and guidance I received from my parents, friends and above all, God. Sonal khera BPT final year

CONTENTS

Chap. No.

Chapter Name

Page No.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Introduction Anatomy of lower limb Biomechanics of hip joint Amputation Below knee amputation Principles of Amputation Transtibial Prosthesis Physiotherapeutic management Gait training Complications Bibliography Appendices Assessment Performa Case Study I & II Prosthetic Evaluation Article I & II

1 3 15 21 26 31 33 50 70 80 81 I II III IV

LISTS OF TABLES

Table no.
2.1 2.2 2.3 2.4 2.5 5.1 7.1 8.1 9.1

Details
Parts of lower limb Attachments to anterior compartment Of thigh Attachments to side of thigh Attachments to gluteal region Attachments to back of thigh Energy expenditure for prosthesis Gait analysis MMT grading Gait abnormalities

Page no.
3 12 12 14 14 27 49 54 79

LIST OF FIGURES

Figure No.
2.1 2.2 2.3 2.4 3.1 3.2 3.3 3.4 4.1 4.2 5.1 7.1 7.2 7.3 7.4 7.5 7.6 7.7 8.1 8.2 8.3 8.4 8.5

Details
Side view of hip muscles Front view of hip muscles Posterior view of hip muscles Lumber plexus Trabeculae system Arthrokinematics of knee Screw home mechanism Reverse screw home mechanism Amputation in lower limb Levels of amputation Incision of below knee amputation PTB prosthesis Thigh corset prosthesis Socket design Hard socket Shrinker socks Cuff suspension Thigh lacer and side joints VAS scale Shoulder stretch Lat pull down Reverse flys Elbow flexion and extension

Page no.
5 5 7 13 16 19 19 20 22 25 26 34 37 40 40 40 43 43 53 57 57 57 57

8.6 8.7 8.8 8.9 8.10 8.11 8.12 8.13 8.14 8.15 8.16 8.17 8.18 8.19 8.20 8.21 9.1 9.2 9.3 9.4 9.5

Straight leg raise Static quadriceps Dynamic quadriceps Abductor muscle strengthening Bed mobility Bridging Positions avoided post amputation VAS scale Bandaging of stump soft liner PPAM aid Post amputation pressure training Isometrics Adductor muscle strengthening Hip extension strengthening Quadriceps strengthening Normal gait Gait training with sticks Gait training in parallel bar Stair training

59 59 59 59 60 60 60 62 65 65 67 67 69 69 69 69 71 73 73 74

Treadmill training

74

INTRODUCTION

BIOMECHANICS

AMPUTATION

PRINCIPLES OF AMPUTATION

TRANSTIBIAL PROSTHESIS

PT MANAGEMENT

GAIT TRAINING

COMPLICATION

BIBLIOGRAPHY

APPENDIX

Appendix I Assessment Form

Demographic Data
Name: Address: Age/ Gender: Phone Number: Occupation: Marital Status: Dominant Side: Religion (for prayer position:

Social Assessment
Home Environment: Support from Families or Relatives: Community Support: Place and Type of Work: Leisure Activities: Financial Status:

Psychological Assessment
Psychosocial Status: Other Cognitive Problem: Emotional Reaction towards Amputation:

Pre-operative Assessment

Physical Assessment
Underlying Cause of Amputee: H/O present illness: Date of onset: Mode of onset: Progression: H/O past illness: Investigation reports Blood and urine examination: X-rays: CT Scan/ MRI: Observation General (built of body): Local (attitude of limb involved): Edema: Muscle atrophy: Wounds/ Scars: Other observation: Muscle Strength: Joint ROM: Functional Mobility: Sensory Evaluation Superficial sensation Touch; Pressure: Pain: Temperature: Two-point Discrimination: Deep Sensations Propioception: Kinesthesis:

Postsurgical Assessment:
Postsurgery Physiological Status Cardiopulmonary status: Vital signs: Pain: Skin Examination: Scar: Other Leisons (size, shape, open, scar tissue):

Moisture: Sensation: Grafts: Dermatological leisons:

Residual Limb Length: Residual Limb Shape: Vascularity: ROM: Pulses: Color: Temperature: Edema: Trophic Changes:

Muscle strength: Sensory Evaluation Superficial sensation Touch; Pressure: Pain: Temperature: Two-point Discrimination: Deep Sensations Kinesthesis Neurological: Phantom pain: Cognitive status: Emotional Status: Propioception:

Gait Analysis:
Swing Phase: Stance Phase: Other Abnormalities:

Appendix II Case Study I

Demographic Data
Name: Address: Age/ Gender: Phone Number: Occupation: Marital Status: Dominant Side: Religion (for prayer position:

Social Assessment
Home Environment: Support from Families or Relatives: Community Support: Place and Type of Work: Leisure Activities: Financial Status:

Psychological Assessment
Psychosocial Status: Other Cognitive Problem: Emotional Reaction towards Amputation:

Pre-operative Assessment Physical Assessment

Underlying Cause of Amputee: H/O present illness: Date of onset: Mode of onset: Progression: H/O past illness: Investigation reports Blood and urine examination: X-rays: CT Scan/ MRI: Observation General (built of body): Local (attitude of limb involved): Edema: Muscle atrophy: Wounds/ Scars: Other observation: Muscle Strength: Joint ROM: Functional Mobility: Sensory Evaluation Superficial sensation Touch; Pressure: Pain: Temperature: Two-point Discrimination: Deep Sensations Propioception: Kinesthesis:

Postsurgical Assessment:
Postsurgery Physiological Status Cardiopulmonary status: Vital signs: Pain: Skin Examination:

Scar: Other Leisons (size, shape, open, scar tissue): Moisture: Sensation: Grafts: Dermatological leisons:

Residual Limb Length: Residual Limb Shape: Vascularity: ROM: Pulses: Color: Temperature: Edema: Trophic Changes:

Muscle strength: Sensory Evaluation Superficial sensation Touch; Pressure: Pain: Temperature: Two-point Discrimination: Deep Sensations Kinesthesis Neurological: Phantom pain: Cognitive status: Emotional Status: Propioception:

Gait Analysis:
Swing Phase: Stance Phase: Other Abnormalities:

Case Study II

Demographic Data
Name: Address: Age/ Gender: Phone Number: Occupation: Marital Status: Dominant Side: Religion (for prayer position:

Social Assessment
Home Environment: Support from Families or Relatives: Community Support: Place and Type of Work: Leisure Activities: Financial Status:

Psychological Assessment
Psychosocial Status: Other Cognitive Problem: Emotional Reaction towards Amputation:

Pre-operative Assessment Physical Assessment

Underlying Cause of Amputee: H/O present illness: Date of onset: Mode of onset: Progression: H/O past illness: Investigation reports Blood and urine examination: X-rays: CT Scan/ MRI: Observation General (built of body): Local (attitude of limb involved): Edema: Muscle atrophy: Wounds/ Scars: Other observation: Muscle Strength: Joint ROM: Functional Mobility: Sensory Evaluation Superficial sensation Touch; Pressure: Pain: Temperature: Two-point Discrimination: Deep Sensations Propioception: Kinesthesis:

Postsurgical Assessment:
Postsurgery Physiological Status Cardiopulmonary status: Vital signs: Pain: Skin Examination: Scar: Other Leisons (size, shape, open, scar tissue): Moisture:

Sensation: Grafts: Dermatological leisons:

Residual Limb Length: Residual Limb Shape: Vascularity: ROM: Pulses: Color: Temperature: Edema: Trophic Changes:

Muscle strength: Sensory Evaluation Superficial sensation Touch; Pressure: Pain: Temperature: Two-point Discrimination: Deep Sensations Kinesthesis Neurological: Phantom pain: Cognitive status: Emotional Status: Propioception:

Gait Analysis:
Swing Phase: Stance Phase: Other Abnormalities:

APPENDIX III TRANSTIBIAL PROSTHETIC EXAMINATION

1. Is the prosthesis as prescribed? 2. Can the client don the prosthesis easily?

Standing
1. 2. 3. 4. 5. 6. 7. Is the client comfortable when standing with the heel midlines 6 inches apart? Is the anterior-posterior alignment satisfactory? Is the medial-lateral alignment satisfactory? Do the contours and color of the prosthesis match the opposite limb? Is the prosthesis the correct length? Is the piston action minimal? Does the socket contact the amputation limb without pinching or gapping?

Suspension
1. Does the suspension component fit the amputation limb properly? 2. Does the cuff, fork strap, or thigh corset have adequate provision for adjustment?

Sitting
1. Can the client sit comfortably with hip and knee flexed 90 ?
0

Walking
2. 3. 4. 5. 6. 7. Is the clients performance in level walking satisfactory? Is the clients performance on stairs and ramps satisfactory? Can the client kneel satisfactorily? Does the suspension function properly? Does the prosthesis operate quietly? Does the client consider the prosthesis satisfactory as to comfort, function and appearance?

Prosthesis off the client

1. Is the skin free of abrasions or other discolorations attributable to this prosthesis? 2. Is the socket interior smooth? 3. Is the posterior wall of the socket of adequate height? 4. Is the construction satisfactory? 5. Does all components function satisfactorily?

APPENDIX IV Article 1
Computer-Aided Thigh Corset Pattern Generation Marc St-Georges, Eng. Claude Levesque, C.P.(c) Carole St-Jean, C.P.(c) Introduction A lower limb prosthesis is essential if upright mobility is to be restored to those who have suffered the loss of a lower limb. An artificial leg is basically composed of a series of components that respectively imitate and simulate the appearance and the function of the lost anatomical parts. Since leg design depends on the geometrical relationship between these components and the interface with the amputee, the prosthetic socket, its alignment on the limb and the means employed to provide suspension are therefore the 1 most significant elements in the limb design. To provide the weight support and control so essential for standing and walking, the prosthetic socket cannot be simply a positive mold of the shape of the remaining limb. It must be designed specifically to support the pressure developed between the residual limb and the prosthesis under dynamic as well as static loading conditions. The main function of the residual limb is that of a lever arm that is used to power and control the prosthesis through the socket interface. The more intimate and accurately defined the socket and the more precise the fit on the residual limb, the more efficient will be the force transfer. Furthermore, the greater the surface area in contact between the residual limb and the socket, the better the fit and thus the better the control of the prosthesis. For these reasons, maximum contact area at residual limb and socket interface is the most desirable. At the Institut de Radaptation de Montrial, a type of socket which is often used is the weight bearing thigh corset. This type of thigh corset, used with trans-tibial amputees, is an adjustable system providing additional weight support and knee stability. The thigh corset is usually fabricated of heavy, seven- to eight-ounce molding leather, a material sufficiently rigid to maintain a proper shape in accordance with biomechanical 2 principles of weight support in the thigh region. This shape is preferred, since the weight is borne mostly on the proximal region of the thigh region. Prosthetic socket design consists of four major interrelated considerations: support, control, suspension and alignment. All these considerations make proper thigh corset pattern production a tedious task. Precise patient measurements are taken in order to produce the technical drawing which is used as the pattern for thigh corset creation. This design procedure requires approximately 30 minutes and design methods vary from practitioner to practitioner. A tool which lends itself very well to doing this task is computer-aided drafting and design (CAD). It allows for standardized, accurate and rapid

pattern generation. Furthermore, the widespread availability of computers, CAD software and computer peripherals and their ever decreasing costs, make computer-aided pattern 3 generation more and more feasible and worthwhile. Materials and Method A computer program has been written using the computer aided drafting and design language (CADL) of the CAD software CADKEY, version 3.02 ($500 US), which runs on an IBM XT or AT (or compatible), with a hard disk, a CGA screen and a graphic display card. The patterns are plotted on a Hewlett Packard model 7475A plotter . The program requires only three input measurements from the user: proximal thigh circumference, distal thigh circumference and finally, thigh corset height. The software is user friendly and the system is easy to use. The user is prompted by the computer for these three measurements. Once these values are entered, the program runs, and automatically displays in a matter of seconds, the desired thigh corset, before the user decides to plot out the final product. Thigh corsets are plotted out on standard 11" x 17" plotting paper in less than two minutes. Thigh corsets that are larger than 16" in circumference or 10" in height are easily plotted in two halves on two separate sheets. Plotting time for these types of corsets is approximately four minutes. Extra large thigh corsets can even be plotted on three separate sheets. Reference points ensure a good alignment of separate sheets when this is necessary. different information such as patient name, date, etc., is recorded on the pattern produced. It is important to note that the thigh corset pattern is scaled down in order to include it in its entirety on an 8.5" x 11" sheet of paper. Furthermore, set-up positions are indicated, as are eyelet holes. The program is written in such a way that the number of eyelet holes is determined according to thigh corset height. There is the possibility of four, five or seven holes. Also, three cubic spline functions are used in the program to respectively draw up the proximal and proximolateral curves of the thigh corset and the postero-distal curves of the thigh corset. The cubic spline functions allow for optimum curve production for varying thigh corset dimensions. For example, the postero-medial region of the pattern varies according to thigh corset height. In the end, a complete thigh corset pattern is produced. No further adjustments or operations are necessary. The leather thigh corset can be cut from the pattern once proper fit and overlap are assured. Discussion and Conclusion The use of computer-aided drafting and design for automatic thigh corset pattern generation has produced preliminary results that are very promising. It is presently used at our amputee clinic to produce half the thigh corset patterns prescribed. Time required to draw up the thigh corset pattern has been reduced from approximately 30 minutes to four minutes, which is the time required by the plotter to plot a complete pattern comprised of two halves. This timesaving method not only is more cost effective (faster fabrication and service delivery), but ensures better quality control for all thigh corset patterns, because each pattern is drawn the same for identical input measurements and patterns are easily corrected or redrawn in the event of an error. Furthermore, automatic pattern generation ensures standardization of the design and drawing processes and the plotting step ensures maximum accuracy of shape reproduction. The only shortcoming of the method is the relatively high cost of the computer equipment and peripherals used to produce the thigh corset pattern. It could run between $6,000 and $7,000 if one does not already have a computer. On the other hand, acquisition of such equipment will certainly prove to be a useful tool in a variety of other applications.

For example, at the Institut de Readaptation de Montreal," the CAD software (CADKEY version 3.02) is used as a simulation tool in wheelchair seating to effectively design seating systems in wheelchair structures at our seating clinics. Also, a new pilot project has been initiated to use CAD for producing precise technical drawings to fabricate lower limb prostheses. This allows for better job definition and task delimitation between the prosthetists and the technicians. In conclusion, computer-aided drafting and design is a worthwhile and cost-effective tool in thigh corset pattern generation. It reduces pattern fabrication time by 85 percent and improves quality control. Volume of client technical files and dossiers is reduced and access for continued consultations and modifications is made easy. Overall, specialists and clients will benefit. Editor's note: Readers who want a copy of a sample program should contact the authors at the above address.

Claude Lvesque is a certified prosthetist at the Montral Rehabilitation Institute, 6300 Ave Darlington, Montreal, Quebec, Canada H35 2J4, (514) 340-2080. Carole St-Jean is a certified prosthetist at the Montral Rehabilitation Institute. Marc St-Georges is a rehabilitation engineer at the Montral Rehabilitation Institute. References: 1. Kottke, F.J. et a!., Krusen's Handbook of Physical Medicine and Rehabilitation, W.B. Saunders Company, Third Edition, Philadelphia, PA, 1982, 1023 pages. 2. American Academy of Orthopaedic Surgeons, Atlas of Limb Prosthetics; Surgical and Prosthetic Principles, The C.V. Mosby Company, St. Louis, MO, 1981, 668 pages. 3. Souter Glass, D., "Leatherwork Pattern Generation by Computer" (Technical Note), Orthotics and Prosthetics, Summer 1987, 41:2, 32 pages.

Journal American academy of orthotist and prosthetist, 1990 vol 2 num 4, pg 309 to 312

Article 2 Modified Joint and Corset Prosthesis Designs One of the aspects of my consulting practice that I find most enjoyable is the chance to see the clever ways colleagues across the country have solved clinical problems. In my travels to various locations in the upper Midwest this spring, I noted several examples of applying the principles of the old-fashioned leather corset and side joint prostheses to solve contemporary clinical problems. Although I cannot cite a written reference, several people have ascribed the basic concepts illustrated here to Carl Caspers, CPO, a wellrespected clinician who formerly practiced in the St. Cloud, Minnesota area and often shared his ideas with area colleagues. The universal indications for joint and corset limbs have been: 1. Unloading a damaged residual limb 2. Stabilizing an unstable knee 3. Increasing mediolateral stability for a short residual limb These benefits must be weighed against the limitations of the traditional molded leather corset and steel side joints, which include: 1. Significant added weight and bulk 2. Hygienic concerns with perspiration-stained leather 3. The hassle of lacing the thigh corset In recent decades, the use of traditional leather corset and side joint prostheses has become increasingly uncommon, being limited primarily to satisfied previous wearers who prefer the familiar "old timey" style of prosthesis that has served them well. I can't remember the last time I recommended the addition of a leather thigh corset to a prosthesis because the limitations of this material makes this approach objectionable to almost all new patients. But, after my travels this year, I have revised my attitude toward the use of side joints. The examples depicted here mitigate many of the limitations of the traditional approach by using modern materials that are lighter, sleeker, more durable, more hygienic, and easier for patients to manage. I have now seen a number of clinical examples where such "modified joint and corset" designs have substantially improved the gait and stability for selected patients, including octogenarians, and have been well accepted and preferred by the amputees themselves. The first example is from Bob Tillges, CPO's practice in Maplewood, Minnesota. The client is a lady who is approaching 90 years of age and has been a successful limited community ambulator using a walker for balance. Unfortunately, she has a residual limb with extremely soft tissue density that makes it physically impossible for her to obtain sufficient mediolateral stability with a corset-less prostheses; an extended trial with a supracondlar/suprapatellar prosthesis was not successful in increasing her stability while ambulating. She also has difficulty when arising from a chair, since her skeletal remnants are essentially unconstrained within the soft tissue envelope due to poor muscle tone.

This modified thigh corset provides excellent mediolateral stability using a lightweight anterior shell that has been laminated over a mold of the patient's thigh. It can be donned in a seated position with a single hookand-loop strap and has proven suitable for patients of all ages, including geriatrics.

This patient had a badly damaged residual limb and required a custom gel liner. The roll-on sleeve suspends the limb-liner combination in the socket, minimizing potentially destructive pistoning. The shuttle pin protruding from the socket allows the patient to don the prosthesis and custom corset from a seated position, and the shuttle lock anchors the socket to the rest of the prosthesis.

Her current artificial limb includes a roll-on locking liner that she finds this easy to don from a seated position. The artificial limb is also donned from a seated position, with her knee flexed 90 degrees. Once the pin has engaged the shuttle lock, the patient swings the anterior shell down against the anterior surface of the thigh and fastens a single encircling hook-and-loop strap to secure it. She reports that it is "a piece of cake" to put on the prosthesis since everything can be done while sitting. The proximal band, in combination with the sidebars, provides ample mediolateral stability and significantly reduces the loading on her residual limb during ambulation. This increases both comfort and stability, enabling her to walk as far as she is physically able to, with confidence. The second example is a somewhat more complicated case where a custom-molded gel liner was required due to severe scarring on the residual limb, which is also quite short.

In this configuration, the patient first dons the gel liner and then the socket, rolling up a knee sleeve to suspend both on the residual limb. A suspension pin, protruding from the end of the socket, engages a shuttle lock thus suspending the prosthesis. As before, the patient then swings the anterior band and sidebars down in contact with the thigh and closes a single hook-and-loop strap. The final example is from Mike Gozola, CP's practice in Rochester, Minnesota that has been used successfully for many years by a young mother and teacher whose residual limb that was severely damaged by the trauma that led to the original amputation. Not only is her skin very fragile due to extensive scarring but her comminuted femoral fractures healed with a valgus angulation that puts tremendous stresses on the knee joint when she walks.

Posterior view of a custom molded thermoplastic thigh corset illustrating the posterior opening to facilitate donning while seated.

Thermoplastic corset and polycentric joints stabilize the knee and partially unload the residual limb, while the thin roll-on locking liner suspends the prosthesis without requiring a waist belt. The polyethylene foam insert is lighter and more durable than an equivalent thickness of gel and facilitates adjustments to the socket over time.

Off-the-shelf elastic knee support from the local discount pharmacy softens the contours of the prosthesis under clothing and protects clothing from the steel polycentric knee joints.

Biomechanically, she has all the indications for a classic joint and corset prosthesis. But, she also wants her prosthesis to be light, hygienic, easy to apply, and inconspicuous under slacks or longer skirts. Mike has used a custom molded thermoplastic thigh shell that encompasses the medial, anterior, and lateral surfaces of her thigh to provide the protection, stabilization, and unloading required.

A three millimeter roll-on silicone liner with shuttle lock provides both suspension and shear reduction. A removable polyethylene foam insert applied over the liner offers added skin protection and facilitates ongoing socket adjustments while being much lighter and more durable than the equivalent thickness of gel cushion liner. To protect her clothing as well as to soften the contours of the prosthesis, this patient applies an off-the-shelf elastic knee support over the polycentric knee joints, extending from the proximal socket to the distal thigh section. She buys the knee supports at the local discount pharmacy, and replaces them every few months as they fray and lose their elasticity. From: John Michaels corner, 2004