Physical and Engineering Sciences in Medicine

https://doi.org/10.1007/s13246-020-00882-3

INVITED REVIEW

A systematic review on design technology and application

of polycentric prosthetic knee in amputee rehabilitation
Rajesh Kumar Mohanty1,2   · R C Mohanty3 · Sukanta Kumar Sabut4

Received: 27 March 2020 / Accepted: 27 May 2020

© Australasian College of Physical Scientists and Engineers in Medicine 2020

Abstract
The objective of this paper is to conduct a systematic review on design technology and clinical application of polycentric
prosthetic knee joint in the rehabilitation of trans-femoral amputees. Relevant studies were identified using electronic
database such as PubMed, EMBASE, SCOPUS and the Cochrane Controlled Trials Register (Rehabilitation and Related
Therapies) up to February 2020. Screening of abstracts and application of inclusion and exclusion criteria were made.
Design, modeling, material use, kinematic study, simulation technique and clinical application of polycentric knee models
used in many developed and developing countries have been reviewed. Out of 516 potentially relevant studies, 43 articles
were included. Specific variables on technical and clinical aspects were extracted and added to summary tables. The results
reveal that polycentric knees have a variety of geometries but the methods for comparing their performances are rare. The
data of structural analysis using different simulation techniques are validated with experimental results for determining
model accuracy. Gait analysis using the polycentric knee components provides a valid tool to correlate with experimental
results. There are well-designed studies on the technological development of polycentric knees, however, high-quality clini-
cal researches are scarce. Conventional clinical knowledge had considerable gaps concerning the effects of polycentric knee
and their mechanical characteristics on human functioning with a lower-limb prosthesis. Still, further research is needed
to develop and implement standardized measures on prosthetic knee joints for their effective use, function, durability, and
cost-effectiveness.

Keywords  Amputation · Clinical application · Finite element · Polycentric · Prosthetic knee · Trans-femoral

Introduction globally [1, 2] and those performed in lower limb accounts

The major cause of amputation may be classified into trau-
matic and dys-vascular whereas oncological disorders and
infection are also prevalent. According to sources, the inci-
dence of amputation is 1.2 to 4.4 per 10,000 population
* Rajesh Kumar Mohanty
rajeshmpo48@gmail.com
1
Centurion University of Technology and Management,
Bhubaneswar, Odisha, India
2
Post Graduate Department of Prosthetics and Orthotics,
Swami Vivekanand National Institute of Rehabilitation
Training and Research, Cuttack, Odisha, India
3
Department of Mechanical Engineering, Centurion
University of Technology & Management, Bhubaneswar,
Odisha, India
4
School of Electronics Engineering, Kalinga Institute
of Industrial Technology, Bhubaneswar, Odisha, India
for majority up to 90% [2]. It is estimated that by 2050, the
numbers may double [3]. According to a survey by World
Health Organization (WHO), the estimated number of ampu-
tees is 40 million in the developing world. As per Census
2011, the population of persons with disabilities in our coun-
try is about 2.68 crore which is 2.22% of total population.
Amputation is one of the major cause of disability in India
but a very few of them (about 5%) have any access to pros-
thetic devices [4].
With lower limb amputations, inconveniences are caused
due to loss of walking ability and performing other activities
of daily living (ADL) along with psychological and social
issues. The most productive way to reestablish walking abil-
ity is through properly designed prosthetic system as shown
in Fig. 1. The prescription of prosthesis is a combination
of art and science predominantly based on factual com-
prehensive understanding. There are broad ranges of pros-
thetic components; however, the yardstick of prescription

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Fig. 1  Above knee amputation and prosthesis
primarily relies on instinctive experiences of physiatrists,
therapists, and prosthetists [5, 6]. In other words, the idea
for a suitable prosthetic prescription is to adjust the mechani-
cal characteristics of a prosthesis to the functional needs of
subjects [7]. Out of all prosthetic components for subjects
with trans-femoral amputation, prosthetic knees are most
vital element that can affect the performance during gait
and ADL. Many works have been performed to improve the
design and performance of prosthetic knees in last few dec-
ades. The optimal design of a prosthetic knee is a fundamen-
tal requirement to restore the lost function, improve cosmetic
appearance and achieve social acceptance.
Prosthetic knees for trans-femoral amputations are distin-
guishable by the different means of linking thigh and shank
(single-axis and polycentric) and by control methods [8].
The single-axis prosthetic knees as displayed in Fig. 2a are
characterized by a fixed center of rotation. However, they
are relatively inexpensive. They simulate the motion of the
anatomic knee with moderate levels of accuracy but are not
sufficiently stable during the stance phase. In contrast, the
polycentric knees as presented in Fig. 2(b) have inherent
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Physical and Engineering Sciences in Medicine
Fig. 2  a Single axis and b polycntric prosthetic knee [12]
stability with constant change in instantaneous center of
rotation (ICOR) at varying knee flexion angle. Compared
to other prosthetic knees, the 4-bar linkage polycentric
mechanism is still most predominant globally. In spite of
its simplicity, it has the feature of inherent stability during
static loading and reproduces natural motion of knee with
high reliability [9]. However, they are comparatively more
expensive. The best compromise solution considering cost,
functionality and aesthetic aspect is a polycentric prosthetic
joint based on the 4-bar linkage mechanism which is widely
described in literature for prosthetic applications [10, 11].
Considering the impact of prosthetic rehabilitation,
problem identification and necessary footsteps required
for improving existing practices in developing countries, a
significant number of publications have been elucidated in
mid-1990s [10, 13–21]. The key issues identified were poor
durability and failure of prosthetic foot, the discomfort due
to inadequate prosthetic socket fit, poor alignment and func-
tioning of components including knee joints. In an extensive
literature survey from 1994 to 2010 on lower limb prosthetic
technology in developing world, J. Andrysek [20] suggested
that there is a requirement for prosthetic components to be
more functional irrespective of continuing action to improve
prosthetic technology. He emphasized on design and devel-
opment of cost effective and durable prosthetic knee joints
through simplifying fabrication techniques [21].
Through systematic literature search with a methodical
strategy, we explored across four major technical databases
and retrieved records were screened for their relevance.
Though, different types of polycentric prosthetic knee
joints have been synthesised globally in last fifteen years,
there has been equivocacy over prescription criteria, design
Physical and Engineering Sciences in Medicine
parameters, kinematic performance of its various designs
and counterparts. Therefore, objectives of this paper is to
review the design, modelling, material use, kinematic study,
simulation techniques, and clinical applications of polycen-
tric knee models and its counterparts.
Methods
Literature search
Our review covers both the technological developments
and clinical applications of polycentric knee joints for pros-
thetic rehabilitation of trans-femoral and higher level lower
extremity amputees. Relevant articles have been obtained
through a search of articles in the PubMed, EMBASE, SCO-
PUS and the Cochrane Controlled Trials Register databases
(Rehabilitation and Related Therapies) up to February 2020.
The following key words have been used in the litera-
ture search: amputation, polycentric, prosthetic knee joint,
technology, materials, lower extremities, finite element,
modelling, design, clinical application, and optimization
techniques.
Study selection
The following topics have been selected for review:
(1) Technology of prosthetic knee devices,
(2) Study of polycentric knee mechanism,
(3) Design, modelling, materials used and kinematic analy-
sis of polycentric knee joint,
(4) Finite element analysis (FEA) and optimization tech-
niques, and
(5) Clinical applications focused on prosthetic rehabilita-
tion of amputees.
This will help in understanding how technological
advancements in designing of prosthetic knees ensure clini-
cal prosthetic rehabilitation of subjects with trans-femoral
amputation. The following inclusion criteria are set for
selection of articles:
a. Study design for clinical analysis ranging from sophisti-
cated randomized controlled trial (RCT) to a simple case
study based on innovations.
b. Patients with only trans-femoral and through-knee
amputation.
c. Outcome measures like subjective findings, ADL meas-
ures, gait parameters and electromyography (EMG) only
d. Study of mechanical polycentric prosthetic knee and its
comparison with counterparts.
Papers were excluded when any of the inclusion criteria
were not met and when their focus centered on joint replac-
ing endo-prosthesis.
Two investigators (R.K.M. and S.S.) screened the
abstracts identified in the database searches. R.K.M. was
responsible for reviewing abstracts identified in PubMed,
EMBASE, and S.S. reviewed abstracts from SCOPUS and
the Cochrane Controlled Trials Register databases (Reha-
bilitation and Related Therapies). These 2 investigators then
applied the inclusion and exclusion criteria to the abstracts.
Abstracts which did not meet the inclusion criteria were
excluded and the reason for exclusion was recorded. Dupli-
cate articles were removed. The remaining full-length arti-
cles were then retrieved and reviewed by these two review-
ers to further determine whether the study met inclusion or
exclusion criteria. A senior investigator (R.C.M.) verified
and made final decision.
Data extraction
The variables that were extracted from the included studies
are design, mechanism, simulation, kinematic, optimiza-
tion and clinical applications of polycentric knee focused
on prosthetic rehabilitation of amputees.
Data synthesis and analysis
Specific variables on technical and clinical aspects were
extracted and added to summary tables. Summary tables
were used to categorize studies according to themes. Dur-
ing screening, grouping of articles are performed by study
design and categorized as technical development, clinical
studies through lab testing and/or field trial. The category
of technical development includes studies focusing on tech-
nology related research and development without patient
clinical trial. Clinical lab testing study involves patients,
lab-based tests and outcome measures like analysis of bio-
mechanics and function. Clinical field trial study involves
time based testing of patients in physical world to know the
actuality. Level of evidence was marked as “A” for studies
with adequate sample size and conducted by RCTs and those
with inconvenient samples using case studies were marked
as “B”.
Results
The flowchart showing the results from literature search was
illustrated in Fig. 3. The search generated abstracts from 512
studies. After applying inclusion and exclusion criteria, a
total of 43 studies were included in the systematic review.
13

Fig. 3  PRISMA Flow chart of
the included studies
Technology for prosthetic knee systems
The technical ability and function of a prosthetic knee joint
significantly facilitate walking pattern that mimics to nor-
mal subjects biomechanics and thus increases efficiency in
energy consumption of amputee walking [21]. Therefore, the
extent to which the amputee can achieve normal gait biome-
chanics highly depends on the appropriate use and integra-
tion of prosthetic knees. Specifically, the literature has drawn
distinctions according to methods of dampening movement
(mechanical friction vs. fluid damping) and method of con-
trol (mechanical design vs. microprocessor regulation) [22].
There is a significant difference in the use of prosthetic knee
technology between developing and developed countries.
Use of prosthetic knee technology in developed countries
On the basis of performance characteristics, the broad cat-
egory of prosthetic knees is mechanical and microproces-
sor-controlled [23]. Swing control single axis knee having
friction or dampening mechanism [24] and weight-activated
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Physical and Engineering Sciences in Medicine
friction brake during heel strike are still being used as old
designs in developed countries [25]. The knee mechanisms
working by fluid-controlled systems offer variable swing
control and cadences [26]. Compared to pneumatic system,
the hydraulic controlled knee offers stable stance control in
addition to achieve a wider range of cadences and walking on
different terrains [27]. An optimized polycentric prosthetic
knee with multiple linkage mechanism with ICOR offers
inherent stance stability and provides better swing clearance
depending on the requirements [28]. The microprocessor
controlled prosthetic knee designs offer changing pneumatic
or hydraulic swing control through on-board sensors and
electronic signal processing [21]. In order to achieve best
functional outcomes of amputees, sampled feedback signals
are programmed and optimized in real time manner.
Use of prosthetic knee technology in developing countries
Most prosthetic knees used in developing countries are
mechanical in nature due to economic constraints. There
is a constant need to develop durable, functional and cost
Physical and Engineering Sciences in Medicine
effective prosthetic knees due to limited opportunity to
approach medical or health services. Single axis knees with
little or no maintenance requirements are commonly used,
however it is less stable and does not offer multiple cadence
[23]. The 4-bar linkage polycentric knees developed from
inexpensive materials and fabrication techniques are widely
used and popular due to good functional and cost effective
characteristics [29]. Constant work towards improvement
in design parameters to improve stability, to suit different
functional demands (cross leg sitting and squatting) and to
improve cosmetic appearance of trans-femoral amputees are
undertaken.
In the context of above discussions, it may be noted that
polycentric knees are commonly used both in developed
and developing countries. According to their designs, 4-bar
linkage, 6-bar linkage [20] and spherical mechanisms [20]
with different functional requirements may be considered for
subjects with trans-femoral amputation. However, the 4-bar
mechanism is commonly used.
Study of polycentric knee mechanism
The 4-bar linkage polycentric knee is of three types: 4-bar
linkage with elevated instantaneous centre [30], hyper-sta-
bilized 4-bar knee mechanism and voluntary control 4-bar
mechanism [27]. The elevated instantaneous center provides
stability at heel contact for subjects who lack active volun-
tary control. The hyper-stabilized knee provides alignment
stability like locked knees for less active amputees. Active
subjects having good hip muscle power can be benefited
with voluntary control 4-bar mechanism that provides stabil-
ity during initial contact and pre-swing [26]. Figure 4 shows
Fig. 4  Orientation of ICOR at different knee flexion of a typical 4-bar
linkage knee [31]
a typical 4-bar linkage knee. The thigh and shin are consid-
ered as a link or bar joining at different points. Together, all
four links join at four points to complete the 4-bar linkage.
Design, modelling and materials used in polycentric
knee
Design
The design of budget trans-femoral prosthesis can be
obtained by utilizing concept of artificial knee joint based
on the 4-bar mechanism. Its kinematic dimensions are deter-
mined by multi-criteria optimization based on systematic
study of parameter space of points uniformly distributed in
multidimensional cube [31]. Some techniques of synthesis
have been investigated by Poliakov et al. [32]. Some latest
design of polycentric prosthetic knee has been studied in
detail [33, 34]. Commercially, different designs are being
offered by world known manufacturers like Ossur, Otto
Bock, Hosmer, Endolite, Teh Lin and others [32]. However,
it should be noted that almost all of them significantly differ
in terms of geometry and function. Figure 5 shows some
schemes of the 4-bar polycentric prosthetic knee and their
centrodes obtained through shank-thigh relative motion.
Thus it can be stated that in spite of the advantages
being offered by these designs, none of them is globally
Fig. 5  Polycentric prosthetic knee joints and their corresponding cen-
troids obtained through shank-thigh relative motion (red) [32]
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 Physical and Engineering Sciences in Medicine

optimal. An overview of polycentric knees manufactured designing a polycentric prosthetic knee joint. Different meth-
by global manufacturers and their technical specifications ods are introduced to optimize the problems including mod-
are presented in Table 1. However, all of them satisfy cer- ern calculations through use of computers.
tain quality criteria which are taken into consideration when

Table 1  Overview of polycentric knees manufactured by global manufacturers

Manufacturer Model Type Max. knee Mass (g) Length (mm) Max. user
flexion (*) weight
(kg)

Otto Bock HealthCare 3R46 [35] Polycentric + hydraulic 110 740 N/A 125
GmbH. Duderstadt, Ger- 3R60 [36] Polycentric + hydraulic 175 845 N/A 125
many
3R78 [37] Polycentric (4 bar) + pneu- 150 750 120 100
matic
3R66 (Pediatric) [38] 4-bar & rotator 165 255 N/A 35
Ossur hf. Reykjavik, Iceland OH7 Hydraulic polycentric knee 150 930 186 136
joint
OP5 Pneumatic polycentric knee 145 900 210 125
joint,
OP2 Pneumatic polycentric knee 160 650 N/A 125
joint
Total knee Jr. (Pediatric) [38] 6-bar & stance flexion 145 340 146 45
Chas. A. Blatchford & KX06 [39] Polycentric prosthetic knee N/A 1230 230 150
Sons Ltd, Hampshire, with hydraulic swing and
United Kingdom  stance control
S400 Polycentric locking knee N/A 678 130 125
S500 Polycentric with pneumatic N/A 882 220 125
swing control
Children’s Transfemoral Polycentric 4-bar 130 333 107 60
Prosthesis (Pediatric)
Fillauer Inc./ Hosmer Dor- MightyMite (Pediatric) [40] Polycentric 4-bar 130 290 108 60
rance Corp. Chattanooga,
TN, United States
DAW Industries San Diego, The 4000 Ultra-Lite™ Polycentric 4-bar 155 669 158 113
CA, United States The 4001 Ultra-Lite™ Polycentric 4-bar 155 591 158 113
5PS10 KD™ With Manual Lock 135 997 210 125
4P00 Ultra-Lite™ Polycentric 5-bar 140 764 188 113
TK-4P0C (Pediatric) [41] Polycentric 4-bar with pneu- 160 369 165 54
matic
Seattle Systems Inc. Poulsbo, NSSK615 Polycentric 4-bar with pneu- 145 1100 N/A 100
WA, United States matic
SSK615 [42] Polycentric 4-bar with pneu- 145 1025 N/A 100
matic
SSK602A Pneumatic 5-bar knee 145 520 N/A 100
SSK610 [41] Polycentric, 4-bar knee 140 281 115 36
Teh Lin Prosthetic & Ortho- A-TGK-5PS10 5-Bar Pneumatic Knee 135 1000 250 100
paedic Co., Taipei, Taiwan A-TGK-4P10 [35] 4-Bar Pneumatic knee 138 1078 265 100
C-TK-4010 4-Bar polycentric knee 140 910 210 100
C-TK-4001S 4-Bar Polycentric knee with 120 880 178 100
manual lock
Proteor Group, Cedex, France  1P200 Pneumatic 4-axis knee 170 743 204 N/A
1M03 [43] 4-axis knee 140 510 166 100
M112 (Pediatric) [41] 4 bar friction 135 323 94 55

N.B. Data were obtained by company literature. N/A = Data not available

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Physical and Engineering Sciences in Medicine

model of a 4-bar polycentric knee using a geometric analy-

sis and the Grashof Law for a double rocker and its design
scheme is shown in Fig. 6 [32]. Let an optimized PMAK has
a four bar linkage structure. Its design scheme is proposed
by Poliakov et.al [32]. and is discussed below. In this mecha-
nism AB is the input link. It is assumed that it is tightly
associated with the hip and moves plane parallel relatively
to 1arbitrarily still link O­ 1O3, fixed to the shank, which is
associated with moving system of coordinates ­O1x1y1. Dur-
ing the motion relative to the joint A, link AB rotates at an
angle θ3 which is taken as an independent generalized coor-
dinate. Thus, θ2 = θ2 (θ3) and θ4 = θ4 (θ3)—the functions of
the generalized coordinate θ3. Rotation angles of all links
are measured from the positive direction of the x-axis and
considered positive if directed counterclockwise.
In order to unify the following notations were introduced:
lO3O1 = x1, lAB = x3, lBO3 = x4, ­xO1 = x5, ­yO1 = x6, γ1 = x7,
θ2 − θF = x8, lAP = x9, γ3 = x10. Here the symbol l denotes the
length of the links indicated in the indexes: ­xO1, ­yO1—the
global Cartesian coordinates of the joint O1:γ1—the inclina-
tion angle of the link O1O3 relative to the x-axis of the global
coordinate system: γ3—the angle between the segments AB
and AP: θF—the knee flexion angle.
From the conditions that the circuit O1ABO3O1is closed,
the following can be obtained:
�
⎛ ⎞
⎜ F1 ± F12 + F22 − F32 ⎟
𝜃2 = 2 arctan ⎜ ⎟ (1)
⎜ F2 + F3 ⎟
Fig. 6  A kinematic model of a 4-bar polycentric knee joint [32]
⎝ ⎠

( ( ) ( ))
Modelling and mathematical model of polycentric knee x1 sin 𝜃2 + x2 sin 𝜃3
joint 𝜃4 = arcsin (2)
x4

From the measurements obtained from CT scan or MRI ( ) ( ) ( )

images and available literatures of the knee, approximate tan 𝜃4 + x7 cos x7 − sin x7
size of the prosthetic knee joint can be constructed using xICR = x5 + ( ) ( ) ⋅ x1 (3)
tan 𝜃4 + x7 − tan 𝜃2 + x7
computer based software for different sagittal radius and
flexion angles [44]. Measurement of the relevant parameters ( )[ ( ) ( ) ( )]
of the knee including mean, variance etc. are important to tan 𝜃2 + x7 tan 𝜃4 + x7 cos x7 − sin x7
yICR = x6 + ( ) ( ) ⋅ x1
design the knee prosthesis. tan 𝜃4 + x7 − tan 𝜃2 + x7
Generally, the trans-femoral prosthesis with polycentric (4)
4-bar linkage knee is subjected to high degrees of wear and ( ) ( )
xP = x5 + x2 cos 𝜃2 + x7 + x9 cos 𝜃3 + x10 + x7 (5)
tear during static and dynamic loading. Therefore, math-
ematical models of the mechanical knees are commonly ( ) ( )
used for kinetic analysis, simulation and determining pos- yP = x6 + x2 sin 𝜃2 + x7 + x9 sin 𝜃3 + x10 + x7 (6)
sible failures [27, 45]. A method for determining a kinematic
where,

( ) ( ) x1 x12 + x22 + x32 − x42 x1 ( )

F1 = sin 𝜃3 , F2 = cos 𝜃3 − , F3 = − + cos 𝜃3
x3 2x2 x3 x2

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 Physical and Engineering Sciences in Medicine

Materials used in polycentric knee
The use of proper materials in any prosthetic knee should be
to eliminate failure with minimum fatigue wear and decay.
An average survival rate of 70% after 16 months of use of
knee prosthesis and an average lifespan 3 to 4 years are
observed from the literature [20, 26].
It is seen from literature that some common materials
used in prosthetic knees in both developing and developed
countries are Nylon 6, Nylon 6–6, oil-filled Nylon, isotactic
polypropylene, acrylonitrile butadiene styrene (ABS), polya-
cetyl resin (Delrin), stainless steel, aluminum (60- series),
titanium, polyethylene (high density), and polyvinyl chlorine
(PVC). Their material properties are presented in Table 2.

Materials used in developed country Finite element analysis (FEA) and optimization

Due to good economic conditions, materials used for the
manufacturing of prosthetic knees in the developed countries
exhibit sufficient strength (good mechanical, thermal and
viscoelastic properties) without considering cost. Mechani-
cal properties of metals or metal alloys (titanium, stainless
steel and aluminium alloys) used in these units should have
high yield strength, hardness, toughness, good fatigue life,
corrosion resistant features [29]. Even some models are
manufactured in the developed markets with cost range
of hundreds of US dollars with polymers, fiber reinforced
plastics and its fabrication technologies for better material
property and durability.
Materials used in developing country
Due to economic constraints and environmental factors
(access to medical care), material selection for develop-
ment of prosthetic knees are from locally available materials
using standard production techniques at relatively cheaper
costs and moderate wear life [29]. Thermoplastics with low
price, easy machinability, low friction, abrasion and wear
properties are generally used for design of prosthetic knees.
They have good recycling and reuse features. Metals of high
strength and relative low machining characteristics are pri-
marily used for load bearing central pylon components.
techniques
To simulate and optimize a functionally effective prosthetic
knee, a mathematical model based technique known as finite
element method (FEM) is considerably used as a valid tool
for any physical system modelling in physics and engineer-
ing disciplines [46]. It plays a vital role in prosthetic design
and development.
Finite element modelling and analysis of stump-socket
interface is performed to determine pressures and shear
stresses [47–50] and is well-suited in the design of various
prosthetic components. FEA enables to estimate collapse of
components through simulation results with the prediction
of knee kinematics. Zach et al. [51] analysed the stability,
stress and contact pressure distribution of the prosthetic knee
implants using FEA. The variations between bipolar and
unipolar knee prosthesis are observed by Lian et al. [52] in
static and dynamic posture. However, application of FEA in
the design and analysis of a prosthetic knee used for trans-
femoral amputees is still lacking [53]. Thus FEA is used to
simulate a polycentric knee under various loading conditions
and the results of experimental validation are furnished to
confirm the accuracy of the model. The design summary of
prosthetic knee model is presented in Table 3.
Optimization and kinematic simulation techniques
are being used successfully for obtaining optimal ICOR

Table 2  Common materials used in prosthetic knee and their mechanical properties

Material Corrosion resist- Yield strength Impact strength Fatigue life Abrasion resistance Coefficient of Density
ance (MPa)@ 20 °C friction (g/cc)

Nylon 6 High 78 9 J/cm2 High High 0.2–0.3 1.13

Nylon 6/6 High 82.7 10.9 kJ/cm2 High High 0.43 1.14
Polypropylene, High 40 15.8 J/cc High High 0.1–0.3 0.9–0.93
isotactic
ABS Medium 42.44 120 kJ/m2 Medium High 0.5 1.04
Delrin High 70 60–350 kJ/m2 High Low 0.2–0.35 1.42
Stainless Steel High 205 47.45 J High High 0.57–0.74 8
Aluminium High 200–600 2–3E4 to Low Low 1.05–1.35 2.70
30–40E4 N/m
(Low)
Titanium High 880 17 J High High 0.3–0.36 4.506
HDPE High 26.2–200 80–400 kJ/m2 Medium Medium 0.2–0.28 0.936–1.46
PVC High 44.8 172 kJ/m2 Medium High 0.23–0.5 1.42

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 Table 3  Summary of FEA and Technical work performed on prosthetic knee joint
Study Title Aim Technical work Conclusion

Kadhim et al. (2020) [54] Evaluation and analysis of different
types of prosthetic knee joint used by strength of prosthetic knee
above knee amputee
Sudeesh et al. (2019) [44] On the possibility of achieving near-
normal swing phase of walking with
passive single-axis and polycentric
knees: a simulation approach
Liu et al. (2019) [45] Kineto-static analysis for four-bar
linkage mechanism of prosthetic
knee joint
Evaluation and analysis of structural
To compare polycentric and single axis
knee for improving design criteria
and enable further development to
provide better functionality
To investigate the prosthetic knee joint,
by means of the bar group method,
and the motion of the prosthetic knee
FEA used to obtain a safety factor
Simulation based dynamic analysis
Mathematical modelling and simula-
tion by motion analysis software
Polycentric 6 bar, knee with hydraulic
unit yielded minimum Von-Mises
stress of 14.24 MPa and a maximum
factor of safety of 3.11
Polycentric knee is superior to single
axis. The analysis showed potential for
well-designed cost effective knee
This method provides a basis for the
designing prosthetic knee mechanism
with longer life and better damping
Physical and Engineering Sciences in Medicine

Price et al. (2019) [55] Design optimization in lower limb
prostheses: a review
Cruz et. al. (2018) [56] Synthesis of a non-Grashof 6-bar
Polycentric knee prostheses using an
evolutionary optimization algorithm
Russell et al. (2018) [57] A kinematic model for the design of a
bi-condylar mechanical knee
Kadhim et al. (2018) [58] Design and manufacturing knee joint
for smart trans-femoral prosthesis
Manger et al. (2018) [59] Optimal material selection for the
construction of a pediatric prosthetic pediatric prosthetic knee
knee
Phanphet et. al. (2017) [60] Above-knee prosthesis design based
on fatigue life using FEM and design from the existing model
of experiments
Sugiyanto et al. (2017) [61] Stress Analysis of Four-Bar Link-
age Transfemoral Prosthetic in Gait
Cycle
joint
To develop a knowledge base and
identify the promising research path-
ways toward designing lower limb
prostheses for optimal biomechanical
and clinical outcomes
To synthesize a polycentric 6-bar
mechanism
To propose a design methodology
for a bi-condylar joint that mimic
anatomic knee
To enhance the passive prosthesis to a
microcontroller-based trans-femoral
prosthesis
To select an optimize material for
To improve the design of knee joint
To investigate the stress distribution
of a prototype of four-bar linkage
mechanical joints
effect
Systematic review Experimental parameterization of
designs and model-based simulations
are necessary for optimal biomechani-
cal design
Differential evolution algorithm based Knee mechanism was compact fol-
numerical optimization and simula- lowing desired trajectory and avoid
tion hyperextension
Kinematic computer model developed Path of COR matched for physical and
in MATLAB. Physical model was computer model with a mean euclid-
tested in squatting with active mark- ean difference of 2.85 mm
ers and reflective cameras
Solid Works for designing and FEA to Aluminium 6061 is most suitable to
discover whether proposed prosthesis manufacture the prosthetic knees with
can bear certain loads features like stability, comfortable,
low cost, light weight, and acceptable
safety factors
FEA simulating the ISO 10,328:2006 Aluminium 7175 is the optimal material
standard for structural testing and for pediatric prosthetic knee
Multi-criteria decision analysis
method
Structural tests by FEA, Morrow’s The optimized design confirmed the
approach for fatigue analysis that finite element prediction
predicts life span of knee component,
and materials used
FEM based on commercial software Based on stress analysis, the developed
Solidworks® is used to analyze Above Knee Prosthesis is safe because
the knee joint reaction due to the the maximum stress is lower than the
dynamic loading when transfemoral yield stress
prosthetic driven for one gait cycle of
motion is applied

13

Table 3  (continued)
Study Title
13
Huiqun et al. (2016) [62] A novel prosthetic knee joint with a
parallel spring and damping mecha-
nism
Diaz et al. (2016) [63] External knee prosthesis with four bar
linkage mechanism
Mihradi et al. (2015) [64] Design of above knee prosthesis: A
finite element stress analysis
Lapapong et al. (2014) [53] Finite element modeling and validation To present a procedure to simulate the FEM to simulate the prosthesis under
of a four-bar linkage prosthetic knee
under static and cyclic strength tests Polycentric knee
Afzal et al. (2014) [65] A cost effective design and analysis of To design a cost effective, light weight System model created using Solid
an active prosthetic knee for trans-
femoral amputees
Amador et al. (2013) [66] Comparison of the contact condi-
tions in the structural analysis of a
polycentric knee prosthesis
Amador et al. (2013) [67] Structural analysis during the design
of polycentric prosthetic knee
Furse et al. (2008) [68] Design and analysis of a prosthetic
knee joint
Valentino et al. (2008) [69] Development of external knee prosthe- To propose a knee design of polycen-
sis with polycentric mechanism
Aim
To design a high performance and low- The influence of the four-bar link-
cost passive PKJ and to evaluate the age parameters on the stability was
performance of the PKJ
To design and construct a prosthetic FEA used to obtain a safety factor
knee external four-bar mechanism
To determine whether or not the four
bar knee design has fulfilled strength
criteria
static and cyclic strength tests for
and durable lower extremity pros-
thetic device
To show the results of the stress
analyses performed during the struc-
tural design of a polycentric knee
prosthesis
To find the proper dimensions of a
polycentric knee under a structural
perspective
To develop an accurate FEA model of
a currently designed prosthetic knee
joint
tric type, which is modular and cost
effective
Technical work Conclusion
Consistency of the designed PKJ and
biological knee found. Experimental
analysed, FEMs of the PKJ’s block results show that no design and quality
performed, and the parameters were problems were found in the fatigue
optimized, and kinematic simulation test. Gait curve is close to that of the
of the ICR curve was conducted healthy leg
The device is intended to be incorpo-
rated into a modular prosthesis and
work in an optimal control mechanism
to regulate the acceleration walk
FEM was used for static loading simu- The results show that the last iteration
lation. Single leg stance condition of 3D model of knee prosthesis has
where the prosthesis hold the weight satisfied the criteria
of whole body was considered for
simulation
The validation results confirm the
the tests, stress distribution induced fidelity of the proposed finite element
and fatigue life. Explicit nonlinear model
transient stress analysis is applied to
determine the strength of prosthesis
Cost controlled by the use of non-expen-
Works®. Structural analysis by sive materials and actuators. Design
ANSYS®, functional verification by kept as simple as possible to increase
Simulink® Software reliability
FEM and three different contact Results show an important difference
conditions between the assembly in the stresses yielded by each of the
parts. The analyses were performed simulated conditions
under the most critical load condition
defined by the standard ISO 10,328
for the principal structural test
Stress analysis by FEM under three For the most critical load condition, 5
different load conditions of the 9 prosthesis components yield a
safety factor less than 1, which impli-
cated a redesign
FEA along with mechanical and clini- Incorporating geometric changes and
cal testing performed strength mechanisms resulted in stress
reduction in critical areas of 2–6 times
the original design
The mechanism was subjected to an The parts support the load produced by
analysis of efforts in ANSYS®, plac- a patient of 160 kg without suffering
ing the analysis on the links where deformation and significant wear
80% of the loads are located
Physical and Engineering Sciences in Medicine
Physical and Engineering Sciences in Medicine
trajectory [56, 57, 62]. Cruz et al. [56] have used numerical
optimization and simulation methods to synthesize a com-
pact 6-bar polycentric mechanism with desired trajectory.
Russell et al. [57] used kinematic computer model with
inputs from cadaver studies, compared it with a prototype
physical model and found matching path for ICOR. FEA
has been used for optimal material selection for prosthetic
knees [58, 59]. Considering ISO 10328 standard for struc-
tural testing and multi-criteria decision analysis methods,
Aluminium 6061 and Aluminium 7175 has been found suit-
able for fabrication of prosthetic knees. Phanphet et al. [60]
have found optimal dimensions for best design for improve-
ment of existing knee prosthesis. The test result confirmed
the finite element prediction under ultimate loading as per
requirements of the ISO 10328 structural test. In another
study Diaz et al. [63] established knee mechanism to sus-
tain body weight up to 100 kg of subjects using FEA incor-
porating aluminum 6063, stainless steel 304 and bronze.
They confirmed that a cost-effective and functional knee
prosthesis with reliable safety factor can be obtained. The
work of Lapapong et al. [53] outlined the virtual static and
cyclic strength tests of a 4-bar linkage prosthetic knee for
confirming ISO 10328:2006 standard. Results of simulation
and validation revealed that FEM is valid and reliable tool
to compute structural stress with accuracy. Afzal et al. [65]
used Solid Works® for creation of model, FEA for structural
analysis and Simulink® software for functional verification
and concluded that using these methods a simple, reliable,
anthropometric and cost effective component can be gener-
ated. The same methodology has been performed success-
fully by Sugiyanto et al. [61] and Kadhim et al. [58]. Amador
et al. [66] performed stress analysis of structural design of a
polycentric knee prosthesis by FEM in three different con-
tact conditions between the assembly parts for standard ISO
10328. In another study, the same authors using FEA sug-
gested for a redesign of polycentric knee that included the
increase in diameter of the axes as well as modifications in
four of the links for obtaining stable kinematic function [67].
The purpose of Furse et al. [68] was to develop an accurate
FEA model to redesign currently used knee component to
enable the part to be injection molded of Delrin by reducing
the main body thickness. The incorporation of various geo-
metric changes and strength mechanisms resulted in stress
reduction in critical areas to 2–6 times the original design.
Valentino et al. [69] explained the three step process carried
out to build a 4-bar polycentric knee using a mechanical
actuator. They used AutoCAD for designing with materials
such as stainless steel 304 and aluminum 6061 and did effort
analysis by using ANSYS. This resulted in a true polycentric
knee with capability of modifying center of rotation with
good clinical results.
Review of clinical application of prosthetic knee
The review of clinical application of prosthetic knee ranged
from pure mechanical system to intelligent microprocessor
control mechanism and presented in Table 4. Level of evi-
dence was marked as “A” for studies with adequate sample
size and conducted by RCTs and those with inconvenient
samples using case studies were marked as “B”. Compared
to mechanical passive prosthetic knee, the Microprocessor
Controlled Knee (MPK) improved reduction in falls [70],
perceived performance and everyday life activity level [71]
and kinetic symmetry for unilateral trans-femoral ampu-
tees walking at self-selected speeds on level ground [72].
Stance phase knee moment between the prosthetic and non-
prosthetic limb showed greater difference. Use of NMPK
reflected a symmetry index of 0.459 as compared to 0.640
when using the MPK. The A-level study based on question-
naires by Boonstra et al. concluded that a Tehlin knee with
pneumatic swing control resulted in a more comfortable with
increased velocity compared to mechanical swing phase con-
trol [73]. This was due to reduced swing time of prosthetic
leg caused by delayed knee flexion. Fast walking speed was
higher with the Tehlin knee (0.02 m/s) than with the 3R20
(0.09 m/s) while comfortable walking speed was not higher
with the Tehlin knee. Walking symmetry in terms of swing
phase duration was closer to 100% with the Tehlin knee than
with the 3R20. However, metabolic cost was higher with the
Tehlin knee [74].
The B-level studies revealed similar findings. The study
by Dumas et al. [77] found no difference in single axis and
polycentric swing control knee joints computed by inverse
dynamics. Knee joint forces and moments presented sub-
stantial errors, especially during the swing phase of gait. The
median errors in percentage of the moment magnitude were
4% and 26% in extension/flexion, 6% and 19% in adduc-
tion/abduction as well as 14% and 27% in internal/external
rotation during stance and swing phase, respectively. The
authors proposed that one should be cautious in using dur-
ing inverse dynamics gait analysis. With advancements in
3D printing technology, Ramakrishnan et al. [78] designed
and studied prosthetic knee out of a carbon-fiber and nylon
composite with gear-mesh coupling. The average peak knee
angle asymmetry of the 3D printed anatomically scalable
prosthesis knee (ASPK) is larger than the Ossur Total Knee.
They observed more strenuous activity with 3D printed
ASPK and suggested that this can be overcome by tuning
the cross-linked spring mechanism to match the dynamics of
the subject better. Many researchers have directly compared
mechanical polycentric with single axis knees and found
improved gait parameters, balance, foot clearance and sym-
metry in favor of polycentric knees [79, 81, 83, 88]. Lon-
caric et al. [79] found statistically significant differences in
favour of the polycentric knee module regarding the mobility
13

scoring, TUG test time, 10-m walking speed and BBS score.
Sensinger et al. [81] differentiated the effects of toe clear-
ance between four-bar mechanisms and single axis knee.
They observed an empirical average of 2.2 cm more mini-
mum toe clearance in four-bar mechanism than single-axis
knee (P < 0.01). In the simulation study, single-axis knees
provided the least clearance (4.6 cm) during prosthetic swing
phase, followed by four-bar knees (5.8 cm), and the two
ankle mechanisms (6.4 and 8.7 cm). In another study, Taheri
and Karimi [83] noticed that the walking velocity with
3R15 knee joint (30.04 ± 0.38 m/min) was less than that of
3R20 (66.081 ± 3 m/min) and showed statistical differences
(P = 0.045). The stride length with 3R15 was 28.8 ± 14.4 m
compared to 46.35 ± 18.3 m for 3R20 (P = 0.045). The per-
centage of stance phase was 65.4 ± 5 for 3R15 and 35.9 ± 7
for 3R20. Farahmand et al. [88] found no significant dif-
ference in spatio-temporal parameters between the intact
and prosthetic limbs of amputees. There were significant
differences in stride length, step length, stepping speed and
step duration of the normal subjects and amputees. The hip
joint of the prosthetic limb of the amputees experienced
lower than normal joint moments (with a maximum value
of 0.97 compared to 1.67 Nm/Kg). Some studies [80, 82,
85] compared polycentric knee with MPK and found mixed
results. Uchytil et al. [80] observed better gait symmetry in
bionic knee compared to mechanically passive knee joint.
The stance and the swing times for amputees with a bionic
knee were similar to those of non-amputees. The swing
time of the prosthetic limb in patients fitted with a mechani-
cally passive knee was longer by 0.042 s (effect size = 2.1)
and the stance time of the non-affected limb was longer by
0.047 s (effect size = 1.07). Barr et al. [82] compared three
knee/foot combinations and observed that maximum brak-
ing force when using the C-leg was 0.31 body weight units
vs. 0.19 and 0.20 for the other two prostheses. On the intact
limb the mean step length progressively increased (55.1;
66.6; 73.2 cm) across the three combinations. The improved
step length was corroborated by progressively greater mean
walking velocity (97.3; 99.7; 112.5 m/sec) and a progressive
decrease in the intact limb initial double support time (14.2;
12.3; 10.5% cycle). Yokogushi et al. [88] had designed an
intelligent based knee with hydraulic and polycentric mecha-
nism and found no significant variation in individuals in
the different cadences and same was noticed in the able
bodied subjects. Some hybrid prosthetic knee incorporating
polycentric with pneumatic or hydraulic control has been
successfully studied [84, 86, 89]. Lythgo et al. [84] found
no significant differences in gait parameters and symmetry.
However, large asymmetries remained across the prostheses
for the temporal measures of step time (20%), single support
(30%), and stance time (19%). Gait speed was 5 cm/s less
with 3R92 than with 3R90 knee joint (P = 0.017). The results
of Sapin et al. [86] revealed that the plantar flexion of the
13
Physical and Engineering Sciences in Medicine
ankle enabled by the hydra-cadence knee seems to increase
stability. No significant difference was found between hydra-
cadence and other mechanical prosthetic knee in terms of
walking speed (1.0 + 0.2 m/s and 1.1 + 0.2 m/s, respectively;
p = 0.54).
In contrast, B-level study by Isakov et al. [91] showed
that hydraulic knee with a locked mechanism may help dys-
vascular subjects to achieve increased velocity compared to
an unlocked unit. Mixed results were also obtained for com-
parative studies on fluid and mechanical friction knee units.
Murray et al. [92] found that hydraulic knee enable the user
to walk with better velocity and improved balance of swing
and stance time. In another study, Jergesen et al. [90] used
newly designed polycentric knee of California Biomechan-
ics Laboratory (UCBL) and observed increased knee flex-
ion afforded by the mechanism and no significant change in
various fundamental gait parameters. The findings of above
contrast studies should be analyzed carefully because their
study sample were older and vascular compared to the stud-
ies of Boonstra et al. [74, 73] and Heller et al. [93] with
active adult groups.
Discussion
Polycentric four or six bar mechanisms have been utilized
successfully to enhance function in rehabilitation of ampu-
tees in developed and developing countries. FEA is carried
out to optimize and validate each step of a prosthetic com-
ponent design including its quality, performance and safety.
Displacement, strain, and stress of the components under
internal and external loads are calculated using the displace-
ment formula of the FEM [94]. FEA and Taguchi method
was shown to be an effective method in optimizing the struc-
tural design of prostheses. Further prosthetic design can be
facilitated based on the degree of importance of the design
factors on the structural behavior of the prosthesis. Design-
ing and synthesis of a knee mechanism for a desired motion
is being done using optimization. The changing parameters
must be observed and regional constraints are applied such
that the final mechanism conforms to them.
Gait analysis of amputees is commonly used clinical
tool to quantify the performance of polycentric knee joints.
From the review of clinical applications of prosthetic knees,
it can be concluded that a prosthesis with fluid controlled
mechanism is better than simple mechanical based friction
devices like polycentric knee in terms of better swing con-
trol, cadence responsiveness and gait symmetry for active
adult population [92, 93]. In contrast, geriatric and/or vas-
cular patients can be benefited much using knee units incor-
porating stance stability such as manual lock and weight
activated friction brake knees and are poor candidates to be
fitted with polycentric designs [91]. Due to less supportive
 Table 4  Clinical applications and findings on prosthetic knee
Study
Kaufman et al. (2018) [70]
Theeven et al. (2012) [71]
Kaufman et al. (2012) [72]
Boonstra et al. (1996) [74]
Boonstra et al. (1995) [73]
Arun et al. (2019) [75]
Arelekattiet al. (2018) [76]
Dumas et al. (2017) [77]
Ramakrishnan et al. (2017) [78]
Loncaric et al. (2016) [79]
Uchytil et al. (2013) [80]
Sensinger et al. (2013) [81]
Barr et al. (2012) [82]
Taheri and Karimi (2012) [83]
Lythgo et al. (2010) [84]
Gerzeli et al. (2009) [85]
Sapin et al. (2008) [86]
Farahmand et al. (2006) [87]
13
Intervention Subjects (N) Outcome Level of
evidence
Non MPK (74% were polycentric) vs. MPK 50 TF Reduction in falls, increased activity and satisfaction in the A
MPK for low mobility subjects
Mechanical vs. MPK 30 TF or KD Participants’ perceptions were significantly higher in the A
MPK compared to mechanical
Passive mechanical knee joint vs. MPK 15 TF and 20 AB MPK resulted in improved gait symmetry and joint kinetics A
Mechanical (Ottobock) vs. pneumatic (Tehlin) swing phase 28 TF In Tehlin Knee, normal and fast walking is easier, duration of A
control swing and stride time improved
Mechanical swing phase control (Otto Bock) and pneumatic 28 TF Six preferred Otto Bock knee and nineteen preferred Tehlin. A
swing phase control (Tehlin knee) Flexing Tehlin knee was easy giving unsafe feeling but
Physical and Engineering Sciences in Medicine
walking was more easy and faster
Polymeric based passive polycentric Knee 3 TF Health related quality of life and global score of prosthetic B
function improved
Passive mechanical knee with automatic lock-unlock mecha- 4 TF Enabled early stance lock and smooth stance to swing transi- B
nism tion
Total Knee 2000 (polycentric knee with a 3-phase swing 10 TF No significant differences in joint moments and joint forces B
control) Vs. Mauch Knee (Single axis swing control) Vs. during stance and swing
C-Leg MPK
Total Knee 2000 Vs. 3D Printed ASPK with weight-actuated 1 TF The ASPK had higher peak knee flexion resulting in exhaust B
lock and cross-linked four-bar spring mechanism walking for compensatory mechanism
Single axis Vs. Polycentric Knee 15 TF Polycentric knee module for people with trans-femoral ampu- B
tation allows better control of balance and speed as well as
greater mobility
Bionic Vs. mechanically passive knee joints 8 TF Bionic knee provided gait symmetry with stance and swing B
time similar to those of able bodied
Single axis vs. Four bar knees 10 TF Four-bar knees provide greater swing clearance than single- B
axis knees
Knee/foot pairs: Four Bar knee & Dynamic Response foot 1 TF Braking action, stability and gait speed improved in C-Leg. B
(Endolite); Total Knee 2000 & Pathfinder I foot (Ossur); and Progressive change observed across all combinations includ-
C-Leg & IC40 C-walk foot (Ottobock) ing increased step length and gait speed, and decreased
double limb support time
Mechanical Knee (Polycentric Four bar Vs. Single axis). i.e. 7 TF The symmetry and speed of walking with 3R20 was more than B
3R 20 Vs. 3R 15 that with 3R15
Mechanical Passive Knee (3R 90 Vs 3R 92) 5 TF Gait and symmetry measures were unchanged B
MPK (C-Leg) vs. mechanical polycentric 100 TF C-leg improved health and quality of life B
Hydracadence Knee vs. other prosthetic knees 11 TF Hydracadence knee offered increased stability. No difference B
in swing hip and knee kinematics observed for both varieties
Mechanical Knee (3R 15—single axis, 3R 20—polycentric, 5 TF and 5 AB The stride length, step length and stepping speed were signifi- B
3R 21—polycentric) cantly higher and the step duration was significantly lower
for normal subjects in comparison with the prosthetic and
sound limbs of the amputees (P < 0:05)
 Physical and Engineering Sciences in Medicine

clinical evidences, it is difficult to interpret to what extent

evidence
Level of MPK prosthetic knees be prescribed in terms of its practical
usefulness. Hence, subject specific considerations on activity

B
B

B
B

B
level and functional requirements should ultimately deter-

found to be an advantage. There was no significant change in

Six bar linkage knee ankle mechanism provided normal squat-
ting pattern, knee moments and knee angle variations during

stride length and walking speed was observed with Hydrau-

The increase in knee flexion afforded by the mechanism was
mine the choice and prescription of the prosthetic knee from

During self-selected and fast walking, increase in cadence,

available options [95].

With locked knee an increase in velocity and heart rate

Some active polycentric knees were developed to control
gait motions using machine learning and control algorithms.
Xu et al. [96] proposed novel four-bar linkage polycentric
Provided stable walking at different cadences

various fundamental gait parameters prosthetic knee based on magneto-rheological (MR) effect.
The driving equation of the MR damper is established and

TF persons with transfemoral amputations, AB able-bodied controls, KD persons with knee disarticulation amputation, MPK microprocessor controlled knee
control algorithm was developed. The results showed that
with the controlled currents by the control algorithm devel-
oped, the knee prosthesis was able to track the motions well
and imitated the natural motions of anatomic knee. Attia
et al. [97] introduced a dynamic model of a four bar mecha-
nism connected by a MR damper to control the motions of
swing phase

daily activities of amputees. A clipped-optimal control algo-

observed

lic Knee
Outcome

rithm was used based on acceleration feedback, along with

MR damper to approximately generate the desired control
force. The model results represent the voltage required for
the MR damper during most daily activities and the results
3 TF and 10 AB

showed that the required voltage depends on displacement,

Subjects (N)

velocity and calculated force. Torres et al. [98] presented

20 TF

17 TF

the design and analysis of active polycentric transfemoral

7 TF
1 TF

knee prosthesis to mimic the human gait. An echo-control

strategy has been proposed for the activation of the knee
Four-bar polycentric prosthetic knee linkage developed by the
University of California Biomechanics Laboratory (UCBL)
Intelligent based knee with hydraulic and polycentric mecha-

prosthesis. The experimental results demonstrated that the

proposed prosthesis was able to bio-mimic the biomechanics
Patil and Chakraborty (1991) [89] Polycentric Knee with Pneumatic swing phase control

of a natural knee during gait and to provide extra power to

the transfemoral amputee during walking. The results have
Hydraulic vs. mechanical constant friction knee

also shown that the minimization of “autonomous intelli-

gence” in an actuated prosthesis, in combination with the
Open-knee vs. locked-knee mechanism

close observation of the user, allowed the incorporation of

the human’s superior control in a cooperative and intuitive
way.

Implications of review

India alone accounts more than 230,000 trans-femoral

Intervention

amputees out of an estimated number of 6.7 million found

in Asia [76]. Prosthetic knees used in developing countries
nism

are mostly passive in nature to meet the huge demand and for
enabling the subjects with trans-femoral amputation achieve
normal kinematics during gait and other ADLs. Polycentric
prosthetic knees with four and six bar mechanisms can be
Yokogushi et al. (2004) [88]

Jergesen et al. (1986) [90]

utilized successfully to enhance stance stability and swing

Murray et al. (1983) [92]
Isakov et al. (1985) [91]

kinematics in developed countries. However, increased

Table 4  (continued)

complexity, cost, associated repair, maintenance and low

strength make these units less appropriate for use in develop-
ing countries for people of all ages [99, 100, 11]. The appli-
cation of polycentric prosthetic knee mechanisms made of
Study

steel or duraluminium is preferred whereas use of titanium

13
Physical and Engineering Sciences in Medicine
or carbon, can make it lighter, but are more expensive [43].
Well-designed polycentric knees focusing on patients’ clini-
cal requirement in daily context could be more effective than
those studied in review.
Summary of evidences
FEA in integration with Taguchi method is carried out to
optimize and validate each step of a prosthetic component
design including its quality, performance and safety in order
to obtain a knee mechanism for a desired motion [94]. Addi-
tionally variations of knee designs can be encouraged based
on the degree of importance of the design variables on the
performance parameters (structural strength) of the prosthe-
sis. Though there are well designed studies on technologi-
cal development of prosthetic knees, clinical researches are
scarce [101]. Majority of clinical studies on human motion
using prosthetic knees have used standardized gait assess-
ment protocols. Gait analysis of amputees using the pros-
thetic knee design is also needed to validate experimental
result [102].
Conclusion
This is the first systematic review that has investigated the
technical and clinical application of polycentric prosthetic
knee for trans-femoral and knee disarticulation amputation.
This systematic review addressed 43 articles. The results
reveal that different types of polycentric prosthetic knee
joints have been synthesised globally in last fifteen years but
there has been equivocacy over prescription criteria, design
parameters, kinematic performance of its various designs
and counterparts. Polycentric knees have a variety of geom-
etries but the methods for comparing their performances
are rare. Currently computer aided engineering assists in
proper selection and design of polycentric knee joints with
better performance, quality and safety. The data of structural
analysis using FEA are validated with experimental results
for determining the model accuracy. Gait analysis of trans-
femoral amputation using the prosthetic knee components
provides a valid tool to correlate the experimental results.
Machine learning technique and control algorithm provide a
new tuning system capable of modifying control parameters
that govern prosthesis dynamics during bipedal gait cycle.
Still further research is needed to develop and implement
standardized measures on prosthetic knee joints for their
effective use, function, durability and cost effectiveness.
Funding:  This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Compliance with ethical standards 
Conflict of interest:  The authors declare that there is no conflict of in-
terest regarding the publication of this article.
Ethical approval:  Not required.
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