Computer Aided Manufacturing software Over the years, there have been advancements in artificial limbs. New plastics and other materials, such as
carbon fiber, have allowed artificial limbs to be stronger and lighter, limiting the amount of extra energy necessary to operate the limb. This is especially important for trans-femoral amputees. Additional materials have allowed artificial limbs to look much more realistic, which is important to trans-radial and transhumeral amputees because they are more likely to have the artificial limb exposed. In addition to new materials, the use of electronics has become very common in artificial limbs. Myoelectric limbs, which control the limbs by converting muscle movements to electrical signals, have become much more common than cable operated limbs. Myoelectric signals are picked up by electrodes, the signal gets integrated and once it exceeds a certain threshold, the prosthetic limb control signal is triggered which is why inherently, all myoelectric controls lag. Conversely, cable control is immediate and physical, and through that offers a certain degree of direct force feedback that myoelectric control does not. Computers are also used extensively in the manufacturing of limbs.
Computer Aided Design and Computer Aided Manufacturing are often used to assist in the design and manufacture of artificial limbs. Most modern artificial limbs are attached to the residual limb (stump) of the amputee by belts and cuffs or by
suction. The residual limb either directly fits into a socket on the prosthetic, or—more commonly today—a liner is used that then is fixed to the socket either by vacuum (suction sockets) or a pin lock. Liners are soft and by that, they can create a far better suction fit than hard sockets. Silicone liners can be obtained in standard sizes, mostly with a circular (round) cross section, but for any other residual limb shape, custom liners can be made. The socket is custom made to fit the residual limb and to distribute the forces of the artificial limb across the area of the residual limb (rather than just one small spot), which helps reduce wear on the residual limb.
Production of prosthetic socket The production of a prosthetic socket begins with capturing the geometry of the residual limb; this process is called shape capture. The goal of this process is to create an accurate representation of the residual limb, which is critical to achieve good socket fit. The custom socket is created by taking a plaster cast of the residual limb or, more commonly today, of the liner worn over their residual limb, and then making a mold from the plaster cast. The commonly used compound is called Plaster of Paris. In recent years, various digital shape capture systems have been developed which can be input directly to a computer allowing for a more sophisticated design. In general, the shape capturing process begins with the digital acquisition of three-dimensional (3D) geometric data from the amputee's residual limb. Data are acquired with either a probe, laser scanner, structured light scanner, or a photographic-based 3D scanning system. After shape capture, the second phase of the socket production is called rectification, which is the process of modifying the model of the residual limb by adding volume to bony prominence and potential pressure points and remove volume from load bearing area. This can be done manually by adding or removing plaster to the positive model, or virtually by manipulating the computerized model in the software. Lastly, the fabrication of the prosthetic socket begins once the model has been rectified and finalized. The prosthetists would wrap the positive model with a semi-molten plastic sheet or carbon fiber coated with epoxy resin to construct the prosthetic socket. Optimal socket fit between the residual limb and socket is critical to the function and usage of the entire prosthesis. If the fit between the residual limb and socket attachment is too loose, this will reduce the area of contact between the residual limb and socket or liner, and increase pockets between residual limb skin and socket or liner. Pressure then is higher, which can be painful. Air pockets can allow sweat to accumulate that can soften the skin. Ultimately, this is a frequent cause for itchy skin rashes. Over time, this can lead to breakdown of the skin. On the other hand, a very tight fit may excessively increase the interface pressures that may also lead to skin breakdown after prolonged use. Artificial limbs are typically manufactured using the following steps: A recent study showed that by stimulating the median and ulnar nerves, according to the information provided by the artificial sensors from a hand prosthesis, physiologically appropriate (near-natural) sensory information could be provided to an amputee. This feedback enabled the participant to effectively modulate the grasping force of the prosthesis with no visual or auditory feedback. In February 2013, researchers from
École Polytechnique Fédérale de Lausanne in Switzerland and the
Scuola Superiore Sant'Anna in Italy, implanted electrodes into an amputee's arm, which gave the patient sensory feedback and allowed for real time control of the prosthetic. With wires linked to nerves in his upper arm, the Danish patient was able to handle objects and instantly receive a sense of touch through the special artificial hand that was created by Silvestro Micera and researchers both in Switzerland and Italy. In July 2019, this technology was expanded on even further by researchers from the
University of Utah, led by Jacob George. The group of researchers implanted electrodes into the patient's arm to map out several sensory precepts. They would then stimulate each electrode to figure out how each sensory precept was triggered, then proceed to map the sensory information onto the prosthetic. This would allow the researchers to get a good approximation of the same kind of information that the patient would receive from their natural hand. Unfortunately, the arm is too expensive for the average user to acquire, however, Jacob mentioned that insurance companies could cover the costs of the prosthetic.
Terminal devices Terminal devices contain a range of hooks, prehensors, hands or other devices.
Hooks Voluntary opening split hook systems are simple, convenient, light, robust, versatile and relatively affordable. A hook does not match a normal human hand for appearance or overall versatility, but its material tolerances can exceed and surpass the normal human hand for mechanical stress (one can even use a hook to slice open boxes or as a hammer whereas the same is not possible with a normal hand), for thermal stability (one can use a hook to grip items from boiling water, to turn meat on a grill, to hold a match until it has burned down completely) and for chemical hazards (as a metal hook withstands acids or lye, and does not react to solvents like a prosthetic glove or human skin).
Hands gripping the myoelectric prosthetic arm of a United States Marine Prosthetic hands are available in both voluntary opening and voluntary closing versions and because of their more complex mechanics and cosmetic glove covering require a relatively large activation force, which, depending on the type of harness used, may be uncomfortable. A recent study by the Delft University of Technology, The Netherlands, showed that the development of mechanical prosthetic hands has been neglected during the past decades. The study showed that the pinch force level of most current mechanical hands is too low for practical use. The best tested hand was a prosthetic hand developed around 1945. In 2017 however, a research has been started with bionic hands by
Laura Hruby of the
Medical University of Vienna. A few open-hardware 3-D printable bionic hands have also become available. Some companies are also producing robotic hands with integrated forearm, for fitting unto a patient's upper arm and in 2020, at the Italian Institute of Technology (IIT), another robotic hand with integrated forearm (Soft Hand Pro) was developed.
Commercial providers and materials Hosmer and
Otto Bock are major commercial hook providers. Mechanical hands are sold by Hosmer and Otto Bock as well; the Becker Hand is still manufactured by the Becker family. Prosthetic hands may be fitted with standard stock or custom-made cosmetic looking silicone gloves. But regular work gloves may be worn as well. Other terminal devices include the V2P Prehensor, a versatile robust gripper that allows customers to modify aspects of it, Texas Assist Devices (with a whole assortment of tools) and TRS that offers a range of terminal devices for sports. Cable harnesses can be built using aircraft steel cables, ball hinges, and self-lubricating cable sheaths. Some prosthetics have been designed specifically for use in salt water.
Lower-extremity prosthetics Lower-extremity prosthetics describes artificially replaced limbs located at the hip level or lower. Concerning all ages Ephraim et al. (2003) found a worldwide estimate of all-cause lower-extremity amputations of 2.0–5.9 per 10,000 inhabitants. For birth prevalence rates of congenital limb deficiency they found an estimate between 3.5 and 7.1 cases per 10,000 births. The two main subcategories of lower extremity prosthetic devices are trans-tibial (any amputation transecting the tibia bone or a congenital anomaly resulting in a tibial deficiency), and trans-femoral (any amputation transecting the femur bone or a congenital anomaly resulting in a femoral deficiency). In the prosthetic industry, a trans-tibial prosthetic leg is often referred to as a "BK" or below the knee prosthesis while the trans-femoral prosthetic leg is often referred to as an "AK" or above the knee prosthesis. Other, less prevalent lower extremity cases include the following: • Hip disarticulations – This usually refers to when an amputee or congenitally challenged patient has either an amputation or anomaly at or in close proximity to the hip joint.
See hip replacement • Knee disarticulations – This usually refers to an amputation through the knee disarticulating the femur from the tibia.
See knee replacement • Symes – This is an ankle disarticulation while preserving the heel pad.
Socket The socket serves as an interface between the residuum and the prosthesis, ideally allowing comfortable weight-bearing, movement control and
proprioception. Socket problems, such as discomfort and skin breakdown, are rated among the most important issues faced by lower-limb amputees.
Shank and connectors This part creates distance and support between the knee-joint and the foot (in case of an upper-leg prosthesis) or between the socket and the foot. The type of connectors that are used between the shank and the knee/foot determines whether the prosthesis is modular or not. Modular means that the angle and the displacement of the foot in respect to the socket can be changed after fitting. In developing countries prosthesis mostly are non-modular, in order to reduce cost. When considering children modularity of angle and height is important because of their average growth of 1.9 cm annually. Additionally it influences gait biomechanics by its shape and stiffness. This is because the trajectory of the center of pressure (COP) and the angle of the ground reaction forces is determined by the shape and stiffness of the foot and needs to match the subject's build in order to produce a normal gait pattern. Andrysek (2010) found 16 different types of feet, with greatly varying results concerning durability and biomechanics. The main problem found in current feet is durability, endurance ranging from 16 to 32 months These results are for adults and will probably be worse for children due to higher activity levels and scale effects. Evidence comparing different types of feet and ankle prosthetic devices is not strong enough to determine if one mechanism of ankle/foot is superior to another. When deciding on a device, the cost of the device, a person's functional need, and the availability of a particular device should be considered. The prosthetic knee is connected to the prosthetic foot by the shank, which is usually made of an aluminum or graphite tube. One of the most important aspect of a prosthetic knee joint would be its stance-phase control mechanism. The function of stance-phase control is to prevent the leg from buckling when the limb is loaded during weight acceptance. This ensures the stability of the knee in order to support the single limb support task of stance phase and provides a smooth transition to the swing phase. Stance phase control can be achieved in several ways including the mechanical locks, relative alignment of prosthetic components, weight activated friction control,
Microprocessor control To mimic the knee's functionality during gait, microprocessor-controlled knee joints have been developed that control the flexion of the knee. Some examples are
Otto Bock's C-leg, introduced in 1997,
Ossur's Rheo Knee, released in 2005, the Power Knee by Ossur, introduced in 2006, the Plié Knee from Freedom Innovations and DAW Industries' Self Learning Knee (SLK). The idea was originally developed by Kelly James, a Canadian engineer, at the
University of Alberta. A microprocessor is used to interpret and analyze signals from knee-angle sensors and moment sensors. The microprocessor receives signals from its sensors to determine the type of motion being employed by the amputee. Most microprocessor controlled knee-joints are powered by a battery housed inside the prosthesis. The sensory signals computed by the microprocessor are used to control the resistance generated by
hydraulic cylinders in the knee-joint. Small valves control the amount of
hydraulic fluid that can pass into and out of the cylinder, thus regulating the extension and compression of a piston connected to the upper section of the knee. The main advantage of a microprocessor-controlled prosthesis is a closer approximation to an amputee's natural gait. Some allow amputees to walk near walking speed or run. Variations in speed are also possible and are taken into account by sensors and communicated to the microprocessor, which adjusts to these changes accordingly. It also enables the amputees to walk downstairs with a step-over-step approach, rather than the one step at a time approach used with mechanical knees. There is some research suggesting that people with microprocessor-controlled prostheses report greater satisfaction and improvement in functionality, residual limb health, and safety. People may be able to perform everyday activities at greater speeds, even while multitasking, and reduce their risk of falls.
Myoelectric A
myoelectric prosthesis uses the electrical tension generated every time a muscle contracts, as information. This tension can be captured from voluntarily contracted muscles by electrodes applied on the skin to control the movements of the prosthesis, such as elbow flexion/extension, wrist supination/pronation (rotation) or opening/closing of the fingers. A prosthesis of this type utilizes the residual neuromuscular system of the human body to control the functions of an electric powered prosthetic hand, wrist, elbow or foot. This is different from an electric switch prosthesis, which requires straps and/or cables actuated by body movements to actuate or operate switches that control the movements of the prosthesis. There is no clear evidence concluding that myoelectric upper extremity prostheses function better than body-powered prostheses. When compared to a body-powered prosthesis, a myoelectric prosthesis may not be as durable, may have a longer training time, may require more adjustments, may need more maintenance, and does not provide feedback to the user. The USSR was the first to develop a myoelectric arm in 1958, while the first myoelectric arm became commercial in 1964 by the Central Prosthetic Research Institute of the
USSR, and distributed by the Hangar Limb Factory of the
UK. Myoelectric prosthesis are expensive, require regular maintenance, and are sensitive to sweat and moisture.
Robotic prostheses Robots can be used to generate objective measures of patient's impairment and therapy outcome, assist in diagnosis, customize therapies based on patient's motor abilities, and assure compliance with treatment regimens and maintain patient's records. It is shown in many studies that there is a significant improvement in upper limb motor function after stroke using robotics for upper limb rehabilitation. In order for a robotic prosthetic limb to work, it must have several components to integrate it into the body's function:
Biosensors detect signals from the user's nervous or muscular systems. It then relays this information to a
microcontroller located inside the device, and processes feedback from the limb and actuator, e.g., position or force, and sends it to the controller. Examples include surface electrodes that detect electrical activity on the skin, needle electrodes implanted in muscle, or solid-state electrode arrays with nerves growing through them. One type of these biosensors are employed in
myoelectric prostheses. A device known as the controller is connected to the user's nerve and muscular systems and the device itself. It sends intention commands from the user to the actuators of the device and interprets feedback from the mechanical and biosensors to the user. The controller is also responsible for the monitoring and control of the movements of the device. An
actuator mimics the actions of a muscle in producing force and movement. Examples include a motor that aids or replaces original muscle tissue. Targeted muscle reinnervation (TMR) is a technique in which
motor nerves, which previously controlled
muscles on an amputated limb, are
surgically rerouted such that they reinnervate a small region of a large, intact muscle, such as the
pectoralis major. As a result, when a patient thinks about moving the thumb of their missing hand, a small area of muscle on their chest will contract instead. By placing sensors over the reinnervated muscle, these contractions can be made to control the movement of an appropriate part of the robotic prosthesis. A variant of this technique is called targeted sensory reinnervation (TSR). This procedure is similar to TMR, except that
sensory nerves are surgically rerouted to
skin on the chest, rather than motor nerves rerouted to muscle. Recently, robotic limbs have improved in their ability to take signals from
the human brain and translate those signals into motion in the artificial limb.
DARPA, the Pentagon's research division, is working to make even more advancements in this area. Their desire is to create an artificial limb that ties directly into the
nervous system.
Robotic arms Advancements in the processors used in myoelectric arms have allowed developers to make gains in fine-tuned control of the prosthetic. The
Boston Digital Arm is a recent artificial limb that has taken advantage of these more advanced processors. The arm allows movement in five axes and allows the arm to be programmed for a more customized feel. Recently the
I-LIMB Hand, invented in Edinburgh, Scotland, by
David Gow has become the first commercially available hand prosthesis with five individually powered digits. The hand also possesses a manually rotatable thumb which is operated passively by the user and allows the hand to grip in precision, power, and key grip modes. Another neural prosthetic is
Johns Hopkins University Applied Physics Laboratory Proto 1. Besides the Proto 1, the university also finished the
Proto 2 in 2010. Early in 2013, Max Ortiz Catalan and Rickard Brånemark of the Chalmers University of Technology, and Sahlgrenska University Hospital in Sweden, succeeded in making the first robotic arm which is mind-controlled and can be permanently attached to the body (using
osseointegration). An approach that is very useful is called arm rotation which is common for unilateral amputees which is an amputation that affects only one side of the body; and also essential for bilateral amputees, a person who is missing or has had amputated either both arms or legs, to carry out activities of daily living. This involves inserting a small permanent magnet into the distal end of the residual bone of subjects with upper limb amputations. When a subject rotates the residual arm, the magnet will rotate with the residual bone, causing a change in magnetic field distribution. EEG (electroencephalogram) signals, detected using small flat metal discs attached to the scalp, essentially decoding human brain activity used for physical movement, is used to control the robotic limbs. This allows the user to control the part directly.
Robotic transtibial prostheses The research of robotic legs has made some advancement over time, allowing exact movement and control. Researchers at the
Rehabilitation Institute of Chicago announced in September 2013 that they have developed a robotic leg that translates neural impulses from the user's thigh muscles into movement, which is the first prosthetic leg to do so. It is currently in testing. Hugh Herr, head of the biomechatronics group at MIT's Media Lab developed a robotic transtibial leg (PowerFoot BiOM). The Icelandic company Össur has also created a robotic transtibial leg with motorized ankle that moves through algorithms and sensors that automatically adjust the angle of the foot during different points in its wearer's stride. Also there are brain-controlled bionic legs that allow an individual to move his limbs with a wireless transmitter.
Prosthesis design The main goal of a robotic prosthesis is to provide active actuation during gait to improve the biomechanics of gait, including, among other things, stability, symmetry, or energy expenditure for amputees. There are several powered prosthetic legs currently on the market, including fully powered legs, in which actuators directly drive the joints, and semi-active legs, which use small amounts of energy and a small actuator to change the mechanical properties of the leg but do not inject net positive energy into gait. Specific examples include The emPOWER from BionX, the Proprio Foot from Ossur, and the Elan Foot from Endolite. Various research groups have also experimented with robotic legs over the last decade. Central issues being researched include designing the behavior of the device during stance and swing phases, recognizing the current ambulation task, and various mechanical design problems such as robustness, weight, battery-life/efficiency, and noise-level. However, scientists from
Stanford University and
Seoul National University has developed artificial nerves system that will help prosthetic limbs feel. This synthetic nerve system enables prosthetic limbs sense
braille, feel the sense of touch and respond to the environment.
Use of recycled materials Prosthetics are being made from recycled plastic bottles and lids around the world. == Direct bone attachment and osseointegration ==