Overview of Knee Disarticulation

Gerald Stark,BSME,CP,FAAOP

Knee Disarticulation
Advantages/Challenges Biomechanics Impression Techniques Interface Designs Knee Types

Knee Disarticulation Prevalence

0.7-2%1 20% in Some Centers2
Copenhagen Toronto

Superior Function Poor Cosmesis Most arent Optimized

Socket Design Alignment

Slowly Declining KD Numbers

Medicare KD Services
400 350 300 Num. of Services 250 200 150 100 50 0 1992 1993 1994 1995 1996 Year 1997 1998 1999 2000 2001 L5310-11 L5150

Knee Disartic Advantages

Dr. Pinzur, Loyola Univ. 2 Full Endbearing
More Physiologic than AK,BK

Longer Lever Arm Better Sitting Balance Self-Suspension

Lower Trimlines

Physiologic
Decreased Blood Loss Resistance to Infection

Growing Use in Children

Preserves Femoral Epiphysis Avoids Bony Overgrowth Direct Load Transfer Grows at a Slower Rate
Growth Restriction Fit as Transfemoral

Knee Disartic Challenges

Different than Transfemoral
Fewer Numbers

Less Cosmetic Length for Componentry

Limited componentry

Accommodate Bulbous End KC Proximal to Distal End

Surgical Techniques
Pat. Tendon Sutured to Cruciate
Retain Patella

Gastroc Wrapped Anterior for Pad Reduction Osteoplasty

Not for Vascular Patients

Sagittal or A-P Closure Gritti-Stokes Amputation IPOP Rarely Provided

Knee Disartic Biomechanics

Full Weight Bearing Fulcrum Under Knee
Center of Rotation Distal

No Prox. Weight Bearing

Non-ischial Wt. Bearing

Proximal Medial Pressures KD inverse of TF Lower Trimlines

Impression Taking
Self-Suspension & Load Bearing 50%-50% Load Bearing
Adjustable Stand

Volumetric Control
Not Applying Tension

Medial Wall Shaping No Ischial or Gluteal Wt Bearing

Cant Tolerate the Weight

Interface Designs
Molded Leather Medial Door Stovepipe-Pelite Buildup Pneumatic Pads or Sleeve Liner w/Suction Liner w/Lock Partial Suction w/TES Belt Segmental Socket w/Strap

Molded Leather Liner

Uncosmetic & Cumbersome Adjustable Contours Difficult to Make
Leather Liner

Adaptable Shape Creates Suspension

Different Tensions

Medial Door
External Strap & Door Volume Adjustable
Dont Need Pads

Condylar Shape Crucial Slightly More Complicated Full End Bearing Can use a Sock

Stovepipe-Pelite Buildup
More Bulky
Increased Wall Thickness

Easy to Use & Make More Enclosed More Padding Good for Bony Limbs Split Distal Cup over Condyles

Pneumatic Pads or Buildup

Pneumatic Pads Silicone Buildup Excellent Suspension
Superior Comfort

Difficult to Fix Volume Change Complicated Construction Thicker Wall

Liner w/Suction
Gel Liner w/ Leak Valve Distal Valve
Constant Leak Mini Valve in Attachment

Most Popular May Inhibit Weight Bearing Volume Dependent

Add Pads

Increases Distal Bulk

Partial Suction w/TES Belt

Hypobaric Sock w/ Valve Proximal Suspension
TES Belt Bulky; Could use SelfSuspension

Not as Volume Dependent Can use a Sock More End Bearing

Liner w/Lock
Liner w/ External Lock
Summit Lock~Coyote Designs

Ski Binding Lock Must Glue On External Hole Accommodate Volume Change

Segmental Socket w/Strap

Zettl Type-Growth Comp. 3 Distal End Cup Proximal Cuff
Expanding Bars

Supracondylar Straps Growth Compensation

Juveniles

Less Contact w/Skin

Knee Designs
External Knee Hinges Single Axis Knee Weight Act. Friction Control Polycentric Hinges Manual Locking Control Options
Friction Hydraulic Pneumatic

External Hinges
Less Cosmetic
Cumbersome, Damages Cloths

No Inherent Stability
Set More Anterior Dictated by KC

Back Check & Ext. Assist Leather Upper

Great Custom Fit Easy to Suspend Accommodates Bulbous End

Exoskeletal Variations

Polycentric
KD Specific Kinematics Smoother Movement Shin Shortening

Less Stability Required

Vertical Anterior Link

Longer Posterior Link

Greater Translation

Proteval Acphapend
More Proximal More Anterior Descends Distally More Voluntary Control Some Involuntary Stability

Century 22 Total Knee

Very Proximal Center Descends Rapidly Lock Mechanism
Toe Moment Needed

Easy Moving 15 mm Clearance

Enhanced Voluntary Control

Proximal Centrode Moves Anterior Easy to Flex Does not Lock Patient Triggered 4-Bar 24mm Clearance

Control Options
Friction Control
Mechanical Spring

Hydraulic
Hosmer Yoke

Pneumatic Manual Locking Knee Stance Flexion Control

References
1) Bennet, A, Limb Prosthetics, 6th edition, Demos Publications, New York, NY, 1989. 2) Pinzur, M., Chapter 19A: Knee Disarticulation/Surgical Procedures, Atlas of Limb Prosthetics, 2nd Edition, Mosby Year book, St. Louis, MO, 1992. 3) Michael, J., Chapter 19A: Knee Disarticulation/Prosthetic Management, Atlas of Limb Prosthetics, 2nd Edition,, Mosby Year book, St. Louis, MO, 1992. 4) Jennings, J., Wontorcik, L., Fitting a Knee Disarticulation as a BK Utilizing the ALPS Locking Pin as a Pseudo-Tibial Lever: A Single Case Review, Journal of Prosthetics & Orthotics, 1998, Vol. 10, Num. 1, pp. 7-10. 5) Kempfer, J. Technical Note: Thermoplastic Use in the Geriatric Knee Disarticulation Prosthesis Num. 1, pp. 38-40.

, Journal of Prosthetics & Orthotics, 1991, Vol. 3,