A systematic review on design technology and application of polycentric prosthetic knee in amputee rehabilitation

A systematic review of energy storing dynamic response foot for prosthetic rehabilitation

The purpose of this paper is to undertake a systematic review on various mechanical design considerations, simulation and optimization techniques as well as the clinical applications of energy storing and return (ESAR) prosthetic feet used in amputee rehabilitation. Methodological databases including PubMed, EMBASE, and SCOPUS were searched till July 2022, and the retrieved records were evaluated for relevance. The design, mechanism, materials used, mechanical and simulation techniques and clinical applications of ESAR foot used in developed and developing nations were reviewed. 61 articles met the inclusion criteria out of total 577 studies. A wide variety of design matrices for energy- storing feet was found, but the clinical relevance of its design parameters is uncommon. Definitive factors on technical and clinical characteristics were derived and included in the summary tables. To modify existing foot failure mechanisms, material selection and multiple experiments must be improved. Gait analysis and International Organization for Standardization (ISO) mechanical testing standards of energy-storing feet were the methods for integrating clinical experimentation with numerical results. To meet technological requirements, various frameworks simulate finite element models of the energy-storing foot, whereas clinical investigations involving gait analysis require proper insight. Analysis of structural behavior under varying loads and its effect on studies of functional gait are limited. For optimal functional performance, durability and affordability, more research and technological advancements are required to characterize materials and standardize prosthetic foot protocols.

Numerical investigation of knee prosthesis stresses in daily activities: Insight into knee rehabilitation and Creation of a new optimal model

Total knee arthroplasty (TKA) is a cornerstone in addressing knee joint disorders, significantly enhancing patients' quality of life. However, despite technological advancements, a comprehensive understanding of the dynamic stresses experienced by knee prostheses during daily activities, particularly under rehabilitation interventions, remains elusive. This study aims to bridge this gap by employing numerical simulations and finite element analysis to elucidate these dynamic stresses and their interaction with rehabilitation protocols. A real-life knee replacement prosthesis model was meticulously constructed through coordinate measuring and 3D scanning, facilitating detailed finite element analysis in ANSYS Workbench version 17.1. Two distinct boundary conditions and loading scenarios were applied, with comparisons made between linear and nonlinear material assumptions. The simulation results using these different boundary condition methods revealed minimal differences. Specifically, at a knee angle of 0°, the relative stress error rate between the two boundary condition types was approximately 1 % (1.11 MPa and 1.099 MPa, respectively). At 15° and 90°, the error rates were 1.9 % and 0.56 %, respectively (10.275 MPa and 10.078 MPa at 15°; 10.275 MPa and 10.078 MPa at 90°). Given these minimal differences, the first type of boundary condition was adopted for the subsequent scenarios to enhance convergence efficiency in the analysis. Moreover, comparative analyses between linear and nonlinear material behaviors demonstrated acceptable agreement, offering insights into potential efficiency gains in simulation methodologies. Building on this foundation, an optimized tibial model was proposed, incorporating geometric alterations to the tray. Quantitative assessments revealed significant reductions, with von Mises stress decreasing by 23.35 % and equivalent strain by 17 % at a knee angle of 140°. Further evaluations at varying angles, including 60°, consistently showed positive influences on stress and strain. These quantitative findings not only contribute valuable insights into the mechanical behavior of knee prostheses but also provide tangible evidence for the efficacy of linear material behavior assumptions. The proposed optimized model exhibits promising potential for enhancing the design and performance of knee prostheses, particularly under critical loading conditions. In conclusion, these results underscore the importance of a nuanced understanding of knee prosthesis behavior during rehabilitation, offering a quantitative foundation for refining existing designs and informing the development of next-generation prostheses.

What's new in pediatric lower limb reconstruction?

The last years brought many advances relevant to lower limb reconstruction. It feels like guided growth has been looked at from every angle, and still there are new emerging concepts like rotational guided growth waiting to be validated. New hexapod external devices are more accurate and easier to use, and new unilateral fixators allow for more versatile and stable fixation and lengthening. Intramedullary nail lengthening has found its place as a standard procedure for various diagnoses in children and young adults. First results of new and exciting approaches like extramedullary implantable nail lengthening and lengthening plates have been reported. Pharmaceutical treatment has changed the course of certain diseases and must be integrated and considered when making a reconstructive treatment plan. As reconstructive surgery is rapidly advancing so are the technical options for prosthetic fitting, which makes it difficult for caregivers as well as for parents to make the decision between reconstruction and amputation surgery for the most severe cases of congenital deficiencies. This review is highlighting new developments of lower limb reconstruction and is reviewing the current literature.

Toward the Development of User-Centered Neurointegrated Lower Limb Prostheses

The last few years witnessed radical improvements in lower-limb prostheses. Researchers have presented innovative solutions to overcome the limits of the first generation of prostheses, refining specific aspects which could be implemented in future prostheses designs. Each aspect of lower-limb prostheses has been upgraded, but despite these advances, a number of deficiencies remain and the most capable limb prostheses fall far short of the capabilities of the healthy limb. This article describes the current state of prosthesis technology; identifies a number of deficiencies across the spectrum of lower limb prosthetic components with respect to users' needs; and discusses research opportunities in design and control that would substantially improve functionality concerning each deficiency. In doing so, the authors present a roadmap of patients related issues that should be addressed in order to fulfill the vision of a next-generation, neurally-integrated, highly-functional lower limb prosthesis.

Development of four-bar polycentric knee joint with stance-phase knee flexion

A conventional 4-bar polycentric knee and solid ankle cushion heel foot (SACH foot) have been commonly used in developing countries. However, they cannot perform stance-phase knee flexion, which makes a person with an amputation walk unnaturally and with less stability. This research proposes a novel design of a 4-bar polycentric knee with stance-phase knee flexion ability (4BSF), which can perform both stance and swing-phase knee flexion, like able-bodied gait. In the proposed conceptual design, the instantaneous center of rotation (ICR) path is repositioned during the stance phase. The ICR was placed in front of the ground reaction force (GRF) to initiate knee flexion during the loading response. The prototype was validated by a single-subject pilot study at the Gait analysis laboratory. The results showed that a person with an amputation walks with stance-phase knee flexion using the proposed 4BSF. The maximum knee flexion angle is more than 10° during the stance phase. Furthermore, when the 4BSF was used with a SACH foot, the amount of time to achieve the foot flat was shorter, and the foot flat duration time was twice as long as the conventional 4-bar polycentric knee.

Lower limb amputation rehabilitation status in India: A review

Rehabilitation of lower limb amputation in developing countries is quite challenging. Though there are basic to highly advanced prostheses available in India, the set-up is still facing difficulties in developing countries. Prosthetic management is difficult due to lack of availability of prostheses and reduced affordability among low income populations. In this review we highlighted the lower limb amputation and prosthetic rehabilitation status in India. Currently, India is advancing well in the rehabilitation field, but further studies are required to provide more evidence and recommendation.

Successful transfemoral prosthesis in a patient with haemophilia A and factor VIII inhibitors: A case report

Haemophilia A patients who develop factor VIII inhibitors pose a challenge with respect to bleeding and orthopaedic management. This is particularly relevant in cases requiring amputation. We present here a case of a patient with severe haemophilia A and inhibitors who had a history of multiple surgeries due to periprosthetic joint infection and a non-healing wound which led to above-knee amputation. Following the implementation of appropriate and suitable transfemoral prosthesis and emicizumab therapy, the patient experienced a significant improvement in mobility and quality of life without any adverse events or bleeding episodes. Additional studies are required to more fully understand treatment options for lower limb amputations in the haemophilia population.

Living with lower limb traumas and below-knee amputation in a Jordanian Late Ottoman nomadic community

OBJECTIVE

Paleopathological analysis is combined with ethnohistorical, ethnographic and ethnomedical reports to assess the sociocultural implications for a historical nomadic Bedouin female following her survival of a below-knee amputation and multiple injuries to the stump.

MATERIALS

A middle-aged female recovered from a nomadic-style burial dated to the Late Ottoman Period (1789-1918) in Jordan's Wadi ath-Thamad region.

METHODS

Macroscopic and radiographic assessment.

RESULTS

A supracondylar femur (Hoffa) fracture, knee complex injury and lower leg amputation were observed on the right lower limb. Other pathological lesions that may have affected movement included bilateral os acromiale, intervertebral disc disease, osteoarthritis and right hook of hamate fracture.

CONCLUSIONS

The individual survived a below-knee amputation, two injuries to the stump, and likely experienced lower back pain. Mobility may have been painful, but she likely functioned within the community performing gender-specific daily tasks within the family tent and designated community female workspaces. Ethnohistoric and ethnographic reports suggest that marital demotion by other wives or a return to her father's tent may have occurred.

SIGNIFICANCE

Healed multiple injuries and amputation affecting one limb are rare in paleopathological literature.

LIMITATIONS

It is uncertain whether the amputation or either of the stump injuries occurred during the same event. If they resulted from separate events, slight hip joint osteoarthritis suggests that the amputation preceded the other injuries.

SUGGESTIONS FOR FURTHER RESEARCH

Full pathological assessment of individuals with amputations may provide additional insight into impairment resolution, health problems and injury arising from impairment following amputation.

Development of Ti-Al-V alloys for usage as single-axis knee prostheses: evaluation of mechanical, corrosion, and tribocorrosion behaviors

Single-axis knee prosthesis is an artificial biomechanical device that provides motion to amputees without the need for assistance appliances. Besides it is mainly composed of metallic materials, the current commercial materials did not group adequate properties for long-term usage or accessible cost. This study produced and characterized Ti-(10 -x)Al-xV (x = 0, 2, and 4 wt.%) alloys for potential use as single-axis knee prostheses. The samples exhibited a gradual decrease in the density values, with proper chemical mixing of the alloying elements on the micro-scale. The phase composition exhibited a primary α phase with a minor α' + β phase for the Ti-8Al-2V and Ti-6Al-4V samples. Due to their different atomic radius compared to Ti, the addition of alloying elements changed the cell parameters. Their selected mechanical properties (Young's modulus, Vickers microhardness, and damping factor) performed better values than the CP-Ti grade 4. The samples also exhibited good corrosion properties against the simulated marine solution. The tribocorrosion resistance of the samples was better than the reference material, with the wear tracks composed of some tribolayers and grooves resulting from adhesive and abrasive wear. The Ti-10Al alloy displayed the best properties and estimated low cost to be used as single-axis knee prostheses.

Design and analysis of polycentric prosthetic knee with enhanced kinematics and stability

This paper describes a continuation of earlier work using the finite element method to conduct an engineering failure analysis of an existing polycentric prosthetic knee. The primary purpose of this work is to enhance the quality of the existing knee which has been reported with multiple cases of failure during its clinical practice in India. A modified design of the polycentric knee has been proposed based on the findings of failure analysis. Simulation-based comparative analysis of polycentric knees has been performed as per the ISO 10328:2016 standard in terms of stress distribution, total contour deformation, safety factor, and fatigue life. The upper extension lever is subjected to static and cyclic loads of 4130 and 1230 N, whereas the lower plate has a translational constraint. The modified polycentric knee prosthesis outperforms static and fatigue strength tests. The standard of the existing knee prosthesis has significantly improved as a result of design variations and integration of high-strength and lightweight aluminium 7075-T6 alloy. The modified polycentric knee prosthesis has a predicted maximum deformation of less than 0.7 mm and a minimum safety factor between 1.7 and 2 compared to 2.66 mm and 1.0 for the existing knee prosthesis. Based on the fatigue simulation results, it is predicted that the modified polycentric knee will have a lifespan of at least ten years indicating a safe design. It has improved alignment stability and kinematics, with a significant weight reduction of 33 g, and a high cost-benefit ratio to reach the maximum amputee population in low-income countries like India.

FATIGUE ANALYSIS OF POLYCENTRIC PROSTHETIC KNEE FOR TRANS-FEMORAL AMPUTATION

A prosthetic knee is predominantly subjected to cyclic action leading to fatigue failure during its operation. However, cyclic failure is more severe as it occurs below the yield strength and may happen even without prior indication. This study presents a cyclic structural analysis of an existing polycentric mechanical prosthetic knee by finite element simulation and its experimental validation as per the ISO 10328:2016 standard. The three-dimensional (3D) model is imported to the ANSYS 20.1 workbench to study stress distribution and fatigue life in the knee for ensuring its safety performance. The maximum von-Mises stresses developed at the front and back joint bars made of A390.0-T5 and A390.0-T6 cast aluminium are 100 and 89[Formula: see text]MPa, respectively, in both loading conditions compared to their mechanical fatigue strength of 89[Formula: see text]MPa. The maximum deformation and average number of cycles for fatigue failure are 2.66 and 2.53[Formula: see text]mm and [Formula: see text] and [Formula: see text] for simulation and experimental results, respectively. These results suggest that this polycentric knee unit has poor fatigue strength and thereby does not meet the ISO structural standard. A validation test has been performed with an average error of 4.75% between the simulation and experiments results showing higher reliability.

Mechanisms and component design of prosthetic knees: A review from a biomechanical function perspective

Prosthetic knees are state-of-the-art medical devices that use mechanical mechanisms and components to simulate the normal biological knee function for individuals with transfemoral amputation. A large variety of complicated mechanical mechanisms and components have been employed; however, they lack clear relevance to the walking biomechanics of users in the design process. This article aims to bridge this knowledge gap by providing a review of prosthetic knees from a biomechanical perspective and includes stance stability, early-stance flexion and swing resistance, which directly relate the mechanical mechanisms to the perceived walking performance, i.e., fall avoidance, shock absorption, and gait symmetry. The prescription criteria and selection of prosthetic knees depend on the interaction between the user and prosthesis, which includes five functional levels from K0 to K4. Misunderstood functions and the improper adjustment of knee prostheses may lead to reduced stability, restricted stance flexion, and unnatural gait for users. Our review identifies current commercial and recent studied prosthetic knees to provide a new paradigm for prosthetic knee analysis and facilitates the standardization and optimization of prosthetic knee design. This may also enable the design of functional mechanisms and components tailored to regaining lost functions of a specific person, hence providing individualized product design.

Conformity assessment with structural strength requirements of mechanical polycentric prosthetic knee used for amputee rehabilitation

Prosthetic restoration is an important component of amputee rehabilitation which may be subjected to a static load of nearly five times of amputees' body weight and is continuously administered to cyclic or fatigue loads during its function. This study presents a structural strength analysis of polycentric mechanical prosthetic knee commonly used in National Institutes in India by finite element simulation and its experimental validation. Static and fatigue analyses have been performed to ensure its structural integrity as per the ISO 10328:2006 standard. Accurate dimensioning of knee components have been obtained using coordinate measuring machine and the 3 D CAD model has been generated by CATIA V5 from the 2 D geometry. The model is imported to the ANSYS 20.1 workbench to study stress distribution in the knee for ensuring its safety performance. The selection of reference planes, application of calculated loads, and position of load line have been done as per the ISO test procedure. Static and cyclic loadings of 4130 N and 1230 N are applied at the top and the bottom plate is given with translational constraints to limit its movement in any direction. Results indicate that the prosthetic knee model is moderately strong enough to outstrip the static strength test. However, the calculated strain and predicted fatigue life during the cyclic test suggest that this knee unit has poor fatigue strength. Validation results with an average error percentage of 3.44 and 10 show higher reliability based on previous study results and experimental tests, respectively.

Characterizing the Gait of People With Different Types of Amputation and Prosthetic Components Through Multimodal Measurements: A Methodological Perspective

Prosthetic gait implies the use of compensatory motor strategies, including alterations in gait biomechanics and adaptations in the neural control mechanisms adopted by the central nervous system. Despite the constant technological advancements in prostheses design that led to a reduction in compensatory movements and an increased acceptance by the users, a deep comprehension of the numerous factors that influence prosthetic gait is still needed. The quantitative prosthetic gait analysis is an essential step in the development of new and ergonomic devices and to optimize the rehabilitation therapies. Nevertheless, the assessment of prosthetic gait is still carried out by a heterogeneous variety of methodologies, and this limits the comparison of results from different studies, complicating the definition of shared and well-accepted guidelines among clinicians, therapists, physicians, and engineers. This perspective article starts from the results of a project funded by the Italian Worker's Compensation Authority (INAIL) that led to the generation of an extended dataset of measurements involving kinematic, kinetic, and electrophysiological recordings in subjects with different types of amputation and prosthetic components. By encompassing different studies published along the project activities, we discuss the specific information that can be extracted by different kinds of measurements, and we here provide a methodological perspective related to multimodal prosthetic gait assessment, highlighting how, for designing improved prostheses and more effective therapies for patients, it is of critical importance to analyze movement neural control and its mechanical actuation as a whole, without limiting the focus to one specific aspect.

An insight into Transfemoral Prostheses: Materials, modelling, simulation, fabrication, testing, clinical evaluation and performance perspectives

INTRODUCTION

A Transfemoral prosthesis restores any limb amputated above the knee. Designing and developing a transfemoral prosthesis that is consistent with human performance is a tough task. While prosthetic components are widely available in the market, ongoing research is being conducted to develop parts that would restore the lost capability, taking into account numerous social, economic and technological considerations.

AREAS COVERED

The present paper provides a comprehensive review about the mechanical aspects and performance of transfemoral prosthesis in recent years based on the research findings on materials, manufacturing methods and evaluations for suitability of the prostheses. The fundamental terminologies as well as technical advancements are covered in order to impart a better knowledge in the area of Lower Limb prostheses. This review also provides a concise description on the role of computers, advanced software packages, sensors and other hardware components for the design, fabrication and testing of transfemoral prosthetic devices in the current environment.

EXPERT OPINION

The current state of lower limb prostheses and future research opportunities are summarised to address upcoming challenges. Based on survey of various research works, adapting modern technology may aid in the development of functional and cost-efficient prosthetic components with superior safety, comfort and quality.