Prosthetics Course 2016

Amputation Rehabilitation Educational Objectives and Prosthetic Use • Review amputation epidemiology A. Esquenazi, MD • Describe the Phases of Amputation John Otto Haas Chair and Professor Rehabilitation Department of PMR • Compare prosthetic components Director Gait & Motion Analysis Lab • Contrast Lower vs Upper Limb and Amputation Rehabilitation Program • Review Prosthetic Prescription MossRehab

Amputation a definition Prevalence of Amputation • Amputation should be considered a reconstructive procedure intended to • Based on data from the NHIS-D there are 1.2 - 1.9 create a functional residual limb capable million persons living in the U.S. with limb loss http://www.cdc.gov/nchs/about/major /nhis_dis/nhis_dis.htm of free weight bearing and function: – Meticulous technique and gentle tissue • The patient population with limb amputations is handling expected to double in 25 years

– Avoidance of skin grafts and adherent scars Estimating prevalence of limb loss : 2005 to 2050 Ar c h PMR , Mar 2008 – Minimal periosteal stripping with balance of muscle forces should always be attempted

Esquenazi Esquenazi

Incidence of Amputation Amputation Levels • There are approximately 50,000 new major limb amputations every year in the US • Transcarpal 18% National Health Interview Survey, 2005 • Wrist Disarticulation 10% • Worldwide estimated number of new amputations • Transradial 31% range between 1,000,000 and 1,500,000 per year • Elbow Disarticulation 5% Inter national c ompar is on of LE amputation r ates Ann Vas c Sur g 2009 • Transhumeral 27% • Shoulder Disarticulation 7% • US rate for LE amputation 47/100,000 vs. • Forequarter 2% 5/100,000 UE amputation

http://www.amputee-coalition.org/people-speak-out/background.html Es quenaz i, and Rehabilitation 2004

Esquenazi

Esquenazi 1 Prosthetics Course 2016

Incidence of Limb Amputation by Level Prevalence of UL Amputation Shoulder Disarticulation 40% Trashumeral Of the 5/100,000 UE amputations in the US Transradial 3.8/100,000 were trauma related, 30% Transtibial 1.3/100,000 were dysvascular related, <1/100,000 were congenital or cancer related. 20% Transfemoral http://www.amputee-coalition.org/people-speak-out/background.html Hip Disarticulation Esquenazi, Disability and Rehabilitation 2004 10%

0%

Esquenazi

Causes of Upper Limb Amputation Upper Limb Amputation by at MossRehab Age Distribution

0-15 16-35 Malignancy

Trauma 36-55 56-90 70% 60% 50% 60% Vascular 40% 50% 63% Congenital 30% 40% 20% 30% 5% 10% 0% 20% 24% 0-15 16-35 36-55 56-90 10% 4% Age Group 0%

Esquenazi Esquenazi

Transcarpal Wrist Disarticulation

Esquenazi Esquenazi

Esquenazi 2 Prosthetics Course 2016

Transradial Elbow Disarticulation

Esquenazi Esquenazi

Transhumeral Shoulder Disarticulation

Esquenazi Esquenazi

Forequarter Amputation Prosthetic Control Options

External Body Cosmetic Hybrid Power Power (Passive)

• Myoelectric • Voluntary • External • Switch control opening • Prefabricated power • Tension * • Voluntary • Customized • Body power • Brain Interface* closing • Custom • Cosmetic

Esquenazi Esquenazi

Esquenazi 3 Prosthetics Course 2016

Passive Terminal Devices Terminal Device Activation Systems • Cosmetic Restoration Body Powered

• Voluntary Opening • Voluntary Closing

External Powered

Esquenazi Esquenazi

Active Terminal Devices Active Terminal Devices:

Body Power BP Voluntary Opening, Hook Voluntary Opening, Hook

Esquenazi Esquenazi

Active Terminal Devices: Active Terminal Devices: BP Voluntary Closing, Hook BP Voluntary Opening Farmers Hook

Esquenazi Esquenazi

Esquenazi 4 Prosthetics Course 2016

Active Terminal Devices: Active Terminal Devices: Body Power, VO & VC Hands BP Voluntary Closing, Hook

More Acceptable Cosmesis

Esquenazi Esquenazi

Partial Hand Partial Hand 3D Printed

Esquenazi Esquenazi

External Power Terminal Devices Myoelectric Control System

Makes use of Powerful Grip + remaining Graded Prehension muscle signals after amputation + Ease of Operation to control Better Cosmesis prosthetic functions

Esquenazi Esquenazi

Esquenazi 5 Prosthetics Course 2016

External Powered UL Multi Articulate Hands prosthetic use • From lateral or tip pinch to multiple grip styles

Esquenazi

Terminal Device Opening Comparative T.D. Force Generation (myo hand vs myo hook)

Michellangelo 40 Lbs. of Pinch Force iLimb Proportional Greifer Myo Hand Mechanical Hand 30 V.O. Hook 10 Bands

20 Average adult male

10

0

Esquenazi

Wrist Components T.D. Opening at Tip for grasp in cm

15 Greiffer Myo Hand Mechanical Hand V.O. Hook Average adult male ETD hook TRS External flexion External flexion 10 I limb Michellangelo

5 centimeters Internal flexion Friction rotation

0

Esquenazi Esquenazi

Esquenazi 6 Prosthetics Course 2016

Electric Wrist Rotation Elbow Components

• Mechanical • Electro-Mechanical • Spring assisted • External power –Switches and sensors – Myoelectric controls

Esquenazi Esquenazi

Mechanical Elbow Designs Shoulder Components

Single Axis ❚ Bulkhead Polycentric ❚ Flexion-Abduction Step-up Hinges Stump Activated ❚ Universal Joint Locks External Locking Internal Locking Elbow

Esquenazi Esquenazi

Prosthetic Suspension Systems

63% of persons with Harness Upper Extremity amputation use a Anatomical Body Powered Suction

Friction

Esquenazi Esquenazi

Esquenazi 7 Prosthetics Course 2016

How does a BP prosthesis Prosthetic Harness Function works • TD is closed by rubber bands Suspension • TD is opened by tension on harness via cable Activation of TD • TD closes when harness relaxes Activation of Elbow • For TH, elbow flexes then locked before TD opens Actuation of elbow lock

Esquenazi Esquenazi

Body Powered Control Systems TR Harness Functions

Ter m i nal Elbow Flexion Elbow Lock Figure 8 Harness Device Functions Biscapular Biscapular Shoulder Scapular abduction & abduction & Disarticulation elevation Latissimus Dorsi Latissimus Dorsi ❚ Suspension, Shoulder ❚TD Activation Biscapular Biscapular Depression & Transhumeral Abduction & Abduction & Humeral Humeral Flexion Humeral Flexion Abduction & Extension Biscapular Transradial Abduction & NA NA Humeral Flexion

Esquenazi Esquenazi

TR Harness Functions TH Harness Functions Dual-control principle Triple-control principle Figure 9 Harness Elbow Locking Dual Control Harness Function ❚ ShoulderFair lead elevation cable system FunctionsBowden cable system

Fair-lead ❚ Suspension,European - ❚TD Activation harness Northwestern - harness ❚ Elbow Activation, ❚ TD Activation

Elbow most be locked to activate terminal device

Esquenazi Esquenazi

Esquenazi 8 Prosthetics Course 2016

Alternative Harness System ShoulderShoulder Disarticulation Disarticulation Harness ExternalBody Powered Powered Prosthesis Prosthesis

Esquenazi

TR Anatomical Suspension Supracondylar Münster socket Silicone Suspension

■ Useful in cases where skin is delicate 2nd to scars ■ Short residual limb friction provides suspension

Esquenazi Esquenazi

Silicone Suspension for TR Suction Suspension body powered prosthesis Myoelectric systems can be suspended with suction Improves the suspension and comfort for some transradial amputees

Esquenazi Esquenazi

Esquenazi 9 Prosthetics Course 2016

Suction & Friction Suspension Bilateral Shoulder for myoelectric THA Disarticulation

Esquenazi Esquenazi

Targeted Muscle Re-innervation (TMR) Targeted Reinnervation

• Nerves must regenerate: 3 months for detectable signal • Need intact brachial plexus • Utilizes existing technology • Time to proficiency much shorter, once training starts • Potential for sensory feedback

Courtesy of Dr. Kuiken Esquenazi

Evolution of Transhumeral Prosthesis Future Developments 22 Movements 22 movements 3 movements 7 movements

Esquenazi Esquenazi

Esquenazi 10 Prosthetics Course 2016

Toileting and Showering Drinking Differences

Esquenazi

Virtual Reality Rehabilitation Primary use of UL prosthesis

60%#

50%#

40%#

30%# General function and prosthetic-device use by site of major traumatic limb loss and conflict. 20%# Vietnam OIF/OEF # % # % 10%# Unilateral Upper Limb N = 47 50 Prosthesis used to Majority of daily tasks 13 27.7 18 36.0 0%# Grasp#/#Li2# Push#/#Pull# Cosmesis# perform: Minority of daily tasks 20 42.6 20 40.0 Total 33 70.3 38 76.0 No prosthesis used 14 29.8 12 24.0 Bilateral Upper Limb Only Self Management N = interventions6 for amputees7 in a virtual world environment. Winkler, Cooper, Esquenazi 2016 Esquenazi Prosthesis used to Majority of daily tasks 1 16.7 5 71.4 perform: Minority of daily tasks 2 33.3 1 14.3 Total 3 50.0 6 85.7

GeneralNo prosthesis function used and prosthetic-device use by site of major3 traumatic50.0 limb loss and1 conflict.14.3 Unilateral Lower Limb N = 178 172 Vietnam OIF/OEF Prosthesis used to Do not walk (1, 2) #2 1.%3 #1 0.6% performUnilateral (by Upper LimbHousehold walker (3) N = 15 47 8.4 10 50 5.8 functionalProsthesis level):used to CommunityMajority of dailywalker tasks (4) 3134 19.127.7 2318 13.436.0 perform: VaryingMinority speed of daily walker tasks (5) 6203 35.442.6 3920 22.740.0 General function and prosthetic-device use by site of major traumatic limb loss and conflict. Unilateral Upper Limb Loss: Total FunctionLow-impact and activities prosthetic (6) 2933 170.3 6device.3 4438 25.676.0 Vietnam OIF/OEF No prosthesis used High-impact activities (7) 147 29.3.98 4512 26.24.20 Satisfaction and Prosthetic Device Use in Vietnam and # % # % TotalUnilateralBilateral Upper Upper Limb Limb Only N N = = 150 476 84.3 162 507 94.2*** OIF/OEF Soldiers NoProsthesis prosthesis used used to MMajoriajorityty of daily tasks 21318 127.716.75.7 10185 5.836.71.4*0* • Prostheses use is more frequent for TRA or distal Multipleperform: Limb: InvolvesMinority a Lower of daily Limb tasks N = 202 67 42.633.3 201 54 40.14.30 PTotalrosthesis used to Do not walk (1, 2) 3353 70.350.07.4 3806 785.76-. 0 levels Noperform prosthesis (by used Household walker (3) 1443 29.50.06.08 1712 1214.334.0.0 • Other hand is used more often in a compensatory BilateralfunctionalUnilateral Upper level): Lower Limb LimbCommunity Only walker (4) N = 12 1786 17.9 12 1727 22.2 fashion for higher levels. Prosthesis used to Do not walk (1, 2) 2 1.3 1 0.6 Prosthesis used to MajoriVaryingty speedof daily walker tasks (5) 191 16.728.4 115 71.420.4 • Most use prostheses (70% Vietnam and 76% perform:perform (by MLowHouseholdinority-impact of walker dailyactivities tasks (3) (6) 1255 33.37.48.4 101 14.318.55.8 Totalfunctional level): HighCommunity-impact walker activities (4) (7) 3324 50.019.13.0 10236 85.718.513.4 OIF/OEF). TotalNo prosthesis used Varying speed walker (5) 47633 70.50.035.41 50391 92.614.322.7** • BP devices are favored by the Vietnam cohort, while UnilateralNo prosthesis Lower used LimbLow - impact activities N (6) = 2029 178 29.916.3* 444 172 7.425.6** OIF/OEF cohort use both myoelectric and BP devices PTotalrosthesis u sed to DHigh o not - impact walk (1, activities 2) N (7) = 27 298 1.3.39 451 283 26.0.62 • Frequency of prosthetic rejection due to ProsthesisperformTotal (by u sed Household walker (3) 23315015 78.084.38.4 25616210 90.5*94.25.8*** ** dissatisfaction is high for the Vietnam cohort (23%) Nofunctional prosthesis level): used Community walker (4) 365248 19.121.815.7 232710 9.5*5.813.4**** Multiple*p < 0.05Limb: Involves Varying a Lower speed Limb walker** p N< (5) 0.01= 63 67 35.4 ***39 p < 0.00154 22.7 and higher for the OIF/OEF cohort (45%) Service Members and Veterans with Major Traumatic Limb Loss from the Vietnam and OIF/OEF Conflicts: Prosthesis used to Do not walk (1, 2) 5 7.4 0 - Survey Methods, Participants,Low and-impact Summary activities Findings (6) JRRD 229 0 1 0 , Reib er,1 G6 et.3 al. an d th e44 P ro sth etics Ex25.6 p ert P an el Esquenazi perform (by HighHousehold-impact walker activities (3) (7) 74 36.0.9 457 26.13.02 McFarland, Winkler, Jones, Heinemann, Esquenazi, Reiber. JRRD 2010. Totalfunctional level): Community walker (4) 15012 84.317.9 16212 94.222.2*** No prosthesis used Varying speed walker (5) 2198 128.45.7 1011 5.820.4** Multiple Limb: InvolvesLow a-impact Lower activities Limb N(6) = 5 67 7.4 10 54 18.5 Prosthesis used to DoHigh not-impact walk (1,activities 2) (7) 52 7.43.0 100 18.5- performTotal (by Household walker (3) 474 70.6.01 507 92.613.0** functionalNo prosthesis level): used Community walker (4) 1220 29.917.9* 124 7.422.2** Total Varying speed walker N (5) = 19 298 28.4 11 283 20.4 Prosthesis used Low-impact activities (6) 2335 78.07.4 25610 90.5*18.5** Esquenazi No prosthesis used High-impact activities (7) 652 21.83.0 1027 9.5*18.5** 11 Total*p < 0.05 ** p < 0.01 47 70. 1 ***50 p < 0.001 92.6** No p rosthesis used 20 29.9* 4 7.4** Total N = 298 283 Prosthesis used 233 78.0 256 90.5*** No prosthesis used 65 21.8 27 9.5*** *p < 0.05 ** p < 0.01 *** p < 0.001

Prosthetics Course 2016

Principle Causes of UL Other Reasons for Rejection: Prostheses Rejection • Limited usefulness • Decreased shoulder mobility • Late fitting • Brachial plexopathy • Excessive weight • Delay in initial prosthetic fitting > • Socket discomfort 6 months • Poor cosmesis • Pain • Poor satisfaction • Hot and humid weather • Not enough training to become proficient user

Esquenazi Esquenazi

Comparison of Upper Limb Prostheses

Passive Body-Powered Battery Powered Body-Powered Advantages Lightest Mod. Lightweight Heaviest Better cosmesis Worst cosmesis Mod. Cosmesis Minimal sensory Best sensory feedback Limited sensory feedback - Heavy Duty Construction No harnessing Most harnessing Less or no harnessing - May be high cost Moderate cost Most costly Passive function Functional Functional - Less Expensive No energy Most energy expenditure expenditure Less energy expenditure - Lighter in Weight May stain easily Most durable More maintenance required - Reduced Cost and Maintenance Choice of terminal devices Choice of TD and elbows No body movement Most body movement to Least body movement to No requiredbody movement operate operate No grasp Weaker grasp (VC) Stronger grasp (active)

Possible longer training time Esquenazi

Body power prosthesis Body-Powered Disadvantages most prescribed - Limited grip force Transradial Rx Transhumeral Rx (shoulder strength and # rubber bands • Double wall socket • Double wall socket tolerance) • VO hook • VO hook - Functional envelope (ROM) is limited • Quick disconnect wrist • Quick disconnect wrist - Harness can be uncomfortable and • Flexible hinges • Internal lock elbow restrictive • Triceps pad • Bowden control cable - Less cosmesis • Figure 8 harness • Figure 8 harness with elbow lock strap - Possible over-use, nerve entrapment syndrome

Esquenazi Esquenazi

Esquenazi 12 4/18/16

Lower Extremity Amputations Lower Limb Among Persons With

20 1997-99 2001-05

1,000 15 per 10

5 adjusted rate - Age 0 Total * Wh ite Black Female Male <6 5 65-74 75+ Race* Gender* Age †

SOURCE: National Hospital Discharge Survey (NHDS) and National Health Interview Survey (NHIS), CDC, NCHS 2012.

Esquenazi

LE Amputation by Age Mortality After Diabetic Related LE Amputation 12% will die in 30 days, 42% in 3 years, 56% in 5 years

• Contributing factors: – Age - Level of amputation – Race - Tobacco use – Renal or cardiac co-morbidity

Esquenazi Esquenazi

Trans-Tibial Amputation Joint Flexion Contracture

• Flexion contractures • Aim is to preserve the knee are frequent • Avoid skin grafts unless to save the knee • Predisposes ulceration • Long posterior flap is preferred • Residual tibia should be beveled and no • Easily prevented with longer than the junction of distal 1/3 early rehabilitation • Fibula should be slightly shorter than tibia • Not easily treated • Perform myodesic closure • Makes prosthetic fitting • Post-operative cast for protection and walking more difficult

WHO/MossRehab amputation rehabilitation manual 2004

1 4/18/16

Post-Operative Casting Immediate Post Operative Pylon IPORD • Rigid dressing: • Prevents edema and joint – Maintains good contractures knee position • Promotes healing and – Controls edema stump maturation – Protects skin from • Allows early weight bearing trauma and in some cases – Allows early ambulation, i.e. trauma rehabilitation

Esquenazi Esquenazi

TF Level Surgical Intervention New Keep-Walking® Device • Always try to preserve the knee • Fish mouth closure • Myoplastic closure to stabilize stump with hip adductors re- attachment distally to improve femoral control

Esquenazi

HO in Amputation Pain in Limb Amputation

• Four major sources of pain: • Incidence in up to 70% of traumatic amputees – Post surgical pain • Less than 30% of – Residual limb pain vascular amputees – Prosthetic related pain • More frequent in TFA –

Esquenazi Pain Management Post Amputation Esquenazi Pain Management in Rehabilitation. Demos 2003

2 4/18/16

Preparatory Prosthesis Phase Heterotopic Ossification

• Pre-prosthetic management HO can • Gait training with temporary produce prosthesis (pylon) pressure • Promote limb maturation at the • Edema control and limb shape prosthetic • Pain management socket • Prosthetic component selection interface

Esquenazi Es quenaz i A, Meier R . Ar c hiv es of PMR 1996.

Prosthetic Rx The Rx • Construction design • Please write a prosthetic Rx for a 64 • Socket nd year old man with left TTA 2 to • Suspension complications from DM. • Connecting parts • The patient works in a restaurant in • Foot Philadelphia • Knee (in TFA or higher) • Cosmetic cover • Accessories

Esquenazi

Prosthesis Selection Criteria TT prostheses

• Desired function • Reliability • Appropriateness • Effectiveness • Weight • Cost

Esquenazi Esquenazi

3 4/18/16

Prosthetic Endoskeletal Systems Feet

• Adjustable – flexion / extension – abd / adduction – rotation – limited translation • Re-alignable • Allows for component interchange or replacement

Esquenazi Esquenazi

SACH Foot Single Axis Ankle-Foot Solid Ankle Cushion Heel Rigid Keel

❚ Widely used since the1950 ❚ Simple, basic, reliable design ❚ For limited ambulators with stable knee

❚ Non-adjustable heel heightFlexible Fore Foot ❚ No energy storageCushion Heel

Esquenazi Esquenazi

Multi-Axis Ankle-Foot Energy Storing Feet

Seattle Foot introduced in mid 80’s Subjective sense of active push-off For increased activity level Moderate to higher cost

Esquenazi Esquenazi

4 4/18/16

Adding Mobility to ES Shock Absorbing and Rotating Designs Pylons Var i -Flex

Ceterus TT Pylon

❚ Adjustable resistance Split design allows some degree of inversion-eversion

Esquenazi Esquenazi

TT Amputation High Performance feet

Esquenazi Esquenazi

Silicone Partial Foot Foot Selection Criteria

❚ Weight ❚ Cost ❚ Desired function ❚ Reliability ❚ Efficiency

Esquenazi Esquenazi

5 4/18/16

Prosthetic Foot Weight Prosthetic Foot Relative Cost

1600 4500

1400 4000

1200 3500$

1000 3000 Cost Cost

gr. 2500 800 2000 600 1500 400 Weight Weight 1000 200 500 0 0 SACH Seattle L(SACH)GreissingerCC II (ES)College ParkC Foot(Hybrid) (Hybrid)Flex FootPower (ES) Foot SACH Seattle lightGreissingerCC II College ParkC Foot Flex FootPower Foot

Esquenazi

Energy Storing Feet Energy Cost of Ambulation at Different Levels of Lower Limb Amputation

100 ❚ No O advantage for slow, level walking 2 80

❚ Clear O2 advantage for higher speeds and 60 inclines 40 ❚ No age restriction for ES feet, think 20 0 function Symes TTA TKA TFA HD Normal % Increase in Energy Expenditure Expenditure Energy in Increase %

Level Esquenazi J A Pod Assoc 91 (1) 13-22 2001

Esquenazi

Transtibial Socket and Suspension Abnormal Pressures

Esquenazi Esquenazi

6 4/18/16

Prosthetic Socks Pressure Distribution

intolerant tolerant

Esquenazi Esquenazi

Transtibial Suspension Sleeve Friction Suspension Iceross Silicone Suspension • Neoprene • Spandex • Elastic rubberized • Rubber

Esquenazi Esquenazi

Anatomic Suspension Anatomic Suspension Supracondylar / Suprapatellar Removable Wall Supracondylar

❚ Minimal pistoning ❚ SC adds ML stability ❚ SP adds hyperextension stop ❚ Easy to don, doff ❚ Localized forces = pressure ❚ Often combined with other suspensions

Esquenazi Esquenazi

7 4/18/16

Strap Suspension Cuff Thigh Corset & Joints ❚ Very short RL ❚ ❚ Amputee-adjustable Delicate or sensitive skin ❚ Knee contracture ❚ Accommodates gross volume changes [e.g. ESRD] ❚ Cannot tolerate full WB ❚ Often requires Waist Belt ❚ Ligamentous disruption ❚ Pistoning inevitable ❚ Bulky, heavy, awkward ❚ Quadriceps atrophy

Esquenazi Esquenazi

Cosmetic Cover

Trans Femoral Componentry

Esquenazi Esquenazi

Transfemoral Sockets Ischial Containment Frame • Plug Fit Suction Socket • Quadrilateral Ischial Weight Bearing • Modified IPOS • Ischial containment

Esquenazi Esquenazi

8 4/18/16

Donning a prosthesis Transfemoral Suspension Push-in Pull-in • Suction • Friction / Vacuum • Anatomical • Straps • External Joint

Esquenazi Esquenazi

Silicone Suspension Suction Socket Suspension

• Difficult to don & doff • Limb volume must be stable • Hygiene • Perspiration • Not adjustable • Very secure • Allows full range of motion

Esquenazi Esquenazi

Silesian Belt TES Belt Pelvic Belt & Hip Joint

❚ Reduces hip torque ❚ Increases ML stability ❚ Bulky, heavy, awkward ❚ Interferes with toileting and seating in a car or low chair

Esquenazi Esquenazi

9 4/18/16

Knee Joints Manual Locking

❚ Knee of last resort ❚ Maximum stability + chronic ❚ Interferes with sitting, falling safely ❚ Try to avoid using 2 locking knees

Esquenazi Esquenazi

Weight Activated Weight Activated Stance Control Stance Control ❚ Adds stance phase weight-activated stability ❚ For limited ambulators + slow walkers ❚ Hip flexion deformity ❚ May make sitting very difficult for bilateral

Esquenazi Esquenazi

Knees Polycentric (4 bar) Carbon Graphite Hydraulic • Reliable • Some maintenance ❚ Excellent stability + good swing • Manually adjustable phase function • Swing & Stance controllers ❚ Use to increase stability and confidence while walking • Rubber seals may dry up over time ❚ Or - to accommodate very long RLs such as KD

Esquenazi Esquenazi

10 4/18/16

Swing / Stance Controllers for Swing / Stance Controllers for Knees Knees

Esquenazi Esquenazi

Man u f actu re r Approxim ate Power Source In te n d e d Hydraulic Cylinder Weight Use r SLK Se lf DAW I ndus tri es 2.1 po unds Lithiu m-io n ba tte ry las ts up t o six K3, K4 Microprocessor Controller Learning Knee (934 g rams ) mon ths de pen ding on us e Smart Ad ap tive Endoli te 3 pou nds Batt eri es last up to 14 days / cha rge K3/ 4 Knee (1361 gra ms ) Plié Freed om 2.3 po unds Lithiu m-io n ba tte ry provides K3, K4 Micro p ro ce sso r Innova tio ns (1043 gra ms ) appr oxima tely 3 6 ho urs o f us e Knee Rheo Knee Ossur 3.59 p oun ds Lithiu m-io n ba tte ry f acilita tes 36 h ou rs K3 (1628 gra ms ) of cons t ant us e

C-Leg Otto Bock 2.5 po unds Lithiu m-io n ba tte ries h old 4 0-45 hours K3, K4 (1143 gra ms ) of po wer

4-Bar Power Trulife 2.2 po unds Batt ery lasts up to 2 y ears d epen ding on K3, K4 Knee (998 g rams ) activity lev el

Fusion Powe r Trulife 3 pou nds Batt ery lasts up to 2 y ears d epen ding on K3, K4 Knee (1361 gra ms ) activity lev el

Ge nium Knee Otto Bock 3.5 po unds Lithiu m-io n ba tte ries h old 4 0-45 hours K3, K4 (1550 gra ms ) of po wer

Esquenazi

Prosthetic Knee Selection Medicare Functional Levels Algorithm (K system) Able to control knee in stance? Level Description No Yes K0 None ambulatory Able to control during Level of activity swing Potential benefit from increase stability K1 Household ambulator Ins ur anc e No Yes K2 Community ambulator

Manual Weight activated locking stance control Polycentric K3 Community ambulator, light sports knee knee Constant MP C friction Hydraulic K4 High level activity, sport

Esquenazi

11 4/18/16

Medicare Components Benefit Microprocessor Functional Level Component Benefit Capability K0 None • Functional Level 3-4 • Provides resistance to SACH or single axis foot flexion/extension during swing phase K1 • Enables variable cadence; ability to No fluid control knee change walking speeds without hesitation Flexible keel, multiaxis foot • On board microprocessor analyzes K2 gait and selects appropriate No fluid control knee resistance for smooth swing phase. Energy storing, flex or multiaxis foot • Provides variable cadence and ability K3 to change walking speeds without Fluid and microprocessor knees hesitation • Added expense due to computer technology K4 All except for powered components • Maintenance is essential

Esquenazi

Newer components Powered components

Esquenazi Esquenazi

Microprocessor Controlled • Patient wears an instrumented insole Powered Prostheses (HP) under the intact foot with a transmitter

• The forces on the insole determine the movement and location of the non amputated leg

• Power Knee calculates and motors adjusts where the prosthetic leg should be

12 4/18/16

Prosthetic Alignment Power Knee Genium Knee

Esquenazi Esquenazi

Prosthetic Alignment Prosthetic Alignment

Esquenazi Esquenazi

The Rx

Prescribe based on function Limited ambulator = basic design Greater activity level = more sophisticated componentry design

Esquenazi Esquenazi

13