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Lower Extremity Prosthetics

Lower extremity prosthetics describes artificially replaced limbs located at the hip level or lower. The two main subcategories of lower extremity prosthetic devices are 1.trans-tibial (any amputation transecting the tibia bone or a congenital anomaly resulting in a tibial deficiency) and 2.trans-femoral (any amputation transecting the femur bone or a congenital anomaly resulting in a femural 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

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.

Knee disarticulations - This usually refers to an amputation through the knee disarticulating the femur from the tibia.

Symes - This is an ankle disarticulation while preserving the heel pad.

Transtibial prosthesis

A transtibial prosthesis is an artificial limb that replaces a leg missing below the knee. Transtibial amputees are usually able to regain normal movement more readily than someone with a transfemoral amputation, due in large part to retaining the knee, which allows for easier movement. In the prosthetic industry a trans-tibial prosthetic leg is often referred to as a "BK" or below the knee prosthesis.

Transfemoral prosthesis

A transfemoral prosthesis is an artificial limb that replaces a leg missing above the knee. Transfemoral amputees can have a very difficult time regaining normal movement. In general, a transfemoral amputee must use approximately 80% more energy to walk than a person with two whole legs.[20] This is due to the complexities in movement associated with the knee. In newer and more improved designs, after employing hydraulics, carbon fibre, mechanical linkages, motors, computer microprocessors, and innovative combinations of these technologies to give more control to the user. In the prosthetic industry a trans-femoral prosthetic leg is often referred to as an "AK" or above the knee prosthesis.

Robotic prostheses

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, force) and sends it to the controller. Examples include wires 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 prosthesis.

Mechanical sensors process aspects affecting the device (e.g., limb position, applied force, load) and relay this information to the biosensor or controller. Examples include force meters and accelerometers.

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.

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, such as artificial hands, can now be made to mimic the appearance of real hands, complete with freckles, veins, hair, fingerprints and even tattoos. Custom-made cosmeses are generally more expensive (costing thousands of US dollars, depending on the level of detail), while standard cosmeses come ready-made in various 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.[17] 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

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. 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.

In 2008, Oscar Pistorius was briefly ruled ineligible for the 2008 Summer Olympics due to an alleged mechanical advantage over runners who have ankles.

In early 2008, Oscar Pistorius, the "Blade Runner" of South Africa, was briefly ruled ineligible to compete in the 2008 Summer Olympics because his prosthetic 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.

The "Luke arm" is an advanced prosthesis currently under trials as of 2008.

 

 

Upper Extremity Prosthetics

Transradial prosthesis

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

Transhumeral prosthesis

A transhumeral prosthesis is an artificial limb that replaces an arm missing above the elbow. Transhumeral amputees experience some of the same problems as transfemoral amputees, due to the similar complexities associated with the movement of the elbow. This makes mimicking the correct motion with an artificial limb very difficult. In the prosthetic industry a trans-humeral prosthesis is often referred to as a "AE" or above the elbow prothesis.

Current technology/manufacturing

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

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.

Most modern artificial limbs are attached to the stump of the amputee by belts and cuffs or by suction. The stump 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 stump 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 stump (rather than just one small spot), which helps reduce wear on the stump. The custom socket is created by taking a plaster cast of the stump or, more commonly today, of the liner worn over the stump, 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 problems with the stump and socket attachment is that a bad fit will reduce the area of contact between the stump and socket or liner, and increase pockets between stump 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. Further down the road, it can cause breakdown of the skin.

Artificial limbs are typically manufactured using the following steps:

Measurement of the stump

Measurement of the body to determine the size required for the artificial limb

Fitting of a silicone liner

Creation of a model of the liner worn over the stump

Formation of thermoplastic sheet around the model – This is then used to test the fit of the prosthetic

Formation of permanent socket

Formation of plastic parts of the artificial limb – Different methods are used, including vacuum forming and injection molding

Creation of metal parts of the artificial limb using die casting

Assembly of entire limb

Body-powered arms

Current body powered arms contain sockets that are built from hard epoxy or carbon fiber. 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. Terminal devices contain a range of hooks, hands or other devices. Hands require a large activation force, which is often uncomfortable. Hooks require a much lower force. 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. Current high tech allows body powered arms to weigh around half to only a third of the weight that a myoelectric arm.

Myoelectric

A myoelectric prosthesis uses electromyography signals or potentials from voluntarily contracted muscles within a person's residual limb on the surface of the skin to control the movements of the prosthesis, such as elbow flexion/extension, wrist supination/pronation (rotation) or hand opening/closing of the fingers. A prosthesis of this type utilizes the residual neuro-muscular system of the human body to control the functions of an electric powered prosthetic hand, wrist or elbow. This is as opposed to an electric switch prosthesis, which requires straps and/or cables actuated by body movements to actuate or operate switches that control the movements of a prosthesis or one that is totally mechanical. It is not clear whether those few prostheses that provide feedback signals to those muscles are also myoelectric in nature. It has a self suspending socket with pick up electrodes placed over flexors and extensors for the movement of flexion and extension respectively.

The first commercial myoelectric arm was developed in 1964 by the Central Prosthetic Research Institute of the USSR, and distributed by the Hangar Limb Factory of the UK.

Robotic limbs

Advancements in the processors used in myoelectric arms has allowed for artificial limbs 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. Raymond Edwards, Limbless Association Acting CEO, was the first amputee to be fitted with the i-LIMB by the National Health Service in the UK. The hand, manufactured by "Touch Bionics" of Scotland (a Livingston company), went on sale on 18 July 2007 in Britain. It was named alongside the Super Hadron Collider in Time magazine's top fifty innovations. Another robotic hand is the RSLSteeper bebionic

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.

Robotic legs exist too: the Argo Medical Technologies ReWalk is an example or a recent robotic leg, targeted to replace the wheelchair. It is marketed as a "robotic pants".

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 reinervated muscle, these contractions can be made to control movement of an appropriate part of the robotic prosthesis.

An emerging 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. The patient then feels any sensory stimulus on that area of the chest, such as pressure or temperature, as if it were occurring on the area of the amputated limb which the nerve originally innervated. In the future, artificial limbs could be built with sensors on fingertips or other important areas. When a stimulus, such as pressure or temperature, activated these sensors, an electrical signal would be sent to an actuator, which would produce a similar stimulus on the "rewired" area of chest skin. The user would then feel that stimulus as if it were occurring on an appropriate part of the artificial limb.

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.

Direct bone attachment / osseointegration

Osseointegration is a new 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 artificial limb is then attached to the abutment. Some of the benefits of this method include the following:

Better muscle control of the prosthetic.

The ability to wear the prosthetic for an extended period of time; with the stump and socket method this is not possible.

The ability for transfemoral amputees to drive a car.

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.