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 PROSTHETICS
• A Hip-Disarticulation consist of the removal of the
“Trying
entireto
legovercome the loss
at the hip joint of three
and results weight-bearing
in the loss of 3 joints, rather
thanmajor
onelimb
or joints:
two, Theis ankle,
extremely
the kneecomplicated.
and the hip Living with a
joint
transfemoral amputation is about 10 times as tough as living with a
• Douglasamputation,
transtibial G. Smith, MDand living in
comments with a hip- or pelvic-level
an article
in the magazine
amputation is perhaps 100 times
In-Motion: … harder. Walking, standing, and
even sitting balance – something that most of us take for granted –
are greatly affected by amputations at the hip or pelvis”
 PROSTHETICS

1. Malignant musculoskeletal tumors (most often in younger patients)

2. Limb ischemia (perivascular disease and complications to diabetes)
3. Trauma (such severe traumas often result in the death of the
patient)
4. Severe lower limbs infections (chronic skin or bone infection)
As a result. . . . . . .
 PROSTHETICS
• Most prosthetist have little experience with this type of amputation
• Only 20% of hip amputees use a prosthetic leg full-time (i.e. 8 to 12
hr./day)
• From these 20%, only a small minority use a prosthetic leg without a
cane or crutch
• This small minority of full time users without walking aids consists
primarily of the young patients with malignant tumors.
• There is a persistent belief within the medical community that most
middle aged hip-disarticulation amputees will ambulate with crutches
or a wheelchair only!!!
I REMEMBER CLEARLY THE SURGEON EXPLAINING TO ME, AS I WAS SIGNING THE CONSENT* PAPERS PRIOR
TO THE SURGICAL PROCEDURE, THAT I WAS GOING TO SPEND THE REST OF MY LIFE ON CRUTCHES

* Consent is is a bit of a misnomer as I had to choose between 1) hip-disarticulation or 2) slowly dying from infection or 3) slowly dying from the I.V. Vancomycin (antibiotic of last resort) eating my body away.
 PROSTHETICS
• I am not an athlete (165lbs/5’11”), and certainly not young (52+),
yet…..
• I am a full-time user AND I walk without a cane and…
• I live a full life and do just about everything I want.
• Granted, there are some limitations. Yes, I can’t play tennis anymore.
Big deal! Yes, I can’t ride motorcycles anymore. That, I do miss indeed
but it’s not the end of the world.
• Is the prosthesis comfortable? Hell no! But it beats using crutches all
day.
• Biggest problem with using crutches is that we loose the use of our
hands. People are always surprised when I say this. What I mean is
that we cannot carry things easily when using crutches.
 PROSTHETICS
• The key to success is to become deeply involved in the process.
• It is easy to believe that “This is as best as it can be!”. These highly trained professional
prosthetists have done their best but I still can’t walk with the damn’ leg. It hurts, I keep
on falling (This I did. 3 broken wrists, 1 rib…). Therefore, I must be the problem. I am not
just good enough. I am too old. I am not trying hard enough. I am too weak, etc…
• True! This highly trained professionals try hard but…
• They lack experience in this domain.
• They don’t have the time to do it right and,
• These types of prosthetic legs are finicky to set up. It takes days of incremental
adjustments to get it just right. (i.e. Efficient to use (not tiring) and stable)
• For example, on my current leg, there are 44 set-screws and other
adjustments, all interacting with each other, altering the geometry and other
parameters of the leg.
PROSTHETICS - SOCKET
• The first socket was a disaster. Eventually, my prosthetist relented and accepted to build a second
one at no cost. Including many modifications I had suggested during numerous discussions.
• This socket is much better but by no mean GOOD.
• From what I have read in several technical articles, it could be much better.
• The problem consist of:
• 1) Finding a prosthetist, that actually knows what he is talking about. Not so easy, as they all claim to
be experts….
• 2) COST. For most non amputees, it is always a surprise. A socket cost around $12,000! (Yes, you are
reading right!) and, the icing on the cake is… MOST insurances do not pay at all, or pay only a minor
fraction of the cost. Prosthetics are included in insurance contracts under durable medical
equipment*. YES, it is covered but maximum payment is limited to……. $2,000/year. Nobody check
these things unless… they lose a limb.
*BTW: I wish they were durable. I have yet to find a knee that last more than 2 years!!
Note: I did the strapping system and ratchet buckles. The dimensions
of the straps are critical in maintaining the proper shape of the socket.
Earlier system used fabric straps that used to stretch over time. Deep recesses over the iliac crest
provides positive support, limiting
“pumping” and increasing toe
PROSTHETICS - SOCKET clearance (my idea)

Triple ski-boots type ratchets and

straps providing a TIGHT fit of the
socket around the pelvis for
improved “feel” and control

Non stretchable heavy duty

Carbon Fiber Socket straps preventing change in
socket geometry with time

Otto Bock 7E7 hip

Side View joint (titanium) Back View
 PROSTHETIC COMPONENTS
The cost of prosthetic components is just astronomical

A typical knee will cost between $10,000 and $30,000

A “computerized” knee between $30,000 and $40,000

A foot between $2,000 and $5,000

A typical pyramid adapter $400 (Al) or $800 (Ti)

PROSTHETIC COMPONENTS
$30,000
TEH-LIN Knee
GRAPHLITE frame
ENDOLITE hydraulics
A few bits or carbon fiber
A handful of ball bearings
A simple hydraulic cylinder
Curb weigh 5lbs
2014 CHEVROLET MALIBU
Incredibly complex machine with thousands of parts. The
results of a century of research in advanced materials and
complex alloys with cutting edge electronics and
unparalleled durability with minimum service. 4-cylinder
2-liter 259HP turbocharged engine, 6 speed automatic
transmission, curb weight 3,547lbs
MAKE SENSE DOESN’T IT?
 HD PROSTHESIS
The first challenge with a hip disarticulation
(HD) prosthetic leg is:
WHERE TO LOCATE THE HIP JOINT?

The Canadian-Type HD prosthesis was

developed in 1954. The hip joint is located
on the front of the socket. It is connected Single Equivalent Force
to the knee joint with an angled tube in (~Projection of CG)
such a way that the axis of the knee is
posterior to the single equivalent force.
 HD PROSTHESIS
Knee Axis

Single Equivalent Force

(Projection of CG)
HD PROSTHESIS 1 The knee axis is posterior to
the SEF line. The resulting
moments will force the knee
to bend in the direction
indicated by the arrows.

Knee Axis

Knee Joint
2 However, the knee is already
fully extended and cannot
extend further.

3 THE KNEE IS STABLE

SEF
HD PROSTHESIS 1 The SEF line is posterior to
the knee axis. The resulting
moments will force the knee
to bend in the direction
indicated by the arrows.

Knee Axis

Knee Joint
2 The knee will buckle under
load.

3 THE KNEE IS UNSTABLE

SEF

ALIGNMENT is the process of

setting up the geometry of the leg
 THE BIOMECAHNICS OF AN HD PROSTHESIS*

Bump stop in hip

joint helps bending
Note that at heel strike the knee
the knee is almost
unstable. AK amputees
use their extensor SEF posterior to
muscles to increase knee axis. The knee
stability. HD amputees bends.
CAN’T!!

* From Charles W. Radcliffe

 PROSTHETIC COMPONENTS
Hip Joint (Ti)
Male/female pyramid
Adapter to refine hip/knee GRAPHLITE/ENDOLITE
Geometry (Ti) Single Axis Knee Height adjustable OSSUR Flex Foot
Sliding adapter (Ti) (Carbon Fiber)
adapter (Ti)

Angled pyramid adapter (15°) (Ti)

Knee rotator
(Critical for driving)
Sliding adapter (Ti)
 Single axis knees are not recommended for HD prosthesis. True but,
A WELL ALIGNED single axis knee works very well in an HD prosthesis

Hip Joint (Ti)

Male/female pyramid
Adapter to refine hip/knee GRAPHLITE/ENDOLITE
Geometry (Ti) Single Axis Knee Height adjustable OSSUR Flex Foot
Sliding adapter (Ti) (Carbon Fiber)
adapter (Ti)

Angled pyramid adapter (15°) (Ti)

Knee rotator
(Critical for driving)
Sliding adapter (Ti)
 HD Prosthesis using the TEH-LIN TGK-5PSO Polycentric 5-Bar
Pneumatic knee with adjustable centroid

Pylon (al)
OSSUR Reflex VSP
Offset adapter (Ti) Foot
THE-LIN 5-BAR KNEE CARBON Pylon
with Ti adapter

Angled pyramid adapter (10°) (Ti)

Knee rotator
(Critical for driving)

Carbon Shock Absorber

 KNEE JOINT

HD – TOE CLEARANCE

L
FOOT

l
T
GROUND FLOOR
 KNEE JOINT

HD – TOE CLEARANCE
Toe Clearance T
Toe clearance is always an issue for all above knee T = R-L
(AK) amputees and a very big issue for HD 𝑻= 𝒍𝟐 + 𝑳𝟐 − 𝑳
amputees.
If the toes hit the floor during the swing phase, the
knee may not lock at heel strike and buckle under
load, resulting in a fall.
AK amputees have good control of their prosthetic
knee and the interface socket/stump provides
enhanced proprioception. HD amputees do not!
To minimize such event, it is customary to shorten FOOT
the prosthetic leg. However, this results in a non
symmetrical gait and pronounced limp.

T
GROUND FLOOR
HD – TOE CLEARANCE
30
One way to minimize the toe clearance is to

C (mm)
increase L. Clearance C as a function of L C
28
The graph shows that by increasing L by
200mm, we gain 8mm of toe clearance. That
may not sound a lot but I can clearly feel a 26
change of 1 or 2mm in length.

However, for practical and cosmetic reasons, 24

L=500-700mm
we want the prosthetic knee to be at the
same level as the “good” knee and for the
22
same reasons we want the prosthetic foot to
be the same size as the good foot.
20

SO, WHAT DO WE DO? l=170mm

L (mm)
18
500 520 540 560 580 600 620 640 660 680 700
HD – TOE CLEARANCE
Centroid
THE POLYCENTRIC KNEE Trajectory

All polycentric knees commercially available are 4-bar designs.

The “5-bar” knees are 4-bar knees with adjustable geometry.

In the 4-bar linkage A-B, C-D, the rotation center of the segment Centroid
B-D relative to A-C is located at the intersection the lines passing
through A-B and B-D. This virtual center of rotation is called
the centroid (or centrode by the O&P community)
The centroid is not fixed but is a function of the angle of
the knee. Note that the centroid moves in the vertical
direction AND in the posterior/anterior direction. This has

L > 500mm
important consequences in term of alignment and
stability.

The polycentric knee allows to increase the distance L

without moving the knee. It is possible to gain up to
10mm in toe clearance with some polycentric knees.
l=170mm
 KNEE JOINT

HD – TOE CLEARANCE
Toe Clearance T
Or, we move the foot! T = R-L
𝑻= 𝒍𝟐 + 𝑳𝟐 − 𝑳
We need to build a foot/shin/knee
assembly in such a way that the toes
will rise in the final phase of the
swing.
Between α = 0 and α = α 1 , β < 90°
For α > α 1 β = 90° α
β = 90° under load α1 FOOT

β=90°

T
GROUND FLOOR
 KNEE JOINT

HD – TOE CLEARANCE
Toe Clearance T
Or, we move the foot! T = R-L
𝑻= 𝒍𝟐 + 𝑳𝟐 − 𝑳
We need to build a foot/shin/knee
assembly in such a way that the toes
will rise in the final phase of the
swing.
Between α = 0 and α = α 1 , β < 90°
For α > α 1 β = 90° α
β = 90° under load α1 FOOT

β=90°

T
GROUND FLOOR
 1P50R Hydracadence II

HD – TOE CLEARANCE
Such a knee/foot system exists. PROTEOR, a French
manufacturer developed such system: The 1P50R
Hydracadence II.

Unfortunately, PROTEOR is poorly distributed in the US.

Nevertheless, I managed to convince my prosthetist to
order such a knee and… what happened then is a disgrace.

The knee was defective, we couldn’t get tech-support in

English, they did not answer any request and eventually
blamed the prosthetist for the faulty knee demanding
$2,000 for repair.

Made me proud to be French!

 1P50R Hydracadence II
HD – TOE CLEARANCE
The 1P50R Hydracadence II is a single axis hydraulic knee.
The coupling between knee angle and foot angle is
hydraulic. In addition, to its unique ability to improve toe
clearance, the system provides a smoother and safer
transition to load bearing at heel strike. It is a very clever
system and it’s a shame that their service and support is so
poor in the US.

I propose to build a similar system using a simpler

mechanical coupling between knee and foot with the
following requirements:

Toe rise for 0 < α < α 1 (terminal phase of swing)

and
rigid foot/knee coupling (90°) for α = 0 and α > α1
HD – TOE CLEARANCE
The kinematics of a hip-joint/knee/foot with such requirements
is beyond the paper and pencil approach.

Three possibilities
1) LEGO
YES! I hear you laughing but you would be surprised to see what can be done with the LEGO technics pieces. I even
built a functioning clock escapement to impress the kids. (Photos lost unfortunately)
2) COMPUTER MODELING
There are many software solutions. However, most are designed for the professional community and very
expensive. In addition, the learning curve with such programs is extremely steep. GOOGLE created SKETCHUP, a
FREE 3D modeling package. It is powerful yet, relatively easy to learn. SKETCHYPHYSICS is a free plugin for
SKETCHUP based on the NEWTON SDK physics engine from NEWTON GAME DYNAMICS. SKETCHYPHYSICS is VERY
buggy but… it is FREE.
3) DO THE MATHS
Solve analytically the motion of each part of the system (Major Trigonometric Cluster F*@!&). Then, simulate in EXCEL.
HD – TOE CLEARANCE – KINEMATICS MODELING

First test of kinematics modeling with Google Sketchup and Sketchyphysics. Sketchup was primarily designed for
architects but can be used for other applications. 3D modelling is never easy but Google developed a user friendly
interface. Sketchyphysics on the other hand is obscure and buggy but is the only free application I could find.
Four-Bar Linkage Animation using Google Sketchup and Sketchyphysics Plug-In
Four-Bar Linkage Animation using Google Sketchup and Sketchyphysics Plug-In
Four-Bar Linkage Animation using Google Sketchup and Sketchyphysics Plug-In
Four-Bar Linkage Animation using Google Sketchup and Sketchyphysics Plug-In
Four-Bar Linkage Animation using Google Sketchup and Sketchyphysics Plug-In
Four-Bar Linkage Animation using Google Sketchup and Sketchyphysics Plug-In
Four-Bar Linkage Animation using Google Sketchup and Sketchyphysics Plug-In
HD – TOE CLEARANCE – KINEMATICS MODELING
Model or a 5-bar linkage KERKYTHEA is extremely
modelled in Sketchup8 and powerful. It is free and…
Rendered in KERKYTHEA TOTALLY user UNFRIENDLY…
Model or a 5-bar linkage KERKYTHEA is extremely
modelled in Sketchup8 and powerful. It is free and…
Rendered in KERKYTHEA TOTALLY user UNFRIENDLY…
Model or a 5-bar linkage KERKYTHEA is extremely
modelled in Sketchup8 and powerful. It is free and…
Rendered in KERKYTHEA TOTALLY user UNFRIENDLY…
Model or a 5-bar linkage KERKYTHEA is extremely
modelled in Sketchup8 and powerful. It is free and…
Rendered in KERKYTHEA TOTALLY user UNFRIENDLY…
HD – KINEMATICS
TEH-LIN, a Taiwanese manufacturer, recently introduced
two 5-bar knees. These knees do not use a proper 5-bar
linkage but offer the possibility of altering the 4-bar
geometry and the centroid trajectory through the motion
of the knee.

It is difficult to measure accurately the geometry of the 4-

bar linkage and their documentation is rather vague on the
effect of the 5-th bar adjustment on knee stability and toe
clearance.

I proposed the following methodology to measure the

centroid trajectory for each knee.
HD – KINEMATICS MEASUREMENTS Adapter

1. Build a test jig consisting of a sheet of ½” plywood on a

stand and a pyramid adapter to support the knee
under test and a 30”x20” foam board
KNEE
2. Build a test foot made of a ½”x1 ½” piece of wood with
three 12mm holes at the normal toe and heel location
and a pyramid adapter Foam Board
3. Connect the test foot to the knee to be tested and
connect the knee to the test jig
4. Install 3 sharpies into each hole and bend the knee up
to 90° of flexion. Test Foot
5. Each sharpie will provide a record of the toe, leg, heel
trajectory.
6. Adjust the 5th bar and repeat the measurement on a
Test Jig
new sheet of foam board.
HD – KINEMATICS PROCESSING
1. Photograph each foam board (SONY DSLR on a tripod)
using a longer focal length (70mm) to minimize
geometric distortions.
2. Process the photos in Photoshop. (Straighten, crop,
normalize)
3. Digitize the curves using ENGAUGE, a freeware curve
digitizing programs (quite good too!)
4. Compute the data in Excel and calculate the centroid
trajectory and toe clearance for each 5th bar
adjustment.

PROJECT IN PROGRESS
The test jig and test foot have been built but no
measurement and processing have been done yet.
HD - ADDENDUM
HD – ADDENDUM (2)
HD ADDENDUM(3)
HD ADDENDUM(4)
TEH-LIN KK950 “FIVE”-BAR POLYCENTRIC KNEE
 x y D
4-Bar linkage
A 0 0 104.5 NOTE: The
Geometry
distance DC
B 103.3 15.9 60.1 is adjustable

KNEE KINEMATIC ANALYSIS C

D
58.3
12.6
-24
-21.4
45.8
24.8

The picture of the 4-bar polycentric prosthetic knee is The coordinates of the joints of the 4-bar linkage are
calibrated in dimensions using Photoshop. The axis measured relative to A, defined as the knee axis of
centered on the shank pylon is plotted, as well as the rotation. The angle of rotation of the knee is defined as
projection of the top pyramid adapter. (Scale 1:1) the angle of the pylon from vertical . (Scale 1:1)
 540mm

200mm
KINEMATIC ANALYSIS
Microsoft Excel

140

40

Shank Pylon

-60
-100 0 100 200 300 400 500 600

KINEMATIC MODELING – Base of Foot (Nominal Leg Length)

 540mm

200mm
KINEMATIC ANALYSIS
Microsoft Excel

140

40

Shank Pylon

-60
-100 0 100 200 300 400 500 600

KINEMATIC MODELING – TOES

KINEMATIC ANALYSIS
Some quick comments:
This is entirely done in EXCEL using video screen capture with VLC media player.

And YES! I did suffer and banged my head on the wall on a few occasions. However, I took the opportunity to
dramatically enrich my vocabulary in trigonometric obscenities… And do not let me into the cluster f#@*#! of video
codecs compatibles with just about nothing else….

1) Between 0° and 40°, the toes do not clear the floor.

2) The gain in toe clearance provided by the polycentric design is very small.
3) The centroid of rotation between 0 and 13 degrees of flexion is BELOW the reference axis!!! However, over the
same range, the centroid remains posterior to the reference axis providing added stability.

Note: The motion of each leg component is calculated from classic trigonometry. The centroid is calculated as the
center of a circle passing through three adjacent points of the trajectory.
KINEMATIC ANALYSIS 40

Toe Elevation Relative to Floor (mm)

Toe elevation
Between 0 and 40°, the apparent vertical
length of the leg exceeds the nominal Toe Circle
20
length (i.e. The toes do not clear the Floor
floor).

The blue curve represent the toes

0
elevation relative to floor for the
polycentric knee.

The orange curve represent the toes

-20
elevation relative to floor for a single axis
knee.

The gain in toe-clearance from the Flexion (°)

-40
polycentric knee is marginal. 0 5 10 15 20 25 30 35 40 45 50
Leg Vertical Length Variation as a Function of Knee Flexion
 5
KINEMATIC ANALYSIS

Difference Polycentric to Single Axis (mm)

The gain in toe clearance from the 4
Polycentric Knee between 0° and 40°
is less than 4mm.
3
The maximum is 3.8mm at 33° of
flexion.
2
The green curve represents the Difference Polycentric-Single Axis

difference in toe elevation relative to

1 Floor
floor between the polycentric knee
and a single axis knee.
Flexion (°)
0
NEXT STEP? VALIDATE THESE RESULTS 0 5 10 15 20 25 30 35 40 45 50
USING THE TEST JIG. NOT DONE YET.
HD - COMPONENTS
• The only way to evaluate and compare the capabilities of commercial prosthetic
components is to test them.
• However, as I explain earlier the cost of these components is astronomical. So, what do
we do?
• Thanks to EBAY, used components are affordable. The current market value of used or
even brand new prosthetic components is around 1 to 2 percent of the retail price.
• YES, YOU READ WELL. 1% TO 2% OF THE RETAIL PRICE!!
• Some examples below….
• TEH-LIN TGK5P00 KNEE MSRP $12,500 EBAY $175 1.4%
• TEH-LIN KK150 KNEE (BRAND NEW) MRSP $15,100 EBAY $160 1.1%
• MOBI OP4 KNEE (BRAND NEW) MSRP $11,000 EBAY $180 1.6%
HD - COMPONENTS

• The prices on EBAY are low today because the demand is low. WHY?
• Prosthetist do not and cannot use used components.
Apparently for insurance reason. Sounds like a good excuse to me, as they
make significant profit on the components.
• The prosthetic market is quite unique as the customer (the amputee)
doesn’t decide what components to use.
HD - COMPONENTS
• The customer has a good medical insurance. The prosthetist will order the
most expensive (not necessarily the most appropriate) components the insurance
accept to pay. If the leg doesn’t work, it will eventually end up on EBAY.
• The customer does not have medical insurance. The prosthetist will order
the cheapest components. Nevertheless, the leg will still cost $20,000 (AK).
The leg doesn’t work and the amputee will sell the components on EBAY.
• The customer does not have medical insurance and doesn’t have $20,000.
NO PROBLEMS! He can buy a pair of crutches at Walgreen for $20! Or,
beg at the traffic light. In less than 15 years, he will have enough money for
a leg… Unless he jumped under the 18-wheeler, of course….
HD - COMPONENTS

• Most customer have complete faith in their prosthetist. Coping

with the grief associated to recent limb loss and with no knowledge of prosthetic
technology and practices, the new amputee relies completely on the person with
the white lab coat talking with complicated words to put them back on two legs
again.
• The very large majority of prosthetists are honest and do the best they can for
their patients. However, they are human, often overworked and with their own
constraints.
• To become a Board Certified O&P practitioner is a 2-year degree, not 7 like an M.D.
Some are good and some are… “less good”.
 HD - COMPONENTS

• We have a large community of amputees in

the US (1.7 millions).
• 91% are lower limb amputees, most
resulting from vascular disease (66%) and
(20%) from trauma. Lower limb amputees
from vascular diseases often suffer from
additional conditions and may not be able
to use their prosthetic leg. In addition, they
have a high mortality rate. The leg Cause of Amputation in the US
components are sold on EBAY.
 HD - COMPONENTS

• Most amputees rely completely on their prosthetists.

• Prosthetists cannot use “used” components.
• There are over 1.5 millions lower extremity amputees in the US.
• Therefore, we have a market with a large supply and low demand.
As a result…….
PROSTHETICS
MY COLLECTION
ORTHO EUROPE ULTIMATE KNEE: Single
Axis – Adjustable hydraulic damping for
flexion and extension – Adjustable
weight activated stance control
 MOBI-OP4: Single Axis – GRAPHLITE TCG-PS0: Polycentric 5-bar with
Adjustable pneumatic damping adjustable centroid– Carbon fiber frame -
for flexion and extension – Adjustable pneumatic damping for flexion and
Weight activated stance control extension –stance flexion control ORTHO EUROPE: 2

PROSTHETICS

Partial collection of
prosthetic knees

ENDOLITE: Single Axis –

Adjustable hydraulic
damping for flexion and
extension – Weight
activated stance control OTTO-BOCK 3R60:
Polycentric–
Adjustable
hydraulic damping
for flexion and
extension – EBC for
stance flexion
ORTHO EUROPE: Single GRAPHLITE
Axis – Adjustable frame/ENDOLITE
hydraulic damping for cylinder: Single Axis –
flexion and extension – Adjustable hydraulic
Weight activated stance damping for flexion and
control extension
 PROSTHETICS

Partial collection
of prosthetic feet
 Pylons with integral
Pyramid Adapter

PROSTHETICS Carbon Fiber

Partial collection of
30mm prosthetic
pylons (aluminum
and carbon fiber) Carbon Fiber

Carbon Fiber

Carbon Fiber
Partial collection of various Adjustable Offset
pyramid adapter/tube Adapter (Titanium)
clamps. Mainly polished
Titanium, some Stainless
Steel and Aluminum. Adjustable Height
Adapter (Titanium)
Male Adapter
(Aluminum)
(Titanium)

Angled Adapter
for HD Prosthesis
(Titanium)