History of Prosthetics

The techniques of Amputation have not changed since the end of the 19th century but prosthetic limbs have shown steady improvements in their designs and weight, their shape and their control mechanism. They are now computerized with brain controlled or myoelectric capability. Unfortunately, the fancier they become the more expensive they are and more, the amputees often prefer the simpler devices because of the difficulties of adaption to a bionic one. Researchers are working in new ways in performing amputations to render a bionic limb more natural and acceptable.

The term Prosthesis (From Greek: Addition, Application, Attachment) is an artificial device able to replace a missing part, lost through trauma, disease or congenital conditions. Prosthetics are intended to restore the normal function of the missing body part. Nowadays, prosthetics are commonly created with CAD (Computer-Aided design), a software interface or by hand. Let us review the Prosthetic devices through the ages.

In a past AMHE Newsletter, we mentioned in an article that the first ever recorded prosthetic device was given to the warrior Queen Vishpala, in the Rigveda. The Egyptians pioneered the idea of having wooden toes. Bronze crown were discovered during the Roman Empire and may have been used for aesthetic purpose. Herodotus, a Greek historian mentioned the story of Hegesistratus, a Greek diviner who cut off his own foot to escape his spartan captors and replace it with a wooden one. A Roman general, Marcus Sergius lost his right hand in battle and used an iron hand allowing him to hold on a shield to return in combat.

The first confirmed use of prosthetic device dated from 950-710 BC. Recently in 2000, Pathologists discovered a mummy near Thebes, buried in the Egyptian Necropolis, with an artificial big toe (Wood and Leather).  During the Middle Age, prosthetic remained quite basic. Debilitated knights would be fitted, so they could hold on their shield, grasp a lance or a sword. A knife held in a leather strap replaced well an amputated right hand. Later during the Renaissance, prosthetics were developed with the use of iron, steel, copper and wood.

In the mid-16th century, Ambroise Pare improved prosthetic design, inventing notably an above knee amputee prosthetic device with a kneeling peg, supplemented by a foot prosthesis in a fixed position dotted with adjustable harness and knee lock control. Others like Peter Verduyn invented a non-locking below knee prosthetics, James Potts visualized a wooden shank and socket, with a steel knee joint. Many others like Sir James Syme produced a Syme prosthesis to fit patient who benefited from a Syme ankle amputation. Benjamin Palmer Selpho added a leg with an anterior spring. Dobois Parmlee invented a suction socket.  Desoutter was the first to use an aluminum prosthesis. All tried to improve the quality of life of the amputee.

Henry Heater Bigg developed arms that allowed a double arm amputee to crochet with an ivory hand. At the end of World War II, the National Academy of Sciences (NAS) advocated better research in the development of Prosthetics with government funding within the Navy, Army, Air Force, and the Veterans Administration.

Limb prostheses include upper and lower extremities prostheses:

Upper Extremity prostheses are used at varying levels of amputation Shoulder disarticulation, Forequarter amputation, Trans-humeral amputation, Elbow disarticulation, mid-forearm amputation, Wrist disarticulation, full or partial hand amputation, finger or partial finger amputation.

The upper limb prosthesis can be divided in three main categories Passive devices, Body powered devices, Externally powered (myoelectric) devices. Passive devices can be for cosmetic purpose or passive tools for leisure or vocational. They can be static with no movable parts or adjustable Hand. Passive devices are useful in bimanual tasks requiring fixation and support of an object. A third of upper limb amputees worldwide uses passive prosthetic hand. Body Powered or cable operated limbs work by attaching a harness and cable around the opposite shoulder to the damaged arm. The third category of prosthetic devices are the myoelectrical arms. These worked by sensing via electrodes when muscles of the arms contract, forcing the artificial hand to open or close. A trans-radial prosthetic arm is often referred to as a Below Elbow (BE) prosthesis. In 2005, DARPA started a revolutionizing prosthetic program for upper extremity amputees.

Lower-extremity prosthetics describes artificially replaced limbs from the hip level or lower. 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 3.5–7.1 cases per 10,000 births.

The Lower extremity prostheses can be divided according to the level of replacement.: Hip dislocation, Transfemoral prosthesis, Knee disarticulation, Transtibial prosthesis, Syme’s amputation, foot and partial foot amputation, and toe. Transtibial and transfemoral are the most common level of amputation and may be performed for congenital anomalies as well as traumatic amputations. A well-known Van Ness Rotationplasty can use a special prosthesis.

The 1980’s bought a revolution in the socket technology of the lower extremity prosthetics. John Sabolich invented the Contoured Adducted Trochanteric-Controlled Alignment Method (CAT-CAM) and other prosthetists converted it into a quadrilateral socket. In 1990’s Microprocessor-controlled prosthetic knees become available rendering ambulation more natural for the lower extremity amputee. Some devices were called Adaptive Prosthesis using Hydraulic control or pneumatic control as well as the microprocessor able to accommodate walking speed. We believe that sophistication can bring the cost of an above knee prosthetic to one million in years to come.

We are maybe reaching a point where there are no limits for a good Orthotist to improvise and provide a functional replacement to an amputated part. They generally perform a mold of the extremity and bring their conceptual design to fabricate prosthesis in using lightweight material at the cutting edge like plastics, carbon fiber, titanium, able also to assure strength and stability. They can add advanced electronical equipment for more stability and control.

Myoelectric limbs bring more sophistication in artificial limbs by converting muscle movements to electrical signals. They utilize the residual neuromuscular system to control the function of an electric powered hand, wrist, elbow or foot. Computer Aided Design and Computer Aided Manufacturing (CAD-CAM) designed, they are slowly replacing upper extremity cable operated prostheses. There is no clear evidence concluding that myoelectric upper extremity prosthesis function better than body-powered prostheses. Advantages in using myoelectrical prosthesis bring cosmetic appeal or may be beneficial to amputee experiencing phantom limb syndrome.

More modern artificial prosthesis can be attached to the stump via belts and cuffs or kept by a suction device rendering possible the residual part to fit into a custom-made socket with silicone liners, helping in the distribution of forces. Newer techniques have used laser-guided measuring and have offered more up to date designs. One will need to minimize pressure on the skin to avoid itchy skin rashes or breakdown. Current technology allows the fabrication of light body powered arms.

Finally, wrist units can promote a voluntary or non-voluntary opening system. Artificial sensors have recently been placed in Switzerland and Italy, to stimulate median or ulnar nerve in the hope to provide a near-natural sensory response while other researchers have already found a way to implant electrodes in the amputated limb or wires linked to the nerves.

Robotic prostheses are often used in rehabilitation of an extremity after stroke, using biosensors and a controller connected to the user’s nerve, the muscular system and the device itself. This controller will monitor and control the movements of the device. An “actuator” mimics the actions of the muscle in producing force. Re-innervation of the motor nerve is surgically performed in intact muscles by targeted muscle re-innervation (TMR).  The Pentagon research division (DARPA) has also improved the robotic limb in transmitting signals from the brain to the prosthesis. Advances in the processor itself have allowed developers to preform fine-tuned control. A manually rotatable thumb allowed the hand to grip with precision and power.

If most prosthesis are attached to the body in a non-permanent way. Researchers are looking for a way to have the prosthetic extremity implanted permanently via “Osseointegration” with an exoprosthesis or an endoprosthesis. This new method looks at attaching the artificial limb to the body, by inserting a titanium bolt into the bone and an abutment to the bolt which extend out of the stump. Well known athletes have already participated in Olympics with exoprosthesis. Sergeant Jerrod Fields, a BKA amputee of the US Army ran the 100 meters at the US Olympic training Center in California and won the gold medal with a time 12.15 seconds on June 13, 2009. Oscar Pistorius also a BKA amputee, was found ineligible to compete with his” blade Runner” at the 2008 Summer Olympics. He used a transtibial exoprosthesis and create such controversy that the Olympic committee hesitated to allow him to run thinking that such prosthesis was providing the athlete of an advantage. He ran in the para-Olympics competition and won all his races that same year but was cleared to participate in the 2012 Summer Olympics. He did represent his country of South Africa at the 1012 Summer Olympic and ran multiple races notably the 400 meters and the 4×400 m relay.

A neural prosthetic is about to see life in John Hopkins University laboratory. Other prosthetic devices from silicone and PVC are performed for cosmesis to replace fingers, hands with designed veins, hairs and even tattoos. The cosmetic prosthesis is generally more expensive. In USA, a prosthetic limb cost up to 95.000 dollars with insurance covering 10 to 50% of the total cost. A trans-radial prosthesis for below elbow amputee (BEA) costs a little less than 10.000 dollars while a trans-humeral prosthesis (AEA) and each prosthesis need to be replaced each 4-to 5 years due to wear and tear. An amputee can benefit prosthetic devices providing basic structural support with no joints etc. at low prices especially for children.

Many researchers are working on new ways in performing amputations in grouping or pairing muscle with different functions to render the bionic extremities more natural to users. Others are wiring the nerves, natural sensors, to re-create a sense of force, touch, power and position to better the newer prostheses functions. The technology is at our fingers and it will take more time to refine the ideas. The future is bright for our amputees. Be patient.

Maxime Coles MD


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