Beyond the basics

Dr. Amna Haider

Special consideration with children
• There are many factors to consider when deciding on prosthetic
treatment for the pediatric candidate. Socket fit is fundamentally
important in the overall fit and function of the prosthesis. If the
socket is comfortable and well fitting, the patient should benefit from
the functionality it is intended to provide. If it is uncomfortable, the
child will reject prosthetic wear. The prosthetist’s expertise will ensure
a properly fitted socket. Some common considerations specific to the
pediatric population in the prosthetic treatment design discussed in
this chapter include frequency of adjustments and replacements,
family involvement, residual limb length, bony overgrowth, alignment,
activity-specific prostheses, and component size.
• Due to growth and higher physical demands of pediatric patients,
more frequent adjustments and replacements should be expected
compared with adults. Typically, a pediatric prosthetic socket should
last 1 year, but this can vary depending on growth spurts and activity
level.4 An endoskeletal prosthesis is designed with some
postfabrication adjustability to allow for adjustments of the prosthesis
and replacement of components (e.g., foot, terminal device, or
socket) as needed. Components can be changed to accommodate
growth, activity levels, and functional demands of the pediatric
• Residual Limb Length
• The length of the residual limb affects the control of the prosthesis and
design selection. Typically, the longer the limb, the more control the patient
has of the prosthesis due to the longer lever arm. A very long or very short
limb results in limited component and design options. With disarticulation,
the pediatric patient preserves growth plates, retains weight-bearing
capability, and avoids bony overgrowth.1,5,6 However, because the
disarticulation is through the joint, aesthetics can be a challenge when
trying to match the intact side. For example, a knee disarticulation
prosthesis will have better control than a short transfemoral prosthesis, but
the prosthetic knee center will be lower than the sound-side knee center.
• Family Involvement
• Family commitment begins with understanding and acceptance of the
condition, prognosis, and treatment recommendations. When the
patient is very young, the prosthetic treatment plan is decided by the
family or caretakers. With age, the child should be more involved in
decisions about prosthetic design and treatment. In addition, the very
young child will require assistance with donning and doffing, which
should progress to independent donning and doffing.
• Bony Overgrowth
• Bony overgrowth or periosteal overgrowth results from transdiaphyseal
amputations3 and is most frequent at the humerus and then the fibula,
tibia, and femur4 To avoid bony overgrowth, it is preferable to perform
joint disarticulation. This also preserves the growth plate.5 When the
soft tissue is unable to grow at the same rate as the underlying bone,
the result is painful overgrowth at the distal end, and this frequently
results in an inability to wear the prosthesis due to pain and
discomfort. A bursa is a good indication of a bony overgrowth
developing.3 Most often surgical intervention is indicated to reduce the
pain associated with the overgrowth.5
• Alignment
• The prosthetist will properly align the prosthesis for maximum comfort and functional
capabilities.. Many congenital limb deficiencies have varying angular deformities that
must be accommodated in prosthetic design, which can come at the expense of
aesthetics.3 Alignment of the lower extremity prosthesis should match that of a normal
child’s gait and weight-bearing alignment. For example, an infant typically walks with
wide-based gait and flexed at the hips and knees, and therefore, the prosthesis should
be aligned similarly.6
• Activity-Specific Prostheses
• While the standard prosthesis is typically used for everyday activities of daily living
(ADLs), school activities, and around the home and community, activity-specific devices
are designed for a single intended activity. Some examples include a running or
swimming prosthesis, neither of which is able to be used for everyday walking. For the
upper extremities, such prostheses can be designed with a variety of terminal devices
for a gymnastics arm or a violin-playing arm, among many other options.
• Component Sizes and Options
• Fewer component options are available to the pediatric population than to the adult
population. Goals and expectations should be discussed with the family and prosthetist
to determine appropriate component selection for the child’s functional level, age, and
• Passive Prostheses
• For the very young child, a passive prosthesis can aid in achieving early
milestones such as sitting by using the prosthesis as a prop for balance or
crawling by using the prosthesis to help.7 As the child grows, a passive
prostheses can continue to be used as a lightweight option for cosmetic
reasons.
• Suspension
• Much like the adult counterpart, traditional harnessing, self-suspending
socket designs, and gel sleeves provide good upper extremity suspension
options. Self-suspension frequently eliminates the need for harnessing but
may require the use of a pull sock.
• Terminal Devices
• TDs can be passive, electric, voluntary opening, or voluntary closing. Voluntary opening
designs for the pediatric population include a hook, or mechanical hands. Although the
glove that goes over the mechanical hand can improve aesthetics, it requires more force
from the child to operate the device and adds to the overall weight.The electric hand
does not require the same force to operate but comes with added weight. Electronic
pediatric hands are categorized in one of two grasp patterns through adolescence—
palmar prehension (hands) and oppositional grasp (Electrohand by Ottobock)—but they
are only available in palmar prehension into adulthood.7
• Myoelectric
• The externally powered prosthesis should begin with single-site activation and progress
to dual-site activation as the child exhibits cognitive capabilities and site control. An
example of single-site activation includes voluntary opening and automatic closing. The
myoelectric components add weight and bulk due to a heavier electric hand and the
addition of sensors and a battery to the design. However, the externally powered devices
eliminate cabling and add aesthetic value. Electric elbows are available to the school age
child, like the VASI 8-12 elbow by Liberating Technologies, which is an example of an
electric elbow available to children and preteens.7 Consulting with the local prosthetist is
important to understand what components are available and best suited to the patient.
Adaptive prosthesis for recreation
Future prosthetic advances
and challenges
• Strengths of bionic limbs
• Promising life-changing benefits of bionic limbs showed by long-term
efficacy studies are compelling for patients. The direct attachment of
the prosthesis through an osseointegrated implant has immediate
benefits. It eliminates all typical burden associated with a socket,
particularly the residuum’s skin problems. It eases attachment and
removal of the prosthesis. It also provides a much more comfortable
sitting position and allows a much larger range of movements.
• Weaknesses of bionic limbs
• Occurrence and severity of adverse events with bone-anchored bionic
prostheses are yet to be fully resolved. Bionic limbs can potentially
cause issues with implant stability, bone fracture, breakage of the
implant parts and infection. All these adverse events have several
common negative effects. They cause pain. They significantly disturb
the lifestyle because they limit usage of the prosthesis for prolonged
duration. They also cost money paid either by the healthcare system
or the users themselves as out-of-pocket expenses.
• Features of the diagnostic device
• Different sensors assess the mechanical constraints applied by the bone-
anchored bionics on the residuum and measure the resulting movements of
the tissues (bone, muscle, tendon, fat, skin) within the residuum. The back
end the device consists of the software integrating all this information into a
personalised digital twin of the residuum. Basically, the digital twin of the
residuum is a virtual replica living inside the computer. It corresponds to the
high-fidelity physics-based model of the different tissues constituting the
residuum. The front end of the device consists of a handheld device (such as a
smartphone) that provides a visual animation of the model in real time so
that patients and clinicians equipped with the device and see can how
movements impact the inside of the body.
• Improving rehabilitation for patients
• The diagnostic device provides a radically new and empowering
experience for patients. It can help them monitor how their loading
positions stimulate specific zones of the implant in real time using a
friendly-user interface and guide them to adopt pain-free positions.
By improving stability, it can reduce risks of loosening, fractures and
infections. It can also allow patients to better inform clinicians about
how a treatment or intervention feels. Altogether, this new approach
can increase the quality of life of individuals suffering from limb loss.
Future surgical and educational
advances and challenges
• Traditionally, EMG signals have been recorded by surface electrodes,
which have the advantage of being non-invasive. However, several
factors may degrade EMG signals interpreted by surface electrodes
and consequently interfere with limb function. These include
anatomic factors such as excessive adipose tissue or a compromised
soft tissue envelope; physical factors that compromise the muscle-
prosthesis interface such as sweat pooling under the device, a change
in limb position, or motion; and “cross talk” between adjacent
muscles [18]. As a result, there has been substantial research into
devices that address communication challenges between the patient
and their prosthetic.
• The investigators implanted four electrodes in the forearm of an adult
volunteer using a 10 mm skin incision. With this approach, the
implants are constructed of two disks connected by a stem and are
designed to provide more reliable muscle signal detection than
traditional surface-based electrodes. One disk is located on the skin
surface while the other rests deep to the dermis; the stem traverses
the skin. The implants have superior electrical properties and less
mechanical interference than current surface-based electrodes. The
authors concluded these novel electrodes could serve as an interface
for myoelectric control in prostheses while surpassing many
drawbacks of traditional surface electrodes.
• Surgical Innovations
• Several recent surgical innovations have improved the functionality of myoelectric prostheses.
• Targeted muscle reinnervation (TMR) is a surgical procedure that gives traumatically or surgically
transected nerves a new motor target. The procedure has dual advantages: preventing or treating
painful neuromas and improving myoelectric prosthesis functionality. By giving the transected
nerve “somewhere to go and something to do,” it regenerates in an organized fashion and is less
likely to develop a painful neuroma After TMR, muscle reinnervated by the transected nerve
produces EMG signals and becomes a myosite, a signal for a myoelectric prosthesis. In this way, a
patient can intuitively control the prosthesis through activation of muscular targets whose identity
and function have been “reassigned” to that of its new motor nerves TMR was first developed
among patients with shoulder disarticulations and above-elbow amputations. However, this
powerful procedure is now being used among patients with transradial, transfemoral, and
transtibial amputations to optimize myoelectric prosthesis functionality (in the upper extremity)
and to prevent and treat painful neuromas (in the upper and lower extremities) [
Restoring sensations
• Many sensory implants are undergoing research and development. These
range from implants placed on or within peripheral nerves to those that
directly stimulate the somatosensory cortex. Cuff electrodes (surgically
implanted electrodes that are wrapped around a peripheral nerve) preserve
nerve integrity, have been used on human subjects in multiple studies, and
have shown long-term stability but lack the high selectivity of more invasive
electrodes
• New implantation techniques including syringe injection (as opposed to
surgical implantation) are under development as new materials and smaller
devices are refined. Some implants, including the USEA, have been able to
simultaneously provide both sensation (light touch and proprioception) and
motor control of prostheses
• Osseointegration
• Osseointegration, or the stable integration of implants into bone, was originally
investigated by Swedish dentist Per-Ingvar Brånemark and was further developed by his
son, Rickard Brånemark. Osseointegrated prostheses such as Brånemark’s Osseoanchored
Prostheses for the Rehabilitation of Amputees (OPRA) device (Integrum, Sweden), the
Compress Transcutaneous Implant) have an intramedullary component connected to a
percutaneous fixture to which the prosthetic limb is attached. Osseointegration addresses
or circumvents many of the complications of and restrictions inherent to socket-based
prostheses, particularly among patients with compromised soft tissue envelopes (e.g.,
decreased tissue compliance, history of skin grafting, persistent ulcerations or wounds,
underlying heterotopic bone, painful neuromas) or a short residual limb. It also eliminates
issues related to socket fit and signal transduction between the myosites and the
electrodes, improving the efficiency of these devices.
• Advanced Rehabilitation: Augmented and Virtual Reality
• Rehabilitation physicians, therapists, and prosthetists have begun to
employ augmented and virtual reality platforms to optimize
prosthesis design, incorporation, and use. On the design side, the
development of a virtual limb prosthesis has been used to test
devices prior to their construction in a virtual reality environment.
The authors describe virtual prostheses as highly versatile and
applicable to multiple rehabilitative situations, to include simulation
of prosthetics prior to production.
•Thank you
•best of luck 