1414 THE JOURNAL OF BONE AND JOINT SURGERY

ANNOTATION

The Jaipur foot

A. P. Arya, L. Klenerman

A. P. Arya, MS(Orth), MChOrth, FRCS(Trauma & Orth), Associate Specialist, Orthopaedic SurgeonUpper Limb Unit, Department of Trauma and Orthopaedic SurgeryKing’s College Hospital, Denmark Hill, London SE5 9RS, UK.

L. Klenerman, ChM, FRCSEd, Eng, Emeritus Professor, University of Liverpool5 Christ’s Court, 26 Victoria Street, Cambridge CB1 1JN, UK.

Correspondence should be sent to Mr A. P. Arya; e-mail: anandparya@gmail.com

©2008 British Editorial Society of Bone and Joint Surgerydoi:10.1302/0301-620X.90B11. 21131 $2.00

J Bone Joint Surg [Br] 2008;90-B:1414-16.Received 8 April 2008;

The Jaipur foot was developed for barefoot amputees by Professor P. K. Sethi. He used local artisans and readily available materials. The prosthesis was cheap and could be made in one hour. It enabled amputees to work in rural conditions, muddy and wet fields and to climb trees. It has been widely used in India, South East Asia and Africa, where local variations to the design have now been made.

The number of amputees worldwide hasrisen alarmingly as a result of the increasingand indiscriminate use of antipersonnel landmines which have been sown in enormousnumbers in rural areas. Even after the cessationof fighting, fresh injuries occur from thedelayed detonation of these weapons.1 Themost likely injury is a traumatic amputation ofthe foot or leg.2 Rehabilitation of the amputeesin countries where the majority of the populacehave a low-income has several major con-straints, the foremost being the availability of anaffordable prosthesis suitable for their lifestyle.The development of the Jaipur prosthetic foot inthe early 1970s has been a major contribution.

Professor P. K. Sethi was Foundation Professorof Orthopaedics at the Sawai Man Singh (SMS)Medical College and Hospital, Jaipur, India. Heobserved that lower-limb amputees preferred touse crutches rather than prostheses fitted with aSolid Ankle Cushion Heel foot (SACH). Thisprosthesis was unsuitable for the demands of a‘floor-sitting’ lifestyle in a warm country such asIndia which were different from those of the‘chair-sitting’ habits of the cold countries ofEurope. Limbs made of polymer with a rigid ter-minal device such as the SACH foot did notallow the amputees to sit on the floor, squat,walk barefoot or work in muddy, wet fields, andthey broke easily. There was an obvious need fora prosthesis suitable for Indian amputees.

Sethi’s first efforts were to modify the SACHfoot. Its solid wooden keel did not allow anymovement and therefore a wedge was removedin order to allow dorsiflexion. This producedlimited movement and resulted in the removalof increasingly larger wedges until almostnothing was left of the proximal section of thekeel. At this stage he abandoned the SACHfoot and introduced a completely new design.

This prosthesis, which he named the ‘JaipurFoot’, consisted of three separate blocks, oneof micro-cellular rubber for the hind foot andthe other two of laminated wood for the ankleand forefoot, appropriately shaped andwrapped by an inner layer of tyre cord rubberand an outer layer of skin-coloured soft rubber,with tough rubber for the sole. The foot wasthen vulcanised in an aluminium die to looklife-like. The forefoot wooden block was laterreplaced with a rubber block, similar to that ofthe hindfoot in order to provide pronation andsupination, and to allow stability on unevenground (Fig. 1). The foot was attached to analuminium socket covered with stockinette,glued, water-proofed and individually paintedin the appropriate skin colour.

The large sponge rubber block at the hindfoot acted as a universal joint, capable of pro-viding multidirectional movements includingdorsi- and plantar flexion, inversion, eversion,adduction and abduction. The foot couldrotate on the leg. This allowed the amputee notonly to squat and sit cross-legged, but also towalk comfortably on uneven terrain, since thefoot could adapt easily to the underlying sur-face (Fig. 2). Being waterproof, it could be usedin mud and water. Its normal appearance was agreat advantage since it did not need a shoeand amputees could walk barefoot, which fol-lowed the custom of not bringing shoes intokitchens or places of worship. The foot wassturdy and tough and could withstand thestresses of everyday use.3,4 Amputees felt verysecure with these feet and they required littlegait training. This was thought to be due to thelarge area of support. The prosthesis could betailor-made in front of the user in less than anhour and cost approximately 250 Indianrupees (£3.00).5

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Sethi first presented his work in Europe in 1971.6 He didnot patent the foot in spite of pressure to do so, since hebelieved that commercialisation would take it out of reachof those who needed it most. The foot was so simple tomake that it could be produced in any village with an arti-san. Because of this novel approach, millions of Jaipur feetwere made locally and fitted to amputees in India, Pakistan,Sri Lanka, Bangladesh, Vietnam, Cambodia, Afghanistanand several African countries.5 By March 2003 a singlenon-government organisation, Bhagwan Mahaveer Vik-lang Sahayata Samiti, had provided 690 480 limbs in Indiaand 15 169 in 19 other countries.7 Lives were transformedsince amputees were made physically and economicallyindependent.

A comparative study of the SACH, Seattle (one of the firstenergy-storing feet in which the forefoot keel was designed tostore energy as a cantilever beam and then return this storedenergy during push off) and the Jaipur foot was carried outto compare their biomechanical properties by measuringground reaction forces.8 Three transtibial amputees partici-pated. Each was provided with an experimental limbadapted to accommodate the three prosthetic feet. The nor-mal foot was used as a control and all wore their usual limbduring control trials. The ground reaction force was mea-sured using a Kistler force plate (5281B, Kistler InstrumentsInc. Amherst, New York), which measured six variablesfrom the vertical and anteroposterior components of groundreaction forces. The normal foot generated significantlylarger ground reaction forces than the prosthetic foot. Thecapacity for shock absorption of the SACH foot was best,but with the Jaipur foot the anteroposterior braking impulse,which represented the force of loading, was significantlylarger and nearer the value for the normal foot. This impliedthat amputees placed more load on it because they felt secureand confident.

The main disadvantage of the Jaipur foot was itsweight. It was heavier than most other prosthetic feet andhad not been standardised. These two factors mitigatedagainst its use in the Western world.

Despite extensive use for many years, it is only recentlythat the International Society for Prosthetics and Orthot-ics, has carried out field trials of the Jaipur foot to assessits durability and performance. Jensen and Raab7 used 81Jaipur feet from two private manufacturers in India andtested them on established amputees at the InternationalRed Cross Committee project in Ho Chi Minh City inVietnam for a mean of 16 (8 to 17) months. All the ampu-tees were active users who walked for distances exceeding1 km and had a median daily use of 14 hours. Theauthors reported that compliance was high and thatnearly all the users were satisfied. At the end of thestudy 27% of the feet had failed and needed exchangingmostly because of fracture of the skin and glidingbetween the sponge rubber layers of the heel block. It wasfelt that since the Jaipur foot was constructed for light-weight Indians, there was a risk of premature breakdownwhen used by heavier persons. This, combined withits manufacture by relatively untrained artisans, wasthought to place it at a disadvantage when usedextensively in the developing world.

Fig. 1

Photograph showing a sagittal section of a Jaipur foot. Note theproximal laminated wooden block. The sponge rubber univer-sal joint consists of several layers glued together. The area cor-responding to the tarsals and metatarsals is occupied byanother sponge rubber block.

Fig. 2

Photograph showing an amputee with a Jaipur foot climbing atree.

1416 A. P. ARYA, L. KLENERMAN

THE JOURNAL OF BONE AND JOINT SURGERY

The Jaipur foot can be used with any superstructure ofthe leg and thigh. The original design by Professor Sethiwas made from aluminium sheets. These have beenreplaced largely by high-density polyethylene. Jensen et al9

reviewed 172 amputees using this type of prosthesis inprojects in Honduras, Uganda and India after a median of35 months. Craftsmanship and fit were assessed as poor in56%. Although there was patient satisfaction in 85% and acompliance rate of 94%, the high-density polyethylene-Jaipur foot transtibial system was not considered to beacceptable, since 49% of users reported walking distancesof less than 1 km and 36% experienced discomfort. Themajor effect on outcome was the poor education and train-ing of the artisans involved. In this respect, Professor Sethi’sdecision not to patent and standardise the Jaipur foot hasproved to be a double-edged sword; although millions offeet have been made, the quality of production and fittinghas been inconsistent.

The concept of the vulcanised rubber foot has becomepopular and different variations have been introduced.Jensen and Treichi10 tested 21 different prosthetic feet, ofwhich 14 were made from vulcanised natural rubber orfoam rubber, produced in many different countries includ-ing Vietnam, Cambodia, Angola and Tanzania.

The Jaipur foot demonstrates the philosophy of usinglocally-available material and resources to find solutions tochallenging problems in the developing world. An analogycan be drawn with the development of the Ilizarov system,

which revolutionised limb reconstruction. The use of localmaterials with which craftsmen are familiar has severaladvantages in that costs can be kept down and, providedthat there is adequate and close supervision, existing crafts-men can quickly be trained as limb-makers. These advan-tages are relevant in areas where funding is scarce and thereis a reservoir of practical and industrious manual workers.

We wish to acknowledge the invaluable help we received from Dr S. Jensen ofthe International Society for Prosthetics and Orthotics, Copenhagen, Denmark.

No benefits in any form have been received or will be received from a com-mercial party related directly or indirectly to the subject of this article.

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national Committee of the Red Cross. BMJ 1991;330:1509-12.3. Sethi PK, Udawat MP, Kasliwal SC, Chandra R. Vulcanized rubber foot for lower limb

amputees. Prosthet Orthot Int 1978;2:125-36.4. Arya AP. Evolution of the Jaipur Foot: dissertation submitted to the University of Liverpool

for MChOrth Examination, 1991.5. No authors listed. South Asian theme issue: no mean feet. BMJ 2004;328:789.6. Sethi PK. A rubber foot for amputees in underdeveloped countries. J Bone Joint Surg [Br]

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amputees in low income countries. Prosthet Orthot Int 2007;31:105-15.8. Arya AP, Lees A, Nirula HC, Klenerman L. A biomechanical comparison of the SACH,

Seattle and Jaipur feet using ground reaction forces. Prosthet Orthot Int 1995;19:37-45.9. Jensen JS, Craig JG, Mtalo LB, Zelaya CM. Clinical field follow-up of high density

polyethylene (HDPE) Jaipur prosthetic technology for trans-tibial amputees. ProsthetOrthot Int 2004;28:230-44.

10. Jensen JS, Treichi HB. Mechanical testing of prosthetic feet utilized in low incomecountries according to ISO - 10328 standards. Prosthet Orthot Int 2007;31:177-206.