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Section 1: General Topics
Figure 1
a wound from the environment. This patient was subsequently treated with a tissue-sparing amputation after injury by a mortar explosion. (Reproduced from Covey DC, Richardson MW, Powell
ET, Mazurek MT, Morgan SJ: Advances in the care of battleeld orthopaedic injuries. Instr Course
Lect 2010;59:427-435.)
Definitive Care
After arrival at the definitive treatment
facility, serial débridement is continued
until the wound is ready for definitive
closure. All means should be used to
preserve limb length, keeping in mind,
Clinical photograph shows the use of n egative-pressure wound therapy to separate
sensation loss, thus resulting in pressure sores in areas of prosthesis contact. Advances in prosthetic liner and
socket technology have decreased the
complications commonly seen in these
insensate tissues.
however, that a stable soft-tissue envelope is the most important factor in a
patient’s ability to wear and ambulate
in a prosthesis. Skin traction may not
work if there is a tenuous soft-tissue envelope that precludes the use of benzoin
for traction. A negative-pressure wound
dressing is a good substitute for skin
traction when used in conjunction with
elastic bands (vessel loops) that are applied under tension in a zig-zag pattern
(Roman sandal pattern) along the skin
edge. As the negative-pressure dressing
assists with fluid evacuation and edema
control, the vessel loops provide skin
traction, gradually bringing the wound
edges closer. Free tissue transfers and
skin grafting also should be considered
to preserve length in a combat amputation, but may have the disadvantage of
Rehabilitation
The concept of multidisciplinary am-
putation care learned at Valley Forge
Army General Hospital during the
Vietnam War was mirrored during the
conflicts in the Global War on Terror.
Three facilities, the Military Advanced
Training Center at Walter Reed Army
Medical Center (now known as Wal-
ter Reed National Military Medical
Center), the Center for the Intrepid at
Brooke Army Medical Center, and the
Comprehensive Combat and Complex
Casualty Care Center at Naval Medical
Center San Diego all focus on a holis-
tic, family- centered care program. The
goal is to return the service member to
the highest quality of life regardless of
injuries. Using specialized care centers
also allows for a strong peer visitation
and mentorship program, providing
accessible, constant peer support and
camaraderie.
52
Revision Surgery
Both elective and nonelective complication rates are high in combat amputations. Tintle et al53 showed that there
was a 53% reoperation rate in patients
sustaining a major lower limb amputation. Postoperative wound infection
was the most common at 27%, followed
by symptomatic heterotopic ossification
(24%), neuromas (11%), scar revision
(8%), and myodesis failure (6%). Revision surgery can be psychologically
challenging to a patient who has made
great strides in his or her rehabilitation
only to have this stopped or delayed by
additional surgery and recovery time.
Therefore, it is important to counsel
patients on this high reoperation rate
during the initial hospitalization and
further inform them that, other than
surgery for infections, they are commonly the ones requesting the revision
surgery.
Summary
Amputations are among the most severe limb injuries seen in war. Care for
personnel with amputations has been
an important clinical concern for the
military in every major conflict in the
20th and 21st centuries. Because few
surgeons or medical teams have substantial clinical experience in caring for
such patients, lapses or inconsistencies
occur. In addition, the techniques and
requirements for patients evacuated
from overseas hospitals differ from those
required by patients treated in civilian
hospitals.
War surgery for amputations is a twostage procedure. Initial care to remove
the limb, prevent infection, and save the
patient’s life is provided at a forward hospital. Length-preserving amputations
should be performed, avoiding guillotine amputations and skin traction. After
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
122
Chapter 9: Wartime Amputations
stabilization, the patient continues along
the evacuation chain, undergoing additional débridements at every echelon
of care. The patient should be treated
with a negative-pressure wound dressing when possible.
As demonstrated in previous conflicts, there is a clear need for amputation centers that specialize in the care of
personnel evacuated from a combat theater. The main advantages of this consolidation of efforts include maintaining
the clinical skills of the nursing staff,
prosthetists, therapists, and surgeons
to facilitate complete healing of the residual limb; fitting with a provisional
prosthesis; rehabilitation; and fitting
with a satisfactory permanent prosthesis. Specialized care centers have been
established by the US military to provide
a team approach to caring for combat
personnel with amputations, with the
goal of returning these individuals to
maximal health and function.
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ex tremity. J Bone Joint Surg Am
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study of bilateral above-the-knee amputees from the Vietnam War. J Bone
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of unilateral transfemoral amputees
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37. Deer PA, Moll JH, LaNoue AM: e
Ertl osteoplastic transtibial amputation (Proceedings). J Bone Joint
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38. Tintle SM, Keeling JJ, Forsberg JA,
Shawen SB, Andersen RC, Potter BK:
Operative complications of combatrelated transtibial amputations: A
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JG, Bagg MR, Holcomb JB: Amputations in U.S. military personnel in the
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46. Medline DOI
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years at war: Comprehensive analysis
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Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
124
Chapter 10
Prosthetic Rehabilitation in Less-Resourced Settings
Carson Harte, CEO Helen Cochrane, CPO(c), MSc
Abstract
A less-resourced setting has been dened as a geographic area with limited nancial, human,
and infrastructure resources. ese conditions are common in low- and middle-income
countries and can represent a substantial barrier to the delivery of appropriate prosthetic
services. Access to services, policies, funding, human resources, and prosthetic technologies
may dier in less-resourced settings compared with conditions in some higher-income
countries. It is helpful to be aware of common commercially available prosthetic systems
used in these challenging environments along with current technological advances.
Keywords: assistive technology; barriers to prosthetic services;
education: prosthetics and orthotics; ICRC polypropylene
technology; Jaipur foot; less-resourced settings; low-income
countries; prosthetics
Introduction
A less-resourced setting (LRS) has been
defined as a geographic area with limited
financial, human, and infrastructure resources. These conditions are common
in low- and middle-income countries
but also can exist in some high-income
countries.1 Assistive technology, such
as prosthetic devices to help individuals with disabilities attain mobility,
achieve equal opportunities, enjoy human rights, and live with dignity, are
limited in these settings.
The World Report on Disability from
the World Health Organization (WHO)
and the World Bank indicates that more
than 1 billion individuals around the
world live with disabilities.3 Conservative population-based estimates
suggest that 0.5% of any population
may benefit from prosthetic and/or
orthotic services;
and Latin America, that includes an
Mr. Harte or an immediate family member serves a s a board member, owner, ocer, or committee
member of the International Society for Prosthetics and Orthotics. Ms. Cochrane or an immediate
family member serves as a board member, owner, ocer, or committee member of the International
Society for Prosthetics and Orthotics.
2-10
3,5,9,11
in Africa, Asia,
estimated 30 million individuals.11 In
many LRSs, the prevalence of disabilities
is reported as higher than in well-resourced settings
increase.
10,12
3,5
Irrespective of the setting,
and is expected to
individuals with disabilities are known
to have poorer health outcomes, lower
educational attainment, reduced social
and economic participation, and higher
overall rates of poverty than those without disabilities.3 Individuals from typical at-risk groups such as women, the
elderly, those with limited education,
and the unemployed are also considered
to be at increased risk of disabilities.3
These trends suggest a cycle of exclusion and a profound effect on those with
disabilities living in an LRS.
10
Access to appropriate, affordable,
sustainable prosthetic services is important in mitigating this effect and presents challenges in LRSs. Appropriate
services require collaboration among a
spectrum of key stakeholders, including
governments, funding agents, educators,
industry, private enterprise, service
providers, and the users of prosthetic
services. Additional requirements include an adequately trained professional
workforce and appropriate technology.
Access to Prosthetic
Services
The service and delivery of prosthetic
devices in LRSs is provided by a range of
stakeholders, which varies from country
to country. The individual responsibilities between stakeholders within each
country are unique and depend on the
resources and capacities of the contributors. Services from referral through
follow-up are often in short supply. They
are commonly centralized in large cities
and are usually located at a substantial
distance from many potential users.
Three major institutional donors,
Deutsche Gesellschaft für Internationale Zusammenarbeit GIZ (formerly
GTZ), the United States Agency for International Development (USAID), and
The Nippon Foundation, have provided
substantial ongoing support to improve
access to assistive technology. Their input has generated activity in education
and technology transfer. A recent impact assessment in East Africa by USAID
indicated that its grants had a positive
effect on the establishment of services,
the appropriateness of service delivery,
and on the lives of individuals with
disabilities.13 However, a recent WHO
statement suggests that despite this
support, there persists a broad lack of
understanding of the benefits and needs
of assistive technologies; a failure of infrastructure to procure, produce, and
2
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
125
Section 1: General Topics
maintain devices; and the absence of a
properly trained workforce.
6
Policy and Funding
Many countries have an existing legislative framework related to disability
and/or rehabilitation. However, systematic barriers exist in the implementation of laws, including a lack of strategic
planning, health infrastructure, health
information systems, and communication strategies. These barriers are further
compounded by a lack of agencies responsible for administering, coordinating, and monitoring complex referral
systems, as well as inadequate consultation with individuals with disabilities.
The provision of assistive technology for mobility is often a low priority
for governments. In a global survey of
114 countries on the equalization of
opportunities for individuals with disabilities, 50% had not passed relevant
legislation, 48% had no policies related
to providing assistive technology, and
36% had not allocated fiscal resources
to develop and supply assistive devices.
The United Nations Convention on
the Rights of Persons with Disabilities
has been an important step toward
providing an accountability framework
for governments. Articles 4, 20, and 26
of the Convention specifically require
member states to ensure access to assistive technology that is provided by
trained professionals.
In 2006, key stakeholders from 35
organizations and agencies agreed to a
common approach to improve access
to good-quality services for individuals
with disabilities. The Prosthetic Orthotic
Programme Guide,5 which was endorsed
by the International Society for Prosthetics and Orthotics (ISPO), provides
support to international and local aid
organizations involved in supporting
the establishment and development of
prosthetic and orthotic services in lowincome settings. The guide recommends
considering the following principles
(among others): Ensure that the project
4
has been proposed by or is supported by
government; support the establishment
of services that provide both prosthetic
and orthotic devices; build local capacity in both technical and managerial
aspects within the program; promote
the ideal that services should be open for
all; work closely with carefully selected
local partners and owners of the service;
build services on existing systems with
respect to such considerations as staff
compensation and the procurement of
materials; carefully consider the selection of technology and components (that
is, consider technology already in use in
the country, realistic expectations for
3
cost, availability, clinical capacity, and
technical capacity); and promote continuous evidence-based research.
5
These guiding principles are considered key to developing services that
are cost effective and sustainable. These
principles are echoed in a 2011 joint
position paper published by WHO and
USAID on the provision of mobility devices in LRSs, which also encourages
2
a comprehensive approach to service
deliver y.
2
Funding limitations are an additional challenge frequently encountered
in LRSs,2 where individuals with disabilities reportedly pay for more than
50% of the cost of assistive technologies.14 Because disability is bidirectionally linked to poverty,3 the challenge
of funding prosthetic services should
not be underestimated. Studies indicate
that individuals with disabilities have
higher costs of living, higher healthcare
expenditures,
3,15
fewer assets, and worse
living conditions.3 In low-income countries with a per capita income as low
as $664 USD,16 it would be particularly
reasonable to suggest that the cost of
prosthetic devices may be unaffordable
for most individuals with disabilities.
In 2014, WHO issued a concept note
on its global cooperation on assistive
health technology (GATE) initiative
to increase access to assistive technology. This concept note stated that the
assistive technology industry is essentially a monopoly; the cost of products
is overly high and does not take advantage of economies of scale; and global
issues exist regarding limited funding
for development and production, weak
or nonexistent procurement systems,
the absence of safety measures, and inadequate servicing and user training in
6
LRSs.
Similarly, in the USAID impact assessment of East Africa, researchers
reported that in Tanzania, Kenya, and
Uganda (the three target countries), constraints related to cost, supply chain,
and limited availability of consumables
had a substantial effect on services.13
These countries reported heavy reliance on international, nongovernmental, and/or charitable organizations to
fund services, which, anecdotally, is also
considered to be true in other LRSs.
It is important that funding agents
understand the complexities of providing prosthetic and orthotic services.
Appropriate, sustainable services are
considered a long-term endeavor and
may require input or support over many
decades to achieve acceptable results.
Short-term assistance for users of prosthetic and orthotic services may generate
few or no lasting results. In short-term
endeavors, after a device wears out, beneficiaries may consider themselves to be
in a worse situation than before having
the device. ISPO recommended that
the long-term objectives be prioritized
over the narrower goal of supporting a
large number of individuals as quickly
as possible.
5
Human Resources
Training a professional work force is
important for the delivery of appropriate services.
sionally trained personnel is a barrier
to providing appropriate services. Similarly, continuing education for existing
personnel is insufficient.2 In the 2005
United Nations survey on equalization opportunities for individuals with
2-4,11,13,17
The lack of profes-
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
126
Chapter 10: Prosthetic Rehabilitation in Less-Resourced Settings
Figure 1
Illustration of the pyramid of training for prosthetic and orthotic professionals.
disabilities, 37 countries reported that
no action had been taken to train personnel in rehabilitation, and 56% reported that the medical knowledge of
healthcare providers related to disability
had not been updated.
2
The ISPO projects that 40,000 professionally trained prosthetists and/or
orthotists are needed for Asia, Africa,
and Latin America and should be supported by as many as 140,000 technicians trained to fabricate prosthetic
and orthotic devices. As many as 75%
of LRSs have no training programs, and
as few as 400 new prosthetists and orthotists graduate from internationally
recognized programs each year. This
indicates that the current training models are insufficient to meet the need for
trained professionals to provide care for
the estimated 30 million individuals
who could benefit from prosthetic and
orthotic services.
11
In recognizing the need for appropriate training in LRSs, WHO and ISPO
have worked together on international
standards and guidelines for training
personnel. The first joint guidelines
were developed in 1991 and have since
been supplemented by detailed guidelines on education and training written
by ISPO. Thirty-eight schools in 26
countries, in both less-resourced and
well-resourced settings, are recognized
by ISPO as meeting the standard for
training of prosthetic and orthotic professionals.18 An additional 81 schools or
national pathways in 50 countries are
currently in various stages of consultation with ISPO to consider working
toward international recognition.
These guidelines consider differences
in educational standards and the need
for services. The guidelines also provide a reference for appropriate training levels for professionals to ensure
that safe, appropriate care is provided,
irrespective of the resources in a given
setting. Training is stratified into three
categories (Figure 1): Category I is the
training level aimed at clinical leadership and advancing services; category
II is the training level aimed at general
clinical service delivery; and category III
is the training level aimed at technical
fabrication of devices without providing
clinical interventions.
When individuals without formal
training provide prosthetic services
in LRSs, poor outcomes have been reported. A 2010 study in the Philippines
found that of 1,494 screened amputees,
122 (8.2%) had a prosthesis, and these
individuals attended the screening
because their prosthesis needed to be
adjusted or replaced because of poor
quality or fit.19 Field tests in two countries where service providers had received 3 weeks of training (but were
not formally trained to international
standards) identified that the recipients
of such services were less intensive users with fewer jobs and that the craftsmanship of the provided devices was
generally considered to be poor.20 These
findings support the need for formally
trained professionals to provide prosthetic services to ensure that resources
and outcomes are optimized.
Prosthetic Technologies
in LRSs
A variety of prosthetic technologies exists
and is widely used in well-resourced settings for many clinical and user- initiated
goals. Research and development of
new or improved prosthetic designs
over the past two decades have focused
largely on these relatively affluent and
resource-rich settings.14 With the expiration of patents on certain prosthetic or
orthotic devices, a new trend has begun
in which products using technologies
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
127
Section 1: General Topics
Figure 2
are common in less-resourced settings. Photograph shows the user of a transtibial prosthesis harvesting rice in a wet and muddy Cambodian eld. (Courtesy of Robert Joiner, Wellington, New
Zealand.)
developed for well-resourced settings
are being manufactured and distributed
in low- and middle-income countries,
with the potential to decrease cost and
increase availability. However, in many
LRSs, these designs are currently cost
prohibitive and are often impractical for
application in local environments and
user activities
Access to materials and equipment
is limited in LRSs. Research and development are needed to identify technologies, materials, methods, and equipment
that are cost effective and do not adversely affect the quality of services.
Frequently, the cost of importation is
high and the demand for devices may be
low because of poor awareness or limited purchasing capacity.2 For most LRSs,
prosthetic services are delivered on a
small scale, often using novel, indigenous designs (Figure 3) and donated or
recycled materials and parts.
In many countries, prostheses are
classified as single-use devices and are
considered appropriate for a single user
only. Reusing a device without approval
Uneven terrain, high humidity, mud, and wet conditions (in various combinations)
by the licensed manufacturer of the
device is prohibited by law because it
potentially reduces performance or effectiveness and presents risks to the user
and treating staff, including mechanical failure and cross contamination.21
Despite such restrictions implemented
in well-resourced settings, secondhand
6,17
(Figure 2).
components (and even complete devices)
are sometimes reused in LRSs. These
items are recycled to extend the useful
life of the technology or to provide limbs
for individuals who otherwise would
have no access to prostheses. This model
5
of service may seem appealing, but it
can be problematic for individuals receiving prosthetic devices and for the
long-term sustainability of services.
Parts are often not interchangeable and
the ability to repair or refurbish parts
can be almost nonexistent. Individuals
who provide such services often have
little or no training and may lack the capabilities to safely and appropriately assess, assemble, fit, and/or align devices.
The technology often cannot be repaired
or replaced in the future, leaving the
Figure 3
made transtibial prosthesis. (Courtesy of Christine Dee, RT RP, RN, BSc , PO, Manila, Philippines.)
Photograph shows a home-
user with no prosthesis or a relatively
basic or unsafe device. Collectively, this
approach to service delivery can potentially do more harm than good.
5
Ikeda et al9 reviewed research and
outcome measures in resource-limited
environments and reported that lack
of durability is a persistent problem. In
addition, although a few specific benchmarks exist for lower limb prosthetic interventions, no upper limb benchmarks
could be identified.
As a result of concerns of the international community, the International
Standards Organization (ISO), with sup
port from ISPO, developed ISO 10328
(prosthetics standard for structural
testing) to ensure safety and assist in
the development of prosthetic devices.22
This minimum standard is considered
an important safety benchmark, and
the authors of this chapter recommend
compliance for prosthetic components
delivered in LRSs.
In the 1996 Consensus Conference
on Appropriate Prosthetics Technol ogy
for Developing Countries,23 the use of
international and national manufacturing standards was considered to
be essential and important in settings
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
128
Chapter 10: Prosthetic Rehabilitation in Less-Resourced Settings
Figure 4
tional transfemoral prosthesis with a Niagara
foot. (Courtesy of Roger V. Gonzalez, PhD, PE, El
Paso, TX.)
Photograph of a Limbs Interna-
without ready access to services. Some
technologies designed for use in LRSs,
such as the International Committee
of the Red Cross (ICRC) systems, the
Limbs International Knee (Figure 4),
and the Alimco limb systems, have met
this standard. Encouragingly, a few additional systems and components are in
the testing phase.
Jensen and Heim24 reported the ISPO
protocol and assessment system for clinical and technical interventions as one
of the most common outcome measures
used for lower limb prosthetic devices in
LRSs. It describes quality standards that
are attainable, and encourages providers
to achieve those standards.
9
Feet
Prosthetic feet have long been reported
as the prosthetic part most likely to fail
in LRSs.23 Durability has been cited as
Figure 5
Paso, TX.)
Photograph of th e Niagara foot prosth esis. (Courtesy of Roge r V. Gonzale z, PhD, PE, El
the most important factor for the prescription and/or selection of prosthetic
feet. Conditions related to climate that
are common in many LRSs such as heat,
moisture, and exposure to ultraviolet
light negatively affect the durability of
prosthetic feet. Several feet designed
for use in LRSs have been tested in
industry-standard static-proof tests and
cyclical loading tests with acceptable
results. However, LRS field tests have
demonstrated that these functional
working environments can result in a
lower level of durability than that identified by laboratory tests alone.
9,20,22
In 2013, a review by Ikeda et al9 reported that polyurethane feet were not
recommended for tropical environments. Vulcanized rubber feet offered
improved durability and therefore were
preferred for tropical environments. Feet
designed for use in LRSs such as the
Niagara foot (Figure 5) met the outlined
needs associated with cost, simplicity,
and durability, although field tests suggested that the durability of the cover
may need improvement.
9
Knees
Low-cost prosthetic knees that take
advantage of existing design principles
have been tested for use in LRSs. Knees
such as the Limbs International Knee
(formerly known as the LeTourneau
Engineering Global Solutions Knee; Fig-
ure 6) and the ReMotion Knee (formerly
known as the Stanford-Jaipur Knee) are
showing potential for improving function and stability at a low cost; however,
independent tests are still needed to verify results.
9
Prosthetic Systems
Considering the scope of the potential
market for prosthetic componentry in
LRSs, only a few specifically designed
prosthetic systems exist. Two of the
main designs used in such settings are
the ICRC Polypropylene Technology and
the Jaipur System.
International Committee
of the Red Cross
In 1979, to provide services in conflict
areas and LRSs, the ICRC launched
its physical rehabilitation program.
The aim of the program was to deliver
good-quality, sustainable services that
promoted the use of technology appropriate to the specific contexts in which
the organization operates. The goal
was to deliver devices that were durable, comfortable, and easy for patients
to use and maintain; easy to learn, use,
and repair; standardized, but compatible with the climate in different regions
of the world; low-cost, but modern and
consistent with internationally accepted
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
129
Section 1: General Topics
Figure 7
Committee of the Red Cross transtibial prosthesis ready for bench alignment. (Courtesy
Figure 6
Engineering Global Solutions Knee. (Courtesy of Roger V. Gonzalez, PhD, PE, El Paso, TX.)
standards; and easily available regarding
the supply chain.
Following early efforts to use locally available raw materials for component manufacture, the ICRC began
using polypropylene sockets in 1988.
In 1991, the first prosthetic knee joint
was produced in Cambodia, followed by
work in Colombia to develop a range of
injection-molded polypropylene prosthetic kits to standardize the organization’s various projects.
Both lower limb and upper limb systems are available. Simple, comprehensive manuals are available describing
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
130
Photographs of the Limbs International Knee, formerly known as the LeTourneau
fabrication and bench alignment of the
systems. Most levels of amputation can
be addressed with the simple range of
modular kits (Figures 7 and 8). Parts
are standardized, interchangeable,
durable, of midrange cost, and can be
ordered internationally. The modular
design facilitates an efficient supply
chain and is easy to fabricate, adjust,
maintain, and repair.
In the ICRC system, each socket is
25
created from an individual cast and
positive plaster model. For transfemoral sockets, a quadrilateral design is
encouraged because the wrap-draped
of Helen Cochrane CPO(c), MSc, Manila, Philippines.)
polypropylene socket generally does not
allow for the frame socket design to be
used effectively with the ischial and ischial/ramal containment sockets.
Transfemoral sockets are suspended
using either a standard or modified Silesian belt. A valve for suction suspension
may be used where appropriate, but pre
scribing suction suspension in tropical
climates should be considered care fully.
Although some individuals can successfully use suction suspension in a tropical
climate, heat and humidity can diminish the skin-socket interface required
to maintain suspension. Muddy, wet,
Photograph of an International
-
Chapter 10: Prosthetic Rehabilitation in Less-Resourced Settings
Figure 8
prosthesis using an International Committee of
the Red Cross single-axis manual locking knee,
a solid ankle c ushion heel foot, and Silesia n suspension. (Courtesy of Helen Cochrane, CPO(c),
MSc, Manila, Philippines.)
Photograph of a transfemoral
Figure 9
kit, which includes a socket attachment cup (A), an alignment disk with a at superior surface and
convex inferior surface (B), a two-part pylon with a concave alignment coupling (C and D), a foot
attachment coupling with a convex superior surface for alignment and a at inferior surface for
solid ankle cushion heel foot attachment (E), and a foot bolt (F). (Courtesy of Helen Cochrane,
CPO(c), MSc, Manila, Philippines.)
Figure 10
thesis kit, which includes a socket attachment plate (A), an attachment coupling for a long transfemoral amputation (B), an attachment cup for a short transfemoral amputation (C), an alignment
disk with a at superior surface and a convex inferior surface (D), a distal pylon attachment with
a concave alignment coupling (E), a foot attachment coupling with a convex superior surface for
alignment and a at inferior surface for solid ankle cushion heel foot attachment (F), and a foot
bolt (G).(Courtesy of Helen Cochrane, CPO(c), MSc, Manila, Philippines.)
Photograph of an International Committee of the Red Cross transtibial prosthesis
Photograph of an International Committee of the Red Cross transfemoral pros-
irregular terrain associated with many
rural areas and some urban areas can result in distraction forces that are higher
than usually expected, especially during
the tropical rainy season. In such instances, it can be difficult to maintain
Figure 11
Manila, Philippines.)
Photograph of a manual locking knee. (Courtesy of Helen Cochrane, CPO(c), MSc,
suspension through suction alone.
The lower limb systems use solid
ankle cushion heel (SACH)-style feet.
The transtibial kits (Figure 9) include
attachment/alignment couplings and
a pylon. The transfemoral kit (Figure
10) adds a manually locking, single-axis
knee joint (Figure 11). Also, a singleaxis hip joint is available for more
proximal amputation levels. Ankle
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
131
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