evidencias protesis en amputados

7/23/2019 Evidencias Protesis en Amputados

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AMPUTACIONES DEL MIEMBROINFERIOR Y DISPOSITIVOS

ORTOPDICOS

HOSPITAL NACIONAL EDGARDO REBAGLIATI MARTINSDEPARTAMENTO DE MEDICINA FSICA Y REHABILITACIN

PRESENTADO POR:MR E.T.C


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Aim of prosthesis fitting

to substitute for a lost part and torestore lost function.

In the lower extremityprosthesis must permitcomfortable ambulationminimal expenditure of energy.

Reduction of energy requirementdepends on minimizing the shift ofthe center of gravity of the bodyduring gaitby a well-fitted socket and properalignment.

But for upper limb:It is difficult to get the function as it

is not possible to replace theNormal Hand

center of gravity of thebody during gait wheeldoes not deviate fromstraight line-henceextreme efficient

Normal human locomotion>2deviation of CG both

horizontally and verticallyhence also efficient


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Power source of prosthesis

Body poweredamputation stump & other limbs.

Externally poweredelectric or battery

More distal the amputationmore the functional ability

( more natural limbcontrol the prosthesis).

used in the upper limb

prosthesis more.


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Level of amputation and prosthesis

Toe disarticulation: toe filling rubber, foam,

wool as spacer to prevent hyperextension of

boot at toe break.

Transmetatarsal amputation: boot with long

steel shank, metatarsal pad and stiff insole.


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Lisfranc's amputation: boot filled with stiff

insole

Chopart's amputation:

1. syme's model prosthesis

2. high collar shoe with toe filler


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Syme's amputation: syme's prosthesis

Syme's prosthesis should have end bearing pad for

shock absorption. Types1.full end bearing i.e. Conventional prosthesis:

Has leather socket and wooden foot piece

Most pts are unable tom bear long time standing

and distance walking

2.CANADIAN SYME'S PROSTHESIS: more distal end

bearing and less proximal PTB weight bearing

Medial window is given to pull bulbous end to the

socket. Also provides suspension over malleoli


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SYME'S PROSTHESIS

3. closed expandable syme's prosthesis: more

PTB bearing and less end bearing

Prescribed for modified syme's amputation

where the lower end is less bulbous and there

is no need for any window

Advantages: better cosmesis and better

suspension


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-Socket

-Suspension system

-Extension joints(knee assembly)

-Shank/pylon

-Terminal device(usually includesfoot and Ankle )


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Suction&Mechl close fitting


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1. End bearing

End of the stump bears the weight

2. Total Contact socket

load is distributed to entire stump

supports all the distal tissues within the closed system

As there is total contact proprioception will be good.

give good sensory feed back.

good control of stump

acts as a circulatory pump

. During stance phase , positive pressure encourages venousreturn;

during swing phase ,negative pressure encourages distal

blood flow.

Socket WT bearing 2 types


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Total Contact socket Used for most older patients

Offers partial suction Suspended by pelvic belt and hip joint that is

attached to socket

A selsian bandage suspension preferred over pelvic

belt as the latter often interferes with sitting


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suspension system -forattaching socket to

body.can be done by

a)belt ,straps or cuff

b)others by suction prosthesis

by Mechanical closefitting or silicon sockhelps to maintainairtight seal

Silesian bandage

Hipjoint,pelvicbandwaist belt


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suspension system-Soft belts Used as primary or auxiliary suspention

Traditional form is silesian belt Simple

disadvantage

hygiene if it is non removable

Discomfort due to constrictive effect

Total elastic suspension (TES)

New ,made ofelasticneoprene lined with smooth Nylon Belt fits around proximal 8 of prosthesis

Hip joint with pelvic band or belt Provides rotational stability

significant mediolateral pelvic stability Essential when abductors are week

and amputees are obese

Silesian bandage

Hip joint,pelvicband waistbelt


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held on by suction and close

anatomical fit most suitable for aboveknee.

eliminates the hip joint andpelvis belt or shoulderharness;

permits free rotator motionabout the hip and eliminates piston action

of the stump in the socket ,permitting greater toeclearance and smoother gait.

No stump sock needed.

closely fitted

create negative pressureduring the swing phase and positive pressure that

expels air through a flapvalve during the stancephase.

The tight fit is applied atthe upper two and half orthree inchesand along the anterior wallof the socket, the reminderstump hangs free.

A groove in the anteromedialwall accommodates theadductor tendons.

Suction socket prosthesis


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Suction socket prosthesis

Indicated foramputees forsmooth residual limbcontours

Volume fluctuantssuch as weight gainand fluid retention contraindications

Disadvantages

Difficulty inobtaining press fit

Ocassional lossofsuction in sittingposition

No medium forabsorbingperspiration

Requirement ofvolume and weightstability


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1. Axis system

2. Friction mechanism3. stabilizers-


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Axis systemSingle axis .

Axis of prosthetic knee is same as that of weightybearing axis

Flexion easier, But stance phase control difficultPosterior off set axis

Axis of prosthetic knee is posterior

Flexion difficult, stance phase control easier

Polycentric. variable center of rotation advantage in both

phases


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Friction mechanism

Constant friction Hinge to dampen knee swing

Allows single speed walking

Most used in children

Not used for older or weakerVariable friction-cadence control

Staggerd friction pads

More friction at extreme ranges,

Less friction at mid swing

Allows walkig at more speed ,but not duraleMedium friction

Oil (hydraulic) friction

Air (pneumatic)friction

Allows best gait pattern best for active patients-expensive

Mediumfriction

(hydraulic)friction

Constant friction


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Intelligent prosthesis (IP)

Programmed to each individualuser during walking to achieve

the smoothest, most energy-saving pattern.

Reacts to speed changes

Intelligence does not extend tounderstanding environmentalconsiderations

Ex. stairs, ramps or uneventerrain.

utilizes electronicsensorsdetect rate and rangeof shank

Provides instantfriction adjustmentsto changes in gaitpattern

C-LEG

Friction mechanism


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Stabilizers

Manual locking knee

left locked in extension,

unlocked whole sitting to permit flexion

Used in weak ,unstable patients primarily

StabilizersManual locking


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1. Endoskeleton

Modular prosthesis

2,Exo skeleton:


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Endoskeleton:centrally located tubularstructure

made of prefabricated.

Made of carbon fibers the load bearing structure The socket used over it Adjustments can be easily

made

These are called Modularprosthesis

Exo skeleton:-conventional artificiallimbs outer visible skinlike-Inner hollow structures.-made of aluminum ,plastic-adjustments are difficult

-accurate measurementshould be there in thebeginning it self.


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Providing contact between tothe ground the foot provides

shock absorption and stabilityduring stance

influences gait biomechanicsby its shape and stiffness.This is because thetrajectory of the centre ofpressure (COP) and the angleof the ground reaction forcesis determined by the shapeand stiffness of the foot and

needs to match the subjectsbuild in order to produce a

normal gait pattern.

The main problem

found in currentfeet is durability,endurance rangingfrom 1632 months [

These results arefor adults and willprobably be worse

for children due tohigher activity levelsand scale effects.


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articulated

Non articulated


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Non articulated

Ex:1)sach Foot(solid Ankle cushion Heal)

2)Madras foot

-modified sachPost TA like look

-sponge between heel&ground

3)Jaipur foot

4) dynamic-new

-spring in keel-energy stored and released

Articulated

SINGLE AXIS

MULTI AXIS


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SACH Foot(solid Ankle cushion Heal)

Some movementt in all directionsUseful when not used for heavy dutyWomen/childrenNot suitable for indian amputies

barefoot/squating cannot


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Jaipur foot

Mcr&vulcanised rubber Looks natural Bare foot

walking/squatingpossible/crossleg/rough

use 3level movmt Inv/eversion possible

hence can walk on

uneven area Cheap-durable-water

resistant


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Single axis ankle and wood foot

Heavy duty activities, rapid plantar flexion at healstrike


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Commonly used varieties of prosthesis

AK prosthesis

preferred design quadrilateral socketpelvic belt Suction prosthesis

BK prosthesis

Patellar tendon bearing

Mechanical Fitor with bar suspension system


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Commonly used varieties of prosthesis

AK prosthesis

quadrilateral socketmedwall high,latwall flat10deg adduction med inclination

pelvic belt

Suction prosthesisBK prosthesis

Patellar tendanbearing

60%pt 40% condyles,post wallMed flare oftibiaalso wt bearing

Mechanical Fit orwith bar suspensionsystem


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Slide the CROW into position,ensuring that the heel is fully

seated within the CROW

The heel needs to be back all theway and in contact with the

bottom of the footplate.

Check by looking along the sidesand the back where it isseparated above the heel.


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Apply the front section of thedevice,

making sure it's sides overlapthe back section


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Apply the instep strap onthe front of the ankle

Fasten all remaining straps


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Skin should be checkedfor redness that does notgo away afterapproximately15 minutes.

Slight redness is commonover the instep and underthe ball of the foot.


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The main objectives of the good

construction of the lower limbprosthesis is to provide and ensure forthe user sufficient certainty, stability,balance, and comfort during the stance

and during the walk to minimize theenergy cost and gait asymmetry.


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Typical transtibial prosthesis

consists of a prosthetic foot, tubeadaptor, and transtibial socket


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Typical transfemoral prosthesis

consists of a prosthetic foot, tubeadaptor, prosthetic knee joint, andtransfemoral socket.


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Lower limb prostheses can be

exoskeletal (prosthesis with theperipheral weight-bearing capacity, theuse of which facilitates the transfer of a

patients weight to the ground along thedevices circumference)


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Most frequently used endoskeletal modular (prosthesis with the central

weight-bearing capacity, the use ofwhich facilitates the transfer of apatientsweight to the ground a tubularstructure in the prosthesis centre).


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Health condition assessment andassignment to a functional regime iscarried out considering the following

aspects:1. assessment of cardiovascular apparatusefficiency, especially in terms of load tolerance,

2. muscular power of a person insured, muscle

tone, and locomotor finding,3. self-sufficiency when applying an orthopaedicprosthetic device,


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4. mobility of a person insured with anorthopaedic prosthetic device,

5. local finding on a residual limb and a

residual limbs bearing capacity,6. psychological preconditions for the useof prosthesis.


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CONSTRUCCIN DE LA PRTESIS

In majority of individuals with both limbs,the weight is distributed in the 50:50ratio which facilitates ideal symmetric

loading of lower limb joints.


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With amputations, the load is oftentransferred through the tuberosity of the

ischium which is unsuitable due tochanged position of the centre of gravityin the frontal plane; the centre of gravity

is moved laterally to the healthy limbside.


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By proper construction and a suitableselection of components it can bearranged that the TF prosthesis

transfers at least 40% of the individualsbody weight.


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Stabilizing activity of the limb/prosthesisdepends on the amputation height, i.e.on residual muscles that remained on

the residual limb.

F t f th ti f


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Factors for the creation ofproperly functioning prosthesis

1.- Selection of appropriatecomponents that depends primarily onthe physical and mental condition of theuser, users activity, and method of use.


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The principal factors for the selection ofprosthetic components are: patients weight

physical activity.


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2.- Residual limbs conditions,amputation height, residual limbsshape(conic smaller circumference on the

distal part than on the proximal part,pear-shaped, cylindrical the samecircumference on the distal and proximal

end), amputation scar, as well as otherproblems or diseases.


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Steps:

1. Basic construction2. static and

3. dynamic correction


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when the prosthesis is constructed, itshould run through the centres of jointsof one limb.

Load line:1. 2mm posterior from the hip joint,2. 15mm anterior from the knee joint and

3. 60mm anterior from the ankle joint.


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In the first phase, it is crucial todetermine the construction line (Fig. 4),which is an arbitrary vertical line towards

which individual prosthesis componentsare positioned according to certain rules(Table 2).


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Table 2 Positioning of components


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Table 2 Positioning of componentsaccording to certain rules

1.- BASIC CONSTRUCCIN


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TT TF


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TF


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2.- STATIC CORRECTION

TT TF


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In the static adjustment, it is important toadjust the correct prosthesis length sothat both limbs are evenly loaded and

the pelvis is leveled. Negative effect on the stance with a

prosthesis is influenced by the shift ofthe load line caused by the plantarflexion of the foot or moving the footforward.


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3.- DYNAMIC CORRECTION


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When a patientsgait is assessed in thesagittal and frontal planes, deviationsfrom the normal step cycle are

examined. The deviations can be caused by

improper construction of the prosthesisor by physical deficiencies, as well as apatientsmental condition.


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During the gait with a prosthesis, thefirst contact of the foot and the ground isimportant, as well as transfer of load on

the foot.


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The foot contact is carried out throughthe heel so that the walking is as naturalas possible, and subsequently the entire

sole surface contactsthe ground andthe load is transferred to the foot.


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It is followed by the foot rolling awayfrom the ground and the push-offthrough the toe, when the energy is

required for the swing phase.


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In this phase, the important role isplayed by the proper selection of a foot(foot roll away from the ground,

adaptation to the surface, compensationmovements, energy accumulation andexpenditure) and a proper position of theknee joint.


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Particularly these components (foot andknee joint) and their proper assemblyaffect the final function of the prosthesis

and thus influence the users activity.


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In the swing phase, the knee function isimportant, as it is necessary to ensurethe movement from flexion to extension

(extension moment of the knee) whichfacilitates the foot transition from plantarflexion to dorsal flexion, i.e. the toeelevation, in order to avoid

stumbling(tropiezos) and subsequent fallof the user [1].


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Biomechanics of the socket


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The residual limb is placed in the socketthat provides rigid and stable attachmentto the limb, which is important for the

control thereof. The prosthesis socket(Fig. 7) can be divided into 3 parts thathave different functions.


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The top part is the so-called seating face. The central part is actually the controlling

socket area with the function to ensurecorrect movement and restrain it in the P-Adirection, which is important during the gait.

The last part is the distal socket end which,in an ideal case, should transfer only 10%of an individuals weight to avoid

inappropriate load transfer and subsequentdamage to soft tissues.


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A socket must be able to transfer the load,

ensure stability,

and provide efficient control during themobility.


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In a standing position, the m. gluteusmedius is stretched; it ensures that thepelvis is maintained in a balancedposition.

In a healthy individual, this process isensured by attaching the femur to theground by a lower limb

In case of the lower limb amputation,this function is taken over by theprosthetic socket.


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Therefore, proper socket shape isimportant, as well as its ML (medial-lateral)and AP (anteroposterior)

dimensions, so that the femur can beattached.

In a transverse oval socket of


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transfemoral prostheses, the pressureon the distal femur end increases and

the body is excessively bending aside toreduce the pressure (Fig. 8 left, middle).

It is a non physiological load transfer as


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It is a non-physiological load transfer, asthe load is transferred through thetuberosity of the ischium, which reducesthe arm of the exerted force and theoverturning moments are increased (Fig. 8right ).


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On the contrary, the longitudinal oval socket facilitates

the physiological transfer, as the rotation

centre is in the hip joint and the pelvisdoes not turn over (the pelvis is in abalanced position) and no unnaturalstabilisation body movements arerequired [5].

Id l O h i / P h i


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Ideal Orthosis / Prosthesis

FunctionalFits well

Light in weight

Easy to useCosmetically acceptable

Easily maintained/repaired

Ideally locally manufactured


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*Wedge: a heelall the way under the shoe

PROSTETIC OPTIONS BALANCE GAIT

http://dictionary.cambridge.org/dictionary/english/heelhttp://dictionary.cambridge.org/dictionary/english/shoehttp://dictionary.cambridge.org/dictionary/english/shoehttp://dictionary.cambridge.org/dictionary/english/heel


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* resilient: ableto quicklyreturnto a previousgood condition.

* fastening: a deviceon a window, door, box, etc. for keepingit closed

The six differenttypes of rockersole.

A,Mild.

B,Heel-to-toe.

C,Toe only.

D,Severe angle.

E,Negative heel. F,Double.
http://dictionary.cambridge.org/dictionary/english/ablehttp://dictionary.cambridge.org/dictionary/english/quicklyhttp://dictionary.cambridge.org/dictionary/english/returnhttp://dictionary.cambridge.org/dictionary/english/previoushttp://dictionary.cambridge.org/dictionary/english/conditionhttp://dictionary.cambridge.org/dictionary/english/devicehttp://dictionary.cambridge.org/dictionary/english/windowhttp://dictionary.cambridge.org/dictionary/english/doorhttp://dictionary.cambridge.org/dictionary/english/boxhttp://dictionary.cambridge.org/dictionary/english/keepinghttp://dictionary.cambridge.org/dictionary/english/closedhttp://dictionary.cambridge.org/dictionary/english/closedhttp://dictionary.cambridge.org/dictionary/english/keepinghttp://dictionary.cambridge.org/dictionary/english/boxhttp://dictionary.cambridge.org/dictionary/english/doorhttp://dictionary.cambridge.org/dictionary/english/windowhttp://dictionary.cambridge.org/dictionary/english/devicehttp://dictionary.cambridge.org/dictionary/english/conditionhttp://dictionary.cambridge.org/dictionary/english/previoushttp://dictionary.cambridge.org/dictionary/english/returnhttp://dictionary.cambridge.org/dictionary/english/quicklyhttp://dictionary.cambridge.org/dictionary/english/able


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Keel= quilla


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Usual Shoe modifications

Heel Raise Total Raise

Arch Support

Thomas Heel Reverse C&E Heel

Sole Wedge

MT Bar Toe wedge

Wedge: a pieceof something, especiallyfood, in

the shapeof a triangle:
http://dictionary.cambridge.org/dictionary/english/piecehttp://dictionary.cambridge.org/dictionary/english/especiallyhttp://dictionary.cambridge.org/dictionary/english/foodhttp://dictionary.cambridge.org/dictionary/english/shapehttp://dictionary.cambridge.org/dictionary/english/trianglehttp://dictionary.cambridge.org/dictionary/english/trianglehttp://dictionary.cambridge.org/dictionary/english/shapehttp://dictionary.cambridge.org/dictionary/english/foodhttp://dictionary.cambridge.org/dictionary/english/especiallyhttp://dictionary.cambridge.org/dictionary/english/piece


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Floor Reaction Orthosis


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Foot

Jaipur foot Sach foot


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Type of Lower Limb Stumps

End Bearing stump

Side bearing or Total

Contact


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B K Prosthesis

ComponentsSuspension

SocketShank/Shin piece

Ankle and footAssembly


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Suspension

Flexible A. SupracondylarCuffB. SleeveC. Suction

Brim Contour A. SupracondylarB. Supra Pateller

Thigh corset consists of

- 2 Metal Bars with knee joints- Corset- Leather/Plastic


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Socket

Hard socket for ideal B.K. Stump Hard Socket with inner liningWeight Bearing

Anteriorly - Lower 3rd of patella-Ligamentum patellee, tibial tuberosity

Posteriorly - Pop. Fosa Laterally - Lat. condyle of tibia and head

of fibula Medially - Med.condyle of tibia


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Shank/Shin Piece

Exoskeleton- Plastic resin andwood

Endoskeleton-Metal/PVC tube

Ankle Foot Assembly


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Non Articulated Articulated

Single Axis Multiple Axis

SACH SAFE

STEN

CARBON COPY II


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Above Knee Prosthesis

Components

Suspension

Socket

Knee Joint

Shank/Shin piece

Ankle foot assembly


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Suspension

SuctionSilesian belt

Pelvic belt with hip jointShoulder suspendor


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Socket

Quadrilateral- Commonlyused

Total contact


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Knee Joint Assembly

Conventional single axis knee- commonly used

Polycentric knee joint

Constant friction knee

Constant friction with friction lock


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Syme Prosthesis

Conventional End weight bearing : -Leather/plastic socket attached to SACH

foot P.T.B. Syme prosthesis : - When heel pad

is not sufficient for weight bearing than P.T.B.type Syme prosthesis is given.

Specifications of

Intelligent Knee Prosthesis


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107

mg 21-22-23-24-25mg 26

Vid 01

DEC-2009

Devices on the marketCompeting companies&Products


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108

The Icelandic company OssurRheo Knee

The German company Otto BockC-leg

The Japan company Nabtesc Hybrid Knee

mg 27

mg 29

mg 28 mg 30

mg 31

mg 32

DEC-2009

Devices on the marketCompeting companies&Products Contd


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Knee Weight 300

Weight Limit 125kg for up to K3, for K4 Frame:100kg

Max. Flexion Angle

Swing Phase Ctrl PneumaticMicroprocessor Magnetic FluidMicroprocessor HydraulicMicroprocessor

Very Wide Cadence Responsive,

Smooth

Artificial Intelligence functionAI Strong Extension Assist

Stance Phase Ctrl HydraulicMRS Magnetic FluidMicroprocessor HydraulicMicroprocessor

Rotary-unitprovide resistance whole

range of knee bending

Resistance of Magnetic Fluid is

relatively weaker than normal hydraulic

one.

Second Modeis available

Battery Life For 2 yearsw/o Recharging daysrechargeable daysrechargeable

When Battery is

Flat

SWNormal Pneumatic Knee

ST: Keep same function

SWFree Motion

STNo Resistance (Dangerous)

SW: Lock Knee

ST: Lock Knee

Gait Sensor MRS-SystemMechanical, Built-in Strain GaugeBuilt-in Strain Gauge Pylon

Adjuster Compact Adapter Pocket PC PC

Hybrid-KneeRheo Knee

C-Leg

Comparison Among High-end Knee Joints [8]

mg 28

mg 30mg 32mg 33 mg 34

mg 35

DEC-2009

Specifications of

Intelligent Knee Prosthesis


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110

mg 21-22-23-24-25mg 26

Vid 01

DEC-2009

Devices on the marketCompeting companies&Products


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111

The Icelandic company Ossur

Rheo Knee

The German company Otto BockC-leg

The Japan company Nabtesco

Hybrid Knee

mg 27

mg 29

mg 28 mg 30

mg 31

mg 32

DEC-2009

Devices on the marketCompeting companies&Products Contd


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Knee Weight 300

Weight Limit 125kg for up to K3, for K4 Frame:100kg

Max. Flexion Angle

Swing Phase Ctrl PneumaticMicroprocessor Magnetic FluidMicroprocessor HydraulicMicroprocessor

Very Wide Cadence Responsive,

Smooth

Artificial Intelligence functionAI Strong Extension Assist

Stance Phase Ctrl HydraulicMRS Magnetic FluidMicroprocessor HydraulicMicroprocessor

Rotary-unitprovide resistance whole

range of knee bending

Resistance of Magnetic Fluid is

relatively weaker than normal hydraulic

one.

Second Modeis available

Battery Life For 2 yearsw/o Recharging daysrechargeable daysrechargeable

When Battery is

Flat

SWNormal Pneumatic Knee

ST: Keep same function

SWFree Motion

STNo Resistance (Dangerous)

SW: Lock Knee

ST: Lock Knee

Gait Sensor MRS-SystemMechanical, Built-in Strain GaugeBuilt-in Strain Gauge Pylon

Adjuster Compact Adapter Pocket PC PC

Hybrid-KneeRheo Knee

C-Leg

Comparison Among High-end Knee Joints [8]

mg 28

mg 30mg 32mg 33 mg 34

mg 35

DEC-2009

GRACIAS


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GRACIAS

evidencias protesis en amputados

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