Leg Prostheses - Eugene Rossouw Prosthetics

Below Knee Amputation Rehabilitation Process

Amputation

After the formalisation of the amputation, a compressive dressing or rigid dressing will be applied immediately after amputation to prevent swelling of the residual limb (stump) tissues. Controlling swelling is important as swelling of the soft tissues causes pain and can result in the suture site and stitches being put under undue tension.

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• Residual Limb – immediately post-operation. The suture line visible at front where muscle and skin are attached to form a soft tissue pad over the bone.

• A wound dressing bandage is placed around the limb – the rigid dressing underneath the limb about to be closed.

• The rigid dressing applied. Air is sucked out of the rigid dressing, causing it to compact and rigidify.

Compression Therapy

After approximately 7 – 10 days, the wound dressing and compression dressing will be removed. The sutures can often be removed after approximately 14 days, depending on the suture site healing. For diabetic or vascular insufficiency patients, the healing may take a little longer.

Compression therapy of the residual limb can commence once the sutures have been removed. The compression therapy has the following advantages:

• It helps to control swelling
• By controlling swelling, it helps to reduce pain
• By controlling swelling, it promotes wound healing
• It reduces and shapes the residual limb soft tissues to be ideal for prosthetic fitting
• It therefore speeds up the rehabilitation process.

Compression therapy can be done by means of elastic bandages wrapped around the residual limb, or better, by means of silicone compression liners. The silicone liners are easier to apply and give consistent graduated compression (higher at the bottom – gradually getting less at the top).

• Post-Op compression silicone liner. Graduated thickness allows graduated compression – more at bottom, gradually less at top.

• The application of the compression therapy silicone liner to the residual limb

• The compression therapy liners are applied in a graduated compression therapy protocol where the silicone liner is used for slightly longer periods of time each day. As the residual limb volume and shape reduce, a smaller size compression liner is applied.
  
  This process is repeated until the prosthetist is satisfied that the volume and shape of the residual limb is suitable for the fitting of a diagnostic socket.

Casting, Manufacture and Fitting of Diagnostic Prosthesis

The diagnostic socket can serve as an interim prosthesis for short-term use to help further shape and reduce the volume of the residual limb. As the name implies, the diagnostic socket also serves to help determine any socket fitting problems, areas of residual limb discomfort and the correct alignment of definitive prosthesis.

• Taking measurements and casting the residual limb to manufacture the prosthetic socket.

• Below Knee Prosthesis with ‘’Diagnostic Socket’’ to determine comfortable socket fit and correct dynamic alignment.

Fitting of Final (Definitive) Leg Prosthesis

Once the residual limb volume and shape has stabilised, the definitive prosthesis can be manufactured. The correct alignment of the diagnostic or interim prosthesis can be transferred to the definitive prosthesis. The prosthetic components used in the diagnostic prosthesis (such as the foot, suspension lock and other attachment components) can be used in the definitive prosthesis. It is therefore simply a replacement of the prosthetic socket.

Cosmetic Covering of leg prosthesis (if applicable)

If the patient desires a cosmetic cover for the prosthesis, it will be the final procedure in the completion of the definitive prosthesis. This can be a simple foam shaped cosmesis covered with a cosmetic stocking, a basic silicone ‘’skin’’ or a high definition silicone "skin" cover that matches the skin colour, skin profile, toes and nails of the contra-lateral limb.

Through Knee (Knee Disarticulation) Prostheses

The Through Knee amputation is the third most common level of amputation of the lower extremities (after below knee and above knee amputations). It is performed when a below knee amputation is not viable, generally where the tissues are damaged or diseased too close to the knee joint which would result in a very short below knee amputation, posing prosthetic fitting problems.

• Through Knee Prosthesis without cosmetic cover.

• Through Knee Prosthesis with high definition cosmetic cover.

If a Below Knee amputation is not viable, then a Through Knee amputation is performed rather than an Above Knee amputation wherever possible. Through Knee amputation has a number of advantages over an Above Knee amputation:

• As the femoral condyles are still remaining, they can support partial weight bearing in the prosthetic socket.
• The prosthetic socket therefore does not have to go as high up to the buttock and ischial bone (sitting bone) as with the Above Knee socket, generally making prosthetic socket fit and sitting especially, more comfortable.
• It leaves a very long residual limb, therefore a long lever arm for good prosthetic limb control.

• SKELETAL ANATOMY OF AN:
  
  1. Above knee amputation
  Amputation done through the shaft of the femur bone.
  
  2. Through knee amputation
  Amputation done through the knee joint – leaving the round femoral condyles.

• Above knee residual limb (left) vs. through knee residual limb (right)

The main disadvantage of the Through Knee amputation is that the knee centers (or axes) of the prosthetic knee and sound limb knee are not equal, due to the fact that the socket materials, attachment components and structural build height of the prosthetic components takes up space – effectively placing the prosthetic knee joint axis lower than that of the sound limb knee.
This causes the through knee prosthesis knee joint to extend further forward from the sound side limb when the amputee is sitting. It is therefore a predominantly cosmetic consideration. The functional advantages of the through knee amputation and prosthesis far outweigh the cosmetic compromise when sitting.

• The prosthetic knee can be seen extending further forward than the sound limb knee when sitting down.

The rehabilitation process, prosthesis manufacturing (casting, socket manufacture and fitting, as well as alignment) is the same as discussed under above knee (transfemoral) amputations. Only the prosthetic socket principles and design are different.

What is a prosthetic leg?

A prosthetic leg, or lower limb prosthesis, is an artificial replacement for part or all of your leg. If you can’t use your leg, either because of a birth defect or amputation, you might use a prosthetic leg to walk.

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A leg prosthesis can replace as much of your leg as you need, from your foot, ankle and shin to your knee, thigh and hip. It can offer you greater mobility and the chance to live a more active lifestyle.

What is the purpose of a prosthetic leg?

Prosthetic limbs are assistive devices to enhance your mobility and independence. They mimic the functions of a human limb to help you do certain things better than you could without them.

Using a prosthetic limb can also help you maintain your overall musculoskeletal health. Making your different side more usable allows you to distribute your body’s workload more evenly across both sides.

What are prosthetic legs made of?

Modern prosthetic legs are made of strong but lightweight materials, like carbon fiber or fiberglass, titanium or aluminum. They also have some softer parts, like foam cushioning and silicone sleeves.

The moving parts at the joints might include mechanical springs and gears or computer microprocessors. Some prosthetic legs include hydraulic or pneumatic cylinders, which make movement smoother.

What do prosthetic legs look like?

Prosthetic legs can look different ways. Some are high-tech and look like robot limbs. Others are more low-tech and skeletal-looking. You can also get different types of “skins” to cover your prosthesis.

Some people customize their prosthetic legs with fun fabrics, logos or tattoos. Others prefer a low-profile look that’s custom-painted to look like their natural legs. Most cosmetic covers are removable.

What are the different types of prosthetic legs?

Different types of prosthetic legs replace different parts of your leg. You might need a prosthesis with an ankle joint, a knee joint and/or a hip joint. Different types also have different mechanisms at the joints.

Some prosthetics are purely mechanical, while others have computerized parts. Some move in limited ways, and others move in many ways. Some are designed for particular sports or other activities.

Amputation levels

Different types of prostheses are available for different types of lower limb amputations, including:

• Transtibial amputation: Amputation through your lower leg.
• Knee disarticulation: Amputation at your knee joint.
• Transfemoral amputation: Amputation above your knee and through your femur.
• Hip disarticulation: Amputation at your hip joint.
• Hindquarter amputation (external hemipelvectomy): Removal of your whole leg and part of your pelvis.

Above-the-knee and below-the-knee prosthetic legs

Your limb deficit or amputation level will determine the level of prosthesis you need. In general, an above-the-knee prosthetic leg is a more complex device than a below-the-knee prosthetic leg.

One difference is the knee joint. If your prosthesis is below the knee, it only needs a shin, ankle and foot, which may or may not be flexible. If it’s above the knee, it’ll need to include a functioning knee joint.

Your knee joint is central to the mechanics of walking. It bears much of your weight and affects your stability and balance on various terrains. It also determines whether your leg can run, bike or swim.

The attachment part of the prosthesis also needs to be more sophisticated, as the prosthesis must attach to a shorter lever arm. Generally, the higher the amputation level, the trickier it is to attach the prosthesis.

Mechanical and bionic legs

The joints in your prosthetic leg may be mechanical or bionic, which means they include computer microprocessors. These microprocessors enable the joints to automatically adjust to different terrain.

Both types have pros and cons. Mechanical legs tend to be more durable, lightweight and affordable than bionic legs. They aren’t “smart,” but you can use them for basic walking and sitting down.

Bionic legs use microprocessors to provide real-time feedback about how you’re using them. They adjust to different activities and environments more like a natural leg would. Some are also programmable.

Both mechanical and bionic legs may include pneumatic or hydraulic components (compressed air or water). These provide adjustable resistance while walking, which allows for a more natural gait pattern.

What are the components of a prosthetic leg?

Prosthetic legs have several components, which are sometimes interchangeable. When you and your prosthetist design your custom prosthesis, you’ll discuss each of these components.

• Socket. The socket is the part that connects your prosthesis to your existing limb. It’s custom-made to fit your existing limb, and you’ll have several fitting appointments to perfect the fit. You’ll usually wear a changeable liner or “sock” between your limb and the socket.
• Suspension. The prosthesis connects to the socket by some type of suspension system. There are many types of prosthesis suspension systems, including straps or belts, suction liners, pin-locking liners, electric vacuum pumps and neoprene sleeves that “grip” the prosthesis.
• Skeleton. This is the “bone” part of a prosthetic leg, which connects the socket with the joint components. It’s also called the connector, adapter or frame. It’s often a type of metal pipe, or pylon, with connecting parts. Sometimes, it’ll have a softer, limb-shaped material over it.
• Joints. An above-the-knee prosthesis will need a knee joint, and sometimes a hip joint. These might be mechanical, pneumatic or hydraulic, and/or powered (bionic). Different types may be better for different people. You’ll also need an ankle joint, but this is usually part of the foot.
• Foot. The prosthetic foot is the terminal device at the end of your prosthetic leg. It may or may not resemble a human foot. Prosthetic feet can be low- or high-tech, with ankles that move in a variety of ways. Special feet can accommodate swimming, running, skiing or other sports.

Who can benefit from a prosthetic leg?

You might benefit from a prosthetic leg if you’ve had a lower limb amputation or have a congenital limb difference that makes walking difficult. However, not everyone benefits equally from a prosthetic leg.

Many factors can influence how much you’re likely to benefit from a prosthetic leg, and what complications you may face along the way. Before recommending one, your provider will want to know:

• Is your existing limb in good condition to use with a prosthesis?
• Do you have much pain in your existing limb or phantom limb?
• How much range of motion does your existing limb have?
• What’s the condition of your other leg?
• What are your mobility goals?
• How much rehabilitation and training can you commit to?
• Do you have insurance coverage or other funding for the type of prosthesis you want?
• What kind of moral support system do you have?

What are the steps involved in getting a prosthetic leg?

Getting a new prosthetic limb and learning to use it is a huge undertaking. It will take time, patience and practice on your part. It may be frustrating at times, and you’ll need to manage your expectations.

Here’s a brief breakdown of the steps involved:

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