Section 3: Human Foot and Ankle Versus

Prosthetic Foot/Ankle Mechanism Function

Prosthetic foot/ankle mechanisms are often studied and
compared on the basis of how they substitute for human foot and
ankle functions. Clinicians caring for persons with limb loss face
no small task in deciding which foot/ankle components to
prescribe for each
individual.
Modern prosthetic practice
includes a growing array of
foot/ankle mechanism
designs that offer a wide
spectrum of functions,
indications, and costs. New
designs and materials have
added properties and motions that blur the lines of the traditional
prosthetic foot/ankle mechanism classification. This constant
innovation requires a greater knowledge of human foot and ankle
function and more descriptive terminology when recommending
prosthetic foot/ankle mechanisms to patients.
Perry lists three main functions of the human foot and ankle as
shock absorption,
weightbearing stability, and
progression.
This section will review human foot and ankle function versus
prosthetic foot/ankle mechanism function, traditional prosthetic
foot classifications, and present information on functional subsets
for prosthetic foot/ankle mechanisms.

THE HUMAN FOOT

HOW THE HUMAN FOOT AND ANKLE ACHIEVES SHOCK

ABSORPTION, WEIGHTBEARING STABILITY AND
PROGRESSION
SHOCK ABSORPTION is an important component of loading
response, when the swinging foot rapidly decelerates from initial
contact to foot-flat. While the foot plays an important role, the
entire limb contributes to shock absorption. Stance phase knee
flexion follows ankle plantarflexion. Eccentric dorsiflexor muscle

action (primarily the tibialis anterior) provides muscular shock

absorption during ankle motion. In addition, the anatomical
structure of the foot contributes to shock absorption through
tarsal mobility and various joint articulations. The foot is fairly
rigid at the point of initial contact, and "unlocks" with a subtle
degree of subtalar joint eversion, accompanied by internal
rotation of the tibia and hip. The series of lower limb joint motions
transforms the lower limb and specifically the foot and ankle
complex into a loose packed structure that accepts weight
bearing and provides shock absorption. As foot flat is achieved
and the ankle rocker mechanism is engaged, body weight
continues to advance over the lower limb, facilitated by motion of
the ankle.
At this point, WEIGHTBEARING
STABILITY is essential as the
contralateral limb leaves the ground.
Advancement of the loading force vector
from the hindfoot to the forefoot places
an increasingly greater demand on
intertarsal and metatarsal alignment to
alter the foot and ankle complex from a
loose packed and flexible structure to
close packed and rigid structure.
Meanwhile, the medial longitudinal arch remains effective at
absorbing energy and adapting to uneven surfaces and variable
ground reaction forces.
After midstance, a series of alignment
changes occur between the hip, knee and
tibia that reverse from internal rotation to
external rotation. External rotation at the hip
and tibia is translated down the kinetic chain
to again transform ankle and foot alignment.
As such, the hindfoot and midfoot tarsals and
forefoot metatarsals and phalanges gradually
transform the foot to a rigid lever structure
capable of transferring loading, providing
stability and assisting in propulsion in late
stance phase. This is achieved through the
relationship between external rotation among
the lower limb joints that is transferred to the
hindfoot. This external rotation is transferred through the ankle
mortise to affect alignment of the talus and produce subtalar
inversion. Subtalar inversion transforms the hindfoot into a more

rigid alignment which begins to "lock" the hindfoot.

As loading continues from midstance to late stance and upon heel
rise, the metatarsalphalangeal joints undergo increasing
dorsiflexion which creates tension upon the plantar fascia to
effectively shorten its length. As the plantar fascia shortens, it
produces the windlass effect which lifts the medial longitudinal
arch and transforms the talonavicular and calcaneocuboid joints
(collectively referred to as the transverse tarsal joint) into a close
packed alignment where the navicular, cuneiforms and cuboid
align similar to the trusses of a bridge. This series of events
effectively completes the "locking" of the subtalar and transverse
tarsal joints which produces a rigid foot and ankle complex to
effectively act as a rigid
lever system capable of
transferring loading
across the foot at the
push off phase of gait.
During this period of
propulsion
or PROGRESSION, the
foot moves into the
forefoot rocker from
terminal stance to preswing. Although the
forefoot remains in
contact with the ground,
the body is progressing
through contralateral
swing in preparation for ipsilateral swing. At the end of stance
phase, forefoot dorsiflexion reaches a peak, maximizing the
windlass effect.

PROSTHETIC FOOT/ANKLE MECHANISMS

HOW FOOT/ANKLE MECHANISMS ACHIEVE SHOCK

ABSORPTION
Prosthetic components often emulate shock absorption functions
of the physiologic foot and ankle, but usually have far fewer
mechanisms to do so. This is because they lack sufficient triplanar

rotary motion or variable loading stability. The heel lever or

posterior cushion plays a major part in the first rocker. In general,
prosthetic foot/ankle mechanisms either attempt to emulate the
shock absorbing lower limb motion during the first rocker, or
attempt a completely different
shock absorption approach.
Recreating the first rocker:
One approach to emulate the shock
absorption that occurs during first
rocker is to attempt to mimic human
foot and ankle anatomy in the prosthesis. The single axis foot
uses a hinge to recreate sagittal plantarflexion and dorsiflexion.
Shock absorption occurs through the dissipation of energy in the
plantarflexion bumper. Material properties of the bumper affect
the amount of energy dissipation.
Trying something different:
Solid ankle designs arose in response to the need for a simpler,
low-maintenance prosthetic foot/ankle mechanism than the
single-axis design. However, the lack of motion in a solid ankle
design necessitated a new approach to shock absorption during
loading response. The cushion heel of the SACH design and
several subsequent ESAR designs provides shock absorption
through material compression. The magnitude of simulated ankle
plantarflexion for the solid ankle cushioned heel (SACH) and
similar "solid" ankle designs is roughly half that of the anatomical
ankle. The Flex-Foot produces only one fourth of the magnitude of
normal ankle plantarflexion motion. Deformation of the cushion
heel of the SACH foot design and several other types of feet
under loading allows shock absorption in the absence of
simulated ankle plantarflexion.

HOW FOOT/ANKLE MECHANISMS ACHIEVE

WEIGHTBEARING STABILITY
Prosthetic foot/ankle mechanisms do not yet offer the degree of
variable flexibility and rigidity provided by the physiologic foot,
ankle and lower limb kinetic chain. Prosthetic foot/ankle
mechanism designs often compromise between the softness at
initial stance and the stiffness required at terminal stance. Usually
designers seem to err toward stiffness, because drop off at
terminal stance (an effect of a prosthetic foot/ankle mechanism

with insufficient rigidity) is undesirable, and even potentially

hazardous. For example, a person with transfemoral limb loss
utilizing a prosthetic foot/ankle mechanism with flexible keel and
forefoot will encounter knee instability due to deformation of the
prosthetic forefoot during terminal stance. With the exception of
the single-axis foot, prosthetic foot/ankle mechanisms usually do
not contain an ankle mortise joint which would facilitate tibial
progression. Combined with a set heel height, this results in
slowing of tibial progression to one half the usual rate. One
disadvantage in foot/ankle mechanism designs with a cushion
type heel is the prolonged "heel-only" contact. This produces an
unstable external knee flexion moment until the forefoot makes
contact. EMG studies reveal prolonged co-contraction of
hamstrings and quadriceps muscle groups to maintain stability.
This could be one reason that a soft heel bumper is typically
recommended for a person with transfemoral limb loss level in
order to prevent an excessive external knee flexion moment.
Knee instability associated with prolonged loading upon the heel
may also result in more falls when persons with limb loss walk on
low-friction surfaces such as wet tile or ice.

HOW FOOT/ANKLE MECHANISMS MAINTAIN PROGRESSION

Progressive stiffness of the prosthetic foot/ankle mechanism is
directly influenced by the composition and geometry of the
forefoot keel. This may consist of multi-carbon plates, a urethane
"sandwich," or a carbon footplate. The geometry of the keel also
influences stiffness. The cross-sectional taper and angle or curve
of the keel as well as the surrounding material provide spring
stiffness. A problem often encountered with many keels
integrated into foam has been that the distal end of the keel
pushes through the foam foot. Although cloth reinforcement has
reduced this tendency, it continues to be a problem with highly
active patients. Observation of ankle moments reveals that
the Flex-Foot keel acts to generate twice the degree of energy
return compared to a SACH foot. Along with being symmetric and
thereby reducing manufacturing costs, a wide blade width
accommodates a wide variety of center of pressure (COP)
pathways, but may decrease efficiency overall.

TRADITIONAL FOOT CLASSIFICATIONS

Foot classifications that have been used since the 1980s include:
Single axis
SACH
Multi-axis
Dynamic response
Single Axis Feet
Single-axis feet attempt to replace part of the anatomical ankle
joint motion by incorporating a hinge at the approximate location
of the transverse tarsal joint. The "single axis" of the foot/ankle
mechanism mimics sagittal plane motion only. Passive control of
plantarflexion and dorsiflexion is provided by variable-stiffness
bumpers.
Single-axis feet differ from solid-ankle designs in several ways.
During loading response, single-axis feet plantarflex. Range of
motion and timing vary depending on bumper properties. A soft
bumper may result in premature foot flat. By contrast, when
bumpers are too firm the single axis foot may simply function as a
solid-ankle foot.
Historically, single axis feet were the first feet that were
laboriously made for the patient with a toe break placed 6 mm
posterior to the metatarsal heads. The forefoot rocker was
positioned so as to augment the patient's movement. Today's
single-axis designs are prefabricated and generally depend on the
alignment capability of the prosthetist to optimize their rollover
characteristics.
SACH feet
As biomechanical understanding and manufacturing capabilities
evolved after World War II, component designers moved toward
better simulating functions of the human foot and ankle complex.
In the late 1950s, studies on the biomechanics of walking resulted
in the creation of thepatellar tendon bearing (PTB) transtibial
prosthesis including the concurrent development of the SACH
foot. Functionally the SACH foot also helped to promote knee
flexion that was
important to PTB
interface designs of
the time.
The heel cushion
compressed under
loading to simulate

ankle plantarflexion and the eccentric contraction of the ankle

dorsiflexors during loading response. The rigid keel simulated the
stiffening effect of the ankle plantarflexors and forefoot dynamics
during late stance. The SACH foot also addressed some of the
maintenance and availability issues of the single axis foot by
incorporating the functions of the single axis foot into an
integrated design.
Observational gait analysis typically reveals prolonged heel
cushion compression of the prosthetic foot/ankle
mechanism.Radcliffe advocated relative ankle plantarflexion
alignment of the prosthetic foot/ankle mechanism in order to
minimize heel cushion compression and to increase foot flat
stability. This was particularly emphasized for stabilizing the
prosthetic knee in the alignment of prostheses for persons with
transfemoral limb loss.

Multi-Axial Feet
Watch the video clip of
a human foot
inversion/eversion detail.
Watch the video clip of the
Pathfinder inversion/eversion
toe detail.
The multi-axial foot/ankle
mechanism was designed to
provide the ability to
accommodate uneven terrain
beyond that of the single axis
foot/ankle mechanism by
allowing motion in all planes,
not just plantar and
dorsiflexion in the sagittal
plane. These foot/ankle
mechanisms can be a simple
split-keel variety, a carbon
plate urethane overmolded
sandwich, a hindfoot
articulation or a combination of these designs.
A split keel design allows for the forefoot of a foot/ankle
mechanism to comply to the underlying surface as it is loaded. It

behaves as two separate levers with a unified proximal junction.

The carbon plate urethane sandwich allows the lower plate to
accommodate ground surface contours while the urethane
exhibits elastic properties to allow for ground compliance and
reduction of ground reaction forces transferred proximally to the
residual limb.
Hindfoot articulations generally have elastic bumpers and
bushings to allow for the plantar aspect of the

The Delrin keel

foot/ankle mechanism to adapt to terrain

of the original

through compression of these elastic

Seattle Foot

members.

Dynamic Response Feet

Dynamic Response foot/ankle mechanisms

Courtesy Seattle

emerged in the 1980s with the objective of

Systems

providing improved response over existing

designs by simulating passive subtalar joint motion within the
prosthetic foot. The SAFE foot (one of the first flexible keel feet)
was introduced followed by the Seattle Foot, The Carbon Copy II
and the Flex-Foot. A plethora of feet falling into the classification
of dynamic response have since been developed.
These designs employ a stiff anterior keel or leaf spring, made
initially of Delrin (a nylon that can be easily machined and
offers consistent spring function and toughness) and
subsequently of phenolic and Fiberglas materials and high
strength carbon plates. This was done theoretically to store spring
potential energy through deformation of the keel in mid to late
stance and return a portion of this energy for propulsion in the
absence of active ankle plantarflexors. These designs were
thought to also offer prolonged foot flat stability, better tibial
progression, and more support distally when compared with SACH
feet.
Although this has not been
verified with quantifiable data,
many users report that dynamic
response feet simply feel more
lifelike when compared with other feet. Some report that although
they like the springiness of the dynamic response feet, they may
find themselves working against the action of the foot when
walking at slower speeds, descending stairs, and even

decelerating after running.

FUNCTIONAL SUBSETS
Recently many foot/ankle mechanism designs have blurred the
lines of these classifications by hybridizing the properties of
different classes, primarily by combining dynamic response feet
with multi-axis attributes. As a result, the traditional classification
system has become outdated with regard to ESAR foot/ankle
mechanisms.
It may be useful to develop a classification system based on the
subsets of individual functional attributes that may be present in
any foot/ankle mechanism. Proposed subsets could include:
Forefoot Keel
Heel Lever
Hindfoot Roller
Flexing Strut
Forefoot Inversion/Eversion
Multiaxis Hindfoot
Integrated Shock

Forefoot Keel
The Forefoot Keel is characteristic of the
most basic ESAR foot/ankle mechanism with
any number of materials and configurations.
The Forefoot Keel can be a single-bladed
member or consist of multiple separate
members to approximate the medial

Copyright Otto
Bock Healthcare

column and lateral column of the

anatomical foot. Stiffness is directly

dependent on the cross section, material, keel

length, and geometry. Some designs use multiple
layers that collapse progressively, and others
use a urethane sandwich, which has a smoothing
effect on the load progression.
Heel Lever
The Heel Lever emulates the
heel rocker, which
contributes to load
acceptance and ankle
plantarflexion
characteristics. Many

An
Copyright
absorber
An absorber
Otto
in

Copyright Otto

Bock
parallel
Healthcare
in series

Bock Healthcare

http://www.oandp.org/olc/lessons/html/200606-14/section_5.asp?
frmCourseSectionId=5828CD65-86D4-45E9-81F0-E996BA425D48
Amputasi berasal dari kata amputare yang kurang lebih diartikan pancung. Amputasi dapat diartikan
sebagai tindakan memisahkan bagian tubuh sebagian atau seluruh bagian ekstremitas, atau dengan kata
lain suatu tindakan pembedahan dengan membuang bagian tubuh (Bruner dan Sudarth, 2002). Tindakan
ini merupakan tindakan yang dilakukan dalam kondisi pilihan terakhir manakala masalah organ yang
terjadi pada ekstremitas sudah tidak mungkin dapat diperbaiki dengan menggunakan teknik lain, atau
manakala kondisi organ dapat membahayakan keselamatan tubuh klien secara utuh atau merusak organ
tubuh yang lain seperti dapat menimbulkan komplikasi infeksi.
Kegiatan amputasi merupakan tindakan yang melibatkan beberapa sistem tubuh seperti sistem
integumen, sistem persyarafan, sistem muskuloskeletal dan sisten cardiovaskuler. Labih lanjut dapat
menimbulkan masalah psikologis bagi klien atau keluarga berupa penurunan citra diri dan penurunan
produktifitas. Seringkali masyarakat merasa takut dan tidak mau untuk diamputasi karena masyarakat
atau klien menggangap hal tersebut sangat berbahaya dan dapat menyebabkan kematian. Padahal
dalam konteks pembedahan, amputasi bertujuan untuk menyelamatkan hidup.
a. Teknik Amputasi
Teknik amputasi ada dua yaitu myodesis dan myoplasty, myodesis adalah mengikatkan group otot tulang
dengan tulang, sedangkan myoplaasty adalah menjahitkan otot dengan jaringan lunak pada sisi yang lain
yaitu pada otot atau fasia sebelahnya (Bruner dan Sudarth, 2002).
b. Sebab-sebab Amputasi
Tindakan amputasi dapat dilakukan pada kondisi (1) trauma berat (cedera akut, luka bakar listrik, luka
bakar dingin), (2) fraktur multiple organ tubuh yang tidak mungkin dapat diperbaiki, (3) kehancuran
jaringan kulit yang tidak mungkin diperbaiki, (4) gangguan vaskuler/sirkulasi pada ekstremitas yang berat,
(5) infeksi yang berat atau beresiko tinggi menyebar ke anggota tubuh lainnya, (6) adanya tumor pada
organ yang tidak mungkin diterapi secara konservatif, (7) deformitas organ.
c. Level Amputasi
Level-level amputasi pada anggota gerak bawah terdiri dari (1) Hemipelvectomy yaitu amputasi tidak
hanya menghilangkan sendi pada hip, tetapi juga menghilangkan sebagian dari pelvic, (2) Hip
disarticulation yaitu amputasi tepat pada sendi panggul,(3) Above Knee yaitu amputasi pada atas lutut,
(4) Knee disarticulation yaitu amputasi tepat pada sendi lutut, (5) Below Kneeyaitu amputasi pada bawah
lutut, (6) Ankle disarticulation yaitu amputasi tepat pada sendi pergelangan kaki, (7) Symes yaitu

amputasi

tepat

pada

sendi

pergelangan

kaki

dengan maleolus

tibia dan fibula ikut

(8) Chopart yaitu amputasi pada sendi talo navicular dan talocuneiforme 1 sampai 3.

http://orthopolist.com/amputasi/

hilang,