Prosthesis

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A man with a lower-extremity prosthesis 86 ACPS Atlanta 1996 Swimming General Views.jpg
A man with a lower-extremity prosthesis

In medicine, a prosthesis (plural: prostheses; from Ancient Greek prosthesis, "addition, application, attachment") [1] or prosthetic implant [2] [3] is an artificial device that replaces a missing body part, which may be lost through trauma, disease, or a condition present at birth (congenital disorder). Prostheses are intended to restore the normal functions of the missing body part. [4] Amputee rehabilitation is primarily coordinated by a physiatrist as part of a inter-disciplinary team consisting of physiatrists, prosthetists, nurses, physical therapists, and occupational therapists. [5] Prostheses can be created by hand or with Computer-Aided Design (CAD), a software interface that helps creators design and analyze the creation with computer-generated 2-D and 3-D graphics as well as analysis and optimization tools. [6]

Medicine The science and practice of the diagnosis, treatment, and prevention of physical and mental illnesses

Medicine is the science and practice of establishing the diagnosis, prognosis, treatment, and prevention of disease. Medicine encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness. Contemporary medicine applies biomedical sciences, biomedical research, genetics, and medical technology to diagnose, treat, and prevent injury and disease, typically through pharmaceuticals or surgery, but also through therapies as diverse as psychotherapy, external splints and traction, medical devices, biologics, and ionizing radiation, amongst others.

Ancient Greek Version of the Greek language used from roughly the 9th century BCE to the 6th century CE

The Ancient Greek language includes the forms of Greek used in Ancient Greece and the ancient world from around the 9th century BCE to the 6th century CE. It is often roughly divided into the Archaic period, Classical period, and Hellenistic period. It is antedated in the second millennium BCE by Mycenaean Greek and succeeded by medieval Greek.

Implant (medicine) medical device manufactured to replace a missing biological structure, support a damaged biological structure, or enhance an existing biological structure

An implant is a medical device manufactured to replace a missing biological structure, support a damaged biological structure, or enhance an existing biological structure. Medical implants are man-made devices, in contrast to a transplant, which is a transplanted biomedical tissue. The surface of implants that contact the body might be made of a biomedical material such as titanium, silicone, or apatite depending on what is the most functional. In some cases implants contain electronics e.g. artificial pacemaker and cochlear implants. Some implants are bioactive, such as subcutaneous drug delivery devices in the form of implantable pills or drug-eluting stents.

Contents

Types

A person's prosthesis should be designed and assembled according to the person's appearance and functional needs. For instance, a person may need a transradial prosthesis, but need to choose between an aesthetic functional device, a myoelectric device, a body-powered device, or an activity specific device. The person's future goals and economical capabilities may help them choose between one or more devices.

Craniofacial prostheses include intra-oral and extra-oral prostheses. Extra-oral prostheses are further divided into hemifacial, auricular (ear), nasal, orbital and ocular. Intra-oral prostheses include dental prostheses such as dentures, obturators, and dental implants.

Craniofacial prosthesis

Craniofacial prostheses are prostheses made by individuals trained in anaplastology or maxillofacial prosthodontics who medically help rehabilitate those with facial defects caused by disease, trauma or birth defects. They have the ability to replace almost any part of the face, but most commonly the ear, nose or eye/eyelids. An ocular prosthesis and hair prosthesis can also be classified as craniofacial prostheses. Prostheses are held in place either by biocompatible drying adhesives, osseointegrated implants, magnets, or another mechanical means such as glasses or straps. Prostheses are designed to be as similar as possible to the natural anatomy of each individual. Their purpose is to cover, protect, and disguise facial disfigurements or underdevelopments.

Ocular prosthesis type of craniofacial prosthesis

An ocular prosthesis, artificial eye or glass eye is a type of craniofacial prosthesis that replaces an absent natural eye following an enucleation, evisceration, or orbital exenteration. The prosthesis fits over an orbital implant and under the eyelids. Though often referred to as a glass eye, the ocular prosthesis roughly takes the shape of a convex shell and is made of medical grade plastic acrylic. A few ocular prostheses today are made of cryolite glass. A variant of the ocular prosthesis is a very thin hard shell known as a scleral shell which can be worn over a damaged or eviscerated eye. Makers of ocular prosthetics are known as ocularists. An ocular prosthesis does not provide vision; this would be a visual prosthesis. Someone with an ocular prosthesis is totally blind on the affected side and has monocular vision.

Dentures prosthetic devices constructed to replace missing teeth

Dentures are prosthetic devices constructed to replace missing teeth, and are supported by the surrounding soft and hard tissues of the oral cavity. Conventional dentures are removable. However, there are many denture designs, some which rely on bonding or clasping onto teeth or dental implants. There are two main categories of dentures, the distinction being whether they are used to replace missing teeth on the mandibular arch or on the maxillary arch.

Prostheses of the neck include larynx substitutes, trachea and upper esophageal replacements,

Larynx voice box, an organ in the neck of amphibians, reptiles, and mammals

The larynx, commonly called the voice box, is an organ in the top of the neck of tetrapods involved in breathing, producing sound, and protecting the trachea against food aspiration. The larynx houses the vocal folds, and manipulates pitch and volume, which is essential for phonation. It is situated just below where the tract of the pharynx splits into the trachea and the esophagus. The word larynx comes from a similar Ancient Greek word.

An electrolarynx, sometimes referred to as a "throat back", is a medical device about the size of a small electric razor used to produce clearer speech by those people who have lost their voicebox, usually due to cancer of the larynx. The most common device is a handheld, battery-operated device placed under the mandible which produces vibrations to allow speech. Earlier non-electric devices were called mechanical larynxes. Along with developing esophageal voice, using a speech synthesizer, or undergoing a surgical procedure, the electrolarynx serves as a mode of speech recovery for laryngectomy patients.

Esophagus organ in vertebrates

The esophagus or oesophagus, commonly known as the food pipe or gullet, is an organ in vertebrates through which food passes, aided by peristaltic contractions, from the pharynx to the stomach. The esophagus is a fibromuscular tube, about 25 centimetres long in adults, which travels behind the trachea and heart, passes through the diaphragm and empties into the uppermost region of the stomach. During swallowing, the epiglottis tilts backwards to prevent food from going down the larynx and lungs. The word oesophagus is the Greek word οἰσοφάγος oisophagos, meaning "gullet".

Somato prostheses of the torso include breast prostheses which may be either single or bilateral, full breast devices or nipple prostheses.

Breast prostheses

Breast prostheses are breast forms intended to simulate breasts. There are a number of materials and designs; although, the most common construction is silicone gel in a plastic skin. Off-the shelf breast prostheses come in a range of shapes and sizes, while customised breast prostheses are moulded to fit an individual's chest by taking an impression of both breasts and sculpting a mirror image. Pals Breast Forms consist of a lifelike gel which can be trimmed to fit with scissors, then sent back for customization. Fabrication of customised prostheses is typically done by an anaplastologist who makes somato prostheses. The areola and nipple may be replicated by being moulded into the breast form or a separate nipple prosthesis may be attached to the breast prosthesis. Both custom made and off-the shelf breast prostheses come in varieties that are designed to either be held in a pocket in a specially designed mastectomy bra or attached to the skin and worn with a standard bra.

Nipple prosthesis

Nipple/Areola prostheses are made of silicone by breast prosthesis manufacturers and anaplastologists for breast cancer survivors who were treated for breast cancer with a mastectomy. Prostheses can be worn weeks after a mastectomy, breast reconstruction, or even nipple reconstruction. As an inexpensive and convenient alternative to surgery, patients may choose to wear them anytime during treatment. Patients who ultimately find nipple prostheses thought that they should be informed of them during the consultation prior to mastectomy.

Penile prostheses are used to treat erectile dysfunction.

A penile prosthesis, or penile implant, is a medical device which is surgically implanted within the corpora cavernosa of the penis during a surgical procedure. The device is indicated for use in men with organic or treatment-resistant impotence or erectile dysfunction that is the result of various physical conditions such as cardiovascular disease, diabetes, pelvic trauma, Peyronie's disease, or as the result of prostate cancer treatments. Less commonly, a penile prosthesis may also be used in the final stage of plastic surgery phalloplasty to complete female to male gender reassignment surgery as well as during total phalloplasty for adult and child patients that need male genital modification.

Limb prostheses

A United States Marine with bilateral prosthetic legs leads a formation run A formation of Marines, firemen and policemen running across Manhattan in 2007.jpg
A United States Marine with bilateral prosthetic legs leads a formation run

Limb prostheses include both upper- and lower-extremity prostheses.

A limb, or extremity, is a jointed, or prehensile, appendage of the human or other animal body. In the human body, the upper and lower limbs are commonly called the arms and the legs, respectively. Arms and legs are connected to torso or trunk.

Upper-extremity prostheses are used at varying levels of amputation: forequarter, shoulder disarticulation, transhumeral prosthesis, elbow disarticulation, transradial prosthesis, wrist disarticulation, full hand, partial hand, finger, partial finger. A transradial prosthesis is an artificial limb that replaces an arm missing below the elbow.

Upper limb prostheses can be categorized in three main categories: Passive devices, Body Powered devices, Externally Powered (myoelectric) devices. Passive devices can either be passive hands, mainly used for cosmetic purpose, or passive tools, mainly used for specific activities (e.g. leisure or vocational). An extensive overview and classification of passive devices can be found in a literature review by Maat et.al. [7] A passive device can be static, meaning the device has no movable parts, or it can be adjustable, meaning its configuration can be adjusted (e.g. adjustable hand opening). Despite the absence of active grasping, passive devices are very useful in bimanual tasks that require fixation or support of an object, or for gesticulation in social interaction. According to scientific data a third of the upper limb amputees worldwide use a passive prosthetic hand. [7] Body Powered or cable operated limbs work by attaching a harness and cable around the opposite shoulder of the damaged arm. The third category of prosthetic devices available are myoelectric arms. These work by sensing, via electrodes, when the muscles in the upper arm move, causing an artificial hand to open or close. In the prosthetics industry, a trans-radial prosthetic arm is often referred to as a "BE" or below elbow prosthesis.

Lower-extremity prostheses provide replacements at varying levels of amputation. These include hip disarticulation, transfemoral prosthesis, knee disarticulation, transtibial prosthesis, Syme's amputation, foot, partial foot, and toe. The two main subcategories of lower extremity prosthetic devices are trans-tibial (any amputation transecting the tibia bone or a congenital anomaly resulting in a tibial deficiency) and trans-femoral (any amputation transecting the femur bone or a congenital anomaly resulting in a femoral deficiency).

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. [8] This is due to the complexities in movement associated with the knee. In newer and more improved designs, hydraulics, carbon fiber, mechanical linkages, motors, computer microprocessors, and innovative combinations of these technologies are employed to give more control to the user. In the prosthetics industry a trans-femoral prosthetic leg is often referred to as an "AK" or above the knee prosthesis.

A transtibial prosthesis is an artificial limb that replaces a leg missing below the knee. A transtibial amputee is 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. Lower extremity prosthetics describes artificially replaced limbs located at the hip level or lower. In the prosthetics industry a trans-tibial prosthetic leg is often referred to as a "BK" or below the knee prosthesis.

Physical therapists are trained to teach a person to walk with a leg prosthesis. To do so, the physical therapist may provide verbal instructions and may also help guide the person using touch or tactile cues. This may be done in a clinic or home. There is some research suggesting that such training in the home may be more successful if the treatment includes the use of a treadmill. [9] Using a treadmill, along with the physical therapy treatment, helps the person to experience many of the challenges of walking with a prosthesis.

In the United Kingdom, 75% of lower limb amputations are performed due to inadequate circulation (dysvascularity). [10] This condition is often associated with many other medical conditions (co-morbidities) including diabetes and heart disease that may make it a challenge to recover and use a prosthetic limb to regain mobility and independence. [10] For people who have inadequate circulation and have lost a lower limb, there is insufficient evidence due to a lack of research, to inform them regarding their choice of prosthetic rehabilitation approaches. [10]

Lower extremity prostheses are often categorized by the level of amputation or after the name of a surgeon: [11] [12]

Prosthetic raw materials

Prosthetic are made lightweight for better convenience for the amputee. Some of these materials include:

  • Plastics:
    • Polyethylene
    • Polypropylene
    • Acrylics
    • Polyurethane
  • Wood (early prosthetics)
  • Rubber (early prosthetics)
  • Lightweight metals:
    • Titanium
    • Aluminum
  • Composites:
    • Carbon fibre [4]

Wheeled prostheses have also been used extensively in the rehabilitation of injured domestic animals, including dogs, cats, pigs, rabbits, and turtles. [13]

History

Prosthetic toe from ancient Egypt Prosthetic toe.jpg
Prosthetic toe from ancient Egypt

Prosthetics have been mentioned throughout history. The earliest recorded mention is the warrior queen Vishpala in the Rigveda. [14] The Egyptians were early pioneers of the idea, as shown by the wooden toe found on a body from the New Kingdom. [15] Roman bronze crowns have also been found, but their use could have been more aesthetic than medical. [16]

An early mention of a prosthetic comes from the Greek historian Herodotus, who tells the story of Hegesistratus, a Greek diviner who cut off his own foot to escape his Spartan captors and replaced it with a wooden one. [17]

Wood and metal prosthetics

The Capua leg (replica) Roman artificial leg of bronze. Wellcome M0012307.jpg
The Capua leg (replica)
Iron prosthetic hand believed to have been owned by Gotz von Berlichingen (1480-1562) Eiserne Hand Glasnegativ 6 cropped.jpg
Iron prosthetic hand believed to have been owned by Götz von Berlichingen (1480–1562)
"Illustration of mechanical hand", c. 1564. Ambroise Pare; prosthetics, mechanical hand Wellcome L0023364.jpg
"Illustration of mechanical hand", c. 1564.
Artificial iron hand believed to date from 1560 to 1600 Iron artificial arm, 1560-1600. (9663806794).jpg
Artificial iron hand believed to date from 1560 to 1600

Pliny the Elder also recorded the tale of a Roman general, Marcus Sergius, whose right hand was cut off while campaigning and had an iron hand made to hold his shield so that he could return to battle. A famous and quite refined [18] historical prosthetic arm was that of Götz von Berlichingen, made at the beginning of the 16th century. The first confirmed use of a prosthetic device, however, is from 950–710 BC. In 2000, research pathologists discovered a mummy from this period buried in the Egyptian necropolis near ancient Thebes that possessed an artificial big toe. This toe, consisting of wood and leather, exhibited evidence of use. When reproduced by bio-mechanical engineers in 2011, researchers discovered that this ancient prosthetic enabled its wearer to walk both barefoot and in Egyptian style sandals. Previously, the earliest discovered prosthetic was an artificial leg from Capua. [19]

Around the same time, François de la Noue is also reported to have had an iron hand, as is, in the 17th Century, René-Robert Cavalier de la Salle. [20] Henri de Tonti had a prosthetic hook for a hand. During the Middle Ages, prosthetic remained quite basic in form. Debilitated knights would be fitted with prosthetics so they could hold up a shield, grasp a lance or a sword, or stabilize a mounted warrior. [21] Only the wealthy could afford anything that would assist in daily life.[ citation needed ]

One notable prosthesis was that belonging to an Italian man, who scientists estimate replaced his amputated right hand with a knife. [22] [23] Scientists investigating the skeleton, which was found in a Longobard cemetery in Povegliano Veronese, estimated that the man had lived sometime between the 6th and 8th centuries AD. [24] [23] Materials found near the man's body suggest that the knife prosthesis was attached with a leather strap, which he repeatedly tightened with his teeth. [24]

During the Renaissance, prosthetics developed with the use of iron, steel, copper, and wood. Functional prosthetics began to make an appearance in the 1500s. [25]

Technology progress before the 20th century

An Italian surgeon recorded the existence of an amputee who had an arm that allowed him to remove his hat, open his purse, and sign his name. [26] Improvement in amputation surgery and prosthetic design came at the hands of Ambroise Paré. Among his inventions was an above-knee device that was a kneeling peg leg and foot prosthesis with a fixed position, adjustable harness, and knee lock control. The functionality of his advancements showed how future prosthetics could develop.

Other major improvements before the modern era:

At the end of World War II, the NAS (National Academy of Sciences) began to advocate better research and development of prosthetics. Through government funding, a research and development program was developed within the Army, Navy, Air Force, and the Veterans Administration.

Lower extremity modern history

An artificial limbs factory in 1941 A Visit To the Artificial Limbs Factory, Queen Mary's Hospital, Roehampton, November 1941 D5731.jpg
An artificial limbs factory in 1941

After the Second World War a team at the University of California, Berkeley including James Foort and C.W. Radcliff helped to develop the quadrilateral socket by developing a jig fitting system for amputations above the knee. Socket technology for lower extremity limbs saw a further revolution during the 1980s when John Sabolich C.P.O., invented the Contoured Adducted Trochanteric-Controlled Alignment Method (CATCAM) socket, later to evolve into the Sabolich Socket. He followed the direction of Ivan Long and Ossur Christensen as they developed alternatives to the quadrilateral socket, which in turn followed the open ended plug socket, created from wood. [29] The advancement was due to the difference in the socket to patient contact model. Prior to this, sockets were made in the shape of a square shape with no specialized containment for muscular tissue. New designs thus help to lock in the bony anatomy, locking it into place and distributing the weight evenly over the existing limb as well as the musculature of the patient. Ischial containment is well known and used today by many prosthetist to help in patient care. Variations of the ischial containment socket thus exists and each socket is tailored to the specific needs of the patient. Others who contributed to socket development and changes over the years include Tim Staats, Chris Hoyt, and Frank Gottschalk. Gottschalk disputed the efficacy of the CAT-CAM socket- insisting the surgical procedure done by the amputation surgeon was most important to prepare the amputee for good use of a prosthesis of any type socket design. [30]

The first microprocessor-controlled prosthetic knees became available in the early 1990s. The Intelligent Prosthesis was the first commercially available microprocessor controlled prosthetic knee. It was released by Chas. A. Blatchford & Sons, Ltd., of Great Britain, in 1993 and made walking with the prosthesis feel and look more natural. [31] An improved version was released in 1995 by the name Intelligent Prosthesis Plus. Blatchford released another prosthesis, the Adaptive Prosthesis, in 1998. The Adaptive Prosthesis utilized hydraulic controls, pneumatic controls, and a microprocessor to provide the amputee with a gait that was more responsive to changes in walking speed. Cost analysis reveals that a sophisticated above-knee prosthesis will be about $1 million in 45 years, given only annual cost of living adjustments. [32]

Upper extremity modern history

In 2005, DARPA started the Revolutionizing Prosthetics program. [33] [34] [35] [36] [37] [38]

Patient procedure

A prosthesis is a functional replacement for an amputated or congenitally malformed or missing limb. Prosthetists are responsible for the prescription, design and management of a prosthetic device.

In most cases, the prosthetist begins by taking a plaster cast of the patient's affected limb. Lightweight, high-strength thermoplastics are custom-formed to this model of the patient. Cutting-edge materials such as carbon fiber, titanium and Kevlar provide strength and durability while making the new prosthesis lighter. More sophisticated prostheses are equipped with advanced electronics, providing additional stability and control. [39]

Current technology and manufacturing

Knee prosthesis manufactured using WorkNC Computer Aided Manufacturing software WorkNC-Knee prosthesis.jpg
Knee prosthesis manufactured using WorkNC Computer Aided Manufacturing software

Over the years, there have been 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 trans-femoral amputees. Additional materials have allowed artificial limbs to look much more realistic, which is important to trans-radial and transhumeral amputees because they are more likely to have the artificial limb exposed. [40]

Manufacturing a prosthetic finger Journal.pone.0019508.g004 prosthetic finger.png
Manufacturing a prosthetic finger

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 signals are picked up by electrodes, the signal gets integrated and once it exceeds a certain threshold, the prosthetic limb control signal is triggered which is why inherently, all myoelectric controls lag. Conversely, cable control is immediate and physical, and through that offers a certain degree of direct force feedback that myoelectric control does not. 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. [40] [41]

Most modern artificial limbs are attached to the residual limb (stump) of the amputee by belts and cuffs or by suction. The residual limb either directly fits into a socket on the prosthetic, or—more commonly today—a liner is used that then is fixed to the socket either by vacuum (suction sockets) or a pin lock. Liners are soft and by that, they can create a far better suction fit than hard sockets. Silicone liners can be obtained in standard sizes, mostly with a circular (round) cross section, but for any other residual limb shape, custom liners can be made. The socket is custom made to fit the residual limb and to distribute the forces of the artificial limb across the area of the residual limb (rather than just one small spot), which helps reduce wear on the residual limb. The custom socket is created by taking a plaster cast of the residual limb or, more commonly today, of the liner worn over the residual limb, and then making a mold from the plaster cast. Newer methods include laser-guided measuring which can be input directly to a computer allowing for a more sophisticated design.

One problem with the residual limb and socket attachment is that a bad fit will reduce the area of contact between the residual limb and socket or liner, and increase pockets between residual limb skin and socket or liner. Pressure then is higher, which can be painful. Air pockets can allow sweat to accumulate that can soften the skin. Ultimately, this is a frequent cause for itchy skin rashes. Over time, this can lead to breakdown of the skin. [8]

Artificial limbs are typically manufactured using the following steps: [40]

  1. Measurement of the residual limb
  2. Measurement of the body to determine the size required for the artificial limb
  3. Fitting of a silicone liner
  4. Creation of a model of the liner worn over the residual limb
  5. Formation of thermoplastic sheet around the model – This is then used to test the fit of the prosthetic
  6. Formation of permanent socket
  7. Formation of plastic parts of the artificial limb – Different methods are used, including vacuum forming and injection molding
  8. Creation of metal parts of the artificial limb using die casting
  9. Assembly of entire limb

Body-powered arms

Current technology allows body powered arms to weigh around one-half to one-third of what a myoelectric arm does.

Sockets

Current body-powered arms contain sockets that are built from hard epoxy or carbon fiber. These sockets or "interfaces" can be made more comfortable by lining them with a softer, compressible foam material that provides padding for the bone prominences. A self-suspending or supra-condylar socket design is useful for those with short to mid-range below elbow absence. Longer limbs may require the use of a locking roll-on type inner liner or more complex harnessing to help augment suspension.

Wrists

Wrist units are either screw-on connectors featuring the UNF 1/2-20 thread (USA) or quick-release connector, of which there are different models.

Voluntary opening and voluntary closing

Two types of body-powered systems exist, voluntary opening "pull to open" and voluntary closing "pull to close". Virtually all "split hook" prostheses operate with a voluntary opening type system.

More modern "prehensors" called GRIPS utilize voluntary closing systems. The differences are significant. Users of voluntary opening systems rely on elastic bands or springs for gripping force, while users of voluntary closing systems rely on their own body power and energy to create gripping force.

Voluntary closing users can generate prehension forces equivalent to the normal hand, up to or exceeding one hundred pounds. Voluntary closing GRIPS require constant tension to grip, like a human hand, and in that property, they do come closer to matching human hand performance. Voluntary opening split hook users are limited to forces their rubber or springs can generate which usually is below 20 pounds.

Feedback

An additional difference exists in the biofeedback created that allows the user to "feel" what is being held. Voluntary opening systems once engaged provide the holding force so that they operate like a passive vice at the end of the arm. No gripping feedback is provided once the hook has closed around the object being held. Voluntary closing systems provide directly proportional control and biofeedback so that the user can feel how much force that they are applying.

A recent study showed that by stimulating the median and ulnar nerves, according to the information provided by the artificial sensors from a hand prosthesis, physiologically appropriate (near-natural) sensory information could be provided to an amputee. This feedback enabled the participant to effectively modulate the grasping force of the prosthesis with no visual or auditory feedback. [42]

In February 2013, researchers from École Polytechnique Fédérale de Lausanne in Switzerland and the Scuola Superiore Sant'Anna in Italy, implanted electrodes into an amputee's arm, which gave the patient sensory feedback and allowed for real time control of the prosthetic. [43] With wires linked to nerves in his upper arm, the Danish patient was able to handle objects and instantly receive a sense of touch through the special artificial hand that was created by Silvestro Micera and researchers both in Switzerland and Italy. [44]

Terminal devices

Terminal devices contain a range of hooks, prehensors, hands or other devices.

Hooks

Voluntary opening split hook systems are simple, convenient, light, robust, versatile and relatively affordable.

A hook does not match a normal human hand for appearance or overall versatility, but its material tolerances can exceed and surpass the normal human hand for mechanical stress (one can even use a hook to slice open boxes or as a hammer whereas the same is not possible with a normal hand), for thermal stability (one can use a hook to grip items from boiling water, to turn meat on a grill, to hold a match until it has burned down completely) and for chemical hazards (as a metal hook withstands acids or lye, and does not react to solvents like a prosthetic glove or human skin).

Hands
Actor Owen Wilson gripping the myoelectric prosthetic arm of a United States Marine Myoelectric prosthetic arm.jpg
Actor Owen Wilson gripping the myoelectric prosthetic arm of a United States Marine

Prosthetic hands are available in both voluntary opening and voluntary closing versions and because of their more complex mechanics and cosmetic glove covering require a relatively large activation force, which, depending on the type of harness used, may be uncomfortable. [45] A recent study by the Delft University of Technology, The Netherlands, showed that the development of mechanical prosthetic hands has been neglected during the past decades. The study showed that the pinch force level of most current mechanical hands is too low for practical use. [46] The best tested hand was a prosthetic hand developed around 1945. In 2017 however, a research has been started with bionic hands by Laura Hruby of the Medical University of Vienna. [47] [48] A few open-hardware 3-d printable bionic hands have also become available. [49] Some companies are also producing robotic hands with integrated forearm, for fitting unto a patient's upper arm. [50] [51]

Commercial providers and materials

Hosmer and Otto Bock are major commercial hook providers. Mechanical hands are sold by Hosmer and Otto Bock as well; the Becker Hand is still manufactured by the Becker family. Prosthetic hands may be fitted with standard stock or custom-made cosmetic looking silicone gloves. But regular work gloves may be worn as well. Other terminal devices include the V2P Prehensor, a versatile robust gripper that allows customers to modify aspects of it, Texas Assist Devices (with a whole assortment of tools) and TRS that offers a range of terminal devices for sports. Cable harnesses can be built using aircraft steel cables, ball hinges, and self-lubricating cable sheaths. Some prosthetics have been designed specifically for use in salt water. [52]

Lower-extremity prosthetics

A prosthetic leg worn by Ellie Cole AustralianParalympianOfTheYear 468.JPG
A prosthetic leg worn by Ellie Cole

Lower-extremity prosthetics describes artificially replaced limbs located at the hip level or lower. Concerning all ages Ephraim et al. (2003) found a worldwide estimate of all-cause lower-extremity amputations of 2.0–5.9 per 10,000 inhabitants. For birth prevalence rates of congenital limb deficiency they found an estimate between 3.5–7.1 cases per 10,000 births. [53]

The two main subcategories of lower extremity prosthetic devices are trans-tibial (any amputation transecting the tibia bone or a congenital anomaly resulting in a tibial deficiency), and trans-femoral (any amputation transecting the femur bone or a congenital anomaly resulting in a femoral deficiency). In the prosthetic industry, a trans-tibial prosthetic leg is often referred to as a "BK" or below the knee prosthesis while the trans-femoral prosthetic leg is often referred to as an "AK" or above the knee prosthesis.

Other, less prevalent lower extremity cases include the following:

  1. Hip disarticulations – This usually refers to when an amputee or congenitally challenged patient has either an amputation or anomaly at or in close proximity to the hip joint.
  2. Knee disarticulations – This usually refers to an amputation through the knee disarticulating the femur from the tibia.
  3. Symes – This is an ankle disarticulation while preserving the heel pad.

Socket

The socket serves as an interface between the residuum and the prosthesis, ideally allowing comfortable weight-bearing, movement control and proprioception. [54] Socket issues, such as discomfort and skin breakdown, are rated among the most important issues faced by lower-limb amputees. [55]

Shank and connectors

This part creates distance and support between the knee-joint and the foot (in case of an upper-leg prosthesis) or between the socket and the foot. The type of connectors that are used between the shank and the knee/foot determines whether the prosthesis is modular or not. Modular means that the angle and the displacement of the foot in respect to the socket can be changed after fitting. In developing countries prosthesis mostly are non-modular, in order to reduce cost. When considering children modularity of angle and height is important because of their average growth of 1.9 cm annually. [56]

Providing contact to the ground, the foot provides shock absorption and stability during stance. [57] Additionally it influences gait biomechanics by its shape and stiffness. This is because the trajectory of the center of pressure (COP) and the angle of the ground reaction forces is determined by the shape and stiffness of the foot and needs to match the subject's build in order to produce a normal gait pattern. [58] Andrysek (2010) found 16 different types of feet, with greatly varying results concerning durability and biomechanics. The main problem found in current feet is durability, endurance ranging from 16–32 months [59] These results are for adults and will probably be worse for children due to higher activity levels and scale effects. Evidence comparing different types of feet and ankle prosthetic devices is not strong enough to determine if one mechanism of ankle/foot is superior to another. [60] When deciding on a device, the cost of the device, a person's functional need, and the availability of a particular device should be considered. [60]

Knee joint

In case of a trans-femoral amputation, there also is a need for a complex connector providing articulation, allowing flexion during swing-phase but not during stance.

Microprocessor control

To mimic the knee's functionality during gait, microprocessor-controlled knee joints have been developed that control the flexion of the knee. Some examples are Otto Bock’s C-leg, introduced in 1997, Ossur's Rheo Knee, released in 2005, the Power Knee by Ossur, introduced in 2006, the Plié Knee from Freedom Innovations and DAW Industries’ Self Learning Knee (SLK). [61]

The idea was originally developed by Kelly James, a Canadian engineer, at the University of Alberta. [62]

A microprocessor is used to interpret and analyze signals from knee-angle sensors and moment sensors. The microprocessor receives signals from its sensors to determine the type of motion being employed by the amputee. Most microprocessor controlled knee-joints are powered by a battery housed inside the prosthesis.

The sensory signals computed by the microprocessor are used to control the resistance generated by hydraulic cylinders in the knee-joint. Small valves control the amount of hydraulic fluid that can pass into and out of the cylinder, thus regulating the extension and compression of a piston connected to the upper section of the knee. [32]

The main advantage of a microprocessor-controlled prosthesis is a closer approximation to an amputee's natural gait. Some allow amputees to walk near walking speed or run. Variations in speed are also possible and are taken into account by sensors and communicated to the microprocessor, which adjusts to these changes accordingly. It also enables the amputees to walk downstairs with a step-over-step approach, rather than the one step at a time approach used with mechanical knees. [63] There is some research suggesting that people with microprocessor-controlled prostheses report greater satisfaction and improvement in functionality, residual limb health, and safety. [64] People may be able to perform everyday activities at greater speeds, even while multitasking, and reduce their risk of falls. [64]

However, some have some significant drawbacks that impair its use. They can be susceptible to water damage and thus great care must be taken to ensure that the prosthesis remains dry. [65]

Myoelectric

A myoelectric prosthesis uses the electrical tension generated every time a muscle contracts, as information. This tension can be captured from voluntarily contracted muscles by electrodes applied on the skin to control the movements of the prosthesis, such as elbow flexion/extension, wrist supination/pronation (rotation) or opening/closing of the fingers. A prosthesis of this type utilizes the residual neuromuscular system of the human body to control the functions of an electric powered prosthetic hand, wrist, elbow or foot. [66] This is different from an electric switch prosthesis, which requires straps and/or cables actuated by body movements to actuate or operate switches that control the movements of the prosthesis. There is no clear evidence concluding that myoelectric upper extremity prostheses function better than body-powered prostheses. [67] Advantages to using a myoelectric upper extremity prosthesis include the potential for improvement in cosmetic appeal (this type of prosthesis may have a more natural look), may be better for light everyday activities, and may be beneficial for people experiencing phantom limb pain. [67] When compared to a body-powered prosthesis, a myoelectric prosthesis may not be as durable, may have a longer training time, may require more adjustments, may need more maintenance, and does not provide feedback to the user. [67]

The USSR was the first to develop a myoelectric arm in 1958, [68] while the first myoelectric arm became commercial in 1964 by the Central Prosthetic Research Institute of the USSR, and distributed by the Hangar Limb Factory of the UK. [69] [70]

Researchers at the Rehabilitation Institute of Chicago announced in September 2013 that they have developed a robotic leg that translates neural impulses from the user's thigh muscles into movement, which is the first prosthetic leg to do so. It is currently in testing. [71]

Robotic prostheses

Brain control of 3D prosthetic arm movement (hitting targets). This movie was recorded when the participant controlled the 3D movement of a prosthetic arm to hit physical targets in a research lab.

Robots can be used to generate objective measures of patient's impairment and therapy outcome, assist in diagnosis, customize therapies based on patient's motor abilities, and assure compliance with treatment regimens and maintain patient's records. It is shown in many studies that there is a significant improvement in upper limb motor function after stroke using robotics for upper limb rehabilitation. [72] In order for a robotic prosthetic limb to work, it must have several components to integrate it into the body's function: Biosensors detect signals from the user's nervous or muscular systems. It then relays this information to a controller located inside the device, and processes feedback from the limb and actuator, e.g., position or force, and sends it to the controller. Examples include surface electrodes that detect electrical activity on the skin, needle electrodes implanted in muscle, or solid-state electrode arrays with nerves growing through them. One type of these biosensors are employed in myoelectric prostheses.

A device known as the controller is connected to the user's nerve and muscular systems and the device itself. It sends intention commands from the user to the actuators of the device and interprets feedback from the mechanical and biosensors to the user. The controller is also responsible for the monitoring and control of the movements of the device.

An actuator mimics the actions of a muscle in producing force and movement. Examples include a motor that aids or replaces original muscle tissue.

Targeted muscle reinnervation (TMR) is a technique in which motor nerves, which previously controlled muscles on an amputated limb, are surgically rerouted such that they reinnervate a small region of a large, intact muscle, such as the pectoralis major. As a result, when a patient thinks about moving the thumb of his missing hand, a small area of muscle on his chest will contract instead. By placing sensors over the reinnervated muscle, these contractions can be made to control the movement of an appropriate part of the robotic prosthesis. [73] [74]

A variant of this technique is called targeted sensory reinnervation (TSR). This procedure is similar to TMR, except that sensory nerves are surgically rerouted to skin on the chest, rather than motor nerves rerouted to muscle. Recently, robotic limbs have improved in their ability to take signals from the human brain and translate those signals into motion in the artificial limb. DARPA, the Pentagon's research division, is working to make even more advancements in this area. Their desire is to create an artificial limb that ties directly into the nervous system. [75]

Robotic arms

Advancements in the processors used in myoelectric arms have allowed developers to make gains in fine-tuned control of the prosthetic. The Boston Digital Arm is a recent artificial limb that has taken advantage of these more advanced processors. The arm allows movement in five axes and allows the arm to be programmed for a more customized feel. Recently the I-LIMB Hand, invented in Edinburgh, Scotland, by David Gow has become the first commercially available hand prosthesis with five individually powered digits. The hand also possesses a manually rotatable thumb which is operated passively by the user and allows the hand to grip in precision, power, and key grip modes.

Another neural prosthetic is Johns Hopkins University Applied Physics Laboratory Proto 1. Besides the Proto 1, the university also finished the Proto 2 in 2010. [76] Early in 2013, Max Ortiz Catalan and Rickard Brånemark of the Chalmers University of Technology, and Sahlgrenska University Hospital in Sweden, succeeded in making the first robotic arm which is mind-controlled and can be permanently attached to the body (using osseointegration). [77] [78] [79]

An approach that is very useful is called arm rotation which is common for unilateral amputees which is an amputation that affects only one side of the body; and also essential for bilateral amputees, a person who is missing or has had amputated either both arms or legs, to carry out activities of daily living. This involves inserting a small permanent magnet into the distal end of the residual bone of subjects with upper limb amputations. When a subject rotates the residual arm, the magnet will rotate with the residual bone, causing a change in magnetic field distribution. [80] EEG (electroencephalogram) signals, detected using small flat metal discs attached to the scalp, essentially decoding human brain activity used for physical movement, is used to control the robotic limbs. This allows the user to control the part directly. [81]

Robotic legs

The research of Robotic legs has made some advancement over time, allowing exact movement and control. A company in Switzerland called Ossur, has created a robotic leg that moves through algorithms and sensors that automatically adjust the angle of the foot during different points in its wearer's stride. Also there are brain-controlled bionic legs that allow an individual to move his limbs with a wireless transmitter. [82]

Prosthesis design

The main goal of a robotic prosthesis is to provide active actuation during gait to improve the biomechanics of gait, including, among other things, stability, symmetry, or energy expenditure for amputees. There are several powered prosthetic legs currently on the market, including fully powered legs, in which actuators directly drive the joints, and semi-active legs, which use small amounts of energy and a small actuator to change the mechanical properties of the leg but do not inject net positive energy into gait. Specific examples include The emPOWER from BionX, the Proprio Foot from Ossur, and the Elan Foot from Endolite. [83] [84] [85] Various research groups have also experimented with robotic legs over the last decade. [86] Central issues being researched include designing the behavior of the device during stance and swing phases, recognizing the current ambulation task, and various mechanical design problems such as robustness, weight, battery-life/efficiency, and noise-level. However, scientists from Stanford University and Seoul National University has developed artificial nerves system that will help prosthetic limbs feel. [87] This synthetic nerve system enables prosthetic limbs sense braille, feel the sense of touch and respond to the environment. [88] [89]

Attachment to the body

Most prostheses can be attached to the exterior of the body, in a non-permanent way. Some others however can be attached in a permanent way. One such example are exoprostheses (see below).

Direct bone attachment and osseointegration

Osseointegration is a method of attaching the artificial limb to the body. This method is also sometimes referred to as exoprosthesis (attaching an artificial limb to the bone), or endo-exoprosthesis.

The stump and socket method can cause significant pain in the amputee, which is why the direct bone attachment has been explored extensively. The method works by inserting a titanium bolt into the bone at the end of the stump. After several months the bone attaches itself to the titanium bolt and an abutment is attached to the titanium bolt. The abutment extends out of the stump and the (removable) artificial limb is then attached to the abutment. Some of the benefits of this method include the following:

The main disadvantage of this method is that amputees with the direct bone attachment cannot have large impacts on the limb, such as those experienced during jogging, because of the potential for the bone to break. [8]

Cosmesis

Cosmetic prosthesis has long been used to disguise injuries and disfigurements. With advances in modern technology, cosmesis, the creation of lifelike limbs made from silicone or PVC has been made possible. Such prosthetics, including artificial hands, can now be designed to simulate the appearance of real hands, complete with freckles, veins, hair, fingerprints and even tattoos. Custom-made cosmeses are generally more expensive (costing thousands of U.S. dollars, depending on the level of detail), while standard cosmeses come premade in a variety of sizes, although they are often not as realistic as their custom-made counterparts. Another option is the custom-made silicone cover, which can be made to match a person's skin tone but not details such as freckles or wrinkles. Cosmeses are attached to the body in any number of ways, using an adhesive, suction, form-fitting, stretchable skin, or a skin sleeve.

Cognition

Unlike neuromotor prostheses, neurocognitive prostheses would sense or modulate neural function in order to physically reconstitute or augment cognitive processes such as executive function, attention, language, and memory. No neurocognitive prostheses are currently available but the development of implantable neurocognitive brain-computer interfaces has been proposed to help treat conditions such as stroke, traumatic brain injury, cerebral palsy, autism, and Alzheimer's disease. [90] The recent field of Assistive Technology for Cognition concerns the development of technologies to augment human cognition. Scheduling devices such as Neuropage remind users with memory impairments when to perform certain activities, such as visiting the doctor. Micro-prompting devices such as PEAT, AbleLink and Guide have been used to aid users with memory and executive function problems perform activities of daily living.

Prosthetic enhancement

Sgt. Jerrod Fields, a U.S. Army World Class Athlete Program Paralympic sprinter hopeful, works out at the U.S. Olympic Training Center in Chula Vista, Calif. A below-the-knee amputee, Fields won a gold medal in the 100 meters with a time of 12.15 seconds at the Endeavor Games in Edmond, OK, on June 13, 2009 Flickr - The U.S. Army - U.S. Army World Class Athlete Program Paralympic.jpg
Sgt. Jerrod Fields, a U.S. Army World Class Athlete Program Paralympic sprinter hopeful, works out at the U.S. Olympic Training Center in Chula Vista, Calif. A below-the-knee amputee, Fields won a gold medal in the 100 meters with a time of 12.15 seconds at the Endeavor Games in Edmond, OK, on June 13, 2009

In addition to the standard artificial limb for everyday use, many amputees or congenital patients have special limbs and devices to aid in the participation of sports and recreational activities.

Within science fiction, and, more recently, within the scientific community, there has been consideration given to using advanced prostheses to replace healthy body parts with artificial mechanisms and systems to improve function. The morality and desirability of such technologies are being debated by transhumanists, other ethicists, and others in general. [91] [92] [93] [94] [ by whom? ] Body parts such as legs, arms, hands, feet, and others can be replaced.

The first experiment with a healthy individual appears to have been that by the British scientist Kevin Warwick. In 2002, an implant was interfaced directly into Warwick's nervous system. The electrode array, which contained around a hundred electrodes, was placed in the median nerve. The signals produced were detailed enough that a robot arm was able to mimic the actions of Warwick's own arm and provide a form of touch feedback again via the implant. [95]

The DEKA company of Dean Kamen developed the "Luke arm", an advanced nerve-controlled prosthetic. Clinical trials began in 2008, [96] with FDA approval in 2014 and commercial manufacturing by the Universal Instruments Corporation expected in 2017. The price offered at retail by Mobius Bionics is expected to be around $100,000. [97]

Further research in April 2019, there have been improvements towards prosthetic function and comfort of 3D-printed personalized wearable systems. Instead of manual integration after printing, integrating electronic sensors at the intersection between a prosthetic and the wearer's tissue can gather information such as pressure across wearer’s tissue, that can help improve further iteration of the these types of prosthetic. [98]

Oscar Pistorius

In early 2008, Oscar Pistorius, the "Blade Runner" of South Africa, was briefly ruled ineligible to compete in the 2008 Summer Olympics because his transtibial prosthesis limbs were said to give him an unfair advantage over runners who had ankles. One researcher found that his limbs used twenty-five percent less energy than those of an able-bodied runner moving at the same speed. This ruling was overturned on appeal, with the appellate court stating that the overall set of advantages and disadvantages of Pistorius' limbs had not been considered.

Pistorius did not qualify for the South African team for the Olympics, but went on to sweep the 2008 Summer Paralympics, and has been ruled eligible to qualify for any future Olympics.[ citation needed ] He qualified for the 2011 World Championship in South Korea and reached the semi-final where he ended last timewise, he was 14th in the first round, his personal best at 400m would have given him 5th place in the finals. At the 2012 Summer Olympics in London, Pistorius became the first amputee runner to compete at an Olympic Games. [99] He ran in the 400 metres race semi-finals, [100] [101] [102] and the 4 × 400 metres relay race finals. [103] He also competed in 5 events in the 2012 Summer Paralympics in London. [104]

Design considerations

There are multiple factors to consider when designing a transtibial prosthesis. Manufacturers must make choices about their priorities regarding these factors.

Performance

Nonetheless, there are certain elements of socket and foot mechanics that are invaluable for the athlete, and these are the focus of today's high-tech prosthetics companies:

Other

The buyer is also concerned with numerous other factors:

Cost and source freedom

High-cost

In the USA a typical prosthetic limb costs anywhere between $15,000 and $90,000, depending on the type of limb desired by the patient. With medical insurance, a patient will typically pay 10%–50% of the total cost of a prosthetic limb, while the insurance company will cover the rest of the cost. The percent that the patient pays varies on the type of insurance plan, as well as the limb requested by the patient. [105] In the United Kingdom, much of Europe, Australia and New Zealand the entire cost of prosthetic limbs is met by state funding or statutory insurance. For example, in Australia prostheses are fully funded by state schemes in the case of amputation due to disease, and by workers compensation or traffic injury insurance in the case of most traumatic amputations. [106] The National Disability Insurance Scheme, which is being rolled out nationally between 2017 and 2020 also pays for prostheses.

Transradial (below the elbow amputation) and transtibial prostheses (below the knee amputation) typically cost between US $6,000 and $8,000, while transfemoral (above the knee amputation) and transhumeral prosthetics (above the elbow amputation) cost approximately twice as much with a range of $10,000 to $15,000 and can sometimes reach costs of $35,000. The cost of an artificial limb often recurs, while a limb typically needs to be replaced every 3–4 years due to wear and tear of everyday use. In addition, if the socket has fit issues, the socket must be replaced within several months from the onset of pain. If height is an issue, components such as pylons can be changed. [107]

Not only does the patient need to pay for their multiple prosthetic limbs, but they also need to pay for physical and occupational therapy that come along with adapting to living with an artificial limb. Unlike the reoccurring cost of the prosthetic limbs, the patient will typically only pay the $2000 to $5000 for therapy during the first year or two of living as an amputee. Once the patient is strong and comfortable with their new limb, they will not be required to go to therapy anymore. Throughout one's life, it is projected that a typical amputee will go through $1.4 million worth of treatment, including surgeries, prosthetics, as well as therapies. [105]

Low-cost

Low-cost above-knee prostheses often provide only basic structural support with limited function. This function is often achieved with crude, non-articulating, unstable, or manually locking knee joints. A limited number of organizations, such as the International Committee of the Red Cross (ICRC), create devices for developing countries. Their device which is manufactured by CR Equipments is a single-axis, manually operated locking polymer prosthetic knee joint. [108]

Table. List of knee joint technologies based on the literature review. [59]

Name of technology (country of origin)Brief descriptionHighest level of

evidence

ICRC knee (Switzerland)Single-axis with manual lockIndependent field
ATLAS knee (UK)Weight-activated frictionIndependent field
POF/OTRC knee (US)Single-axis with ext. assistField
DAV/Seattle knee (US)Compliant polycentricField
LIMBS International M1 knee (US)Four-barField
JaipurKnee (India)Four-barField
LCKnee (Canada)Single-axis with automatic lockField
None provided (Nepal)Single-axisField
None provided (New Zealand)Roto-molded single-axisField
None provided (India)Six-bar with squattingTechnical development
Friction knee (US)Weight-activated frictionTechnical development
Wedgelock knee (Australia)Weight-activated frictionTechnical development
SATHI friction knee (India)Weight-activated frictionLimited data available
Low-cost above-knee prosthetic limbs: ICRC Knee (left) and LC Knee (right) Low cost prosthetic limbs.jpg
Low-cost above-knee prosthetic limbs: ICRC Knee (left) and LC Knee (right)

A plan for a low-cost artificial leg, designed by Sébastien Dubois, was featured at the 2007 International Design Exhibition and award show in Copenhagen, Denmark, where it won the Index: Award. It would be able to create an energy-return prosthetic leg for US $8.00, composed primarily of fiberglass. [109]

Prior to the 1980s, foot prostheses merely restored basic walking capabilities. These early devices can be characterized by a simple artificial attachment connecting one's residual limb to the ground.

The introduction of the Seattle Foot (Seattle Limb Systems) in 1981 revolutionized the field, bringing the concept of an Energy Storing Prosthetic Foot (ESPF) to the fore. Other companies soon followed suit, and before long, there were multiple models of energy storing prostheses on the market. Each model utilized some variation of a compressible heel. The heel is compressed during initial ground contact, storing energy which is then returned during the latter phase of ground contact to help propel the body forward.

Since then, the foot prosthetics industry has been dominated by steady, small improvements in performance, comfort, and marketability.

With 3D printers, it is possible to manufacture a single product without having to have metal molds, so the costs can be drastically reduced. [110]

Jaipur Foot , an artificial limb from Jaipur, India, costs about US$40.

Open-source robotic prothesis

There is currently an open-design Prosthetics forum known as the "Open Prosthetics Project". The group employs collaborators and volunteers to advance Prosthetics technology while attempting to lower the costs of these necessary devices. [111] Open Bionics is a company that is developing open-source robotic prosthetic hands. It uses 3D printing to manufacture the devices and low-cost 3D scanners to fit them, with the aim of lowering the cost of fabricating custom prosthetics. A review study on a wide range of printed prosthetic hands, found that although 3D printing technology holds a promise for individualised prosthesis design, it is not necessarily cheaper when all costs are included. The same study also found that evidence on the functionality, durability and user acceptance of 3D printed hand prostheses is still lacking. [112]

Low-cost prosthetics for children

Artificial limbs for a juvenile thalidomide survivor 1961-1965 Artificial limbs for a thalidomide child, 1961-1965. (9660575567).jpg
Artificial limbs for a juvenile thalidomide survivor 1961–1965

In the USA an estimate was found of 32,500 children (<21 years) that suffer from major paediatric amputation, with 5,525 new cases each year, of which 3,315 congenital. [113]

Carr et al. (1998) investigated amputations caused by landmines for Afghanistan, Bosnia and Herzegovina, Cambodia and Mozambique among children (<14 years), showing estimates of respectively 4.7, 0.19, 1.11 and 0.67 per 1000 children. [114] Mohan (1986) indicated in India a total of 424,000 amputees (23,500 annually), of which 10.3% had an onset of disability below the age of 14, amounting to a total of about 43,700 limb deficient children in India alone. [115]

Few low-cost solutions have been created specially for children. Examples of low-cost prosthetic devices include:

Pole and crutch

This hand-held pole with leather support band or platform for the limb is one of the simplest and cheapest solutions found. It serves well as a short-term solution, but is prone to rapid contracture formation if the limb is not stretched daily through a series of range-of motion (RoM) sets. [56]

Bamboo, PVC or plaster limbs

This also fairly simple solution comprises a plaster socket with a bamboo or PVC pipe at the bottom, optionally attached to a prosthetic foot. This solution prevents contractures because the knee is moved through its full RoM. The David Werner Collection, an online database for the assistance of disabled village children, displays manuals of production of these solutions. [116]

Adjustable bicycle limb

This solution is built using a bicycle seat post up side down as foot, generating flexibility and (length) adjustability. It is a very cheap solution, using locally available materials. [117]

Sathi Limb

It is an endoskeletal modular lower limb from India, which uses thermoplastic parts. Its main advantages are the small weight and adaptability. [56]

Monolimb

Monolimbs are non-modular prostheses and thus require more experienced prosthetist for correct fitting, because alignment can barely be changed after production. However, their durability on average is better than low-cost modular solutions.[ citation needed ]

Cultural and social theory perspectives

A number of theorists have explored the meaning and implications of prosthetic extension of the body. Elizabeth Grosz writes, "Creatures use tools, ornaments, and appliances to augment their bodily capacities. Are their bodies lacking something, which they need to replace with artificial or substitute organs?...Or conversely, should prostheses be understood, in terms of aesthetic reorganization and proliferation, as the consequence of an inventiveness that functions beyond and perhaps in defiance of pragmatic need?" [118] Elaine Scarry argues that every artifact recreates and extends the body. Chairs supplement the skeleton, tools append the hands, clothing augments the skin. [119] In Scarry's thinking, "furniture and houses are neither more nor less interior to the human body than the food it absorbs, nor are they fundamentally different from such sophisticated prosthetics as artificial lungs, eyes and kidneys. The consumption of manufactured things turns the body inside out, opening it up to and as the culture of objects." [120] Mark Wigley, a professor of architecture, continues this line of thinking about how architecture supplements our natural capabilities, and argues that "a blurring of identity is produced by all prostheses." [121] Some of this work relies on Freud's earlier characterization of man's relation to objects as one of extension.

See also

Related Research Articles

Amputation removal of a body extremity by trauma, prolonged constriction, or surgery

Amputation is the removal of a limb by trauma, medical illness, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventative surgery for such problems. A special case is that of congenital amputation, a congenital disorder, where fetal limbs have been cut off by constrictive bands. In some countries, amputation of the hands, feet or other body parts is or was used as a form of punishment for people who committed crimes. Amputation has also been used as a tactic in war and acts of terrorism; it may also occur as a war injury. In some cultures and religions, minor amputations or mutilations are considered a ritual accomplishment.

Phantom limb The sensation that an amputated or missing limb is still attached

A phantom limb is the sensation that an amputated or missing limb is still attached. Approximately 60 to 80% of individuals with an amputation experience phantom sensations in their amputated limb, and the majority of the sensations are painful. Phantom sensations may also occur after the removal of body parts other than the limbs, e.g. after amputation of the breast, extraction of a tooth or removal of an eye . Phantom limb sensation intensity can also be related to better control of the remnant muscles.

A pegleg is a prosthesis, or artificial limb, fitted to the remaining stump of a human leg. Its use dates to antiquity.

Neuroprosthetics is a discipline related to neuroscience and biomedical engineering concerned with developing neural prostheses. They are sometimes contrasted with a brain–computer interface, which connects the brain to a computer rather than a device meant to replace missing biological functionality.

Prosthetics, the artificial replacement of organic limbs or organs, often play a role in fiction, particularly science fiction, as either plot points or to give a character a beyond normal appearance. Numerous works of literature, television, and films feature characters who have prosthetics attached.

A Prosthetist and Orthotist, as defined by The World Health Organization, is a healthcare professional with overall responsibly of Prosthetics & Orthotics treatment, who can supervise and mentor the practice of other personnel. They are clinicians trained to assess the needs of the user, prescribe treatment, determine the precise technical specifications of prosthesis and Orthosis, take measurements and image of body segments, prepare model of the evaluation, fit devices and evaluate treatment outcome.

James Foort, is a Canadian inventor, artist, and innovator in the field of prosthetic limbs. Foort was born on December 10, 1921, in New West Minster, British Columbia. In 1941, after spending his childhood as a fisherman and part-time high school student, he joined the Air Force as a wireless operator. When World War II ended, he attended the College of Victoria, where he finished his high school credits. He earned BASc and MASc degrees in Chemical Engineering at the University of Toronto, 1946 - 1951.

Targeted reinnervation enables amputees to control motorized prosthetic devices and to regain sensory feedback. The method was developed by Dr. Todd Kuiken at Northwestern University and Rehabilitation Institute of Chicago and Dr. Gregory Dumanian at Northwestern University Division of Plastic Surgery.

Therdchai Jivacate is a Thai orthopedic surgeon and inventor known for his humanitarian activities in providing free prosthetic limbs to impoverished amputees, and for his development of techniques allowing low-cost, high-quality prostheses to be made from local materials. The activities of the Prostheses Foundation, which he founded in 1992 under royal sponsorship from the Princess Mother Srinagarindra, have expanded beyond the borders of Thailand to Malaysia, Laos, and Burma. Jivacate has established Thailand's first and only educational institution of occupational therapy at Chiang Mai University. He has also created an educational programme for children suffering from chronic diseases at Maharaj Hospital in Nakhon Ratchasima. In 2008, he was given the Ramon Magsaysay Award for Public Service.

Össur hf. is an Icelandic company that develops, manufactures and sells non-invasive orthopaedics equipment, including bracing and support products, compression therapy, and prosthetics. The company's headquarters is in Reykjavík, and it has offices in the Americas, Europe, and Asia, with distributors in other markets.

T42 is a disability sport classification for disability athletics, applying to athletes with single above the knee amputations or a disability that is comparable. This class includes ISOD classified A2 and A9 competitors.

T43 is a disability sport classification for disability athletics, applying to athletes with "Double below knee amputation or similar disability." It includes ISOD classified athletes from the A4 and A9 classes.

Mechanics of Oscar Pistoriuss running blades

The mechanics of the running blades used by South African Paralympic runner Oscar Pistorius depend on special carbon-fiber-reinforced polymer prosthetics. Pistorius has double below-the-knee amputations and competes in both non-disabled and T44 amputee athletics events. Pistorius's eligibility to run in international non-disabled events is sanctioned by the International Association of Athletics Federations (IAAF).

The Michelangelo Hand is a fully articulated robotic hand prosthesis developed by the German prosthetics company Ottobock and its American partner Advanced Arm Dynamics. It is the first prosthesis to feature an electronically actuated thumb which mimics natural human hand movements. The Michelangelo Hand can be used for a variety of delicate everyday tasks, was first fitted to an Austrian elective-amputee in July 2010 and has been in use by military and civilian amputees in the United States and United Kingdom since 2011.

Proportional myoelectric control

Proportional myoelectric control can be used to activate robotic lower limb exoskeletons. A proportional myoelectric control system utilizes a microcontroller or computer that inputs electromyography (EMG) signals from sensors on the leg muscle(s) and then activates the corresponding joint actuator(s) proportionally to the EMG signal.

Robotic prosthesis control is a method for controlling a prosthesis in such a way that the controlled robotic prosthesis restores a biologically accurate gait to a person with a loss of limb. This is special branch of control that has an emphasis on the interaction between humans and robotics.

Amputee sports classification is a disability specific sport classification used for disability sports to facilitate fair competition among people with different types of amputations. This classification was set up by International Sports Organization for the Disabled (ISOD), and is currently managed by IWAS who ISOD merged with in 2005. Several sports have sport specific governing bodies managing classification for amputee sportspeople.

A3 is an amputee sport classification used by the International Sports Organization for the Disabled (ISOD) for people with acquired or congenital amputations. A3 classified sportspeople have both legs amputated below knee. Their amputations impact their sport performance, including having balance issues, increased energy costs, higher rates of oxygen consumption, and issues with their gait. Sports people in this class are eligible to participate in include athletics, swimming, sitting volleyball, archery, weightlifting, badminton, lawn bowls, sitzball and wheelchair basketball.

A4 is an amputee sport classification used by the International Sports Organization for the Disabled (ISOD).for people with acquired or congenital amputations. People in this class have one leg amputated below the knee. Their amputations impact their sport performance, including having balance issues, increased energy costs, higher rates of oxygen consumption, and issues with their gait. Sports people in this class are eligible to participate in include athletics, swimming, sitting volleyball, archery, weightlifting, wheelchair basketball, amputee basketball, amputee football, lawn bowls, and sitzball.

Gait deviations

Gait deviations are nominally referred to as any variation of standard human gait, typically manifesting as a coping mechanism in response to an anatomical impairment. Lower-limb amputees are unable to maintain the characteristic walking patterns of an able-bodied individual due to the removal of some portion of the impaired leg. Without the anatomical structure and neuromechanical control of the removed leg segment, amputees must use alternative compensatory strategies to walk efficiently. Prosthetic limbs provide support to the user and more advanced models attempt to mimic the function of the missing anatomy, including biomechanically controlled ankle and knee joints. However, amputees still display quantifiable differences in many measures of ambulation when compared to able-bodied individuals. Several common observations are whole-body movements, slower and wider steps, shorter strides, and increased sway.

References

Citations

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