Prosthesis

For other uses, see Prosthesis (disambiguation).Not to be confused with Orthotic.

In medicine, a prosthesis (plural: prostheses;

A man with two prosthetic arms playing table football

from Ancient Greek prósthesis, “addition, application,attachment”[1]) is an artificial device that replaces a miss-ing body part, which may be lost through trauma, disease,or congenital conditions. Prosthetic amputee rehabilita-tion is primarily coordinated by a prosthetist and an inter-disciplinary team of health care professionals includingpsychiatrists, surgeons, physical therapists, and occupa-tional therapists.

1 Types

A person’s prosthesis should be designed and assem-bled according to the patient’s appearance and functionalneeds. For instance, a patient may need a transradial pros-thesis, but need to choose between an aesthetic functionaldevice, a myoelectric device, a body-powered device, oran activity specific device. The patient’s future goals andeconomical capabilities may help them choose betweenone or more devices.Craniofacial prostheses include intra-oral and extra-oralprostheses. Extra-oral prostheses are further dividedinto hemifacial, auricular (ear), nasal, orbital and ocular.Intra-oral prostheses include dental prostheses such asdentures, obturators, and dental implants.Prostheses of the neck include larynx substitutes, tracheaand upper esophageal replacements,Somato prostheses of the torso include breast prostheseswhich may be either single or bilateral, full breast devices

or nipple prostheses.

1.1 Limb prostheses

A United States Marine with bilateral prosthetic legs leads a for-mation run

Limb prostheses include both upper- and lower-extremityprostheses.Upper-extremity prostheses are used at varying lev-els of amputation: forequarter, shoulder disarticulation,transhumeral prosthesis, elbow disarticulation, transra-dial prosthesis, wrist disarticulation, full hand, partialhand, finger, partial finger.A transradial prosthesis is an artificial limb that replacesan arm missing below the elbow. Two main types ofprosthetics are available. Cable operated limbs work byattaching a harness and cable around the opposite shoul-der of the damaged arm. The other form of prostheticsavailable are myoelectric arms. These work by sensing,

1

2 2 HISTORY

via electrodes, when the muscles in the upper arm move,causing an artificial hand to open or close. In the pros-thetic industry a trans-radial prosthetic arm is often re-ferred to as a “BE” or below elbow prosthesis.Lower-extremity prostheses provide replacements atvarying levels of amputation. These include hip disar-ticulation, transfemoral prosthesis, knee disarticulation,transtibial prosthesis, Syme’s amputation, foot, partialfoot, and toe. The two main subcategories of lower ex-tremity prosthetic devices are trans-tibial (any amputa-tion transecting the tibia bone or a congenital anomalyresulting in a tibial deficiency) and trans-femoral (anyamputation transecting the femur bone or a congenitalanomaly resulting in a femoral deficiency).A transfemoral prosthesis is an artificial limb that replacesa leg missing above the knee. Transfemoral amputees canhave a very difficult time regaining normal movement. Ingeneral, a transfemoral amputee must use approximately80% more energy to walk than a person with two wholelegs.[2] This is due to the complexities in movement as-sociated with the knee. In newer and more improved de-signs, hydraulics, carbon fiber, mechanical linkages, mo-tors, computer microprocessors, and innovative combi-nations of these technologies are employed to give morecontrol to the user. In the prosthetic industry a trans-femoral prosthetic leg is often referred to as an “AK” orabove the knee prosthesis.[3]

A transtibial prosthesis is an artificial limb that replaces aleg missing below the knee. A transtibial amputee is usu-ally able to regain normal movement more readily thansomeone with a transfemoral amputation, due in largepart to retaining the knee, which allows for easier move-ment. Lower extremity prosthetics describes artificiallyreplaced limbs located at the hip level or lower. In theprosthetic industry a trans-tibial prosthetic leg is often re-ferred to as a “BK” or below the knee prosthesis.

2 History

Prosthetic toe from ancient Egypt

Prosthetics have been mentioned throughout history. The

Iron prosthetic hand believed to have been owned by Götz vonBerlichingen (1480–1562)

Artificial iron hand believed to date from 1560–1600

earliest recorded mention is the warrior queen Vishpalain the Rigveda.[4] The Egyptians were early pioneers ofthe idea, as shown by the wooden toe found on a bodyfrom the New Kingdom.[5] Roman bronze crowns havealso been found, but their use could have been more aes-thetic than medical.[6]

An early mention of a prosthetic comes from the Greekhistorian Herodotus, who tells the story of Hegesistratus,a Greek diviner who cut off his own foot to escape hisSpartan captors and replaced it with a wooden one.[7]

2.1 Wood and metal hands

Pliny the Elder also recorded the tale of a Roman general,Marcus Sergius, whose right hand was cut off while cam-paigning and had an iron hand made to hold his shieldso that he could return to battle. A famous and quiterefined[8] historical prosthetic arm was that of Götz vonBerlichingen, made at the beginning of the 16th cen-tury. The first confirmed use of a prosthetic device, how-

2.3 Lower extremity modern history 3

ever, is from 950-710 B.C.E. In 2000, research pathol-ogists discovered a mummy from this period buried inthe Egyptian necropolis near ancient Thebes that pos-sessed an artificial big toe. This toe, consisting of woodand leather, exhibited evidence of use. When reproducedby bio-mechanical engineers in 2011, researchers discov-ered that this ancient prosthetic enabled its wearer to walkboth barefoot and in Egyptian style sandals. Previously,the earliest discovered prosthetic was an artificial leg fromCapua.[9]

An artificial limbs factory in 1941

Around the same time, François de la Noue is also re-ported to have had an iron hand, as is, in the 17th Century,René-Robert Cavalier de la Salle.[10] During the Mid-dle Ages, prosthetic remained quite basic in form. De-bilitated knights would be fitted with prosthetics so theycould hold up a shield, grasp a lance or a sword, or sta-bilize a mounted warrior.[11] Only the wealthy could af-ford anything that would assist in daily life. During theRenaissance, prosthetics developed with the use of iron,steel, copper, and wood. Functional prosthetics began tomake an appearance in the 1500s.

2.2 Technology progress before the 20thcentury

An Italian surgeon recorded the existence of an amputeewho had an arm that allowed him to remove his hat, openhis purse, and sign his name.[12] Improvement in ampu-tation surgery and prosthetic design came at the hands ofAmbroise Paré. Among his inventions was an above-kneedevice that was a kneeling peg leg and foot prosthesis witha fixed position, adjustable harness, and knee lock con-trol. The functionality of his advancements showed howfuture 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 shankand socket, a steel knee joint and an articulated foot

that was controlled by catgut tendons from the kneeto the ankle. Came to be known as “Anglesey Leg”or “Selpho Leg”.

• Sir James Syme – A new method of ankle amputa-tion that did not involve amputating at the thigh.

• Benjamin Palmer – Improved upon the Selpho leg.Added an anterior spring and concealed tendons tosimulate natural-looking movement.

• Dubois Parmlee – Created prosthetic with a suctionsocket, polycentric knee, and multi-articulated foot.

• Marcel Desoutter & Charles Desoutter – First alu-minium prosthesis[13]

• Henry Heather Bigg, and his son Henry RobertHeather Bigg, won the Queen’s command to pro-vide “surgical appliances” to wounded soldiers afterCrimea War. They developed arms that allowed adouble arm amputee to crochet, and a hand that feltnatural to others based on ivory, felt, and leather.[14]

At the end of World War II, the NAS (National Academyof Sciences) began to advocate better research and devel-opment of prosthetics. Through government funding, aresearch and development program was developed withinthe Army, Navy, Air Force, and the Veterans Adminis-tration.

2.3 Lower extremity modern history

Socket technology for lower extremity limbs saw arevolution of advancement during the 1980s when JohnSabolich C.P.O., invented the Contoured AdductedTrochanteric-Controlled Alignment Method (CAT-CAM) socket, later to evolve into the Sabolich Socket.He followed the direction of Ivan Long and Ossur Chris-tensen as they developed alternatives to the quadrilateralsocket, which in turn followed the open ended plugsocket, created from wood.[15] The advancement wasdue to the difference in the socket to patient contactmodel. Prior to this, sockets were made in the shapeof a square shape with no specialized containment formuscular tissue. New designs thus help to lock in thebony anatomy, locking it into place and distributingthe weight evenly over the existing limb as well as themusculature of the patient. Ischial containment is wellknown and used today by many prosthetist to help inpatient care. Variations of the ischial containment socketthus exists and each socket is tailored to the specificneeds of the patient. Others who contributed to socketdevelopment and changes over the years include TimStaats, Chris Hoyt, and Frank Gottschalk. Gottschalkdisputed the efficacy of the CAT-CAM socket- insistingthe surgical procedure done by the amputation surgeonwas most important to prepare the amputee for good useof a prosthesis of any type socket design.[16]

4 4 CURRENT TECHNOLOGY AND MANUFACTURING

The first microprocessor-controlled prosthetic knees be-came available in the early 1990s. The Intelligent Pros-thesis was first commercially available microprocessorcontrolled prosthetic knee. It was released by Chas. A.Blatchford & Sons, Ltd., of Great Britain, in 1993 andmade walking with the prosthesis feel and look morenatural.[17] An improved version was released in 1995 bythe name Intelligent Prosthesis Plus. Blatchford releasedanother prosthesis, the Adaptive Prosthesis, in 1998. TheAdaptive Prosthesis utilized hydraulic controls, pneu-matic controls, and a microprocessor to provide the am-putee with a gait that was more responsive to changesin walking speed. Cost analysis reveals that a sophisti-cated above-knee prosthesis will be about $1 million in45 years, given only annual cost of living adjustments.[18]

3 Patient procedure

A prosthesis is a functional replacement for an amputatedor congenitally malformed or missing limb. Prosthetistsare responsible for the prescription, design and manage-ment of a prosthetic device.In most cases, the prosthetist begins by taking a plastercast of the patient’s affected limb. Lightweight, high-strength thermoplastics are custom-formed to this modelof the patient. Cutting-edge materials such as carbonfiber, titanium and Kevlar provide strength and durabilitywhile making the new prosthesis lighter. More sophisti-cated prostheses are equipped with advanced electronics,providing additional stability and control.[19]

4 Current technology and manu-facturing

Knee prosthesis manufactured using WorkNC Computer AidedManufacturing software

Over the years, there have been advancements in arti-ficial limbs. New plastics and other materials, such ascarbon fiber, have allowed artificial limbs to be strongerand lighter, limiting the amount of extra energy necessary

to operate the limb. This is especially important for trans-femoral amputees. Additional materials have allowed ar-tificial limbs to look much more realistic, which is impor-tant to trans-radial and transhumeral amputees becausethey are more likely to have the artificial limb exposed.[20]

Manufacturing a prosthetic finger

In addition to newmaterials, the use of electronics has be-come very common in artificial limbs. Myoelectric limbs,which control the limbs by converting muscle movementsto electrical signals, have become much more commonthan cable operated limbs. Myoelectric signals are pickedup by electrodes, the signal gets integrated and once itexceeds a certain threshold, the prosthetic limb controlsignal is triggered which is why inherently, all myoelec-tric controls lag. Conversely, cable control is immediateand physical, and through that offers a certain degree ofdirect force feedback that myoelectric control does not.Computers are also used extensively in the manufacturingof limbs. Computer Aided Design and Computer AidedManufacturing are often used to assist in the design andmanufacture of artificial limbs.[20][21]

Most modern artificial limbs are attached to the stump ofthe amputee by belts and cuffs or by suction. The stumpeither directly fits into a socket on the prosthetic, or—more commonly today—a liner is used that then is fixedto the socket either by vacuum (suction sockets) or a pinlock. Liners are soft and by that, they can create a farbetter suction fit than hard sockets. Silicone liners can beobtained in standard sizes, mostly with a circular (round)cross section, but for any other stump shape, custom lin-ers can be made. The socket is custom made to fit theresidual limb and to distribute the forces of the artifi-cial limb across the area of the stump (rather than justone small spot), which helps reduce wear on the stump.The custom socket is created by taking a plaster cast ofthe stump or, more commonly today, of the liner wornover the stump, and then making a mold from the plas-ter cast. Newer methods include laser guided measuringwhich can be input directly to a computer allowing for a

4.1 Body-powered arms 5

more sophisticated design.One problemwith the stump and socket attachment is thata bad fit will reduce the area of contact between the stumpand socket or liner, and increase pockets between stumpskin and socket or liner. Pressure then is higher, whichcan be painful. Air pockets can allow sweat to accumulatethat can soften the skin. Ultimately, this is a frequentcause for itchy skin rashes. Further down the road, it cancause breakdown of the skin.[2]

Artificial limbs are typically manufactured using the fol-lowing steps:[20]

1. Measurement of the stump

2. Measurement of the body to determine the size re-quired for the artificial limb

3. Fitting of a silicone liner

4. Creation of a model of the liner worn over the stump

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 vacuumforming and injection molding

8. Creation of metal parts of the artificial limb usingdie casting

9. Assembly of entire limb

4.1 Body-powered arms

Current high tech allows body powered arms to weigharound one-half to one-third of what a myoelectric armdoes.

4.1.1 Sockets

Current body-powered arms contain sockets that are builtfrom hard epoxy or carbon fiber. These sockets or “in-terfaces” can be made more comfortable by lining themwith a softer, compressible foam material that providespadding for the bone prominences. A self suspending orsupra-condylar socket design is useful for those with shortto mid range below elbow absence. Longer limbs may re-quire the use of a locking roll-on type inner liner or morecomplex harnessing to help augment suspension.

4.1.2 Wrists

Wrist units are either screw-on connectors featuring theUNF 1/2-20 thread (USA) or quick-release connector, ofwhich there are different models.

4.1.3 Voluntary opening and voluntary closing

Two types of body powered systems exist, voluntaryopening “pull to open” and voluntary closing “pull toclose”. Virtually all “split hook” prostheses operate witha voluntary opening type system.More modern “prehensors” called GRIPS utilize volun-tary closing systems. The differences are significant.Users of voluntary opening systems rely on elastic bandsor springs for gripping force, while users of voluntaryclosing systems rely on their own body power and energyto create gripping force.Voluntary closing users can generate prehension forcesequivalent to the normal hand, upwards to or exceedingone hundred pounds. Voluntary closing GRIPS requireconstant tension to grip, like a human hand, and in thatproperty they do come closer to matching human handperformance. Voluntary opening split hook users are lim-ited to forces their rubber or springs can generate whichusually is below 20 pounds.

4.1.4 Feedback

An additional difference exists in the biofeedback createdthat allows the user to “feel” what is being held. Volun-tary opening systems once engaged provide the holdingforce so that they operate like a passive vice at the endof the arm. No gripping feedback is provided once thehook has closed around the object being held. Voluntaryclosing systems provide directly proportional control andbiofeedback so that the user can feel how much force thatthey are applying.A recent study showed that by stimulating the medianand ulnar nerves, according to the information providedby the artificial sensors from a hand prosthesis, physio-logically appropriate (near-natural) sensory informationcould be provided to an amputee. This feedback enabledthe participant to effectively modulate the grasping forceof the prosthesis with no visual or auditory feedback.[22]

Researchers from Ècole Polytechnique Fédérale De Lau-sanne in Switzerland and the Scuola Superiore Sant'Annain Italy, implanted the electrodes into the amputee’s armin February 2013. The study, published Wednesday inScience Translational Medicine, details the first time sen-sory feedback has been restored allowing an amputeeto control an artificial limb in real-time.[23] With wireslinked to nerves in his upper arm, the Danish patient wasable to handle objects and instantly receive a sense oftouch through the special artificial hand that was createdby Silvestro Micera and researchers both in Switzerlandand Italy.[24]

6 4 CURRENT TECHNOLOGY AND MANUFACTURING

4.1.5 Terminal devices

Terminal devices contain a range of hooks, prehensors,hands or other devices.

Hooks Voluntary opening split hook systems are sim-ple, convenient, light, robust, versatile and relatively af-fordable. Hooks obviously do not match a normal humanhand in both appearance and overall versatility.However, a hook’s material tolerances can also exceedand surpass the normal human hand for mechanical stress(one can even use a hook to slice open boxes or as ahammer whereas the same is not possible with a normalhand), for thermal stability (one can use a hook to gripitems from boiling water, to turn meat on a grill, to hold amatch until it has burned down completely) and for chem-ical hazards (as a metal hook withstands acids or lye, anddoes not react to solvents like a prosthetic glove or humanskin).

Actor Owen Wilson gripping the myoelectric prosthetic arm of aUnited States Marine

Hands Prosthetic hands are available in both volun-tary opening and voluntary closing versions and be-cause of their more complex mechanics and cosmeticglove covering require a relatively large activation force,which, depending on the type of harness used, may beuncomfortable.[25] A recent study by the Delft Univer-sity of Technology, The Netherlands, showed that the de-velopment of mechanical prosthetic hands has been ne-glected during the past decades. The study showed thatthe pinch force level of most current mechanical hands istoo low for practical use.[26] The best tested hand was aprosthetic hand developed around 1945.

4.1.6 Commercial providers and materials

Hosmer and Otto Bock are major commercial hookproviders. Mechanical hands are sold by Hosmer andOtto Bock as well; the Becker Hand is still manufacturedby the Becker family. Prosthetic hands may be fitted withstandard stock or custom-made cosmetic looking siliconegloves. But regular work gloves may be worn as well.Other terminal devices include the V2P Prehensor, a ver-satile robust gripper that allows customers to modify as-pects of it, Texas Assist Devices (with a whole assortmentof tools) and TRS that offers a range of terminal devicesfor sports. Cable harnesses can be built using aircraftsteel cables, ball hinges and self lubricating cable sheaths.Some prosthetics have been designed specifically for usein salt water.[27]

4.2 Lower-extremity prosthetics

A prosthetic leg worn by Ellie Cole

Lower-extremity prosthetics describes artificially re-placed limbs located at the hip level or lower. Concerningall ages Ephraim et al. (2003) found a worldwide estimateof all-cause lower-extremity amputations of 2.0–5.9 per10,000 inhabitants. For birth prevalence rates of congen-ital limb deficiency they found an estimate between 3.5–7.1 cases per 10,000 births.[28]

The two main subcategories of lower extremity prosthetic

4.3 Myoelectric 7

devices are trans-tibial (any amputation transecting thetibia bone or a congenital anomaly resulting in a tibialdeficiency), and trans-femoral (any amputation transect-ing the femur bone or a congenital anomaly resulting ina femoral deficiency). In the prosthetic industry a trans-tibial prosthetic leg is often referred to as a “BK” or belowthe knee prosthesis while the trans-femoral prosthetic legis often referred to as an “AK” or above the knee pros-thesis.Other, less prevalent lower extremity cases include thefollowing:

1. Hip disarticulations – This usually refers to when anamputee or congenitally challenged patient has ei-ther an amputation or anomaly at or in close prox-imity to the hip joint.

2. Knee disarticulations – This usually refers to an am-putation through the knee disarticulating the femurfrom the tibia.

3. Symes – This is an ankle disarticulation while pre-serving the heel pad.

4.2.1 Socket

This important part serves as an interface betweenthe residuum and the prosthesis, allowing com-fortable weight-bearing, movement control andproprioception.[29] Its fitting is one of the most chal-lenging aspects of the entire prosthesis. The difficultiesaccompanied with the socket are that it needs to have aperfect fit, with total surface bearing to prevent painfulpressure spots. It needs to be flexible, but sturdy, to allownormal gait movement but not bend under pressure.

4.2.2 Shank and connectors

This part creates distance and support between the knee-joint and the foot (in case of upper-leg prosthesis) or be-tween the socket and the foot. The type of connectorsthat are used between the shank and the knee/foot deter-mines whether the prosthesis is modular or not. Modularmeans that the angle and the displacement of the foot inrespect to the socket can be changed after fitting. In de-veloping countries prosthesis mostly are non-modular, inorder to reduce cost. When considering children mod-ularity of angle and height is important because of theiraverage growth of 1.9 cm annually.[30]

4.2.3 Foot

Providing contact to the ground, the foot provides shockabsorption and stability during stance.[31] Additionally itinfluences 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 de-termined by the shape and stiffness of the foot and needsto match the subject’s build in order to produce a normalgait pattern.[32] Andrysek (2010) found 16 different typesof feet, with greatly varying results concerning durabilityand biomechanics. The main problem found in currentfeet is durability, endurance ranging from 16–32 months[33] These results are for adults and will probably be worsefor children due to higher activity levels and scale effects.

4.2.4 Knee joint

In case of a trans-femoral amputation there also is a needfor a complex connector providing articulation, allowingflexion during swing-phase but not during stance.

Microprocessor control To mimic the knee’s func-tionality during gait, microprocessor-controlled kneejoints have been developed that control the flexion ofthe knee. Some examples are Otto Bock’s C-leg, intro-duced in 1997, Ossur’s Rheo Knee, released in 2005, thePower Knee by Ossur, introduced in 2006, the Plié Kneefrom Freedom Innovations[34] and DAW Industries’ SelfLearning Knee (SLK).[35]

The idea was originally developed by Kelly James, aCanadian engineer, at the University of Alberta.[36]

A microprocessor is used to interpret and analyse signalsfrom knee-angle sensors and moment sensors. The mi-croprocessor receives signals from its sensors to deter-mine the type of motion being employed by the amputee.Most microprocessor controlled knee-joints are poweredby a battery housed inside the prosthesis.The sensory signals computed by the microprocessor areused to control the resistance generated by hydrauliccylinders in the knee-joint. Small valves control theamount of hydraulic fluid that can pass into and out of thecylinder, thus regulating the extension and compressionof a piston connected to the upper section of the knee.[18]

The main advantage of a microprocessor-controlled pros-thesis is closer approximation to an amputee’s naturalgait. Some allow amputees to walk near walking speed orrun. Variations in speed are also possible and are takeninto account by sensors and communicated to the micro-processor, which adjusts to these changes accordingly. Italso enables the amputees to walk down stairs with a step-over-step approach, rather than the one step at a time ap-proach used with mechanical knees.[37] However, somehave some significant drawbacks that impair its use. Theycan be susceptible to water damage and thus great caremust be taken to ensure that the prosthesis remains dry.

4.3 Myoelectric

Amyoelectric prosthesis uses electromyography signalsor potentials from voluntarily contracted muscles within

8 4 CURRENT TECHNOLOGY AND MANUFACTURING

a person’s residual limb on the surface of the skin tocontrol the movements of the prosthesis, such as elbowflexion/extension, wrist supination/pronation (rotation) orhand opening/closing of the fingers. A prosthesis of thistype utilizes the residual neuro-muscular system of thehuman body to control the functions of an electric pow-ered prosthetic hand, wrist, elbow or foot.[38] This is asopposed to an electric switch prosthesis, which requiresstraps and/or cables actuated by body movements to ac-tuate or operate switches that control the movements of aprosthesis or one that is totally mechanical. It is not clearwhether those few prostheses that provide feedback sig-nals to those muscles are also myoelectric in nature. It hasa self-suspending socket with pick-up electrodes placedover flexors and extensors for the movement of flexionand extension respectively.The USSR was the first to develop a myoelectric arm in1958,[39] while the first myoelectric arm became com-mercial in 1964 by the Central Prosthetic Research In-stitute of the USSR, and distributed by the Hangar LimbFactory of the UK.[40][41]

Researchers at the Rehabilitation Institute of Chicago an-nounced in September 2013 that they have developed arobotic leg that translates neural impulses from the user’sthigh muscles into movement, which is the first prostheticleg to do so. It is currently in testing.[42]

4.4 Robotic prostheses

Main articles: Neural prosthetics and Powered exoskele-ton § Current productsFurther information: Robotics § Touch, 3-D printing,and Open-source hardware

Robots can be used to generate objective measures of pa-tient’s impairment and therapy outcome, assist in diagno-sis, customize therapies based on patient’s motor abili-ties, and assure compliance with treatment regimens andmaintain patient’s records. It is shown in many studiesthat there is a significant improvement in upper limb mo-tor function after stroke using robotics for upper limbrehabilitation.[43] In order for a robotic prosthetic limbto work, it must have several components to integrate itinto the body’s function: Biosensors detect signals fromthe user’s nervous or muscular systems. It then relays thisinformation to a controller located inside the device, andprocesses feedback from the limb and actuator (e.g., po-sition, force) and sends it to the controller. Examples in-clude surface electrodes that detect electrical activity onthe skin, needle electrodes implanted in muscle, or solid-state electrode arrays with nerves growing through them.One type of these biosensors are employed in myoelectricprostheses.A device known as the controller is connected to the user’snerve and muscular systems and the device itself. It sendsintention commands from the user to the actuators of the

device, and interprets feedback from the mechanical andbiosensors to the user. The controller is also responsiblefor the monitoring and control of the movements of thedevice.An actuator mimics the actions of a muscle in producingforce and movement. Examples include a motor that aidsor replaces original muscle tissue.Targeted muscle reinnervation (TMR) is a technique inwhich motor nerves, which previously controlled muscleson an amputated limb, are surgically rerouted such thatthey reinnervate a small region of a large, intact muscle,such as the pectoralis major. As a result, when a patientthinks about moving the thumb of his missing hand, asmall area of muscle on his chest will contract instead. Byplacing sensors over the reinervated muscle, these con-tractions can be made to control movement of an appro-priate part of the robotic prosthesis.[44][45]

A variant of this technique is called targeted sensory rein-nervation (TSR). This procedure is similar to TMR, ex-cept that sensory nerves are surgically rerouted to skin onthe chest, rather than motor nerves rerouted to muscle.Recently, robotic limbs have improved in their ability totake signals from the human brain and translate those sig-nals into motion in the artificial limb. DARPA, the Pen-tagon’s research division, is working to make even moreadvancements in this area. Their desire is to create an ar-tificial limb that ties directly into the nervous system.[46]

4.4.1 Robotic arms

Advancements in the processors used in myoelectric armshas allowed developers to make gains in fine tuned con-trol of the prosthetic. The Boston Digital Arm is a re-cent artificial limb that has taken advantage of these moreadvanced processors. The arm allows movement in fiveaxes and allows the arm to be programmed for a morecustomized feel. Recently the i-Limb hand, invented inEdinburgh, Scotland, by David Gow has become the firstcommercially available hand prosthesis with five individ-ually powered digits. The hand also possesses a manuallyrotatable thumb which is operated passively by the userand allows the hand to grip in precision, power and keygrip modes.Another neural prosthetic is Johns Hopkins UniversityApplied Physics Laboratory Proto 1. Besides the Proto1, the university also finished the Proto 2 in 2010.[47]Early in 2013, Max Ortiz Catalan and Rickard Bråne-mark of the Chalmers University of Technology, andSahlgrenska University Hospital in Sweden, succeededin making the first robotic arm which is mind-controlledand can be permanently attached to the body (usingosseointegration).[48][49][50]

An approach that is very useful is called arm rotationwhich is common for unilateral amputees which is an am-putation that affects only one side of the body; and also

9

essential for bilateral amputees, a person who is miss-ing or has had amputated either both arms or legs, toperform tasks of daily living. This involves inserting asmall permanent magnet into the distal end of the resid-ual bone of subjects with upper limb amputations. Whena subject rotates the residual arm, the magnet will rotatewith the residual bone, causing a change in magnetic fielddistribution.[51] EEG signals which is electroencephalo-gram, a test that detects electrical activity in the brainusing small flat metal discs attached to your scalp, es-sentially decoding human brain activity used for physicalmovement, are used to control the robotic limbs. This isvery essential being that it provides a more lively affectto the robotic limb, giving oneself control over the part asif it was their own.[52]

4.4.2 Robotic legs

Robotic legs have also been developed: the ArgoMedicalTechnologies ReWalk is an example or a recent roboticleg, targeted to replace the wheelchair. It is marketed asa “robotic pants”.[53] Walk Again project is developing asimilar device.[54]

5 Attachment to the body

Most prostheses can be attached to the exterior of thebody, in a non-permanent way. Some others however canbe attached in a permanent way. One such example areexoprostheses (see below).

5.1 Direct bone attachment and osseointe-gration

Main article: Osseointegration

Osseointegration is a method of attaching the artificiallimb to the body. This method is also sometimes re-ferred to as exoprosthesis (attaching an artificial limb tothe bone), or endo-exoprosthesis.The stump and socket method can cause significant painin the amputee, which is why the direct bone attachmenthas been explored extensively. The method works by in-serting a titanium bolt into the bone at the end of thestump. After several months the bone attaches itself tothe titanium bolt and an abutment is attached to the ti-tanium bolt. The abutment extends out of the stump andthe (removable) artificial limb is then attached to the abut-ment. Some of the benefits of this method include thefollowing:

• Better muscle control of the prosthetic.

• The ability to wear the prosthetic for an extendedperiod 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 amputeeswith the direct bone attachment cannot have large impactson the limb, such as those experienced during jogging,because of the potential for the bone to break.[2]

6 Cosmesis

Cosmetic prosthesis has long been used to disguise in-juries and disfigurements. With advances in moderntechnology, cosmesis, the creation of lifelike limbs madefrom silicone or PVC has been made possible. Suchprosthetics, including artificial hands, can now be de-signed to simulate the appearance of real hands, com-plete with freckles, veins, hair, fingerprints and even tat-toos. Custom-made cosmeses are generally more expen-sive (costing thousands of U.S. dollars, depending on thelevel of detail), while standard cosmeses come premadein a variety of sizes, although they are often not as real-istic as their custom-made counterparts. Another optionis the custom-made silicone cover, which can be made tomatch a person’s skin tone but not details such as frecklesor wrinkles. Cosmeses are attached to the body in anynumber of ways, using an adhesive, suction, form-fitting,stretchable skin, or a skin sleeve.

7 Cognition

Main article: Neuroprosthetics

Unlike neuromotor prostheses, neurocognitive prosthe-ses would sense or modulate neural function in orderto physically reconstitute or augment cognitive processessuch as executive function, attention, language, andmem-ory. No neurocognitive prostheses are currently availablebut the development of implantable neurocognitive brain-computer interfaces has been proposed to help treat con-ditions such as stroke, traumatic brain injury, cerebralpalsy, autism, and Alzheimer’s disease.[55] The recentfield of Assistive Technology for Cognition concerns thedevelopment of technologies to augment human cogni-tion. Scheduling devices such as Neuropage remind userswith memory impairments when to perform certain ac-tivities, such as visiting the doctor. Micro-prompting de-vices such as PEAT, AbleLink and Guide have been usedto aid users with memory and executive function prob-lems perform activities of daily living.

10 9 DESIGN CONSIDERATIONS

8 Prosthetic enhancement

Further information: Powered exoskeleton § ResearchIn addition to the standard artificial limb for everyday

Sgt. Jerrod Fields, a U.S. Army World Class Athlete ProgramParalympic sprinter hopeful, works out at the U.S. OlympicTraining Center in Chula Vista, Calif. A below-the-knee am-putee, Fields won a gold medal in the 100 meters with a timeof 12.15 seconds at the Endeavor Games in Edmond, Okla., onJune 13, 2009

use, many amputees or congenital patients have speciallimbs and devices to aid in the participation of sports andrecreational activities.Within science fiction, and, more recently, within thescientific community, there has been consideration givento using advanced prostheses to replace healthy bodyparts with artificial mechanisms and systems to improvefunction. The morality and desirability of such tech-nologies are being debated by transhumanists, other ethi-cists, and others in general.[56][57][58][59] Body parts suchas legs, arms, hands, feet, and others can be replaced.The first experiment with a healthy individual appears tohave been that by the British scientist Kevin Warwick. In2002, an implant was interfaced directly into Warwick’snervous system. The electrode array, which containedaround a hundred electrodes, was placed in the mediannerve. The signals produced were detailed enough thata robot arm was able to mimic the actions of Warwick’s

own arm and provide a form of touch feedback again viathe implant.[60]

The DEKA company of Dean Kamen developed the“Luke arm”, an advanced prosthesis under clinical trialsin 2008.[61]

8.1 Oscar Pistorius

In early 2008, Oscar Pistorius, the “Blade Runner” ofSouth Africa, was briefly ruled ineligible to compete inthe 2008 Summer Olympics because his transtibial pros-thesis limbs were said to give him an unfair advantageover runners who had ankles. One researcher found thathis limbs used twenty-five percent less energy than thoseof an able-bodied runner moving at the same speed. Thisruling was overturned on appeal, with the appellate courtstating that the overall set of advantages and disadvan-tages of Pistorius’ limbs had not been considered. Pis-torius did not qualify for the South African team for theOlympics, but went on to sweep the 2008 Summer Par-alympics, and has been ruled eligible to qualify for anyfuture Olympics. He qualified for the 2011World Cham-pionship in South Korea and reached the semifinal wherehe ended last timewise, he was 14th in the first round, hispersonal best at 400m would have given him 5th place inthe finals.At the 2012 Summer Olympics in London, Pistoriusbecame the first amputee runner to compete at anOlympic Games.[62] He ran in the 400 metres racesemifinals,[63][64][65] and the 4 × 400 metres relay racefinals.[66]

He also competed in 5 events in the 2012 Summer Para-lympics in London.[67]

In November 2012 new artificial muscles made from nan-otech yarns and infused with paraffin wax were shown tolift more than 100,000 times their own weight, and gen-erate 85 times more mechanical power than the naturalmuscle of the same dimensions, according to scientists.(Science Daily) (Science)

9 Design considerations

There are multiple factors to consider when designing atranstibial prosthesis. Manufacturers must make choicesabout their priorities regarding these factors.

9.1 Performance

Nonetheless, there are certain elements of socket and footmechanics that are invaluable for the athlete, and these arethe focus of today’s high-tech prosthetics companies:

• Fit – athletic/active amputees, or those with bonyresidua, may require a carefully detailed socket fit;

10.2 Low-cost 11

less-active patients may be comfortable with a 'totalcontact' fit and gel liner

• Energy storage and return – storage of energy ac-quired through ground contact and utilization of thatstored energy for propulsion

• Energy absorption – minimizing the effect of highimpact on the musculoskeletal system

• Ground compliance – stability independent of ter-rain type and angle

• Rotation – ease of changing direction

• Weight – maximizing comfort, balance and speed

• Suspension – how the socket will join and fit to thelimb

9.2 Other

The buyer is also concerned with numerous other factors:

• Cosmetics

• Cost

• Ease of use

• Size availability

10 Cost and source freedom

10.1 High-cost

A typical prosthetic limb costs anywhere between$15,000 and $90,000, depending on the type of limb de-sired by the patient. With medical insurance, a patientwill typically pay 10%–50% of the total cost of a pros-thetic limb, while the insurance company will cover therest of the cost. The percent that the patient pays varies onthe type of insurance plan, as well as the limb requestedby the patient.[68]

Transradial (below the elbow amputation) and transtib-ial prostheses (below the knee amputation) typicallycost between US $6,000 and $8,000, while transfemoral(above the knee amputation) and transhumeral prosthet-ics (above the elbow amputation) cost approximatelytwice as much with a range of $10,000 to $15,000 andcan sometimes reach costs of $35,000. The cost of anartificial limb often recurs, while a limb typically needsto be replaced every 3–4 years due to wear and tear ofeveryday use. In addition, if the socket has fit issues, thesocket must be replaced within several months from theonset of pain. If height is an issue, components such aspylons can be changed.[69] [70]

Not only does the patient need to pay for their multipleprosthetic limbs, but they also need to pay for physicaland occupational therapy that come along with adaptingto living with an artificial limb. Unlike the reoccurringcost of the prosthetic limbs, the patient will typically onlypay the $2000 to $5000 for therapy during the first yearor two of living as an amputee. Once the patient is strongand comfortable with their new limb, they will not be re-quired to go to therapy anymore. Throughout one’s life,it is projected that a typical amputee will go through $1.4million worth of treatment, including surgeries, prosthet-ics, as well as therapies.[68]

10.2 Low-cost

See also: 3D printing

Low-cost above-knee prostheses often provide only basicstructural support with limited function. This function isoften achieved with crude, non-articulating, unstable, ormanually locking knee joints. A limited number of or-ganizations, such as the International Committee of theRed Cross (ICRC), create devices for developing coun-tries. Their device which is manufactured by CR Equip-ments is a single-axis, manually operated locking polymerprosthetic knee joint.[71]

Table. List of knee joint technologies based on the liter-ature review.[33]

Low-cost above-knee prosthetic limbs: ICRC Knee (left) and LCKnee (right)

A plan for a low-cost artificial leg, designed by SébastienDubois, was featured at the 2007 International DesignExhibition and award show in Copenhagen, Denmark,where it won the Index: Award. It would be able to createan energy-return prosthetic leg for US $8.00, composedprimarily of fiberglass.[72]

Prior to the 1980s, foot prostheses merely restored basicwalking capabilities. These early devices can be charac-terized by a simple artificial attachment connecting one’sresidual limb to the ground.

12 11 LOW-COST PROSTHETICS FOR CHILDREN

The introduction of the Seattle Foot (Seattle Limb Sys-tems) in 1981 revolutionized the field, bringing the con-cept of an Energy Storing Prosthetic Foot (ESPF) to thefore. Other companies soon followed suit, and beforelong, there were multiple models of energy storing pros-theses on the market. Each model utilized some variationof a compressible heel. The heel is compressed duringinitial ground contact, storing energy which is then re-turned during the latter phase of ground contact to helppropel the body forward.Since then, the foot prosthetics industry has been dom-inated by steady, small improvements in performance,comfort, and marketability.With 3D printers, it is possible to manufacture a singleproduct without having to have metal molds, so the costscan be drastically reduced.[73]

Jaipur Foot, an artificial limb from Jaipur, India, costsabout US$40.

10.3 Open-source robotic prothesis

See also: Open-source hardware, Modular design, 3Dprinting, and Thingiverse

There is currently an open design Prosthetics forumknown as the "Open Prosthetics Project". The group em-ploys collaborators and volunteers to advance Prostheticstechnology while attempting to lower the costs of thesenecessary devices.[74]

Another open-source prosthetics design forum is called“PATCH Project”. This forum is specially focused onthe development of prosthetics and tools for children indeveloping countries. The website is focused on storingand spreading information and improving development ofopen-source low-cost solutions.[75]

Open Bionics is a company that is developing open-source robotic prosthetic hands. It uses 3D printing tomanufacture the devices and low-cost 3D scanners to fitthem, with the aim of lowering the cost of fabricatingcustom prosthetics.[76]

11 Low-cost prosthetics for chil-dren

See also: open-source hardware and 3D printing

In the USA an estimate was found of 32,500 children(<21 years) that suffer from major paediatric amputa-tion, with 5,525 new cases each year, of which 3,315congenital.[77] Carr et al. (1998) investigated amputa-tions caused by landmines for Afghanistan, Bosnia andHerzegovina, Cambodia and Mozambique among chil-

dren (<14 years), showing estimates of respectively 4.7,0.19, 1.11 and 0.67 per 1000 children.[78] Mohan (1986)indicated in India a total of 424,000 amputees (23,500annually), of which 10.3% had an onset of disability be-low the age of 14, amounting to a total of about 43,700limb deficient children in India alone.[79]

Few low-cost solutions have been created specially forchildren. Underneath some of them can be found.

Artificial limbs for a juvenile thalidomide survivor 1961–1965

11.1 Pole and crutch

This hand-held pole with leather support band or platformfor the limb is one of the simplest and cheapest solutionsfound. It serves well as a short-term solution, but is proneto rapid contracture formation if the limb is not stretcheddaily through a series of range-of motion (RoM) sets [80]

11.2 Bamboo, PVC or plaster limbs

This also fairly simple solution comprises a plaster socketwith a bamboo or PVC pipe at the bottom, optionally at-tached to a prosthetic foot. This solution prevents con-tractures because the knee is moved through its full RoM.The David Werner Collection, an online database for theassistance of disabled village children, displays manualsof production of these solutions [81]

13

11.3 Adjustable bicycle limb

This solution is built using a bicycle seat post up sidedown as foot, generating flexibility and (length) adjusta-bility. It is a very cheap solution, using locally availablematerials.[82]

11.4 Sathi Limb

It is an endoskeletal modular lower limb from India,which uses thermoplastic parts. Its main advantages arethe small weight and adaptability.[80]

11.5 Monolimb

Monolimbs are non-modular prostheses and thus requiremore experienced prosthetist for correct fitting, becausealignment can barely be changed after production. How-ever, their durability on average is better than low-costmodular solutions.

12 Cultural and Social Theory Per-spectives

A number of theorists have explored the meaning and im-plications of prosthetic extension of the body. ElizabethGrosz writes, “Creatures use tools, ornaments, and appli-ances to augment their bodily capacities. Are their bodieslacking something, which they need to replace with arti-ficial or substitute organs?...Or conversely, should pros-theses be understood, in terms of aesthetic reorganizationand proliferation, as the consequence of an inventivenessthat functions beyond and perhaps in defiance of prag-matic need?"[83] Elaine Scarry argues that every artifactrecreates and extends the body. Chairs supplement theskeleton, tools append the hands, clothing augments theskin.[84] In Scarry’s thinking, “furniture and houses areneither more nor less interior to the human body than thefood it absorbs, nor are they fundamentally different fromsuch sophisticated prosthetics as artificial lungs, eyes andkidneys. The consumption of manufactured things turnsthe body inside out, opening it up to and as the cultureof objects.”[85] Mark Wigley, a professor of architec-ture, continues this line of thinking about how architec-ture supplements our natural capabilities, and argues that“a blurring of identity is produced by all prostheses.”[86]Some of this work relies on Freud's earlier characteriza-tion of man’s relation to objects as one of extension.

13 See also• Bionics

• Robotic arm

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16 16 EXTERNAL LINKS

16 External links• Afghan amputees tell their stories at Texas gather-ing, Fayetteville Observer

• Can modern prosthetics actually help reclaim thesense of touch?, PBS Newshour

• A hand for Rick, Fayetteville Observer

17

17 Text and image sources, contributors, and licenses

17.1 Text• Prosthesis Source: https://en.wikipedia.org/wiki/Prosthesis?oldid=735696285 Contributors: Damian Yerrick, Bryan Derksen, The

Anome, William Avery, SimonP, Heron, Montrealais, Michael Hardy, Chris-martin, Ronz, Darrell Greenwood, Searchit, Dysprosia, Tp-bradbury, Tempshill, Oaktree b, Finlay McWalter, SD6-Agent, Chuunen Baka, Robbot, ZimZalaBim, Nurg, Meelar, Jondel, Sj, Danio, Jfd-wolff, Macrakis, DocSigma, Beland, Loremaster, Swisswuff, Jesster79, Brianhe, Dbachmann, Martpol, Bender235, CanisRufus, Huntster,Mwanner, Bobo192, Giraffedata, VBGFscJUn3, 99of9, GK, Alansohn, Atomicthumbs, Melaen, RJFJR, Oleg Alexandrov, Daranz, Bo-brayner, Richard Arthur Norton (1958- ), Ruud Koot, Rjwilmsi, Georgelazenby, Fish and karate, FlaBot, Nihiltres, Gurch, Mordicai, Bg-white, E Pluribus Anthony, Banaticus, YurikBot, Wavelength, Hairy Dude, Orothain, RussBot, Tubantia, Romanc19s, Grafen, Kvn8907,Deodar~enwiki, Rmky87, Blitterbug, Supten, Ochiwar, Zzuuzz, Jacklee, Ecnassianer, Anclation~enwiki, Bdve, SmackBot, InverseHy-percube, McGeddon, KVDP, Cactus Wren, Yamaguchi , Ianjm, NCurse, Thumperward, Miquonranger03, Isaacsurh, Papa November,SchfiftyThree, Frap, Rodoval, Jwillbur, Onorem, Alexmcfire, Agentogden, Memming, “alyosha”, LeoNomis, Tompot~enwiki, Mostly-harmless, Pkeets, Alþykkr, Ohconfucius, Bouncingmolar, Delphii, Mukadderat, Tktktk, Ckatz, 16@r, Beetstra, NBMATT, Bhekare,Xiaphias, Allamericanbear, Cancrine, Levineps, Torana, Wafulz, Centered1, Matt Cole, FilipeS, Cydebot, Ryan, Gogo Dodo, Antho-nyhcole, JFreeman, Lugnuts, Englishnerd, Njan, James-davis, Thijs!bot, Epbr123, BI1082006, Daniel, John254, James086, Nick Num-ber, Orvilleduck, AntiVandalBot, Vanjagenije, Kuteni, Matthew Fennell, .anacondabot, DCwom, Magioladitis, Jeff Dahl, JamesBWatson,Kakomu, NLLIC, Bubba hotep,WhatamIdoing, Theroadislong, Cpl Syx, TheRanger, DGG,MartinBot, R'n'B, Nono64, Trusilver, Adavidb,Herbythyme, Davidprior, Irtazakazmi, Belovedfreak, Hiyahiyahiya, Biglovinb, Dennis Myts, Treisijs, BernardZ, Idioma-bot, VolkovBot,Macedonian, Philip Trueman, Oshwah, Gune, Technopat, Rei-bot, Nfk17, BotKung, Jtehmom, Eubulides, Corwinlw, Gkrupa15, DocJames, Michaelsbll, Simbamford, FlyingLeopard2014, MattW93, Calliopejen1, Josconklin, Matthew Yeager, Aristolaos, GlassCobra,Flyer22 Reborn, MaynardClark, Oxymoron83, Dodger67, Denisarona, Escape Orbit, Neznanec, ImageRemovalBot, Martarius, ClueBot,The Thing That Should Not Be, Celtiknot, Mild Bill Hiccup, Bradka, PhilDWraight, Ashashyou, Sitara9, DryCorp, Arjayay, Ngebendi,Jinlye, Frozen4322, SchreiberBike, Saebjorn, Thingg, Callinus, Apparition11, XLinkBot, Tarheel95, Dthomsen8, Badgernet, Noctibus,Swapnaah, Addbot, Some jerk on the Internet, Electron, MrOllie, Derek the driver, Bigdave1300, Gpeterw, Favonian, Emdrgreg, Light-bot, Smeagol 17, Krano, Luckas-bot, Yobot, Themfromspace, Fraggle81, CvetanPetrov1940, Dkelsero, THEN WHO WAS PHONE?,Mqa, Thundera m117, AnomieBOT, Eaglesmoon, DemocraticLuntz, Jim1138, Materialscientist, Citation bot, Xqbot, Jordiferrer, Anony-mous from the 21st century, Omnipaedista, RibotBOT, Amaury, CalmCalamity, 78.26, Kikodawgzzz, Gdl1234, N419BH, Smallman12q,Sabolich, A little insignificant, OgreBot, Citation bot 1, Maxnegro, I dream of horses, Lesath, LittleWink, Tom.Reding, Tsetsalullu, MKFI,Tim1357, FoxBot, Trappist the monk, TangoFett, Jonkerz, Reaper Eternal, Andreldritch, RjwilmsiBot, Ripchip Bot, Druidhills, Emaus-Bot, Look2See1, Riskiebiz, GoingBatty, Cmwikiaccount, Sxoa, Dcirovic, K6ka, Tanner Swett, ZéroBot, Lacon432, Ebrambot, Bamyers99,Wayne Slam, Senjuto, SBaker43, Rangoon11, AGandhi-NJITWILL, GrayFullbuster, ClueBot NG, Jack Greenmaven, CocuBot, Lyla1205,Satellizer, A520, Braincricket, Kasir, Widr, Ehaaland, International Hearing Society, Gilesrick, Ideal05, Helpful Pixie Bot, Lhughey3, Reg-ulov, Jhemstreet5, BG19bot, Virtualerian, PhnomPencil, FootballIsTheBestSportEver, MusikAnimal, JoVEscied, OttawaAC, Glacialfox,Aks23121990, Justincheng12345-bot, Wolfguy258, Mr.lackadaisical, Ankababel, Cyberbot II, ChrisGualtieri, Achyut55, Khazar2, Euro-CarGT, AELfun5, MadGuy7023, Webeditoruk, Bilingual2000, Albert Garney, CPO, Rohicare, SFK2, Xyphoid, Ctyldsley, Eric rombokas,Bram.sterke, Writerfromupnorth, DevonJamesKing, 069952497a, Wburke1727, Bobradocy, Doonhamer57, CensoredScribe, Pxto, MD-physiatrist, Kharkiv07, Lotfbf, Femsociality, Legoman 86, Bobjob21, Sgowris2, Clemens Schroeder, Fixuture, Anazre, Ejester, Lagoset,Monkbot, Asucur, Amortias, Anderfo, MRD2014, KH-1, Rjbundra, Crystallizedcarbon, Orduin, Nubel ahmed, Caprockranger, Mal-varado9, KasparBot, Jasminefields2014, Kuskem15, Markask137, ClareGS, GSS-1987, Bobstarthy, GreenC bot and Anonymous: 348

17.2 Images• File:A_Visit_To_the_Artificial_Limbs_Factory,_Queen_Mary’{}s_Hospital,_Roehampton,_November_1941_D5731.jpgSource: https://upload.wikimedia.org/wikipedia/commons/7/72/A_Visit_To_the_Artificial_Limbs_Factory%2C_Queen_Mary%27s_Hospital%2C_Roehampton%2C_November_1941_D5731.jpg License: Public domain Contributors: http://media.iwm.org.uk/iwm/mediaLib//41/media-41851/large.jpg Original artist: Ministry of Information Photo Division Photographer

• File:Ambox_important.svg Source: https://upload.wikimedia.org/wikipedia/commons/b/b4/Ambox_important.svg License: Public do-main Contributors: Own work, based off of Image:Ambox scales.svg Original artist: Dsmurat (talk · contribs)

• File:Army_prosthetic.jpg Source: https://upload.wikimedia.org/wikipedia/commons/7/71/Army_prosthetic.jpg License: Public domainContributors: Available from the U.S. Army’s website, http://web.archive.org/web/http://www4.army.mil/armyimages/armyimage.php?photo=1836 Original artist: ?

• File:Artificial_limbs_for_a_thalidomide_child,_1961-1965._(9660575567).jpg Source: https://upload.wikimedia.org/wikipedia/commons/b/bd/Artificial_limbs_for_a_thalidomide_child%2C_1961-1965._%289660575567%29.jpg License: CC BY-SA 2.0 Contrib-utors: Artificial limbs for a thalidomide child, 1961-1965. Original artist: Science Museum London / Science and Society Picture Library

• File:AustralianParalympianOfTheYear_468.JPG Source: https://upload.wikimedia.org/wikipedia/commons/3/34/AustralianParalympianOfTheYear_468.JPG License: CC BY-SA 2.5 au Contributors: Own work Original artist: Toby Hudson

• File:Commons-logo.svg Source: https://upload.wikimedia.org/wikipedia/en/4/4a/Commons-logo.svg License: CC-BY-SA-3.0 Contribu-tors: ? Original artist: ?

• File:Eiserne_Hand_Glasnegativ_6_cropped.jpg Source: https://upload.wikimedia.org/wikipedia/commons/8/81/Eiserne_Hand_Glasnegativ_6_cropped.jpg License: CC BY 3.0 Contributors: Generallandesarchiv Karlsruhe 498-1 Nr. 5110 Bild 1 (Digitalisat). Originalartist: Wilhelm Kratt

• File:Flickr_-_The_U.S._Army_-_U.S._Army_World_Class_Athlete_Program_Paralympic.jpg Source: https://upload.wikimedia.org/wikipedia/commons/8/8c/Flickr_-_The_U.S._Army_-_U.S._Army_World_Class_Athlete_Program_Paralympic.jpg License: Publicdomain Contributors: U.S. Army World Class Athlete Program Paralympic Original artist: The U.S. Army

• File:Folder_Hexagonal_Icon.svg Source: https://upload.wikimedia.org/wikipedia/en/4/48/Folder_Hexagonal_Icon.svg License: Cc-by-sa-3.0 Contributors: ? Original artist: ?

18 17 TEXT AND IMAGE SOURCES, CONTRIBUTORS, AND LICENSES

• File:Free-to-read_lock_75.svg Source: https://upload.wikimedia.org/wikipedia/commons/8/80/Free-to-read_lock_75.svg License: CC0Contributors:Adapted from <a href='//en.wikipedia.org/wiki/File:Open_Access_logo_PLoS_white_green.svg' class='image' ti-tle='Open_Access_logo_PLoS_white_green.svg'><img alt='Open_Access_logo_PLoS_white_green.svg' src='//upload.wikimedia.org/wikipedia/commons/thumb/9/90/Open_Access_logo_PLoS_white_green.svg/9px-Open_Access_logo_PLoS_white_green.svg.png'width='9' height='14' srcset='//upload.wikimedia.org/wikipedia/commons/thumb/9/90/Open_Access_logo_PLoS_white_green.svg/14px-Open_Access_logo_PLoS_white_green.svg.png 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/9/90/Open_Access_logo_PLoS_white_green.svg/18px-Open_Access_logo_PLoS_white_green.svg.png 2x' data-file-width='640' data-file-height='1000'/></a>Original artist:This version:Trappist_the_monk (talk) (Uploads)

• File:Handicapped_Accessible_sign.svg Source: https://upload.wikimedia.org/wikipedia/commons/e/eb/Handicapped_Accessible_sign.svg License: Public domain Contributors: Own work, made to the specifications of the 2004 edition of Standard Highway Signs (signD9-6). Original artist: Ltljltlj (talk · contribs)

• File:Iron_artificial_arm,_1560-1600._(9663806794).jpg Source: https://upload.wikimedia.org/wikipedia/commons/e/eb/Iron_artificial_arm%2C_1560-1600._%289663806794%29.jpg License: CC BY-SA 2.0 Contributors: Iron artificial arm, 1560-1600. Originalartist: Science Museum London / Science and Society Picture Library

• File:Journal.pone.0019508.g004_prosthetic_finger.png Source: https://upload.wikimedia.org/wikipedia/commons/a/aa/Journal.pone.0019508.g004_prosthetic_finger.png License: CC BY 2.5 Contributors: PLoS ONE, http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0019508 Original artist: John-John Cabibihan, Department of Electrical and Computer Engineering, National Uni-versity of Singapore, Singapore

• File:Low_cost_prosthetic_limbs.jpg Source: https://upload.wikimedia.org/wikipedia/commons/1/18/Low_cost_prosthetic_limbs.jpgLicense: CC BY-SA 3.0 Contributors: Own work Original artist: Afurse

• File:Myoelectric_prosthetic_arm.jpg Source: https://upload.wikimedia.org/wikipedia/commons/6/6e/Myoelectric_prosthetic_arm.jpgLicense: Public domain Contributors: DVIDS Archive Original artist: Petty Officer 2nd Class Greg Mitchell of the United States Navy

• File:Prosthetic_toe.jpg Source: https://upload.wikimedia.org/wikipedia/commons/6/67/Prosthetic_toe.jpg License: Copyrighted freeuse Contributors: http://www.egyptarchive.co.uk/html/hidden_treasures/hidden_treasures_31.html Original artist: Jon Bodsworth

• File:Question_book-new.svg Source: https://upload.wikimedia.org/wikipedia/en/9/99/Question_book-new.svg License: Cc-by-sa-3.0Contributors:Created from scratch in Adobe Illustrator. Based on Image:Question book.png created by User:Equazcion Original artist:Tkgd2007

• File:Split-arrows.svg Source: https://upload.wikimedia.org/wikipedia/commons/a/a7/Split-arrows.svg License: Public domain Contribu-tors: ? Original artist: ?

• File:USMC-07775.jpg Source: https://upload.wikimedia.org/wikipedia/commons/8/89/USMC-07775.jpg License: Public domain Con-tributors: http://www.marines.mil/unit/hqmc/PublishingImages/2007/wtcrun-001.jpg Original artist: ?

• File:WorkNC-Knee_prosthesis.jpg Source: https://upload.wikimedia.org/wikipedia/commons/0/0b/WorkNC-Knee_prosthesis.jpg Li-cense: CC BY-SA 2.0 Contributors: http://www.flickr.com/photos/cadcamzone/4662442453 Original artist: Sescoi CAD/CAM

17.3 Content license• Creative Commons Attribution-Share Alike 3.0