1. Prosthetics-P101

2. Prosthetic Objectives Amputee perspective Prosthetic process – Existing amputee v. New amputee Component selection criteria – Suspension – Materials – Alignment – Pr(x) Feet – Pr(x) Knees

3. Amputee perspective Prosthetic process Existing Amputee – Ill fitting – Repair cost will outweigh new socket/prosthesis – Begin Prosthetic process New Amputee – Order/Call to see new amputee for a protective dressing, shrinker and or consultation – F/u patient to Surgeon removal of sutures/staples – Begin Prosthetic process Soft Removable Dressing

4. Amputee perspective Prosthetic process (cont’d) Amputee – Begin Prosthetic process – Begin Therapy process – Initial Evaluation – Functional Testing AmpnoPro & AmpPro – PM&R Pre-prosthetic Evaluation – Component Selection

5. Lower Extremity Prosthetic Evaluation Name, age, Hgt, Wgt, Sex Amputation Level, side Other amputations Ortho, neuro copathologies Existing User Living Status Living Environment – Uneven terrain, carpet, hard surfaces Health comorbidities Medications/Treatments Ambulatory Aids Vocational Needs Pre-amputation activities Patient Feedback of current device Upper Extremity ROM, MMT, dexterity

6. Lower Extremity Prosthetic Evaluation Residual Limb Features Amputation Level Skin health Boney, invaginated areas ROM, MMT Contractures Functional Testing – AmpnoPro/AmpPro Limb Length Contralateral limb Features Diabetic Callused Wounds Toe, Foot, T.T, T.F, HD

7. Lower Extremity Functional Testing Outcome Measures in Lower Limb Prosthetics K-Levels K-Levels: K-levels are defined by Medicare based on an individual's ability or potential to ambulate and navigate their environment. Once it is determined in which K-level an individual resides, it can be determined which prosthetic components are covered by Medicare. Bilaterals Gait characteristics of persons with bilateral transtibial amputations, Po-Fu Su, MS Steven A. Gard, PhD, Robert Lipschutz, CP, Todd A Kuiken, MD, PhD

8. AmpNoProAmpProK-levelDescriptionFoot/Ankle AssembliesKnee Units 0-8n/aK0Patient does NOT have the ability or potential to ambulate or transfer w/o assistance & prosthesis does not enhance their quality of life or mobility Not Eligible 9-2015-26K1 Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulatory. External keel, SACH feet or single axis/feet Single-axis, constant friction knee 21-2827-36K2 Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. Flexible-keel feet & multi-axial ankle/foot Polycentric, constant friction knee 29-3637-42K3Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to transverse most environmental barriers and may have vocational, therapeutic or exercise activity that demands prosthetic utilization beyond simple locomotion. Flex foot, and flex-walk systems, energy storing feet, multi-axial ankle/feet, or dynamic response feet Fluid & Pneumatic Control knee 37-4343-47K4Has the ability or potential for prosthetic ambulation that exceeds the basic ambulation skills, exhibiting high impact, stress, or energy levels, typical of the prosthetic demands of the child, active adult, or athlete Any ankle foot system appropriateAny knee system appropriate

9. Examples

10. BK Socket/Suspension selection Socket Style – Patella Tendon Bearing(PTB) – Total Surface Bearing(TSB) Suspension Liners/Sleeves Research – Öderberg, JPO 2003 PTB Socket Style TSB Socket Style

11. Suspension/Liner Selection Cushion Locking Distal Locking Suction

12. Fitting process 1.Check Socket 2.Temporary Socket 3.Definitive 1. Check 2. Temporary 3. Definitive

13. Foot Selection Criteria Foot/Ankle Assemblies K0Not eligible for prosthesis K1 External keel, SACH feet or single axis ankle/feet K2 Flexible-keel feet and multi-axial ankle/feet K3 Flex foot and flex-walk systems, energy storing feet, multi-axial ankle/feet, or dynamic response feet K4 **Any ankle foot system appropriate Patient Wgt. Activity Level Carrying Loads Foot size Foot Build Hgt.

14. Effect of wrong category of feet Premature failure Delayed/Absent Energy Return Bumpers require more maintenance Gait Deviations Skin Breakdown The AmputeeOT

15. K1-Level Foot Selection K1-ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence

16. K2-Level Foot Selection K2-Flexible-keel feet and multi-axial ankle/feet

17. K3-Level Foot Selection K3-energy storing feet, multi-axial ankle/feet, or dynamic response feet

18. K4-Level Foot Selection K4-exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels

19. Alignment Bench/Static/Dynamic Proper Standing Balance Easier use of foot functions Increased socket comfort Increase Energy return

20. Efficacy of D.R.F

21. AK Socket Selection Socket Design – Quadrilateral – Ischial/ Ramal containment More Anatomical Quadrilateral Ischial Containment

22. Prosthetic Knee Selection K1 Single Axis- Locking Manual Locking (K1) Polycentric (K2) Weight Activated Stance Control (K1-K2) Single Axis Constant Friction Outside Hinges Polycentric Knee

23. Knee Features Locking Mechanism Wgt. Activated Stance Control Geometric Lock Stance Phase Flexion Stumble Recovery=Stance Phase Control Stance Extension Assist Stance Flexion Resist Microprocessor Control – C-Leg, Rheo, Plie, Orion

24. References 1.https://med.noridianmedicare.com/web/jddme/education/event- materials/op-claim-qa 2.Po-Fu Su, MS, Gard, S., PhD, Lipschutz, R., CP, Kuiken T., MD, PhD, 2007. Gait characteristics of persons with bilateral transtibial amputations. JRRD Vol 44 Num 4, 491-502 3.Öderberg, B., 2003. Roentgen Stereophotogrammetric Analysis of Motion between Bone and the Socket in a Transtibial Amputation Prosthesis: A Case Study. JPO Vol 15 Num 3, 95-101 4.Atlas of Limb Prosthetics 5.Sinitski, E.H., et al., 2011. Biomechanics of the ankle-foot system during stair ambulation: Implications for design of advances ankle-foot prosthesis. Journal of Biomechanics DOI:10.1016/j.jbiomech.2011.11.007