Prosthesis

In medicine, a prosthesis (pl.: prostheses; from Ancient Greek: πρόσθεσις, romanized: prósthesis,
lit. 'addition, application, attachment'),[1] or a prosthetic implant,[2][3] is an artificial device that replaces
a missing body part, which may be lost through physical trauma, disease, or a condition present at birth
(congenital disorder). Prostheses may restore the normal functions of the missing body part, [4] or may
perform a cosmetic function.

A person who has undergone an amputation is sometimes referred to as an amputee, however, this term
may be offensive.[5] Rehabilitation for someone with an amputation is primarily coordinated by a
physiatrist as part of an inter-disciplinary team consisting of physiatrists, prosthetists, nurses, physical
therapists, and occupational therapists.[6] Prostheses can be created by hand or with computer-aided
design (CAD), a software interface that helps creators design and analyze the creation with computer-
generated 2-D and 3-D graphics as well as analysis and optimization tools.[7]

Types
A person's prosthesis should be designed and assembled according to the person's appearance and
functional needs. For instance, a person may need a transradial prosthesis, but the person needs to choose
between an aesthetic functional device, a myoelectric device, a body-powered device, or an activity
specific device. The person's future goals and economical capabilities may help them choose between one
or more devices.

Craniofacial prostheses include intra-oral and extra-oral prostheses. Extra-oral prostheses are further
divided into hemifacial, auricular (ear), nasal, orbital and ocular. Intra-oral prostheses include dental
prostheses, such as dentures, obturators, and dental implants.

Prostheses of the neck include larynx substitutes, trachea and upper esophageal replacements,

Somato prostheses of the torso include breast prostheses which may be either single or bilateral, full
breast devices or nipple prostheses.

Penile prostheses are used to treat erectile dysfunction, correct penile deformity, perform phalloplasty
procedures in cisgender men, and to build a new penis in female-to-male gender reassignment surgeries.

Limb prostheses
Limb prostheses include both upper- and lower-extremity prostheses.

Upper-extremity prostheses are used at varying levels of amputation: forequarter, shoulder

disarticulation, transhumeral prosthesis, elbow disarticulation, transradial prosthesis, wrist disarticulation,
full hand, partial hand, finger, partial finger. A transradial prosthesis is an artificial limb that replaces an
arm missing below the elbow.
Upper limb prostheses can be categorized in three main
categories: Passive devices, Body Powered devices, and
Externally Powered (myoelectric) devices. Passive devices can
either be passive hands, mainly used for cosmetic purposes, or
passive tools, mainly used for specific activities (e.g. leisure or
vocational). An extensive overview and classification of
passive devices can be found in a literature review by Maat
[Link].[8] A passive device can be static, meaning the device has
no movable parts, or it can be adjustable, meaning its
configuration can be adjusted (e.g. adjustable hand opening). An example of two upper-extremity
Despite the absence of active grasping, passive devices are prosthetics, one body-powered (right
very useful in bimanual tasks that require fixation or support of arm), and another myoelectric (left arm)
an object, or for gesticulation in social interaction. According
to scientific data a third of the upper limb amputees worldwide
use a passive prosthetic hand.[8] Body Powered or cable-operated limbs work by attaching a harness and
cable around the opposite shoulder of the damaged arm. A recent body-powered approach has explored
the utilization of the user's breathing to power and control the prosthetic hand to help eliminate actuation
cable and harness.[9][10][11] The third category of available prosthetic devices comprises myoelectric
arms. This particular class of devices distinguishes itself from the previous ones due to the inclusion of a
battery system. This battery serves the dual purpose of providing energy for both actuation and sensing
components. While actuation predominantly relies on motor or pneumatic systems,[12] a variety of
solutions have been explored for capturing muscle activity, including techniques such as
Electromyography, Sonomyography, Myokinetic, and others.[13][14][15] These methods function by
detecting the minute electrical currents generated by contracted muscles during upper arm movement,
typically employing electrodes or other suitable tools. Subsequently, these acquired signals are converted
into gripping patterns or postures that the artificial hand will then execute.

In the prosthetics industry, a trans-radial prosthetic arm is often referred to as a "BE" or below elbow
prosthesis.

Lower-extremity prostheses provide replacements at varying levels of amputation. These include hip
disarticulation, transfemoral prosthesis, knee disarticulation, transtibial prosthesis, Syme's amputation,
foot, partial foot, and toe. 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).

A transfemoral prosthesis is an artificial limb that replaces a leg missing above the knee. Transfemoral
amputees can have a very difficult time regaining normal movement. In general, a transfemoral amputee
must use approximately 80% more energy to walk than a person with two whole legs.[16] This is due to
the complexities in movement associated with the knee. In newer and more improved designs, hydraulics,
carbon fiber, mechanical linkages, motors, computer microprocessors, and innovative combinations of
these technologies are employed to give more control to the user. In the prosthetics industry, a trans-
femoral prosthetic leg is often referred to as an "AK" or above the knee prosthesis.
A transtibial prosthesis is an artificial limb that replaces a leg missing below the knee. A transtibial
amputee is usually able to regain normal movement more readily than someone with a transfemoral
amputation, due in large part to retaining the knee, which allows for easier movement. Lower extremity
prosthetics describe artificially replaced limbs located at the hip level or lower. In the prosthetics industry,
a trans-tibial prosthetic leg is often referred to as a "BK" or below the knee prosthesis.

Prostheses are manufactured and fit by clinical prosthetists. Prosthetists are healthcare professionals
responsible for making, fitting, and adjusting prostheses and for lower limb prostheses will assess both
gait and prosthetic alignment. Once a prosthesis has been fit and adjusted by a prosthetist, a rehabilitation
physiotherapist (called physical therapist in America) will help teach a new prosthetic user to walk with a
leg prosthesis. To do so, the physical therapist may provide verbal instructions and may also help guide
the person using touch or tactile cues. This may be done in a clinic or home. There is some research
suggesting that such training in the home may be more successful if the treatment includes the use of a
treadmill.[17] Using a treadmill, along with the physical therapy treatment, helps the person to experience
many of the challenges of walking with a prosthesis.

In the United Kingdom, 75% of lower limb amputations are performed due to inadequate circulation
(dysvascularity).[18] This condition is often associated with many other medical conditions (co-
morbidities) including diabetes and heart disease that may make it a challenge to recover and use a
prosthetic limb to regain mobility and independence.[18] For people who have inadequate circulation and
have lost a lower limb, there is insufficient evidence due to a lack of research, to inform them regarding
their choice of prosthetic rehabilitation approaches.[18]

Lower extremity prostheses are often categorized by

the level of amputation or after the name of a
surgeon:[19][20]

Transfemoral (Above-knee)
Transtibial (Below-knee)
Ankle disarticulation (more commonly known
as Syme's amputation)
Knee disarticulation (also see knee
replacement) Types of prosthesis used for replacing joints in the
Hip disarticulation, (also see hip human body
replacement)
Hemi-pelvictomy
Partial foot amputations (Pirogoff, Talo-Navicular and Calcaneo-cuboid (Chopart), Tarso-
metatarsal (Lisfranc), Trans-metatarsal, Metatarsal-phalangeal, Ray amputations, toe
amputations).[20]
Van Nes rotationplasty

Prosthetic raw materials

Prosthetic are made lightweight for better convenience for the amputee. Some of these materials include:

Plastics:
Polyethylene
Polypropylene
 Acrylics
Polyurethane
Wood (early prosthetics)
Rubber (early prosthetics)
Lightweight metals:

Aluminum
Composites:

Carbon fiber reinforced polymers[4]

Wheeled prostheses have also been used extensively in the rehabilitation of injured domestic animals,
including dogs, cats, pigs, rabbits, and turtles.[21]

History
Prosthetics originate from the ancient Near East circa 3000 BCE,
with the earliest evidence of prosthetics appearing in ancient
Egypt and Iran. The earliest recorded mention of eye prosthetics is
from the Egyptian story of the Eye of Horus dated circa 3000 BC,
which involves the left eye of Horus being plucked out and then
restored by Thoth. Circa 3000-2800 BC, the earliest
archaeological evidence of prosthetics is found in ancient Iran,
where an eye prosthetic is found buried with a woman in Shahr-i
Shōkhta. It was likely made of bitumen paste that was covered Prosthetic toe from ancient Egypt
with a thin layer of gold. [22] The Egyptians were also early
pioneers of foot prosthetics, as shown by the wooden toe found on
a body from the New Kingdom circa 1000 BC.[23] Another early textual mention is found in South Asia
circa 1200 BC, involving the warrior queen Vishpala in the Rigveda.[24] Roman bronze crowns have also
been found, but their use could have been more aesthetic than medical.[25]

An early mention of a prosthetic comes from the Greek historian Herodotus, who tells the story of
Hegesistratus, a Greek diviner who cut off his own foot to escape his Spartan captors and replaced it with
a wooden one.[26]

Wood and metal prosthetics

Pliny the Elder also recorded the tale of a Roman general, Marcus Sergius, whose right hand was cut off
while campaigning and had an iron hand made to hold his shield so that he could return to battle. A
famous and quite refined[28] historical prosthetic arm was that of Götz von Berlichingen, made at the
beginning of the 16th century. The first confirmed use of a prosthetic device, however, is from 950 to 710
BC. In 2000, research pathologists discovered a mummy from this period buried in the Egyptian
necropolis near ancient Thebes that possessed an artificial big toe. This toe, consisting of wood and
leather, exhibited evidence of use. When reproduced by bio-mechanical engineers in 2011, researchers
discovered that this ancient prosthetic enabled its wearer to walk both barefoot and in Egyptian style
sandals. Previously, the earliest discovered prosthetic was an artificial leg from Capua.[29]
 Around the same
time, François de
la Noue is also
reported to have
had an iron hand,
as is, in the 17th
century, René- A wooden prosthetic leg from Shengjindian cemetery,
Robert Cavalier circa 300 BCE, Turpan Museum. This is "the oldest
de la Salle. [30] functional leg prosthesis known to date".[27]
Henri de Tonti
had a prosthetic
hook for a hand.
During the
Middle Ages,
prosthetics
remained quite
basic in form.
Debilitated Iron prosthetic hand believed to have been owned by
knights would be Götz von Berlichingen (1480–1562)
The Capua leg (replica)
fitted with
prosthetics so
they could hold up a shield, grasp a lance or a sword, or stabilize a
mounted warrior.[31] Only the wealthy could afford anything that would
assist in daily life.[32]

One notable prosthesis was that belonging to an Italian man, who

scientists estimate replaced his amputated right hand with a knife.[33][34]
Scientists investigating the skeleton, which was found in a Longobard
cemetery in Povegliano Veronese, estimated that the man had lived
sometime between the 6th and 8th centuries AD.[35][34] Materials found
near the man's body suggest that the knife prosthesis was attached with a
leather strap, which he repeatedly tightened with his teeth.[35]

During the Renaissance, prosthetics developed with the use of iron, steel,
copper, and wood. Functional prosthetics began to make an appearance in
"Illustration of mechanical
the 1500s.[36]
hand", c. 1564

Technology progress before the 20th century

An Italian surgeon recorded the existence of an amputee who had an arm that allowed him to remove his
hat, open his purse, and sign his name.[37] Improvement in amputation surgery and prosthetic design
came at the hands of Ambroise Paré. Among his inventions was an above-knee device that was a kneeling
peg leg and foot prosthesis with a fixed position, adjustable harness, and knee lock control. The
functionality of his advancements showed how future prosthetics could develop.

Other major improvements before the modern era:

Pieter Verduyn – First non-locking below-knee (BK) prosthesis.

 James Potts – Prosthesis made of a wooden shank and
socket, a steel knee joint and an articulated foot that was
controlled by catgut tendons from the knee to the ankle.
Came to be known as "Anglesey Leg" or "Selpho Leg".
Sir James Syme – A new method of ankle amputation
that did not involve amputating at the thigh.
Benjamin Palmer – Improved upon the Selpho leg.
Added an anterior spring and concealed tendons to
simulate natural-looking movement.
Dubois Parmlee – Created prosthetic with a suction
socket, polycentric knee, and multi-articulated foot.
Marcel Desoutter & Charles Desoutter – First aluminium
prosthesis[38]
Henry Heather Bigg, and his son Henry Robert Heather
Bigg, won the Queen's command to provide "surgical
appliances" to wounded soldiers after Crimea War. They Artificial iron hand believed to date
developed arms that allowed a double arm amputee to from 1560 to 1600
crochet, and a hand that felt natural to others based on
ivory, felt and leather.[39]
At the end of World War II, the NAS (National Academy of Sciences) began to advocate better research
and development of prosthetics. Through government funding, a research and development program was
developed within the Army, Navy, Air Force, and the Veterans Administration.

Lower extremity modern history

After the Second World War, a team at the University of
California, Berkeley including James Foort and C.W. Radcliff
helped to develop the quadrilateral socket by developing a jig
fitting system for amputations above the knee. Socket technology
for lower extremity limbs saw a further revolution during the
1980s when John Sabolich C.P.O., invented the Contoured
Adducted Trochanteric-Controlled Alignment Method (CATCAM)
socket, later to evolve into the Sabolich Socket. He followed the
An artificial limbs factory in 1941 direction of Ivan Long and Ossur Christensen as they developed
alternatives to the quadrilateral socket, which in turn followed the
open ended plug socket, created from wood.[40] The advancement
was due to the difference in the socket to patient contact model. Prior to this, sockets were made in the
shape of a square shape with no specialized containment for muscular tissue. New designs thus help to
lock in the bony anatomy, locking it into place and distributing the weight evenly over the existing limb
as well as the musculature of the patient. Ischial containment is well known and used today by many
prosthetist to help in patient care. Variations of the ischial containment socket thus exists and each socket
is tailored to the specific needs of the patient. Others who contributed to socket development and changes
over the years include Tim Staats, Chris Hoyt, and Frank Gottschalk. Gottschalk disputed the efficacy of
the CAT-CAM socket- insisting the surgical procedure done by the amputation surgeon was most
important to prepare the amputee for good use of a prosthesis of any type socket design.[41]
The first microprocessor-controlled prosthetic knees became available in the early 1990s. The Intelligent
Prosthesis was the first commercially available microprocessor-controlled prosthetic knee. It was released
by Chas. A. Blatchford & Sons, Ltd., of Great Britain, in 1993 and made walking with the prosthesis feel
and look more natural.[42] An improved version was released in 1995 by the name Intelligent Prosthesis
Plus. Blatchford released another prosthesis, the Adaptive Prosthesis, in 1998. The Adaptive Prosthesis
utilized hydraulic controls, pneumatic controls, and a microprocessor to provide the amputee with a gait
that was more responsive to changes in walking speed. Cost analysis reveals that a sophisticated above-
knee prosthesis will be about $1 million in 45 years, given only annual cost of living adjustments.[43]

In 2019, a project under AT2030 was launched in which bespoke sockets are made using a thermoplastic,
rather than through a plaster cast. This is faster to do and significantly less expensive. The sockets were
called Amparo Confidence sockets.[44][45]

Upper extremity modern history

In 2005, DARPA started the Revolutionizing Prosthetics
program.[46][47][48][49][50][51] According to DARPA, the goal of
the $100 million program was to "develop an advanced
electromechanical prosthetic upper limb with near-natural control
that would dramatically enhance independence and quality of life
for amputees."[52][53] In 2014, the LUKE Arm developed by Dean
DARPA Revolutionizing Prosthetics
Kamen and his team at DEKA Research and Development Corp.
- The LUKE Arm
became the first prosthetic arm approved by FDA that "translates
signals from a person's muscles to perform complex tasks,"
according to FDA.[53][54] Johns Hopkins University and the U.S. Department of Veteran Affairs also
participated in the program.[53][55]

Design trends moving forward

There are many steps in the evolution of prosthetic design trends that are moving forward with time.
Many design trends point to lighter, more durable, and flexible materials like carbon fiber, silicone, and
advanced polymers. These not only make the prosthetic limb lighter and more durable but also allow it to
mimic the look and feel of natural skin, providing users with a more comfortable and natural
experience.[56] This new technology helps prosthetic users blend in with people with normal ligaments to
reduce the stigmatism for people who wear prosthetics. Another trend points towards using bionics and
myoelectric components in prosthetic design. These limbs utilize sensors to detect electrical signals from
the user's residual muscles. The signals are then converted into motions, allowing users to control their
prosthetic limbs using their own muscle contractions. This has greatly improved the range and fluidity of
movements available to amputees, making tasks like grasping objects or walking naturally much more
feasible.[56] Integration with AI is also on the forefront to the prosthetic design. AI-enabled prosthetic
limbs can learn and adapt to the user's habits and preferences over time, ensuring optimal functionality.
By analyzing the user's gait, grip, and other movements, these smart limbs can make real-time
adjustments, providing smoother and more natural motions.[56]

Patient procedure
A prosthesis is a functional replacement for an amputated or congenitally malformed or missing limb.
Prosthetists are responsible for the prescription, design, and management of a prosthetic device.

In most cases, the prosthetist begins by taking a plaster cast of the patient's affected limb. Lightweight,
high-strength thermoplastics are custom-formed to this model of the patient. Cutting-edge materials such
as carbon fiber, titanium and Kevlar provide strength and durability while making the new prosthesis
lighter. More sophisticated prostheses are equipped with advanced electronics, providing additional
stability and control.[57]

Current technology and manufacturing

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
Knee prosthesis manufactured
exposed.[58] using WorkNC Computer Aided
Manufacturing software
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
Manufacturing a prosthetic finger 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.[58][59]

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.[60] 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.[61] 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.[62]

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.[63]
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.[60] For the computerized model, it can be 3D printed using
a various of material with different flexibility and mechanical strength.[64]

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.[16] On the other hand, a very tight fit may excessively increase the
interface pressures that may also lead to skin breakdown after prolonged use.[65]

Artificial limbs are typically manufactured using the following steps:[58]

1. Measurement of the residual limb

2. Measurement of the body to determine the size required for the artificial limb
3. Fitting of a silicone liner
4. Creation of a model of the liner worn over the residual limb
5. Formation of thermoplastic sheet around the model – This is then used to test the fit of the
prosthetic
6. Formation of permanent socket
7. Formation of plastic parts of the artificial limb – Different methods are used, including
vacuum forming and injection molding
8. Creation of metal parts of the artificial limb using die casting
 9. Assembly of entire limb

Body-powered arms
Current technology allows body-powered arms to weigh around one-half to one-third of what a
myoelectric arm does.

Sockets
Current body-powered arms contain sockets that are built from hard epoxy or carbon fiber. These sockets
or "interfaces" can be made more comfortable by lining them with a softer, compressible foam material
that provides padding for the bone prominences. A self-suspending or supra-condylar socket design is
useful for those with short to mid-range below elbow absence. Longer limbs may require the use of a
locking roll-on type inner liner or more complex harnessing to help augment suspension.

Wrists
Wrist units are either screw-on connectors featuring the UNF 1/2-20 thread (USA) or quick-release
connector, of which there are different models.

Voluntary opening and voluntary closing

Two types of body-powered systems exist, voluntary opening "pull to open" and voluntary closing "pull
to close". Virtually all "split hook" prostheses operate with a voluntary opening type system.

More modern "prehensors" called GRIPS utilize voluntary closing systems. The differences are
significant. Users of voluntary opening systems rely on elastic bands or springs for gripping force, while
users of voluntary closing systems rely on their own body power and energy to create gripping force.

Voluntary closing users can generate prehension forces equivalent to the normal hand, up to or exceeding
one hundred pounds. Voluntary closing GRIPS require constant tension to grip, like a human hand, and in
that property, they do come closer to matching human hand performance. Voluntary opening split hook
users are limited to forces their rubber or springs can generate which usually is below 20 pounds.

Feedback
An additional difference exists in the biofeedback created that allows the user to "feel" what is being
held. Voluntary opening systems once engaged provide the holding force so that they operate like a
passive vice at the end of the arm. No gripping feedback is provided once the hook has closed around the
object being held. Voluntary closing systems provide directly proportional control and biofeedback so
that the user can feel how much force that they are applying.

In 1997, the Colombian Prof. Álvaro Ríos Poveda, a researcher in bionics in Latin America, developed an
upper limb and hand prosthesis with sensory feedback. This technology allows amputee patients to
handle prosthetic hand systems in a more natural way.[66]

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.[67]

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.[68] 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.[69]

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.[70]

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
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.[71] 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.[72] 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.[73][74] A few open-hardware 3-D printable bionic hands have also become
available.[75] Some companies are also producing robotic hands with integrated forearm, for fitting unto a
patient's upper arm[76][77] and in 2020, at the Italian Institute of Technology (IIT), another robotic hand
with integrated forearm (Soft Hand Pro) was developed.[78]

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.[79]
Actor Owen Wilson gripping the
Lower-extremity prosthetics myoelectric prosthetic arm of a
United States Marine
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.[80]

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:

A prosthetic leg worn by Ellie Cole
1. 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
2. Knee disarticulations – This usually refers to an amputation through the knee disarticulating
the femur from the tibia. See knee replacement
3. 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.[81] Socket problems, such as discomfort and skin
breakdown, are rated among the most important issues faced by lower-limb amputees.[82]

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.[83]

Foot
Providing contact to the ground, the foot provides shock absorption and stability during stance.[84]
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.[85]
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[86] 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.[87] 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.[87]

Knee joint
In case of a trans-femoral (above knee) amputation, there also is a need for a complex connector
providing articulation, allowing flexion during swing-phase but not during stance. As its purpose is to
replace the knee, the prosthetic knee joint is the most critical component of the prosthesis for trans-
femoral amputees. The function of the good prosthetic knee joint is to mimic the function of the normal
knee, such as providing structural support and stability during stance phase but able to flex in a
controllable manner during swing phase. Hence it allows users to have a smooth and energy efficient gait
and minimize the impact of amputation.[88] 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,[89] relative alignment of prosthetic
components,[90] weight activated friction control,[90] and polycentric mechanisms.[91]

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).[92]

The idea was originally developed by Kelly James, a Canadian engineer, at the University of Alberta.[93]

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.[43]

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.[94] There is some
research suggesting that people with microprocessor-controlled prostheses report greater satisfaction and
improvement in functionality, residual limb health, and safety.[95] People may be able to perform
everyday activities at greater speeds, even while multitasking, and reduce their risk of falls.[95]

However, some have some significant drawbacks that impair its use. They can be susceptible to water
damage and thus great care must be taken to ensure that the prosthesis remains dry.[96]

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.[97] 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.[98] Advantages to using a myoelectric upper
extremity prosthesis include the potential for improvement in cosmetic appeal (this type of prosthesis
may have a more natural look), may be better for light everyday activities, and may be beneficial for
people experiencing phantom limb pain.[98] 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.[98]
Prof. Alvaro Ríos Poveda has been working for several years on a non-invasive and affordable solution to
this feedback problem. He considers that: "Prosthetic limbs that can be controlled with thought hold great
promise for the amputee, but without sensorial feedback from the signals returning to the brain, it can be
difficult to achieve the level of control necessary to perform precise movements. When connecting the
sense of touch from a mechanical hand directly to the brain, prosthetics can restore the function of the
amputated limb in an almost natural-feeling way." He presented the first Myoelectric prosthetic hand with
sensory feedback at the XVIII World Congress on Medical Physics and Biomedical Engineering, 1997,
held in Nice, France.[99][100]

The USSR was the first to develop a myoelectric arm in 1958,[101] 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.[102][103] The Myoelectric prosthesis are expensive requires regular
maintenance, sensitive to sweat and moisture affecting sensor performance.

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.[104] In order for a robotic prosthetic limb to work, it Brain control of 3D prosthetic arm
must have several components to integrate it into the body's movement (hitting targets). This
function: Biosensors detect signals from the user's nervous or movie was recorded when the
muscular systems. It then relays this information to a participant controlled the 3D
movement of a prosthetic arm to hit
microcontroller located inside the device, and processes feedback
physical targets in a research lab.
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.[105][106]
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.[107]

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.[108]

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.[109] 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).[110][111][112]

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.[113] 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.[114]

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.[115]

Hugh Herr, head of the biomechatronics group at MIT's Media Lab developed a robotic transtibial leg
(PowerFoot BiOM).[116][117]

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.[118]

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.[119] 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.[120][121][122] Various research groups have also experimented with robotic legs
over the last decade.[123] 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.[124] This synthetic nerve system enables prosthetic limbs sense braille, feel the
sense of touch and respond to the environment.[125][126]

Use of recycled materials

Prosthetics are being made from recycled plastic bottles and lids around the world.[127][128][129][130][131]

Direct bone attachment and osseointegration

Most prostheses are attached to the exterior of the body in a non-permanent way. The stump and socket
method can cause significant pain for the person, which is why direct bone attachment has been explored
extensively.

Osseointegration is a method of attaching the artificial limb to the body by a prosthetic implant. This
method is also sometimes referred to as exoprosthesis (attaching an artificial limb to the bone), or endo-
exoprosthesis. Endoprosthesis are prosthetic joint implants which remain wholly inside the body such as
knee and hip replacement implants.

The method works by inserting a titanium bolt into the bone at the end of the stump. After several months
the bone attaches itself to the titanium bolt and an abutment is attached to the titanium bolt. The abutment
extends out of the stump and the (removable) artificial limb is then attached to the abutment. Some of the
benefits of this method include the following:

Better muscle control of the prosthetic.

The ability to wear the prosthetic for an extended period of time; with the stump and socket
method this is not possible.
The ability for transfemoral amputees to drive a car.
The main disadvantage of this method is that amputees with the direct bone attachment cannot have large
impacts on the limb, such as those experienced during jogging, because of the potential for the bone to
break.[16]

Cosmesis
Cosmetic prosthesis has long been used to disguise injuries and disfigurements. With advances in modern
technology, cosmesis, the creation of lifelike limbs made from silicone or PVC, has been made
possible.[132] Such prosthetics, including artificial hands, can now be designed to simulate the appearance
of real hands, complete with freckles, veins, hair, fingerprints and even tattoos. Custom-made cosmeses
are generally more expensive (costing thousands of U.S. dollars, depending on the level of detail), while
standard cosmeses come premade in a variety of sizes, although they are often not as realistic as their
custom-made counterparts. Another option is the custom-made silicone cover, which can be made to
match a person's skin tone but not details such as freckles or wrinkles. Cosmeses are attached to the body
in any number of ways, using an adhesive, suction, form-fitting, stretchable skin, or a skin sleeve.

Cognition
Unlike neuromotor prostheses, neurocognitive prostheses would sense or modulate neural function in
order to physically reconstitute or augment cognitive processes such as executive function, attention,
language, and memory. No neurocognitive prostheses are currently available but the development of
implantable neurocognitive brain-computer interfaces has been proposed to help treat conditions such as
stroke, traumatic brain injury, cerebral palsy, autism, and Alzheimer's disease.[133] The recent field of
Assistive Technology for Cognition concerns the development of technologies to augment human
cognition. Scheduling devices such as Neuropage remind users with memory impairments when to
perform certain activities, such as visiting the doctor. Micro-prompting devices such as PEAT, AbleLink
and Guide have been used to aid users with memory and executive function problems perform activities
of daily living.

Prosthetic enhancement
In addition to the standard artificial limb for everyday use, many amputees or congenital patients have
special limbs and devices to aid in the participation of sports and recreational activities.

Within science fiction, and, more recently, within the scientific community, there has been consideration
given to using advanced prostheses to replace healthy body parts with artificial mechanisms and systems
to improve function. The morality and desirability of such technologies are being debated by
transhumanists, other ethicists, and others in general.[134][135][136][137] Body parts such as legs, arms,
hands, feet, and others can be replaced.

The first experiment with a healthy individual appears to have been that by the British scientist Kevin
Warwick. In 2002, an implant was interfaced directly into Warwick's nervous system. The electrode array,
which contained around a hundred electrodes, was placed in the median nerve. The signals produced
were detailed enough that a robot arm was able to mimic the actions of
Warwick's own arm and provide a form of touch feedback again via the
implant.[138]

The DEKA company of Dean Kamen developed the "Luke arm", an

advanced nerve-controlled prosthetic. Clinical trials began in 2008,[139]
with FDA approval in 2014 and commercial manufacturing by the
Universal Instruments Corporation expected in 2017. The price offered at
retail by Mobius Bionics is expected to be around $100,000.[140]

Further research in April 2019, there have been improvements towards

prosthetic function and comfort of 3D-printed personalized wearable
systems. Instead of manual integration after printing, integrating
electronic sensors at the intersection between a prosthetic and the wearer's Sgt. Jerrod Fields works out
tissue can gather information such as pressure across wearer's tissue, that at the U.S. Olympic Training
can help improve further iteration of these types of prosthetic.[141] Center in Chula Vista,
California.

Oscar Pistorius
In early 2008, Oscar Pistorius, the "Blade Runner" of South Africa, was briefly ruled ineligible to
compete in the 2008 Summer Olympics because his transtibial prosthesis limbs were said to give him an
unfair advantage over runners who had ankles. One researcher found that his limbs used twenty-five
percent less energy than those of a non-disabled runner moving at the same speed. This ruling was
overturned on appeal, with the appellate court stating that the overall set of advantages and disadvantages
of Pistorius' limbs had not been considered.

Pistorius did not qualify for the South African team for the Olympics, but went on to sweep the 2008
Summer Paralympics, and has been ruled eligible to qualify for any future Olympics. He qualified for the
2011 World Championship in South Korea and reached the semi-final where he ended last timewise, he
was 14th in the first round, his personal best at 400m would have given him 5th place in the finals. At the
2012 Summer Olympics in London, Pistorius became the first amputee runner to compete at an Olympic
Games.[142] He ran in the 400 metres race semi-finals,[143][144][145] and the 4 × 400 metres relay race
finals.[146] He also competed in 5 events in the 2012 Summer Paralympics in London.[147]

Design considerations
There are multiple factors to consider when designing a transtibial prosthesis. Manufacturers must make
choices about their priorities regarding these factors.

Performance
Nonetheless, there are certain elements of socket and foot mechanics that are invaluable for the athlete,
and these are the focus of today's high-tech prosthetics companies:

Fit – athletic/active amputees, or those with bony residua, may require a carefully detailed
socket fit; less-active patients may be comfortable with a 'total contact' fit and gel liner
 Energy storage and return – storage of energy acquired through ground contact and
utilization of that stored energy for propulsion
Energy absorption – minimizing the effect of high impact on the musculoskeletal system
Ground compliance – stability independent of terrain type and angle
Rotation – ease of changing direction
Weight – maximizing comfort, balance and speed
Suspension – how the socket will join and fit to the limb

Other
The buyer is also concerned with numerous other factors:

Cosmetics
Cost
Ease of use
Size availability

Design for Prosthetics

A key feature of prosthetics and prosthetic design is the idea of “designing for disabilities.” This might
sound like a good idea in which people with disabilities can participate in equitable design but this is
unfortunately not true. The idea of designing for disabilities is first problematic because of the underlying
meaning of disabilities. It tells amputees that there is a right and wrong way to move and walk and that if
amputees are adapted to the surrounding environment by their own means, then that is the wrong way.
Along with that underlying meaning of disabilities, many people designing for disabilities are not actually
disabled. “Design for disability" from these experiences, takes disability as the object - with the feeling
from non-disabled designers that they have properly learned about their job from their own simulation of
the experience. The simulation is misleading and does a disservice to disabled people - so the design that
flows from this is highly problematic. Engaging in disability design should be… with, ideally, team
members who have the relevant disability and are part of communities that matter to the research.[148]
This leads to people, who do not know what the day-to-day personal experiences are, designing materials
that do not meet the needs or hinder the needs of people with actual disabilities.

Cost and source freedom

High-cost
In the USA a typical prosthetic limb costs anywhere between $15,000 and $90,000, depending on the
type of limb desired by the patient. With medical insurance, a patient will typically pay 10%–50% of the
total cost of a prosthetic limb, while the insurance company will cover the rest of the cost. The percent
that the patient pays varies on the type of insurance plan, as well as the limb requested by the patient.[149]
In the United Kingdom, much of Europe, Australia and New Zealand the entire cost of prosthetic limbs is
met by state funding or statutory insurance. For example, in Australia prostheses are fully funded by state
schemes in the case of amputation due to disease, and by workers compensation or traffic injury
insurance in the case of most traumatic amputations.[150] The National Disability Insurance Scheme,
which is being rolled out nationally between 2017 and 2020 also pays for prostheses.

Transradial (below the elbow amputation) and transtibial prostheses (below the knee amputation)
typically cost between US $6,000 and $8,000, while transfemoral (above the knee amputation) and
transhumeral prosthetics (above the elbow amputation) cost approximately twice as much with a range of
$10,000 to $15,000 and can sometimes reach costs of $35,000. The cost of an artificial limb often recurs,
while a limb typically needs to be replaced every 3–4 years due to wear and tear of everyday use. In
addition, if the socket has fit issues, the socket must be replaced within several months from the onset of
pain. If height is an issue, components such as pylons can be changed.[151]

Not only does the patient need to pay for their multiple prosthetic limbs, but they also need to pay for
physical and occupational therapy that come along with adapting to living with an artificial limb. Unlike
the reoccurring cost of the prosthetic limbs, the patient will typically only pay the $2000 to $5000 for
therapy during the first year or two of living as an amputee. Once the patient is strong and comfortable
with their new limb, they will not be required to go to therapy anymore. Throughout one's life, it is
projected that a typical amputee will go through $1.4 million worth of treatment, including surgeries,
prosthetics, as well as therapies.[149]

Low-cost
Low-cost above-knee prostheses often provide only basic structural support with limited function. This
function is often achieved with crude, non-articulating, unstable, or manually locking knee joints. A
limited number of organizations, such as the International Committee of the Red Cross (ICRC), create
devices for developing countries. Their device which is manufactured by CR Equipments is a single-axis,
manually operated locking polymer prosthetic knee joint.[152]

Table. List of knee joint technologies based on the literature review.[86]

 Highest level of
Name of technology (country of origin) Brief description evidence

ICRC knee (Switzerland) Single-axis with manual lock Independent field

ATLAS knee (UK) Weight-activated friction Independent field

POF/OTRC knee (US) Single-axis with ext. assist Field

DAV/Seattle knee (US) Compliant polycentric Field

LIMBS International M1 knee (US) Four-bar Field

JaipurKnee (India) Four-bar Field

LCKnee (Canada) Single-axis with automatic lock Field

None provided (Nepal) Single-axis Field

None provided (New Zealand) Roto-molded single-axis Field

None provided (India) Six-bar with squatting Technical development

Friction knee (US) Weight-activated friction Technical development

Wedgelock knee (Australia) Weight-activated friction Technical development

SATHI friction knee (India) Weight-activated friction Limited data available

A plan for a low-cost artificial leg, designed by Sébastien Dubois,

was featured at the 2007 International Design Exhibition and
award show in Copenhagen, Denmark, where it won the Index:
Award. It would be able to create an energy-return prosthetic leg
for US $8.00, composed primarily of fiberglass.[153]

Prior to the 1980s, foot prostheses merely restored basic walking

capabilities. These early devices can be characterized by a simple
artificial attachment connecting one's residual limb to the ground.
Low-cost above-knee prosthetic
The introduction of the Seattle Foot (Seattle Limb Systems) in limbs: ICRC Knee (left) and LC
1981 revolutionized the field, bringing the concept of an Energy Knee (right)
Storing Prosthetic Foot (ESPF) to the fore. Other companies soon
followed suit, and before long, there were multiple models of
energy storing prostheses on the market. Each model utilized some variation of a compressible heel. The
heel is compressed during initial ground contact, storing energy which is then returned during the latter
phase of ground contact to help propel the body forward.

Since then, the foot prosthetics industry has been dominated by steady, small improvements in
performance, comfort, and marketability.

With 3D printers, it is possible to manufacture a single product without having to have metal molds, so
the costs can be drastically reduced.[154]

Jaipur foot, an artificial limb from Jaipur, India, costs about US$40.

Open-source robotic prosthesis

There is currently an open-design Prosthetics forum known as the
"Open Prosthetics Project". The group employs collaborators and
volunteers to advance Prosthetics technology while attempting to
lower the costs of these necessary devices.[155] Open Bionics is a
company that is developing open-source robotic prosthetic hands.
They utilize 3D printing to manufacture the devices and low-cost
3D scanners to fit them onto the residual limb of a specific patient.
Open Bionics' use of 3D printing allows for more personalized
Star Wars themed "Hero Arm" by
designs, such as the "Hero Arm" which incorporates the users
Open Bionics
favourite colours, textures, and even aesthetics to look like
superheroes or characters from Star Wars with the aim of lowering
the cost. A review study on a wide range of printed prosthetic hands found that 3D printing technology
holds a promise for individualised prosthesis design, is cheaper than commercial prostheses available on
the market, and is more expensive than mass production processes such as injection molding. The same
study also found that evidence on the functionality, durability and user acceptance of 3D printed hand
prostheses is still lacking.[156]

Low-cost prosthetics for children

In the USA an estimate was found of 32,500 children (<21 years) had a
major paediatric amputation, with 5,525 new cases each year, of which
3,315 congenital.[157]

Carr et al. (1998) investigated amputations caused by landmines for

Afghanistan, Bosnia and Herzegovina, Cambodia and Mozambique
among children (<14 years), showing estimates of respectively 4.7, 0.19,
1.11 and 0.67 per 1000 children.[158] Mohan (1986) indicated in India a
total of 424,000 amputees (23,500 annually), of which 10.3% had an onset
of disability below the age of 14, amounting to a total of about 43,700
limb deficient children in India alone.[159]

Few low-cost solutions have been created specially for children. Examples Artificial limbs for a juvenile
of low-cost prosthetic devices include: thalidomide survivor 1961–
1965

Pole and crutch

This hand-held pole with leather support band or platform for the limb is one of the simplest and cheapest
solutions found. It serves well as a short-term solution, but is prone to rapid contracture formation if the
limb is not stretched daily through a series of range-of motion (RoM) sets.[83]

Bamboo, PVC or plaster limbs

This also fairly simple solution comprises a plaster socket with a bamboo or PVC pipe at the bottom,
optionally attached to a prosthetic foot. This solution prevents contractures because the knee is moved
through its full RoM. The David Werner Collection, an online database for the assistance of disabled
village children, displays manuals of production of these solutions.[160]

Adjustable bicycle limb

This solution is built using a bicycle seat post up side down as foot, generating flexibility and (length)
adjustability. It is a very cheap solution, using locally available materials.[161]

Sathi Limb
It is an endoskeletal modular lower limb from India, which uses thermoplastic parts. Its main advantages
are the small weight and adaptability.[83]

Monolimb
Monolimbs are non-modular prostheses and thus require more experienced prosthetist for correct fitting,
because alignment can barely be changed after production. However, their durability on average is better
than low-cost modular solutions.[162]

Cultural and social theory perspectives

A number of theorists have explored the meaning and implications of prosthetic extension of the body.
Elizabeth Grosz writes, "Creatures use tools, ornaments, and appliances to augment their bodily
capacities. Are their bodies lacking something, which they need to replace with artificial or substitute
organs?...Or conversely, should prostheses be understood, in terms of aesthetic reorganization and
proliferation, as the consequence of an inventiveness that functions beyond and perhaps in defiance of
pragmatic need?"[163] Elaine Scarry argues that every artifact recreates and extends the body. Chairs
supplement the skeleton, tools append the hands, clothing augments the skin.[164] In Scarry's thinking,
"furniture and houses are neither more nor less interior to the human body than the food it absorbs, nor
are they fundamentally different from such sophisticated prosthetics as artificial lungs, eyes and kidneys.
The consumption of manufactured things turns the body inside out, opening it up to and as the culture of
objects."[165] Mark Wigley, a professor of architecture, continues this line of thinking about how
architecture supplements our natural capabilities, and argues that "a blurring of identity is produced by all
prostheses."[166] Some of this work relies on Freud's earlier characterization of man's relation to objects
as one of extension.

Negative social implications

Prosthetics play a vital role in how a person perceives themselves and how other people perceive them.
The ability to conceal such use enabled participants to ward off social stigmatization that in turn enabled
their social integration and the reduction of emotional problems surrounding such disability.[167] People
that lose a limb first have to deal with the emotional result of losing that limb. Regardless of the reasons
for amputation, whether due to traumatic causes or as a consequence of illness, emotional shock exists. It
may have a smaller or larger amplitude depending on a variety of factors such as patient age, medical
culture, medical cause, etc. As a result of amputation, the research participants' reports were loaded with
drama. The first emotional response to amputation was one of despair, a severe sense of self-collapse,
something almost unbearable.[168] Emotional factors are just a small part of looking at social
implications. Many people who lose a limb may have lots of anxiety surrounding prosthetics and their
limbs. After surgery, for an extended period of time, the interviewed patients from the National Library of
Medicine noticed the appearance and increase of anxiety. A lot of negative thoughts invaded their minds.
Projections about the future were grim, marked by sadness, helplessness, and even despair. Existential
uncertainty, lack of control, and further anticipated losses in one's life due to amputation were the primary
causes of anxiety and consequently ruminations and insomnia.[168] From losing a leg and getting a
prosthetics there were also many factors that can happen including anger and regret. The amputation of a
limb is associated not only with physical loss and change in body image but also with an abrupt severing
in one's sense of continuity. For participants with amputation as a result of physical trauma the event is
often experienced as a transgression and can lead to frustration and anger.[168]

Ethical concerns
There are also many ethical concerns about how the prosthetics are made and produced. A wide range of
ethical issues arise in connection with experiments and clinical usage of sensory prostheses: animal
experimentation; informed consent, for instance, in patients with a locked-in syndrome that may be
alleviated with a sensory prosthesis; unrealistic expectations of research subjects testing new devices.[169]
How prosthetics come to be and testing of the usability of the device is a major concern in the medical
world. Although many positives come when a new prosthetic design is announced, how the device got to
where it is leads to some questioning the ethics of prosthetics.

Debates
There are also many debates among the prosthetic community about whether they should wear prosthetics
at all. This is sparked by whether prosthetics help in day-to-day living or make it harder. Many people
have adapted to their loss of limb making it work for them and do not need a prosthesis in their life. Not
all amputees will wear a prosthesis. In a 2011 national survey of Australian amputees, Limbs 4 Life found
that 7 percent of amputees do not wear a prosthesis, and in another Australian hospital study, this number
was closer to 20 percent.[170] Many people report being uncomfortable in prostheses and not wanting to
wear them, even reporting that wearing a prosthetic is more cumbersome than not having one at all.
These debates are natural among the prosthetic community and help us shed light on the issues that they
are facing.

Notable users of prosthetic devices

Henry William Paget, 1st Marquess of Anglesey (1768–1854), whose leg was amputated at
the Battle of Waterloo
Marie Moentmann (1900–74), child survivor of industrial accident
Terry Fox (1958–81), Canadian athlete, humanitarian, and cancer research activist
Oscar Pistorius (born 1986), South African former professional sprinter
 Harold Russell (1914–2002), WWII veteran, Academy Award-winning actor

See also
Artificial heart
Bionics
Capua Leg
Cybernetics
Cyborg
Robotic arm
Transhumanism
Whole brain emulation

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External links
Afghan amputees tell their stories at Texas gathering ([Link]
ghan-amputees-tell-their-stories-at-texas-gathering/article_45beb9dd-9c3d-5291-ba43-0aa0
[Link]), Fayetteville Observer
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deographer-rick-allen-overcomes-near-fatal-accident), Fayetteville Observer
 What is prosthesis, prosthetic limb and its various component ([Link]
hat-is-prosthetic-limbs-and-its-component/) Archived ([Link]
010914/[Link] 2022-
07-18 at the Wayback Machine
I have one of the most advanced prosthetic arms in the world – and I hate it ([Link]
[Link]/culture/cyborg-chic-bionic-prosthetic-arm-sucks) by Britt H. Young
A systematic review of randomised controlled trials assessing effectiveness of prosthetic
and orthotic interventions ([Link]
0192094)

Retrieved from "[Link]