Interface load analysis for computer-aided design of below-knee prosthetic sockets

Effects of Prosthetic Socket Design on Residual Femur Motion Using Dynamic Stereo X-Ray - A Preliminary Analysis

Individuals with transfemoral amputation experience relative motion between their residual limb and prosthetic socket, which can cause inefficient dynamic load transmission and secondary comorbidities that limit mobility. Accurately measuring the relative position and orientation of the residual limb relative to the prosthetic socket during dynamic activities can provide great insight into the complex mechanics of the socket/limb interface. Five participants with transfemoral amputation were recruited for this study. All participants had a well-fitting, ischial containment socket and were also fit with a compression/release stabilization socket. Participants underwent an 8-wk, randomized crossover trial to compare differences between socket types. Dynamic stereo x-ray was used to quantify three-dimensional residual bone kinematics relative to the prosthetic socket during treadmill walking at self-selected speed. Comfort, satisfaction, and utility were also assessed. There were no significant differences in relative femur kinematics between socket types in the three rotational degrees of freedom, as well as anterior-posterior and medial-lateral translation (p > 0.05). The ischial containment socket demonstrated significantly less proximal-distal translation (pistoning) of the femur compared to the compression/release stabilization socket during the gait cycle (p < 0.05), suggesting that the compression/release stabilization socket provided less control of the residual femur during distal translation. No significant differences in comfort and utility were found between socket types (p > 0.05). The quantitative, dynamic analytical tools used in the study were sensitive to distinguish differences in three-dimensional residual femur motion between two socket types, which can serve as a platform for future comparative effectiveness studies of socket technology.

Developing an Analogue Residual Limb for Comparative DVC Analysis of Transtibial Prosthetic Socket Designs

Personalised prosthetic sockets are fabricated by expert clinicians in a skill- and experience-based process, with research providing tools to support evidence-based practice. We propose that digital volume correlation (DVC) may offer a deeper understanding of load transfer from prosthetic sockets into the residual limb, and tissue injury risk. This study’s aim was to develop a transtibial amputated limb analogue for volumetric strain estimation using DVC, evaluating its ability to distinguish between socket designs. A soft tissue analogue material was developed, comprising silicone elastomer and sand particles as fiducial markers for image correlation. The material was cast to form an analogue residual limb informed by an MRI scan of a person with transtibial amputation, for whom two polymer check sockets were produced by an expert prosthetist. The model was micro-CT scanned according to (i) an unloaded noise study protocol and (ii) a case study comparison between the two socket designs, loaded to represent two-legged stance. The scans were reconstructed to give 108 µm voxels. The DVC noise study indicated a 64 vx subvolume and 50% overlap, giving better than 0.32% strain sensitivity, and ~3.5 mm spatial resolution of strain. Strain fields induced by the loaded sockets indicated tensile, compressive and shear strain magnitudes in the order of 10%, with a high signal:noise ratio enabling distinction between the two socket designs. DVC may not be applicable for socket design in the clinical setting, but does offer critical 3D strain information from which existing in vitro and in silico tools can be compared and validated to support the design and manufacture of prosthetic sockets, and enhance the biomechanical understanding of the load transfer between the limb and the prosthesis.

Analysis of Pressure Distribution in Transfemoral Prosthetic Socket for Prefabrication Evaluation via the Finite Element Method

In this study, we estimated and validated the pressure distribution profile between the residuum and two types of prosthetic sockets for transfemoral amputees by utilizing a finite element analysis. Correct shaping of the socket for an appropriate load distribution is a critical process in the design of lower-limb prosthesis sockets. The pressure distribution profile provides an understanding of the relationship between the socket design and the level of subject comfortability. Estimating the pressure profile is important, as it helps improve the prosthesis through an evaluation of the socket design before it undergoes the fabrication process. This study focused on utilizing a magnetic resonance imaging (MRI)-based three-dimensional (3D) model inside a predetermined finite element simulation. The simulation was predetermined by mimicking the actual socket-fitting environment. The results showed that the potential MRI-based 3D model simulation could be used as an estimation tool for a pressure distribution profile due to the high correlation coefficient value (R² > 0.8) calculated when the pressure profiles were compared to the experiment data. The simulation also showed that the pressure distribution in the proximal area was higher (~30%) than in the distal area of the prosthetic socket for every subject. The results of this study will be of tremendous interest for fabricators through the use of a finite element model as an alternative method for the prefabrication and evaluation of prosthetic sockets. In future prosthetic socket fabrications, less intervention will be required in the development of a socket, and the participation of the subject in the socket-fitting session will not be necessary. The results suggest that this study will contribute to expanding the development of an overall prefabrication evaluation system to allow healthcare providers and engineers to simulate the fit and comfort of transfemoral prosthetics.

Effect of Local Neck Anatomy on Localized One-Dimensional Measurements of Arterial Stiffness: A Finite-Element Model Study

Cardiovascular diseases (CVD) are the most prevalent cause of death in the Western World, and their prevalence is only expected to rise. Several screening modalities aim at detecting CVD at the early stages. A common target for early screening is common carotid artery (CCA) stiffness, as reflected in the pulse wave velocity (PWV). For assessing the CCA stiffness using ultrasound (US), one-dimensional (1D) measurements along the CCA axis are typically used, ignoring possible boundary conditions of neck anatomy and the US probe itself. In this study, the effect of stresses and deformations induced by the US probe, and the effect of anatomy surrounding CCA on a simulated 1D stiffness measurement (PWVus) is compared with the ground truth stiffness (PWVgt) in 60 finite-element models (FEM) derived from anatomical computed tomography (CT) scans of ten healthy male volunteers. Based on prior knowledge from the literature, and from results in this study, we conclude that it is safe to approximate arterial stiffness using 1D measurements of compliance or pulse wave velocity, regardless of boundary conditions emerging from the anatomy or from the measurement procedure.

A bio-inspired platform to modulate myogenic differentiation of human mesenchymal stem cells through focal adhesion regulation

The use of human mesenchymal stem cells (hMSCs) in cardiac-tissue engineering has gained widespread attention and many reports have shown that matrix compliance, micro/nano-patterns could be some of the important biophysical cues that drive hMSCs differentiation. Regardless of the type of biophysical induction cues, cells mainly explore their environment via focal adhesion (FA) and FA plays an important role in many cellular behaviours. Therefore, it is hypothesized that FA modulation through materials manipulation could be an important cue for modulation that would result in the stem cell lineage commitment. In this work, the FA of hMSCs is modulated by a novel microcontact printing method using polyvinyl alcohol as a trans-print media which can successfully print proteins on soft polydimethylsiloxane (PDMS). The FA is successfully modified into dense FA and elongated FA by micropatterning square and rectangular patterns on 12.6 kPa PDMS respectively. Additionally, the combined effects of stiffness of PDMS substrates (hard (308 kPa), intermediate (12.6 kPa)) and FA patterning on hMSCs differentiation are studied. The results indicate that dense FA does not induce myogenesis while elongated FA can promote cytoskeleton alignment and further myogenesis on PDMS with intermediate stiffness of 12.6 kPa. However, on stiff substrate (308 kPa), with or without patterns, the cytoskeleton alignment and myogenesis are not obvious. This demonstrates for the first time that it is possible to induce the differentiation of hMSCs by regulating the FA using a materials platform even in the absence of any biochemical factors. It also shows that there is a synergistic effect between FA regulation and matrix stiffness that results in a more specific and higher up-regulated myogenesis. This platform presents a new chemical/biological-free method to engineer the myogenic differentiation of hMSCs.

INTERFACE PRESSURE AND GAIT ANALYSIS IN DIFFERENT WALKING SPEEDS AND ON THE BELOW-KNEE AMPUTEES WITH MULTIPLE AXIS PROSTHETIC FOOT PROSTHESIS

Interface stresses are an important consideration in stump and socket for a prosthetic limb to a person with transtibial amputation. During stance phase of the gait cycle, the prosthetic socket is expected to support and distribute the entire body weight of the patient. Excessive stresses between stump and socket will induce pain, discomfort and breakdown of soft tissues. The objectives of this study are to investigate the differences of gait, the maximum forces and pressures between stump and socket during different walking speed. Motion analysis system was applied to investigate the kinematics and kinetics of the gait and the Pedar system was used to measure the maximum forces and pressures between stump and socket during different walking speeds. Fifteen male subjects with transtibial amputation were collected in this research. These subjects were required to walk in three different speeds (85 steps/min, 95 steps/min, 115 steps/min). The maximum force, pressure and forcetime integrals in head of fibula, patellar ligament, medial condyle of tibia, tibial end and fibular end were recorded. The results showed that, the range of motion and the moment in hip, knee and ankle joint increased as the walking speed. Maximum forces and pressures in the measured areas had no significant difference in multiple axis prosthetic foot when the walking speed increased. The distributions of the force-time integrals were the same when compared with maximum force and the pain scale of subjects' subjective feeling. Walking speed would not influence the maximum force and pressure when subjects were in single axis prosthetic foot. This study provided the objective and subjective data for prosthetist or physician when applied on amputees.

Biomechanics of Pressure Ulcer in Body Tissues Interacting with External Forces during Locomotion

Forces acting on the body via various external surfaces during locomotion are needed to support the body under gravity, control posture, and overcome inertia. Examples include the forces acting on the body via the seating surfaces during wheelchair propulsion, the forces acting on the plantar foot tissues via the insole during gait, and the forces acting on the residual-limb tissues via the prosthetic socket during various movement activities. Excessive exposure to unwarranted stresses at the body-support interfaces could lead to tissue breakdowns commonly known as pressure ulcers, often presented as deep-tissue injuries around bony prominences or as surface damage on the skin. In this article, we review the literature that describes how the involved tissues respond to epidermal loading, taking into account both experimental and computational findings from in vivo and in vitro studies. In particular, we discuss related literature about internal tissue deformation and stresses, microcirculatory responses, and histological, cellular, and molecular observations.

Internal mechanical conditions in the soft tissues of a residual limb of a trans-tibial amputee

Most trans-tibial amputation (TTA) patients use a prosthesis to retain upright mobility capabilities. Unfortunately, interaction between the residual limb and the prosthetic socket causes elevated internal strains and stresses in the muscle and fat tissues in the residual limb, which may lead to deep tissue injury (DTI) and other complications. Presently, there is paucity of information on the mechanical conditions in the TTA residual limb during load-bearing. Accordingly, our aim was to characterize the mechanical conditions in the muscle flap of the residual limb of a TTA patient after donning the prosthetic socket and during load-bearing. Knowledge of internal mechanical conditions in the muscle flap can be used to identify the risk for DTI and improve the fitting of the prosthesis. We used a patient-specific modelling approach which involved an MRI scan, interface pressure measurements between the residual limb and the socket of the prosthesis and three-dimensional non-linear large-deformation finite-element (FE) modelling to quantify internal soft tissue strains and stresses in a female TTA patient during static load-bearing. Movement of the truncated tibia and fibula during load-bearing was measured by means of MRI and used as displacement boundary conditions for the FE model. Subsequently, we calculated the internal strains, strain energy density (SED) and stresses in the muscle flap under the truncated bones. Internal strains under the tibia peaked at 85%, 129% and 106% for compression, tension and shear strains, respectively. Internal strains under the fibula peaked at substantially lower values, that is, 19%, 22% and 19% for compression, tension and shear strains, respectively. Strain energy density peaked at the tibial end (104kJ/m(3)). The von Mises stresses peaked at 215kPa around the distal end of the tibia. Stresses under the fibula were at least one order of magnitude lower than the stresses under the tibia. We surmise that our present patient-specific modelling method is an important tool in understanding the etiology of DTI in the residual limbs of TTA patients.

Using computational simulation to aid in the prediction of socket fit: A preliminary study

This study illustrates the use of computational analysis to predict prosthetic socket fit. A simple indentation test is performed by applying force to the residual limb of a trans-tibial amputee through an indenter until the subject perceives the onset of pain. Computational finite element (FE) analysis is then applied to evaluate the magnitude of pressure underlying the indenter that initiates pain (pain threshold pressure), and the pressure at the prosthetic socket-residual limb interface. The assessment of socket fit is examined by studying whether or not the socket-limb interface pressure exceeds the pain threshold pressure of the limb. Based on the computer-aided assessment, a new prosthetic socket is then fabricated and fitted to the amputee subject. Successful socket fit is achieved at the end of this process. The approach of using computational analysis to aid in assessing socket fit allows a more efficient evaluation and re-design of the socket even before the actual fabrication and fitting of the prosthetic socket. However, more thorough investigations are required before this approach can be widely used. A subsequent part of this paper discusses the limitations and suggests future research directions in this area.

Real-time patient-specific finite element analysis of internal stresses in the soft tissues of a residual limb: a new tool for prosthetic fitting

Fitting of a prosthetic socket is a critical stage in the process of rehabilitation of a trans-tibial amputation (TTA) patient, since a misfit may cause pressure ulcers or a deep tissue injury (DTI: necrosis of the muscle flap under intact skin) in the residual limb. To date, prosthetic fitting typically depends on the subjective skills of the prosthetist, and is not supported by biomedical instrumentation that allows evaluation of the quality of fitting. Specifically, no technology is presently available to provide real-time continuous information on the internal distribution of mechanical stresses in the residual limb during fitting of the prosthesis, or while using it and this severely limits patient evaluations. In this study, a simplified yet clinically oriented patient-specific finite element (FE) model of the residual limb was developed for real-time stress analysis. For this purpose we employed a custom-made FE code that continuously calculates internal stresses in the residual limb, based on boundary conditions acquired in real-time from force sensors, located at the limb-prosthesis interface. Validation of the modeling system was accomplished by means of a synthetic phantom of the residual limb, which allowed simultaneous measurements of interface pressures and internal stresses. Human studies were conducted subsequently in five TTA patients. The dimensions of bones and soft tissues were obtained from X-rays of the residual limb of each patient. An indentation test was performed in order to obtain the effective elastic modulus of the soft tissues of the residual limb. Seven force sensors were placed between the residual limb and the prosthetic liner, and subjects walked on a treadmill during analysis. Generally, stresses under the shinbones were approximately threefold higher than stresses at the soft tissues behind the bones. Usage of a thigh corset decreased the stresses in the residual limb during gait by approximately 80%. Also, the stresses calculated during the trial of a subject who complained about pain and discomfort were the highest, confirming that his socket was not adequately fitted. We conclude that real-time patient-specific FE analysis of internal stresses in deep soft tissues of the residual limb in TTA patients is feasible. This method is promising for improving the fitting of prostheses in the clinical setting and for protecting the residual limb from pressure ulcers and DTI.

A quasi-dynamic nonlinear finite element model to investigate prosthetic interface stresses during walking for trans-tibial amputees

BACKGROUND

To predict the interface pressure between residual limb and prosthetic socket for trans-tibial amputees during walking.

METHODS

A quasi-dynamic finite element model was built based on the actual geometry of residual limb, internal bones and socket liner. To simulate the friction/slip boundary conditions between the skin and liner, automated surface-to-surface contact was used. Besides variable external loads and material inertia, the coupling between the large rigid displacement of knee joint and small elastic deformation of residual limb and prosthetic components were also considered.

RESULTS

Interface pressure distribution was found to have the same profile during walking. The high pressures fall over popliteal depression, middle patella tendon, lateral tibia and medial tibia regions. Interface pressure predicted by static or quasi-dynamic analysis had the similar double-peaked waveform shape in stance phase.

INTERPRETATION

The consideration of inertial effects and motion of knee joint cause 210% average variation of the area between the pressure curve and the horizontal line of pressure threshold between two cases, even though there is only a small change in the peak pressure. The findings in this paper show that the coupling dynamic effects of inertial loads and knee flexion must be considered to study interface pressure between residual limb and prosthetic socket during walking.

Regional differences in pain threshold and tolerance of the transtibial residual limb: Including the effects of age and interface material

OBJECTIVES

To compare the pain threshold (the minimum pressure inducing pain) and pain tolerance (the maximum tolerable pressure) of different regions of the residual limbs of amputees by the indentation method and to evaluate the interface pressure distribution and distortion of the skin surface on indentation by finite element (FE) analysis.

DESIGN

Crossover trial.

SETTING

Rehabilitation engineering center.

PARTICIPANTS

Eight transtibial amputees for indentation test and 1 for FE analysis.

INTERVENTIONS

The load applied to the residual limbs using a Pelite or polypropylene indenter attached to a force transducer was increased until subjects could no longer tolerate the load. An FE model was built to simulate the indentation process with the experimentally recorded pain threshold used to load the indenters against the soft tissues.

MAIN OUTCOME MEASURES

Pain threshold and tolerance and interface pressure and distortion of soft tissues.

RESULTS

The patellar tendon and distal end of the fibula were the best and the worst load-tolerant regions, respectively. Some regions with a thicker layer of soft tissue had lower pain thresholds and tolerance than those with a thinner tissue layer. There was a trend for pain threshold and tolerance to decrease with age. The FE model showed that the peak pressure at the skin surface was very close when both indenters were loaded against the soft tissue at pain threshold limit.

CONCLUSIONS

Contrary to common beliefs, regions with a thicker layer of soft tissue did not have a higher load-tolerant ability than thin-skinned regions. Pain threshold and tolerance could be age dependent. The FE model suggests that pain is triggered when peak pressure is applied to the residual limb exceeding a certain limit.

Load transfer mechanics between trans-tibial prosthetic socket and residual limb--dynamic effects

The effects of inertial loads on the interface stresses between trans-tibial residual limb and prosthetic socket were investigated. The motion of the limb and prosthesis was monitored using a Vicon motion analysis system and the ground reaction force was measured by a force platform. Equivalent loads at the knee joint during walking were calculated in two cases with and without consideration of the material inertia. A 3D nonlinear finite element (FE) model based on the actual geometry of residual limb, internal bones and socket liner was developed to study the mechanical interaction between socket and residual limb during walking. To simulate the friction/slip boundary conditions between the skin and liner, automated surface-to-surface contact was used. The prediction results indicated that interface pressure and shear stress had the similar double-peaked waveform shape in stance phase. The average difference in interface stresses between the two cases with and without consideration of inertial forces was 8.4% in stance phase and 20.1% in swing phase. The maximum difference during stance phase is up to 19%. This suggests that it is preferable to consider the material inertia effect in a fully dynamic FE model.

Finite element modeling of the contact interface between trans-tibial residual limb and prosthetic socket

Finite element method has been identified as a useful tool to understand the load transfer mechanics between a residual limb and its prosthetic socket. This paper proposed a new practical approach in modeling the contact interface with consideration of the friction/slip conditions and pre-stresses applied on the limb within a rectified socket. The residual limb and socket were modeled as two separate structures and their interactions were simulated using automated contact methods. Some regions of the limb penetrated into the socket because of socket modification. In the first step of the simulation, the penetrated limb surface was moved onto the inner surface of the socket and the pre-stresses were predicted. In the subsequent loading step, pre-stresses were kept and loadings were applied at the knee joint to simulate the loading during the stance phase of gait. Comparisons were made between the model using the proposed approach and the model having an assumption that the shape of the limb and the socket were the same which ignored pre-stress. It was found that peak normal and shear stresses over the regions where socket undercuts were made reduced and the stress values over other regions raised in the model having the simplifying assumption.

Effects of liner stiffness for trans-tibial prosthesis: a finite element contact model

The socket liner plays a crucial role in redistribution of the interface stresses between the stump and the socket, so that the peak interface stress could be reduced. However, how the peak stress is affected by various liner stiffnesses is still unknown, especially when the phenomenon of the stump slide within the socket is considered. This study employed nonlinear contact finite element analyses to study the biomechanical reaction of the stump sliding with particular attention to the liner stiffness effects of the trans-tibial prosthesis. To validate the finite element outcomes, experimental measurements of the interface stresses and sliding distance were further executed. The results showed that the biomechanical response of the stump sliding are highly nonlinear. With a less stiff liner, the slide distance of the stump would increase with a larger contact area. However, this increase in the contact area would not ensure a reduction in the peak interface stress and this is due to the combined effects of the non-uniform shape of the socket and the various sliding distances generated by the different liner stiffnesses.

Integration of plantar soft tissue stiffness measurements in routine MRI of the diabetic foot

OBJECTIVE

A method of measuring mechanical properties of plantar soft tissues in vivo by integrating a photoelastic technique into an MRI system is presented.

BACKGROUND

Plantar tissue stiffening in the diabetic foot is associated with development of ulcers at the highest-pressure sites. MRI is used as an effective means of demonstrating tissue damage caused by diabetic ulceration.

DESIGN

The new measurement method uses the indentation of a sphere into the plantar tissue, which is simultaneously scanned by MRI. The indentation force is obtained using the photoelastic technique while tissue deflection is measured on the MRI scans, to yield a characteristic load-displacement curve.

METHODS

Applicability of the proposed method in characterizing the plantar tissue stiffness and indentation patterns of two young normal subjects and two older diabetic patients was tested.

RESULTS

Significantly higher effective shear and elastic moduli were measured for the diabetic plantar tissue compared with that of normal. For the diabetic patients, local stiffness in proximity of the 1st metatarsal head was substantially larger than in other sites, and this could be associated with initial tissue ulceration at this location.

RELEVANCE

The present method seems applicable as a practical means of identifying regions in the diabetic plantar tissue that are vulnerable to ulceration, and can be easily integrated into routine MRI scans for assessing tissue damage in these patients.

Comparison of computational analysis with clinical measurement of stresses on below-knee residual limb in a prosthetic socket

Interface pressures and shear stresses between a below-knee residual limb and prosthetic socket predicted using finite element analyses were compared with experimental measurements. A three-dimensional nonlinear finite element model, based on actual residual geometry and incorporating PTB socket rectification and interfacial friction/slip conditions, was developed to predict the stress distribution. A system for measuring pressures and bi-axial shear stresses was used to measure the stresses in the PTB socket of a trans-tibial amputee. The FE-predicted results indicated that the peak pressure of 226 kPa occurred at the patellar tendon area and the peak shear stress of 50 kPa at the anterolateral tibia area. Quantitatively, FE-predicted pressures were 11%, on average, lower than those measured by triaxial transducers placed at all the measurement sites. Because friction/slip conditions between the residual limb and socket liner were taken into consideration by using interface elements in the FE model, the directions and magnitudes of shear stresses match well between the FE prediction and clinical measurements. The results suggest that the nonlinear mechanical properties of soft tissues and dynamic effects during gait should be addressed in future work.

In vivo indentation of lower extremity limb soft tissues

In vivo rate-controlled indentation tests were conducted on the soft tissues of the residual limbs of five individuals with trans-tibial amputation and the right calf of five nonamputees. Force relaxation trials were also conducted. The cyclic indentation tests indicated that the bulk soft tissue response to compressive load is nonlinear and rate-dependent. Inter- and intrasubject stiffness variations were observed. The force relaxation studies indicated that approximately 55-95% relaxation may occur, with equilibration typically occurring in less than 60 s. Most of this relaxation (35-80%) occurred within 5 s after loading.

Finite element modelling of a residual lower-limb in a prosthetic socket: a survey of the development in the first decade

A review is presented of the existing finite element models developed from 1987 to 1996 for the biomechanics of lower-limb prostheses. Finite element analysis can be a useful tool in investigating the mechanical interaction between the residual limb and its prosthetic socket, and in computer-aided design and computer-aided manufacturing of prosthetic sockets. Various assumptions and simplifications are made in these models to simplify the actual problem with complex geometry, material properties, boundary and interfacial conditions, as well as loading situations. The analyses can provide the information on the stress distribution at the stump/socket interface and within the residual limb tissues. More recently, nonlinear models have been developed taking into consideration the process of socket rectifications, the slip/friction conditions and material large deformation. The models so far developed have provided some basic understanding of the biomechanics. Comparison of the predictions of these models with experimental measurements indicated that the predicted stresses were within the ranges measured, although one-to-one correspondence was difficult to achieve. Further research is still required in order to improve these models to obtain higher precision in the results taking into account nonlinear and dynamic effects.

Clinical investigation of the pressure and shear stress on the trans-tibial stump with a prosthesis

A system for measuring pressures and bi-axial shear stresses at the body support interfaces has been developed. This system has been used, in five unilateral trans-tibial amputees, to investigate the stresses at multiple points on the residual limb and prosthetic socket interface during standing and walking. The subjects investigated regularly used a patellar-tendon-bearing socket. The maximum peak pressure at the measured points was 320 kPa over the popliteal area during walking. The maximum shear stress was 61 kPa over the medial tibia area. Variable wave-forms of stress during walking were observed at the different measured points. The influence of the angular alignment on the stresses was investigated on one subject. It was found that a miss-alignment of +/- 8 degrees produced a change in peak longitudinal shear stress of between 8% and 11.5%.

A rate-controlled indentor for in vivo analysis of residual limb tissues

A tissue tester was designed to enable rate-controlled indentation of the bulk soft tissues of lower extremity residual limbs. The tissue tester employs a digital linear actuator that implements rate-controlled indentation, and a load cell that measures the reaction force resulting from tissue indentation. Viscoelastic phenomena such as preconditioning, hysteresis and force relaxation can be assessed, and the effect of varying indentation rates on soft tissue stiffness can be investigated. The device accommodates indentor excursions up to 30 mm, indentation at rates of 0 to 10 mm/s, reaction forces up to 44 N, and multiple loading/unloading cycles. The tissue tester is controlled via a notebook personal computer with a PCMCIA data acquisition card. The tissue testing trials are automated and the entire test system is portable and amenable for use in a clinical or research environment. System output consists of force-displacement curves from cyclic loading, and force-time curves following ramped-step indentation. The mean indentor positioning error was 0.071 (+/-0.75)% of the desired displacement. This error varied as a function of indentation and was approximately independent of the indentation rate. Indentation rates were accurate to within 0.94(+/-0.68)% of the desired value and also varied with indentation. Indentation of a viscoelastic foam yielded force-displacement curves that were consistent with that obtained from an Instron universal testing machine.

Lower extremity residual limb slippage within the prosthesis

OBJECTIVE

The ability to measure skin surface slippage relative to the internal wall of a lower extremity prosthesis under various loading conditions is important for evaluation of socket fit and function, and creation of finite element models. Skin surface three-dimensional (3D) shape measurements with tracking of fiducial displacements in situ under axial loading of the prosthesis have not previously been reported. Analysis of slippage within the prosthesis has been performed using a new experimental measurement method based on spiral x-ray computed tomography (SXCT) imaging.

DESIGN

Small lead markers were placed on the residuum of an adult with a below-knee amputation, and SXCT scans were obtained with the prosthesis in situ under two static axial loading conditions (44.5N and 178N). The 3D scan data were used to assess slippage with three methods: gross displacement of the tibia and distal end of the residuum; relative displacement of markers; and distance measurements between markers.

RESULTS

The markers affixed to the below-knee skin surface within the prosthesis were measured. The skin slipped from 2 to 6 mm relative to the internal prosthesis wall when an additional load of 133.5N was applied in the axial direction to the distal end of the prosthesis. The tibial remnant moved 10.0 mm distally relative to the prosthesis internal wall.

CONCLUSION

This method provides a feasible means for measuring residuum skin slippage relative to the prosthesis and skin deformation relative to tibia within an in situ prosthesis under load.

Finite element modeling and experimental verification of lower extremity shape change under load

Prediction and measurement of residuum shape change inside the prosthesis under various loading conditions is important for prosthesis design and evaluation. Residual limb surface measurements with the prosthesis in situ were used for construction of a finite element model (FEM). These surface measurements were obtained from volumetric computed tomography. A new experimental method for modeling the shape of the in situ lower residual limb was developed based on spiral X-ray computed tomography (SXCT) imaging. The p-version of the finite element method was used for estimating the material properties from known load and displacement data. A homogeneous, isotropic, linear constitutive model with accommodation of the constitutive soft and hard tissues of the residuum was evaluated with static axial loading applied to the in situ prosthesis and compared with experimental results obtained in a human volunteer. Two FEMs were created for similar coronal cross sections of the below knee residuum under two loading conditions. Agreement between observed (from SXCT) and predicted (from FEA) residual limb shape changes inside the prosthesis were maximized with a single modulus of elasticity for the residuum soft tissue of 0.06 MPa, consistent with previously published results. This methodology provides a framework to predict and objectively evaluate FEMs and determine residuum material properties by inverse methods.

Automated hexahedral mesh generation from biomedical image data: applications in limb prosthetics

A general method to generate hexahedral meshes for finite element analysis of residual limbs and similar biomedical geometries is presented. The method utilizes skeleton-based subdivision of cross-sectional domains to produce simple subdomains in which structured meshes are easily generated. Application to a below-knee residual limb and external prosthetic socket is described. The residual limb was modeled as consisting of bones, soft tissue, and skin. The prosthetic socket model comprised a socket wall with an inner liner. The geometries of these structures were defined using axial cross-sectional contour data from X-ray computed tomography, optical scanning, and mechanical surface digitization. A tubular surface representation, using B-splines to define the directrix and generator, is shown to be convenient for definition of the structure geometries. Conversion of cross-sectional data to the compact tubular surface representation is direct, and the analytical representation simplifies geometric querying and numerical optimization within the mesh generation algorithms. The element meshes remain geometrically accurate since boundary nodes are constrained to lie on the tubular surfaces. Several element meshes of increasing mesh density were generated for two residual limbs and prosthetic sockets. Convergence testing demonstrated that approximately 19 elements are required along a circumference of the residual limb surface for a simple linear elastic model. A model with the fibula absent compared with the same geometry with the fibula present showed differences suggesting higher distal stresses in the absence of the fibula. Automated hexahedral mesh generation algorithms for sliced data represent an advancement in prosthetic stress analysis since they allow rapid modeling of any given residual limb and optimization of mesh parameters.

Frictional action at lower limb/prosthetic socket interface

The frictional action at stump/socket interface is discussed by a simplified model and finite element model analyses and clinical pressure measurements. The friction applied to the stump skin produces stresses within tissue and these stresses may damage the tissues and affect their normal functions. The combination of normal and shear stresses is considered to be a critical factor leading to amputee's discomfort and tissue damage. However, friction at the stump/socket interface has a beneficial action. A simplified residual limb model and a finite element model using real geometry have been developed to analyse the support action of friction. Both results show that the friction plays a critical role both in supporting the load of the amputee's body during the support phase of the gait cycle and in preventing the prosthesis from slipping off the limb during swing phase. Pressure at the below-knee socket during walking were measured with conditions of different friction. The results reveal that a larger pressures was produced at the lubricated interface than at the normal interface. A proper choice of coefficient of friction will balance the requirements of relief of load stress and reduction of slip with the general ability to support loads.

Development of a non-linear finite element modelling of the below-knee prosthetic socket interface

A non-linear finite element model has been established to predict the pressure and shear stress distribution at the limb-socket interface in below-knee amputees with consideration of the skin-liner interface friction and slip. In this model, the limb tissue and socket liner were respectively meshed into 954 and 450 three-dimensional eight-node isoparametric brick elements, based on measurements of an individual's amputated limb surface; the bone was meshed into three-dimensional six-node triangular prism elements, based on radiographic measurements of the individual's residual limb. The socket shell was assumed to be a rigid boundary. An important feature of this model is the use of 450 interface elements (ABAQUS INTER4) which mimic the interface friction condition. The results indicate that a maximum pressure of 226 kPa, shear stress of 53 kPa and less than 4 mm slip exist at the skin-liner interface when the full body weight of 800 N is applied to the limb. The results also show that the coefficient of friction is a very sensitive parameter in determining the interface pressures, shear stresses and slip. With the growth of coefficient of friction, the shear stresses will increase, while the pressure and slip will decrease.

Interface mechanics in external prosthetics: review of interface stress measurement techniques

Instrumentation to measure accurately the stresses at the interface of a residual limb and prosthetic socket has a strong potential for use in prosthetic treatment. As a tool in the clinical setting, the device would allow a clinician to identify sites of excessive loading, information which could then be combined with clinical assessment of skin quality to determine regions of potential skin breakdown. Stress distributions for different prosthetic designs could be compared, facilitating a clinician's judgement to determine the optimal design for a patient. The instrumentation would have additional use in research as an evaluation tool for computer-based finite-element (FE) models. Stump-socket FE models predict stress distributions for proposed socket designs, thus offering advantages over interface stress measurement because evaluation can be conducted before a prosthesis is fabricated or put on an amputee patient. However, FE models must first be proven valid against experimental measurements before they can be considered accurate predictors of interface stresses. Current interface stress measurement techniques are described, with a concentration on a physical explanation of the advantages and limitations with each technique. New emerging technologies are discussed which are instruments that have been described but for which no data collected on amputees have been reported in the literature. The important new features of those technologies are also discussed.

Mathematical modeling of noninvasive blood pressure estimation techniques--Part I: Pressure transmission across the arm tissue

A mathematical model of the arm tissue mechanical behavior under the effect of external pressure loads is presented. The model has been used to study stress and strain distribution across the tissue, and pressure transmission to the brachial artery, when the arm is compressed by two adjacent cuffs independently inflated. Using this configuration, the tissue elastic parameters (Young modulus and Poisson ratio) can be individually identified using a simple and noninvasive experimental procedure. Model validation has been achieved by comparing its results with data obtained experimentally on 10 subjects. These comparisons demonstrate that the proposed model may constitute a simple but valid new tool able to describe tissue behavior, subjected to external pressures, with sufficient accuracy. Joined with a model of brachial hemodynamics, it might contribute to improve our understanding of noninvasive blood pressure estimation techniques.