A Manual for Above-Knee Amputees

Preface
The objective of this manual is to make readily available to "above-knee"
amputees, including persons who have had a knee disarticulation, hip-
disarticulation or hemipelvectomy, the information generally provided to them
orally by members of the treatment team- the medical doctor, the physical
therapist, the prosthetist, and others. Included, also is additional information that
we hope will be interesting and useful to persons with an amputation at the level of
the knee and above.
An amputation results in a disabling condition. However, with modern prostheses
and treatment methods, and when the musculature is good, the circulation is
adequate, and there is an absence of excessive scarring, the unilateral aboveknee
and knee-disarticulation amputees can do many of the things they could before
amputation.
During the past few years the International Standards Organization has developed a
standard method of describing amputations and prostheses that is being adapted
worldwide. Of special importance here is the use of "trans-femoral" in place of
"above-knee" to identify an amputation between the knee and hip joint. This term
has been adopted to avoid confusion with disarticulation at the hip and amputations
through the pelvis.
In recent years, there has arisen an aversion to the use of the word "stump" in
referring to that part of the limb that is left after amputation, and attempts have
been made to find another term that could be used. This has proven to a difficult, if
not impossible, task because there is no synonym in the English language for
"stump." The terms "residual limb" and simply "limb" which have been suggested
are ambiguous at best, and since nothing better seems available, the word "stump"
has been retained by the International Standards Organization and is used here to
avoid confusion.
Many people have contributed to the success of previous editions of this booklet,
but we want to express special appreciation to Ted Muilenburg, Jon Holmes, Ted
Thranhardt, Richard Bailey, and Ron Spiers for reviewing with care our drafts of
this edition and making many helpful suggestions.

A Manual for Above-Knee Amputees

The Amputation
Amputations are caused by accidents, disease, and
congenital disorders. Approximately 74% are due to
peripheral vascular disease (poor circulation of the
blood) and cancer; 23% are due to accidents, and 3% are due to a problem found at
birth.
The accidents most likely to result in amputation are traffic accidents, followed by
farm and industrial accidents.
Amputations in the case of disease are performed as a lifesaving measure. The
diseases that cause the most amputations are peripheral vascular disease (poor
circulation of the blood) and cancer.
A congenital disorder or defect of a limb present at birth is not an amputation, but
rather a lack of development of part or all of a limb. A person born with a limb
deficiency. usually can be helped by use of an artificial limb.
Sometimes amputation of part of a deformed limb or other surgery may be
desirable before the application of an artificial limb.
There are more than 1.5 amputees per 1000 people in the United States and
Canada, and therefore more than 380,000 amputees in the U.S. at the present time.
Above-knee (trans-femoral) amputees form the second largest group of amputees.
Surgeons preserve as much length in thigh amputations as is medically feasible
because longer stumps provide better control over the prosthesis. Experienced
surgeons avoid leaving unnecessary skin and muscle. Disarticulation at the knee
preserves the entire thigh, and, in addition, permits "end-bearing", or the ability of
the stump to carry a substantial portion of the body weight over the end.

A Manual for Above-Knee Amputees

The Immediate Postsurgical Period

Nearly every amputee feels quite depressed immediately after the surgery, except
possibly those who have suffered intense pain for a period just prior to the
amputation. This depression is usually replaced early by a will to resume an active
life.
The dressing applied by the surgeon is either "rigid," usually made of plaster-of-
Paris, or "soft," using ordinary cotton bandaging techniques.
When a rigid dressing is used it is left on for 10 to 14 days during which time most
of the healing has taken place. When the soft dressing is used, elastic bandages are
used soon after surgery to aid circulation. The bandages are removed and reapplied
throughout the day. (Instructions for application of elastic bandages are given in
the next section)
Regardless of the type of dressing used, exercises are extremely important to
prevent tightening of the muscles, or contractures, which, when present prevent
efficient use of a prosthesis.
Some DON'Ts that will prevent muscle tightening, or contractures, are shown
below.

A Manual for Above-Knee Amputees

Fitting the Prosthesis

In general, the earlier a prosthesis is fitted, the better it is for the amputee. One of
the most difficult problems facing the amputee and the treatment team is edema, or
swelling of the stump, owing to the accumulation of fluids. Edema will be present
to some extent in all cases, and it makes fitting of the prosthesis difficult, but
certain measures can be taken to reduce the amount of edema. The use of a rigid
dressing seems to control edema. After the rigid dressing has been removed and
when a prosthesis is not being worn, elastic bandages are used to keep edema from
developing. The amputee is taught the proper technique for bandaging and is
generally expected 'to do this for himself as shown on the next page.
For the average adult two or three elastic bandages six inches wide are used.
During application, the bandages should be stretched to about two-thirds of the
limit of the elastic, and the greatest tension should be around the end of the stump.
The stump should be kept bandaged at all times, but the bandage should be
changed every four or six hours. It must never be kept in place for more than 12
hours without rebandaging. If throbbing should occur, the bandage must be
removed and rewrapped. Edema occurs rapidly when the stump is left unbandaged
so it is very important to replace the bandage without delay.
Special elastic "shrinker" socks are available for use instead of elastic bandages,
and while not considered by some to be as effective as a properly applied elastic
bandage a shrinker sock is better than a poorly applied elastic bandage.
Whether elastic bandage or shrinker sock is used, it should be removed at least
three times daily and the stump should be massaged vigorously for 10-15 minutes.
The bandage or sock must reapplied immediately after the massage.

1. Begin by placing one end of a rolled 6-inch wide elastic bandage on the
upper part of the thigh and wrap it around the stump toward the rear.
2. Bring the roll through the legs and over the end of the front of the thigh.

3. Bring the roll across the back and on across the lower stomach area.
4. Continue to wrap around the thigh, across the back and lower stomach area
until the roll is suspended. Attach the end of the roll with the metal clips that
are included with the bandage.
5. With a second roll of elastic bandage, begin to wrap the stup from the upper
outer surface diagonally toward the lower inner surface.

6. Bring the roll of bandage around the back of the stump and upward
diagonally.
 7. Bring the roll of bandage behind the uper part of the stump.
8. Continue to wrap the stump in an overlapping fashion until the entire stump
is covered. Fasten the end of the second roll of bandage to the first bandage.

A Manual for Above-Knee Amputees

The Preparatory Prosthesis

Fitting a prosthesis as soon alter surgery as possible helps to
combat edema. A preparatory prosthesis is frequently used
for several weeks or months until the stump has stabilized
before the "permanent" or definitive prosthesis is provided.
The socket of the preparatory prosthesis may be made of
either plaster-of-Paris or a plastic material, and is attached to
an artificial foot by a lightweight tube or strut, often called a
"pylon." When indicated, a suction socket is used. Most
pylons are designed so that the alignment of the foot with
respect to the socket can' be changed when it is needed.
Although a variety of shoes may be worn with artificial
limbs, the patient should consult with the prosthetist before
selecting shoes to be used with the prosthesis, because heel
height is a major factor in alignment of the artificial leg.
A belt about the waist is usually used to help keep the preparatory prosthesis on the
stump properly. At least one prosthetic sock is worn between the socket and stump
to provide for ventilation and general comfort. Most prosthetic socks are woven of
virgin lamb's wool, but socks of synthetic yarns are available also. Prosthetic socks
are used to prevent skin abrasion and to provide ventilation. They are available in
several thicknesses - most commonly 1-ply, 3-ply, 5-ply, and 6-ply. Additional
socks can be used to compensate for stump shrinkage if the amount of shrinkage is
not too great. The prosthetist and therapist can suggest the sock or socks to be
used, but only the patient can determine the proper selection.
Prosthetic socks must be changed daily to reduce the chance of skin irritation or
dermatitis.
Prosthetic socks require special care in laundering. Instructions are provided by
each manufacturer.
A special woven nylon sock known as a prosthetic sheath is used by many
amputees between the skin and regular prosthetic sock to provide additional
protection from abrasion. The sheath also allows perspiration to escape to the
prosthetic sock and thus to the atmosphere.
Special Note:
Regardless of the functions provided by the most sophisticated mechanical devices,
the most important factors in the usefulness of an artificial leg are fitting of the
socket and alignment of the various parts with respect to the body and to each
other. Fitting and alignments are difficult procedures that require a great deal of
skill on the part of the prosthetist and a great deal of cooperation on the part of the
patient. During fitting and alignment of the first prothesis, it is necessary for the
prosthetist to train the amputee in the basic principles of walking. Fitting affects
alignment, alignment affects fitting, and both affect comfort and function.
Extensive training is carried out later by the physical therapist.
 A Manual for Above-Knee Amputees

The Definitive Above-Knee Prosthesis

The above-knee prosthesis has four major parts: the socket; the knee system; the
shank; and the foot-ankle system.
A variety of sockets, knees, shanks, feet, and ankles are available and can be
combined to produce a prosthesis that best meets the needs of each individual
amputee.
Description of the components most used in the United States are given in the
following sections.

A Manual for Above-Knee Amputees

 The Socket
The socket is the basis for the connection between the user and the prosthesis. It
always provides the means for transferring the weight of the amputee to the ground
by way of the rest of the prosthesis.
The shape of the socket is critical to comfort and function. The socket must not
restrict circulation, yet it cannot be loose. Most sockets for above-knee prostheses
cover the entire stump. There are several designs available to take maximum
advantage of the muscles in the stump of the individual amputee for control of the
prosthesis and for transferring the weight of the amputee to the floor.
Most sockets are made of a rigid plastic, but some amputees prefer a flexible
socket supported by a rigid frame because comfort during walking and sitting
seems to be improved.
For most patients, the prosthesis can be held in place by "suction", or a vacuum,
provided by a close fit between stump and socket. This is known as a suction
socket. Nothing is worn between the stump and socket. when circulation is
marginal or precarious, a looser fit is provided, a woolen sock is worn over the
stump, and the socket is held in place by a "Silesian Bandage".

A Manual for Above-Knee Amputees

The Knee System

 If the above-knee amputee is to have a normal appearance
while walking, the prosthesis must have a knee joint that will
not buckle as he rolls over the artificial foot during the stance
phase of walking.
The simplest way to achieve this is to use mechanical friction
about a bolt that connects the socket (thigh) to the shank. The
bolt is located behind the path of the weight of the body to
the floor so that it will not buckle when the user is standing
straight. The mechanical friction, which may be a simple
adjustable brake, keeps the shank from swinging forward too fast as the user
swings the artificial leg through to the next step. The chief limitation in the single-
axis, constant friction design is that appearance is normal at only one speed of
walking for a given setting of friction, The amputee must be very careful in
walking, especially on uneven surfaces, to avoid stumbling.
A great deal of effort has been spent over the Years
developing knee systems which overcome the
limitations of the single-axis, constant friction knee.
Many designers have been successful to some degree,
but because of the simplicity of the constant friction
design, no new system has totally displaced it.
Weight Actuated Knee Brake
The second level of complexity in knee systems is the
use of a weight-actuated brake with constant friction.
Two bolts are used at the knee, so that when one pivots
about the other when the amputee is standing, the force
of the body weight engages a brake that keeps the knee
from buckling.

Polycentric Knees
To provide better control of the above-knee prosthesis
during standing and the stance phase of walking than can be
provided with a single axis knee, designers have used
mechanical linkages between the socket and shank that, in
effect provide for a moving center of rotation. Such designs
are known as polycentric knees. Used originally for the
knee-disarticulation case, polycentric knees now also used in
prostheses for higher levels, especially when stability at heel
strike is desirable. The swing phase control may be either
mechanical friction or hydraulic resistance. The one
limitation of the polycentric design is that range of motion
about the knee may be restricted to some degree but not
enough for it to be objectionable to most users.
Hydraulic Knees
To allow the amputee to vary his speed of
walking, a number of hydraulic devices are
available. In the simplest system, the piston is
attached to a pivot in the thigh section of the
prosthesis behind the knee bolt, and the cylinder
is attached to a pivot in the shank. Because of the
way oil acts when forced through a small hole the
amount of resistance required for a given velocity
of walking is provided automatically.
The most complex knee systems of those
available are those which control of both swing
and stance phase with a single hydraulic cylinder.
Braking of the knee is brought about automatically when the knee begins to
buckle, without interfering with normal flexion and extension of the knee. The
same system permits the velocity of walking to be varied at will. These features are
appreciated most by very active amputees.
The prescription for the prosthesis is based on activity level and particular needs of
each amputee.

A Manual for Above-Knee Amputees

Shanks
The primary purpose of the shank is to transfer the vertical loads caused by the
weight of the amputee to the foot and on to the floor. Two types are available:
Crustacean, or exoskeletal, where the forces are carried through the outside walls
of the hollow shank which is shaped like a leg; and endoskeletal, or pylon, where
the forces are carried through a central structure, usually a tube and the shape of
the leg is provided by a foam covering.
Each design has advantages and disadvantages. The endoskeletal systems offer the
most life-like appearance and "feel", but require more care to maintain. The
crustacean design is suitable for heavy duty. Most endoskeletal parts are designed
for moderate or light duty, but heavy duty systems are available.
Another advantage of some of the endoskeletal systems is that knee units of greater
complexity can be introduced as the amputee becomes more proficient or his
functional needs change.

A Manual for Above-Knee Amputees

Ankle-Foot Systems
A variety of artificial foot designs is available, each having its advantages and
disadvantages. Feet currently available can be divided into two classes: articulated
-those with moving joints, and non-articulated. Those with moving joints generally
require more maintenance and are slightly heavier than most of the non-articulated
kind.

Articulated feet may have one or more joints. The single-

axis foot (one-joint) provides for ankle action that is
controlled by two rubber bumpers either of which can be changed to permit more
or less motion as needed. It is often used to assist in keeping the knee stable.

A multi-axis foot is often recommended for people who

have to walk on uneven surfaces because it allows some
motion about all three axes of the ankle. It is, of course,
slightly heavier than the other types of feet and is apt to
require more maintenance as well.

The simplest type of non-articulated foot is the SACH (solid

ankle-cushion heel) Foot. The keel is rigid. Ankle action is
provided by the soft rubber heel which compresses under
load during the early part of the stance phase of walking.
The rubber heel wedges are available in three densities: soft,
medium, and hard.

The SAFE (solid ankle-flexible-endoskeletal) Foot has the

same action as the SACH plus the ability for the sole to
conform to slightly irregular surfaces and thus makes it
easier for the amputee to walk over uneven terrain. Feet of
this type make walking easier because of the flexibility, and
are sometimes called "flexible keel" feet.

In recent years, there has been a proliferation of new

designs for artificial feet. Most are capable ofabsorbing
energy in a "flexible" keel during the "roll-over" part of
the stance phase of walking and springing back
immediately to provide push-off, or assistance in getting
the toe off of the ground, to start the swing phase of
walking. Although the original idea was to provide the
active athlete with more function, amputees who are a lot
less active have found these designs useful. These
designs are often called
"dynamic response" feet.
Most of the non-articulated
feet are available with toes
moulded in to provide a very
realistic appearance.

There are available still other ankle-foot systems that

incorporate the shank and eliminate the need for a
mechanical connection between the foot and shank.
The shank-ankle-foot is usually made of a specially
developed plastic composite that responds nicely to
the forces created during the stance phase of walking.
These lightweight systems seem to have most of the advantages of more
conventional designs, while providing an additional function.

Transverse Rotation Device

A transverse rotation unit allows some rotation about the long axis of the shank
when it is installed in the shank between the ankle and the socket. The idea of
providing this function seems to be sound, but the difficulty in designing and
manufacturing a unit that is reliable has restricted its acceptance.

A Manual for Above-Knee Amputees

Above-Knee Prosthesis Fabrication

Whether the prosthesis is to be a crustacean or an
endoskeletal (often called "modular") type, the
prosthetist begins by wrapping the stump with
plaster-of-Paris bandages to obtain a negative
mold. A positive model is made by filling the
negative mold with a mixture of plaster-of-Paris
and water, and allowing it to harden.
After modification of the model to provide the
proper characteristics in the finished socket, a
plastic socket is formed over it. The first socket
is usually transparent for use as "test" or "check"
socket to determine if further modifications are needed.
A new method being used by some prosthetists for obtaining a modified model of
the stump involves use of a computer and automatic machinery.
Known as CAD/CAM, (Computer-Aided Design \ Computer-Aided
Manufacturing), this system permits prosthetists to modify the model more easily
since it does not require making and carving an actual plaster model.
The socket is mounted on an adjustable leg for walking trials, and when both the
prosthetist and the amputee are satisfied, the limb is ready for the finishing
procedures. The crustacean shank may be of plastic-covered wood or all plastic.
The endoskeletal type uses carved foam rubber over the supporting tube and the
entire prosthesis is encased in a latex or fabric stocking.
Steps in the fabrication of a plastic prosthesis for the trans-femoral amputee are:
1. A negative mold of the stump is made by wrapping it with a wetted
plaster-of-Paris bandages.
2. The cast is filled with a mixture of plaster of Paris and water to make a
positive model.
3. After modifications have been made to the positive model to make sure
that the pressure on the stump will be distributed properly, a check, or
test, socket is made by forming a heated sheet of a clear plastic over the
modified model.
4. The clear plastic socket is tried on to make sure that it fits properly.
5. A new positive model is made by filling the clear test socket with a
mixture of plaster of Paris and water.
6. The socket to be used on the definitive prosthesis is formed over the
model either by using a mixture of plastic resin and cloth or by forming
a heated sheet of plastic over the model.
7. &
8. The definitive socket is attached to an adjustable leg for alignment and
walking trials.
9. The finished prosthesis may be either the crustacean or the
endoskeleton type.
 A Manual for Above-Knee Amputees

Donning the Sucton Socket

A number of methods of donning the suction socket
have been devised through the years. Each amputee
needs to experiment to determine the method that seems
easiest for him.
The three most popular methods seem to be:
1. Use of a nylon stocking or a single layer of
tubular stockinet over the stump and removing it
through the valve hole as the stump is "pumped"
into the socket.
2. Use of tubular stockinet that has been doubled
over the stump and removing the stockinet by
pulling the end of the outer layer through the
valve hole as the stump is "pumped" into the
socket.
3. Use of an elastic bandage that has been wrapped
tightly around the upper half of the stump and
then pulled through the valve hole as the stump is
"pumped" into the socket.
Various devices have been made available from time to
time with the purpose of making the donning of the
prosthesis easier, but none seem to have been used
widely.
Air bubbles between the socket and stump result in discomfort. The valve is
opened as the stump is forced into the socket to expel any air bubbles that may
develop and to reestablish suction when it is lost after sitting or for any reason.

A Manual for Above-Knee Amputees

Care of the Stump

The stump must be washed daily to avoid irritations and infection. A mild soap and
warm water are recommended.
The interior of the socket must be kept clean as well by washing daily with warm
water and a mild soap. Use of detergents should be avoided.
Some amputees have found a hair dryer to be very useful in drying the stump and
the inner walls of the socket.
When prosthetic socks are used, they should be replaced daily with newly
laundered ones; more often, in warm humid weather. The socks should be washed
in warm water with a mild soap. Manufacturers recommend that socks be rotated
on at least a three or four-day schedule to allow the fibers to retain their original
position.
Prosthetic socks must be applied carefully to avoid wrinkles which can cause skin
problems.
Reductions in the size of the stump can be accommodated by adding one or more
prosthetic socks.
Prosthetic socks are woven especially for their intended use and are available in
three thicknesses and a variety of sizes.
The thicknesses generally available are 3-ply, 5-ply, and 6-ply. With this
combination, various thicknesses can be obtained as follows:
One 3-ply = 3 plies
One 5-ply = 5 plies
Two 3-ply = 6 plies
One 3-ply + One 5-ply= 8 plies
One 6-ply sock can be used instead of two 3-ply socks.
Some amputees have found that use of a one-ply cotton cast sock provides a
satisfactory way to obtain still finer adjustment in thickness. When the amputee has
trouble in obtaining comfort by a combination of prosthetic socks, he should
consult with his prosthetist immediately.

A Manual for Above-Knee Amputees

Training
Extensive training in the use of an above-knee prosthesis is usually necessary if
optimum gait and comfort are to be obtained. Early training is provided by the
prosthetist during fitting trials.
Physical therapists usually provide the additional training as required. The new
prosthesis should be worn initially for short periods and wearing time increased
each day depending upon individual situations.
One of the greatest problems in obtaining good performance and maximum
comfort is overweight of the amputee, especially the aboveknee. Fluctuations in
body weight are reflected in the stump where changes in volume result in poor fit,
discomfort, and consequently poor performance. A reasonable exercise program
and a sensible diet are important factors in the health and well being of every one,
but even more so in the case of the amputee.
Slight reduction in size of the stump can be accommodated by adjustments to the
socket, but the prosthetist can do little about expanding the size of a socket and
almost any increase in size of the stump means a new prosthesis, or, at the least, a
new socket.