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9

What to expect during the making of your prosthesis

Evaluation

Generally, the sooner your prosthesis is fitted, the shorter your rehabilitation is likely to be, so once you’ve appointed a prosthetist, the design and manufacture of your first prosthesis should begin as soon as possible.

The first step is a thorough evaluation in which the prosthetist reviews your physical condition, specifically the condition of your residual limb and whether it has healed sufficiently to accommodate the pressures of the prosthesis on your skin. The evaluation will include your lifestyle requirements, with questions like these:

• Do you have an office job, or is your work more physically demanding?
• Do you walk mainly indoors?
• Are the areas around your house and work flat, or are there many slopes?
• Do you often climb stairs?

And so on. These questions are important, because the answers will help the prosthetist decide what types of components to include in the design of your prosthesis. For example, some components are designed to support less active people struggling to maintain the ideal balance of safety, comfort and mobility, and others for people who are keen to become increasingly mobile. The prosthetist takes all of this and more into account in trying to design the best prosthetic leg for you.

Good idea

The best time to discuss future financial arrangements is during the initial evaluation. Read the section on financial considerations for more information.

Capturing the shape of the residual limb

The next step for the prosthetist is to capture the shape of your residual limb and take measurements for the prosthesis. This may happen during the initial evaluation, or during a next appointment, depending on when you appoint the prosthetist, the prosthetist’s schedule and so on. Capturing the shape can almost be described as developing a “blueprint” for your residual limb so that a well-fitting, comfortable socket can be designed, taking the unique shape of your residual limb into account. As this is the basis of the suspension for the prosthesis – in other words, where the prosthetic leg is attached to your residual limb – it’s vitally important to capture the shape accurately. Soft tissue changes shape when pressure is applied, which makes this is one of the hardest parts of the prosthetist’s job − and explains why choosing an experienced prosthetist can make a big difference to your life. It helps if the residual limb is shaped in a way that makes designing a socket simpler, which is why we emphasise the correct post-operative treatment during the wound healing phase.

There are various ways of capturing the shape of the residual limb such as casting directly on the residual limb with an air pressure system, or by using digital scanners, but the most common method is to apply plaster of Paris to get a cast of the limb.

Fitting the diagnostic socket

Using the shape taken from the cast, your prosthetist will now manufacture a diagnostic or “test” socket to evaluate whether that shape will fit comfortably to your residual limb. The diagnostic socket is typically fitted at the following appointment, as it takes time for the socket to be manufactured, modified and perfected before the final socket is made. The test socket is made from a transparent plastic material, not intended for permanent use, but able to adjusted. Once you and the prosthetist are both satisfied with the design and the comfort of the fit, prosthetic components will be assembled and aligned with you in a standing position, a process called “static alignment”. If the result is a stable, comfortable prosthesis, you should soon be able to take your first steps!

Learning to walk

Think of your first steps as a learning experience: some people walk well right from the beginning, but most take time. It’s all part of the journey to reach your own potential. There’s no need to rush: use this phase of the rehabilitation process to get to know how your prosthetic leg works and how your body interacts with it, and ask all the questions you need. Accept that you’ll have to work hard to regain your independence, because disciplined exercise is a vital part of regaining mobility. It’s also normal to experience some pain and discomfort during the first month after surgery, but know that as your limb heals, walking will become more and more comfortable.

Early gait training under the close supervision of a physiotherapist, biokineticist and/or prosthetist is essential so that you learn to walk in the best possible way. Learning to walk with a prosthesis requires you to adopt new techniques; and it’s far better to develop a good walking technique from the outset than to try to correct an inefficient technique later. Your physiotherapist or biokineticist, assisted by your prosthetist, will recommend special exercises aimed at training the specific muscles needed to walk with your prosthetic leg. Typical exercises are illustrated here, but please remember that they are just suggestions and may not be the best exercises for your specific circumstances. Always follow the advice given by the medical professionals in your team, because they have made an expert physical assessment of your individual situation.

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A physiotherapist or biokineticist who specialises in treating people with limb loss and is well informed about prosthetic components can make a major contribution to your rehabilitation. For example, prosthetic knee mechanisms don’t all work the same way, and a competent physiotherapist or biokineticist will be able to teach you different techniques for walking downstairs, for instance, depending on the type of prosthetic mechanism you’re using. Insist on being referred to a gait training specialist, as this is a vital part of reintegration.

Fitting the final prosthesis

The residual limb will go through a process of healing and changing shape as it stabilises over time. This is due to a combination of factors, the main one being fluid changes in your body. The muscles in the limb will atrophy (shrink) since they aren't functioning the way they used to, you may gain or lose weight, and you may lose muscle tone. However, once you start walking again, you'll build back some of that muscle tone and might return to your normal weight. Because your residual limb will continue to change shape, the socket attaching your prosthetic leg to it will, at some point, no longer fit perfectly. As you can imagine, a socket that doesn’t fit well may move around, which could have a negative effect on aspects like your safety, energy consumption and comfort. There are ways to manage this temporarily, for instance by putting extra socks over your residual limb, but eventually a new, correctly fitting socket has to be made. Depending on how much your residual limb changes shape, this might have to be done several times, but eventually the limb will stabilise − and at this point a long-term socket can be manufactured for your prosthesis.

Follow-up

Although this long-term socket should fit properly for much longer than the initial, temporary socket(s), you'll have to get updated sockets made at regular intervals in future. Some adjustments may also be needed now and then as your ability and activity increase and your body adjusts. This process has no clear, predefined conclusion, and there is never a “final leg”, simply because your body is a dynamic system that changes over time, and also because prosthetic components have a limited life. How long the interval between each new socket will be is difficult to predict and varies from patient to patient, but typically it could be three years, with minor adjustments possibly having to be made in between. Please remember, a correctly fitting, comfortable socket is critically important, and you should always give this top priority.

The fitting and manufacture of the prosthesis is both a science and an art, but the two most important aspects of a good prosthesis are indisputably the design of a well-fitting socket with optimal suspension and the correct alignment of the prosthetic components in relation to the residual limb. A good prosthetist always takes special care to make a socket that fits your residual limb perfectly and ensures that the components are aligned correctly.

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Establish a maintenance schedule for your prosthetic components. Clearly define what your prosthetist will be responsible for and what you can look after yourself. Taking proper care of the components that you rely on for your mobility will increase your quality of life and save you money in the long run.