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Section 2: Upper Limb
Figure 11
cedes incision for development of a Tikho-Linberg resection and reconstruction. The procedure involves the anterior limb for protection of the
subclavian to axillary artery and brachial plexus, the posterior ap for dealing with the resection, and a longitudinal extension over the trapezius to
facilitate exposure and later tension-free closure. B, Intraoperative photograph shows the proximal humerus and tumor contained with the deltoid.
Because the tumor broke into the joint, a periscapular resection was needed. C, Intraoperative photograph shows exposure and osteotomy of the
proximal humerus prior to resection. D, Posterior-superior intraoperative view of the scapular resection. E, Postoperative radiograph shows creation
of a prosthetic pseudarthrosis, with suture tape placed through holes in the prosthesis to the chest wall for stability.
allows safe delivery of the tumor proximally. A partial scapulectomy usually
does not need to be reconstructed. The
abductors are retained; however, most
of the other resections will combine
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
282
Images of a patient with dedierentiated chondrosarcoma of the proximal humerus. A, Intraoperative photograph of a typical Mer-
proximal humeral replacement with
scapular reconstruction.
If a Malawar type I or V resection is
being performed, the preferred method of reconstruction is an allograft
composite reverse total shoulder with
glenoid allograft. Other methods include
an intercalary spacer with dowel into
the clavicle, endoprosthetic proximal
humeral replacement with polyethylene
Chapter 22: Amputations About the Shoulder: Surgical Considerations
Figure 12
latissimus ap (A) and a split-thickness skin graft (B).
Intraoperative photographs of morbidity in a scapulectomy after radiation. Medial angle ap necrosis necessitated a contralateral
terephthalate aortic graft to reconstruct
the capsule, or osteoarticular allograft.
If a total resection of both the proximal humerus and the scapula (Malawar
type VI) is required, a constrained or
unconstrained humeroscapular prosthesis, which can have numerous complications, must be considered. The proximal
humerus also can be reconstructed with
an allograft prosthetic composite coupled to a scapular prosthesis.
23,24,27
Scapulectomy
Scapulectomy is a shoulder-level resection alternative to amputation for rare
indications mostly caused by a tumor
involving only the scapula or infection
that has so devitalized the periscapular soft tissues as to render the scapula
unsalvageable. Syme28 originally described his experience with the procedure in 1857 and discussed many of the
same complications seen today—major wound dehiscence and severe loss
of strength in the shoulder girdle
19,29, 30
(Figure 12).
The patient can be positioned either
prone or lateral for this procedure; however, the author of this chapter prefers
to drape the arm with the patient in a
prone position to facilitate adduction
and internal rotation of the limb and
to bring the inferior angle of the scapula dorsally. The technique involves an
incision that begins at the lateral edge
of the acromion and follows in line with
the Judet approach to scapular fixation.30 The incision traverses medially
to the medial angle and then courses
distally to meet the inferior angle. The
trapezius, rhomboid, and levator muscles are then transected, and the arm
is brought into adduction and internal
rotation behind the patient’s back to
deliver the inferior angle of the scapula. The inferior angle is then placed on
tension with a bone hook, and the latissimus dorsi is transected. The dissection
then continues along the subscapular
space to its medial capsular extent. At
this point, the supraspinatus, infraspinatus, and serratus muscles are divided,
and the proximal trapezius is divided
from the scapular spine and the acromion. Elevating the specimen dorsally
then brings the brachial plexus and the
axillary vessels into view and allows
ligation of the superficial cervical, descending scapular, and suprascapular
vessels and the suprascapular nerve. The
acromioclavicular joint is then disarticulated, and the coracoclavicular joints
are transected to allow delivery of the
scapula. After the conjoined tendon is
detached, the specimen is delivered to
the back table. Soft-tissue remnants
can then be used to stabilize the clavicle with a transosseous suture or suture
anchors and, in a similar manner, stabilize the acromial remnant and create a
deltoid suspension. The flaps are closed
over a minimum of two drains, and the
wound is covered with an incisional
negative-pressure wound dressing with
a compressive elastic wrap. The author
of this chapter prefers to allow scar tissue to form for 7 to 14 days to minimize
the risk of hematoma and seroma. Patients are asked to wear a compressive
shoulder sleeve for 4 to 6 weeks.
Claviculectomy
Paratracheal, esophageal, and other neck
malignancies are the usual indications
for clavicular resections.31 Occasionally,
it will be necessary to perform a partial
or complete resection of the clavicle for
isolated chondrosarcoma of the clavicle
or osteomyelitis after radiation for other
neoplasms. The procedure is relatively
simple, with an incision that follows the
anterior border of the clavicle from the
sternoclavicular joint to the acromioclavicular joint. Dissection begins medially by dividing the sternocleidomastoid
muscles in a fashion that allows identification and protection of the external
jugular vein. Next, the dissection proceeds laterally with transection of the
trapezius and deltoid insertion on the
superior clavicle. The acromioclavicular
joint is then disarticulated, and the
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
283
Section 2: Upper Limb
conoid and trapezoid ligaments are divided. The work then proceeds medially
again under the clavicle; this is greatly
facilitated by using a forceps to elevate
the medial edge. This process usually
brings the subclavius muscle into view,
which often is resected with the tumor
because the margin is usually very close
along the subclavian artery and vein.
The sternoclavicular joint is disarticulated, and the clavicle is removed. Dead
space is mitigated by careful, layered
closure over drains. No attempt is made
to reconstruct the clavicular strut.31 As
with a scapulectomy, the author of this
chapter prefers to allow scar tissue to
form for 7 to 14 days; postural exercises
are then started to emphasize rhomboid
and periscapular strength to “open up”
the thoracic outlet.
Summary
Shoulder-level amputations are complex
and challenging surgical procedures. To
provide optimal patient care, the surgeon must understand the indications
for such procedures along with limb
salvage alternatives. Complications are
frequent and often require creative solutions, including local or free flap coverage. Although these procedures entail
loss of function and disfigurement,
they offer the patient the potential for
disease-free survival or recovery from
a massive traumatic injury.
References
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14. Enneking WF, Dunham W, Gebhardt
MC, Malawar M, Pritchard DJ: A
system for the functional evaluation
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surgical treatment of tumors of the
musculoskeletal system. Clin Orthop
Relat Res 1993;286:241-246. Medline
15. Kumar D, Grimer RJ, Abudu A, Carter SR, Tillman RM: Endoprosthetic
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16. Marcove RC, Lewis MM, Huvos
AG: En bloc upper humeral interscapulo-thoracic resection: e Tikho-Linberg procedure. Clin Orthop
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17. Voggenreiter G, Assenmacher S,
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18. Linberg BE: Interscapulo-thoracic
resection for malignant tumors of
the shoulder joint region. J Bone Joint
Surg 1928;10:344-349.
19. Nakamura S, Kusuzaki K, Murata
H, etal: Clinical outcome of total
scapulectomy in 10 patients with primary malignant bone and so-tissue
tumors. J Surg Oncol 1999;72(3):130-
135. Medline DOI
20. Weiland AJ, Moore JR, Daniel RK:
Vascularized bone autogras: Experience with 41 cases. Clin Orthop Relat
Res 1983;174:87-95. Medline
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Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
284
Chapter 22: Amputations About the Shoulder: Surgical Considerations
Deciencies: Surgical, Prosthetic,
and Rehabilitation Principles, ed 3.
Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2004,
pp 251-261.
22. Damron TA, Rock MG, O’Connor
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Ovost E, Poyn B, Trouilloud P: e
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S, Ishii S: Reconstruction and limb
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free vascularised bular gra. J Bone
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25. Capanna E, Giunti A, Biagini R,
Ferruzzi A: Modular endoprosthesis
for humerus and Tikho-Linberg
resection, in Yamamuro T, ed: New
Developments for Limb Salvage in
Musculoskeletal Tumors. Tokyo,
Japan, Springer, 1989, pp 547-555.
26. Clarke A, Dewnany G, Neumann L,
Wallace WA: Glenothoracic fusion:
An adjunct to radical scapulectomy.
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535. Medline
27. Mankin HJ, Gebhardt MC, Jennings LC, Springeld DS, Tomford
WW: Long-term results of allogra
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bone tumors. Clin Orthop Relat Res
1996;324:86-97. Medline DOI
28. Syme J: On disarticulation of the
scapula from the shoulder-joint.
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29. Rodriguez JA, Craven JE, Heinrich
S, Wilson S, Levine EA: Current
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30. Das Gupta TK: Scapulectomy:
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© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
285
Chapter 23
Amputations About the Shoulder:
Prosthetic Management
Branden Petersen, BS, CP
Abstract
e complex functionality of the natural shoulder, elbow, wrist, and hand are awe inspiring, both individually and as a collective whole. e coupling of accurate, coordinated
movements with sensory input provides humans with an amazing instrument to perform
intricate functions. Replacing the exquisitely designed complex structure at and distal to
the natural shoulder region with a mechanical prosthesis presents many challenges. e
short lever arm, involvement of multiple joints, and diminished excursion capabilities
create functional limitations in a prosthesis and oen dictate the selection of components.
ere are many possible presentations of amputations in the shoulder region that require
prosthetic management; some of the most common are humeral neck amputation, glenohumeral disarticulation (shoulder disarticulation), and interscapulothoracic amputation.
Socket design, interface materials, suspension methods, alignment, and component
considerations can aect the successful use of a prosthesis in the shoulder region and must
be carefully considered. ere are several approaches to prosthetic management, including
no prosthesis use; protective shoulder caps; and passive, adaptive, body-powered, hybrid,
and externally powered systems. All aspects of prosthetic management should be discussed
with the amputee during his or her initial evaluation.
Keywords: brachial plexus injury; forequarter; glenohumeral
disarticulation; humeral neck amputation; intercalary amputation;
interscapulothoracic; pattern recognition; shoulder disarticulation;
targeted muscle reinnervation; Tikhoff-Linberg resection
Introduction
Amputations in the shoulder region are
relatively uncommon and are generally
related to malignant lesions, trauma,
and congenital etiologies.
plete loss of an upper limb is a substantial loss. Replacing that exquisitely
designed natural limb with a mechanical limb presents many challenges, including short lever arms, multiple joint
involvement, and diminished excursion
capabilities.
3,4
In addition, proximal
amputation levels can limit componentry selection and may require the use
Neither Mr. Petersen nor any immediate family member has received anything of value from or
has stock or stock options held in a commercial company or institution related directly or indirectly
to the subject of this chapter.
1,2
The com-
of externally powered components for
improved functional outcomes.5 Indi
viduals with shoulder-level amputations
often reject the use of a prosthesis for
a variety of reasons, including socket
discomfort, lack of heat dissipation, the
weight of the prosthesis, and displeasing
appearance.
6-8
Based on the literature,
the overall rejection rate for a high-level
upper limb prosthesis ranges from 32%
to 65%.
6-10
However, with advances in
modern socket designs and materials,
many of these rejection factors have
been addressed.
Figure 1
vidual with an amputation at the level of the
humeral neck.
Clinical photograph of an indi-
Amputations and deficiencies in the
shoulder region present in a range of
configurations; however, this chapter
will focus on humeral neck amputation,
glenohumeral (shoulder) disarticulation,
and interscapulothoracic (forequarter)
amputation. These levels of amputation
differ in their clinical presentation but
are managed prosthetically in a very
similar fashion.
-
Amputation Levels
3
Amputations and deficiencies about
the shoulder region present differently
and require different fitting considerations.11 It is important to understand
the unique clinical presentations and
functional capabilities of each level of
amputation when designing a prosthesis
for the shoulder region.
Patients with an amputation at the
level of the humeral neck typically have
an intact glenohumeral joint and a considerably shortened residual humerus
(Figure 1). Because the residual limb
does not have the necessary length to
be fitted with standard transhumeral
socket designs, thoracic-style sockets
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
287
Section 2: Upper Limb
Figure 2
vidual with a glenohumeral disarticulation.
Clinical photograph of an indi-
are generally chosen. A glenohumeral
disarticulation is an amputation through
the glenohumeral joint or a disarticulation of the humeral head from the
glenoid cavity (Figure 2). Individuals
with an interscapulothoracic amputation have undergone complete removal
of the shoulder girdle, including the
scapula and the lateral two-thirds of
the clavicle (Figure 3).
Evaluation
The initial stage in designing a prosthesis requires a comprehensive patient
evaluation. This evaluation is essential
to the development of the most appropriate prosthetic prescription to meet
an individual patient’s psychosocial and
functional needs. Prosthetic components should be matched to the patient’s
physical characteristics, customary activities of daily living, and vocational
goals. The physical findings from the
residual limb examination as well as any
associated injuries must be considered.
The rehabilitation team should take
great care in gathering the necessary
information during the evaluation and
design of the prosthesis.
information on the amputation level,
the characteristics of the residual limb,
the location of scarring, preinjury hand
dominance, the results of myoelectric
and manual muscle testing, range of motion, and the presence of phantom pain
or sensation can assist in designing the
prosthesis, including component selection. Comorbidities, including diabetes,
12,13
Obtaining
Figure 3
vidual with a interscapulothoracic amputation.
Clinical photograph of an indi-
overuse symptoms, decreased functionality of the sound side, and any history
of neck and back pain, provide further
guidance in determining the most appropriate prosthetic approach.
A thorough understanding of the patient’s work-related tasks also is necessary in designing the prosthesis. In some
instances, a visit to the patient’s worksite
may be necessary to better understand
vocational requirements and justify the
components being provided. In other
cases, the patient may be transitioning
to a new occupation. Understanding
the requirements of current and future
vocational goals is an important consideration in prosthetic design.
The clinical evaluation lays the foundation for selecting the design and control of the prosthesis. During the patient
evaluation process, the conceptual design of the prosthesis begins to develop.
The size, shape, and features of the socket for the shoulder region become apparent based on the needs and abilities of
the individual. For example, if a patient
has an amputation at the humeral neck
level, the use of the movable humeral
head to activate force-sensitive resistors
or switches is a consideration in the
design of the prosthesis. Alternatively,
strong, distinct muscle contractions allow for the consideration of myoelectric
control strategies. Taking into account
the individual’s unique capabilities to
control the prosthesis helps in the creation of a device that more easily permits
intuitive learning.
Figure 4
anterior proximal casting compression techniques commonly used in modern thoracic
level sockets. (Courtesy of J. Thomas Andrew,
CP, FAAOP, Ability Prosthetic Systems, Salt Lake
City, UT.)
Superior photographic view of
Shoulder Region
Socket Design
Socket designs for the shoulder region
have substantially evolved from the
original bucket-style sockets, which
encompassed the entire shoulder proximally, extended 6 inches distally from
the axilla, and wrapped around nearly to the midline of the torso in their
anterior and posterior dimensions. The
contributions of many clinicians and
researchers have reduced the bulk of
these sockets, improved heat dissipation, enhanced suspension, incorporated advanced materials, and refined
harnessing techniques.
When designing a socket for the
shoulder region, the clinician must consider the type of prosthesis, heat dissipation, suspension, stability, comfort, and
frame placement. The prosthetic socket
can be evaluated in the following five
critical support areas: anterior proximal,
posterior proximal, lateral wall, anterior distal, and posterior distal. A critical
evaluation of these five support areas
with respect to suspension, soft-tissue
loading, force couples during prosthesis
use, comfort, and stability will collectively provide the framework for design
of a prosthetic socket for the shoulder
region.
During the molding process, it is
necessary to provide anterior proximal
compression over the pectoralis and
14-16
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
288
Figure 5
vidual demonstrating that with the shoulder
joint exed and gravity acting on the humeral
section and forearm, a rotational torque is created on the socket (curved arrow). The torque
force couples experienced are located in the
posterior proximal (PP) and anterior distal (AD)
aspects of the socket interface during exion
activities and require socket support.
Clinical photograph of an indi-
infraspinatus muscles (Figure 4). This
compression creates a wedge shape that
assists with suspension, axial loading,
rotational stability, and maintaining
electrode contact in externally powered
prosthetic designs. The anterior socket
trim line is typically located inferior to
the clavicle for improved comfort. The
posterior proximal trim line is located
over the supraspinatus and is responsible for load bearing as well as reducing
distal migration of the socket. The lateral wall connects the proximal and the
distal sockets. This area assists with the
transfer of forces to the inferior aspect
of the socket. The lateral wall is generally 3 to 5 inches wide, assists with
soft-tissue containment, and broadens
the surface area of the socket for force
transmission.
Chapter 23: Amputations About the Shoulder: Prosthetic Management
the laminated surface created difficulties
in maintaining socket position. With the
development of frame-type sockets, the
laminated sockets were largely replaced
by flexible thermoplastic inner sockets.
The flexible thermoplastic material
provided greater friction and improved
comfort compared with laminated sock-
Figure 6
wearing a frame-type socket with a exible inner socket material and an external laminated
frame. The exible thermoplastic inner socket
material provid es greater friction an d improved
comfort compared with laminated sockets.
Photograph of an individual
ets (Figure 6).
In recent years, there has been a shift
from traditional thermoplastic socket
interfaces to silicone rubber materials.
A high consistency rubber (HCR) silicone socket offers several advantages
over thermoplastic materials. It can be
manufactured to the desired thickness
Socket torque increases when the
shoulder or elbow joint is flexed. The
resultant torque produces force couples at the anterior distal and posterior
proximal aspects of the socket interface
(Figure 5). The anterior distal and posterior proximal socket regions assist
with torque stabilization and should
be dynamically simulated during diagnostic socket fitting to ensure that
the necessary force couple support has
been achieved. In contrast, because of
the predominance of the force couple
previously described, the posterior distal aspect of the socket can be reduced
to a smaller area of support. This area
of the socket generally assists with rotational stability and is useful in activities
involving shoulder and elbow extension.
and stiffness (shore durometer), allowing
the prosthetist to have localized control
over the physical properties of the socket construction. The HCR silicone socket design for a shoulder disarticulation
generally includes an over-the-shoulder
strap that is integrated into the silicone
(Figure 7). This strap, coupled with the
high coefficient of friction of HCR silicone, helps prevent distal migration of
the prosthesis that could occur during
use. The strap fits the contour of the
shoulder exactly and is soft and flexible
so it moves with the patient to provide
greater comfort than other strap materials used in this application. Because
the HCR silicone is custom pigmented
to approximate the general skin tone of
the amputee and the strap is continuous
with the inside surface of the socket, the
Socket Material Selection
The selection of appropriate socket interface materials is a critical factor in
the overall successful application of a
prosthesis for the shoulder region. In
general, socket interface materials with
a higher coefficient of friction assist in
maintaining the position of the socket
on short residual limbs. Securing the
position of the socket assists in maintaining the optimal mechanics of the
prosthesis.
In the past, rigid, laminated hard
sockets were commonly used; however, the low friction characteristics of
cosmetic appearance is good. To provide greater comfort in the transition
area from a rigid structure to a patient’s
body, the HCR silicone socket is made
to extend farther than the composite
frame to which it is attached. If there
are particularly sensitive or bony areas
that require additional cushioning, silicone gel pads can be integrated into the
HCR silicone to provide excellent padding for improved comfort and function.
This feature is especially useful when
a hybrid or body-powered prosthesis
is used, because high forces may be
needed for activation.
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
289
Section 2: Upper Limb
Figure 7
custom, high consistency rubber (HCR) socket
for a myoelectric shoulder disarticulation prosthesis. Note the HCR axilla padding. (Courtesy
of Jack Uellendahl, CPO, Hanger Clinic, Austin,
TX.)
Photograph of a patient with a
Component Setup
Considerations
Proper component selection and setup
is key to the successful use of a prosthesis. When designing a prosthesis for the
shoulder region, the device is essentially
fabricated twice—once during an expedited provisional fitting to evaluate
the function and biomechanics of the
prosthesis and then a second time in
the form of the definitive prosthesis.
The initial provisional fitting involves
evaluating the fit of the test socket, the
location and alignment biomechanics of
the components, the harness design, the
configuration of the control inputs, and
the consistency of the resultant control.
After these factors are deemed satisfactory, the definitive prosthesis is fabricated
based on the provisional template.
Several factors should be considered
with respect to the prosthetic shoulder
joint. Many individuals benefit from a
shoulder joint that allows free swinging in the sagittal plane. The freeing
of the shoulder joint affords improved
posture and gait, decreases extraneous
body motions to accomplish certain
tasks, and diminishes the forces on the
individual’s residual limb.17 Free swinging shoulder joints should be aligned
perpendicular to the ground and in 10°
to 15° of internal rotation for improved
midline positioning. For individuals
with amputations at the level of the
humeral neck, the prosthetic shoulder
joint is sometimes placed inferior to the
humeral neck. Although this placement
does not provide a natural appearance,
it allows the weight of the components
to be situated closer to the body and
reduces the torque and lateral bulk of
the prosthesis.
4
Prosthetic elbow alignment also has
key considerations. The elbow joint
is typically placed to approximate the
center of the sound side elbow joint or
slightly more proximal. The more proximal placement of the elbow joint center
decreases the pendulum effect perceived
by the amputee and generally improves
the functionality of the prosthesis. In
addition, the more proximal placement
of the elbow joint allows improved seating capabilities in chairs with a side arm.
These benefits must be balanced against
a shorter prosthetic appearance, which
is often less cosmetically acceptable. For
improved functionality, the elbow joint
axis of rotation should be perpendicular
to gravity.
Because a prosthesis for the shoulder region replaces several joints, it is
desirable to use wrist components that
have multiple positioning capabilities.
For body-powered devices, flexion and
spring rotation wrist units are frequently
used to improve the individual’s ability
to place the terminal device in multiple
positions during midline tasks. For externally powered devices, electric wrist
rotation is a consideration in individuals with a unilateral amputation and an
essential component for those with a
bilateral upper limb amputation.
With respect to prosthetic suspension, there are several variations of chest
strap harnesses. Harness designs for the
shoulder region can be challenging and
elaborate depending on functional and
suspension goals. However, the chest
strap is the most commonly used harness to prevent socket displacement.
Prosthetic Approaches
The seven general categories for prosthetic approaches for the shoulder region
are as follows: no prosthesis; protective
shoulder caps; passive oppositional restorations; and adaptive, body- powered,
hybrid, and externally powered prostheses (Table 1). Because certain types
of prostheses are contraindicated for
some activities, an individual may require secondary prostheses to accomplish the many activities of daily living
and work-related tasks. Secondary prostheses are essential for individuals with
bilateral upper limb amputations.
No Prosthesis
Individuals with amputations about the
shoulder region comprise a small patient
population. In general, prostheses for
the shoulder region are less functional
and more likely to be abandoned when
compared with prostheses for moredistal amputation levels. Factors that
contribute to rejection of a prosthesis are
decreased functional benefit, socket discomfort, weight, heat retention, loss of
sensory feedback after the residual limb
is covered by the socket, and appear-
6,7
ance.
The choice of not using a prosthesis for the shoulder region should be
presented as an option. However, it is
also common for amputees to request
a prosthesis several years after amputation because of overuse symptoms in
the sound-side upper limb. Although
overuse syndrome does not affect all
amputees, this syndrome should be
discussed when options for prosthesis
use are presented.
Protective Shoulder Caps
Amputees often report improved security of their residual limb after it is covered and protected. A shoulder cap can
protect the residual limb from bumps
9,18
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
290
Chapter 23: Amputations About the Shoulder: Prosthetic Management
Tab le 1
Shoulder Region Prosthetic Options: Advantages and Disadvantages
Prosthesis Type Functionality Advantages Disadvantages
No prosthesis use Not applicable Heat dissipation
No harness
No socket comfort issues
Shoulder cap Restores shoulder
Oppositional passive
restoration
Adaptive Function for a specic
Body-powered Functional grasp and
VO = voluntary opening, VC = voluntary closing, EMG = electromyography.
shape and protection
Opposition function Lightweight
activity
elbow positioning
Small socket footprint
Lightweight
Protects sensitive residual limb
At the interscapulothoracic level,
assists with maintaining clothing
in position by shoulder shape
reconstruction
Restores a more natural slope and
appearance of the shoulder
Small socket footprint
Protects residual limb
Good cosmesis restoring body
image
Multiple glove type options
Restoration of functional limb
length
Simple design
Lightweight
Suited for a specic task
Lower cost
Low maintenance
Multiple activity-specic terminal
device options
Adaptive terminal devices could
be incorporated into a passive
body-powered or a myoelectric
prosthesis design
Lighter in weight than externally
powered prostheses
Possibility of a smaller socket
footprint
Multiple terminal devices available
(VO, VC, and adaptive)
Designed for heavy-duty tasks
Low maintenance cost
Mechanically simple
Water and debris resistance
Proprioceptive feedback through
the harness
Limitations for bimanual function
Residual limb protection limited
Increases potential for future development
of overuse syndromes
Balance
Requires a harness
Heat dissipation reduced
Small harness required
Low heat dissipation
Custom gloves costly
Poor o-the-shelf glove durability
Some devices are designed for one activity
and may not function well with other
tasks
Poor cosmesis
Specialty designs typically do not have the
appearance of a normal prosthesis
Requires body force and excursion to
function and is dicult for high-level
amputations
Poor cosmesis
Requires a harness for function
Highest energy expenditure for controlling
the prosthesis
Requires 4.5 inches of excursion coupled
with force for components to function at
end range.
Individuals with a shoulder region ampu-
tation have approximately 50% of the
excursion needed to bring components
to their end range of function, and those
with an interscapulothoracic level am-
putation have approximately 25% of the
needed operational excursion
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
291
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