prosthesis types indications design recent advances 2024 2025

ls /home/daytona/workspace/ && mkdir -p /home/daytona/workspace/prosthesis-pptx

prosthesis types indications design biomaterials recent advances 2024 2025 osseointegration AI myoelectric

prosthesis osseointegration neural interface recent advances

mkdir -p /home/daytona/workspace/prosthesis-pptx && ls /home/daytona/workspace/p…

~/prosthesis-pptx/build.js

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pres.title = "Prosthesis: Indications, Design & Recent Advances";

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// ════════════════════════════════════════════════════════════════════════════
// SLIDES
// ════════════════════════════════════════════════════════════════════════════

// ── SLIDE 1: Title ──────────────────────────────────────────────────────────
titleSlide(pres,
  "Prosthesis\nIndications, Design &\nRecent Advances",
  "A Comprehensive Clinical Review  |  2026"
);

// ── SLIDE 2: Outline ────────────────────────────────────────────────────────
contentSlide(pres, 2, "Presentation Outline", [
  { text: "Definition & Historical Perspective", bold: true },
  { text: "Classification of Prostheses" },
  { text: "Indications for Prosthetic Use" },
  { text: "Biomaterials & Engineering Principles" },
  { text: "Limb Prostheses: Upper & Lower Extremity" },
  { text: "Orthopedic Joint Prostheses (Hip, Knee, Shoulder)" },
  { text: "Cardiac & Vascular Prostheses" },
  { text: "Dental & Maxillofacial Prostheses" },
  { text: "Sensory Prostheses (Ocular, Auditory)" },
  { text: "Urological & Reconstructive Prostheses" },
  { text: "Design Principles & Fixation" },
  { text: "Complications & Management" },
  { text: "Recent Advances & Future Directions" },
]);

// ── SECTION 1 BANNER ────────────────────────────────────────────────────────
sectionBanner(pres, 1, "Definition & History");

// ── SLIDE 3: Definition ─────────────────────────────────────────────────────
contentSlide(pres, 3, "What is a Prosthesis?", [
  { text: "An artificial device that replaces or augments a missing or impaired body part", bold: true },
  { text: "Derived from Greek: 'prosthesis' = addition or attachment" },
  { text: "Encompasses external devices (limb prostheses) and internal implants (joint replacements, heart valves)" },
  { text: "Distinguished from orthoses: orthoses support existing structures; prostheses replace absent ones" },
  { text: "Goal: restore function, appearance, or both - improving quality of life" },
  { text: "Multidisciplinary field: surgery, bioengineering, rehabilitation, materials science" },
], { note: "Campbell's Operative Orthopaedics 15e | Schwartz's Principles of Surgery 11e" });

// ── SLIDE 4: History ────────────────────────────────────────────────────────
contentSlide(pres, 4, "Historical Milestones", [
  { text: "~1500 BCE – Egyptian toe prosthesis (wood & leather) - oldest known example", bold: false },
  { text: "~300 BCE – Roman bronze leg (Capua leg) for above-knee amputation" },
  { text: "16th century – Ambroise Paré: hinged mechanical hand & lower limb prostheses" },
  { text: "World War I & II – mass casualties drove innovation; aluminum, lightweight alloys introduced" },
  { text: "1950s-60s – Total hip replacement (Charnley); acrylic cement fixation" },
  { text: "1970s – Modular knee prostheses; carbon-fiber composites" },
  { text: "1990s-2000s – Osseointegration, porous ingrowth surfaces, cementless fixation" },
  { text: "2010s-2020s – Myoelectric limbs, 3D printing, AI-controlled exoprostheses" },
], { note: "Source: Campbell's Operative Orthopaedics 15e, 2026" });

// ── SLIDE 5: Epidemiology ───────────────────────────────────────────────────
contentSlide(pres, 5, "Epidemiology & Global Burden", [
  { text: "~57 million people worldwide live with limb loss (WHO estimate)" },
  { text: "Developing countries account for ~80% of amputee population" },
  { text: "Leading causes: peripheral vascular disease/diabetes (~54%), trauma (~45%), cancer (<2%)" },
  { text: ">1 million joint replacements performed annually in the USA alone" },
  { text: "Global prosthetics market valued at ~$9 billion (2024), projected $15B by 2030" },
  { text: "Increased demand driven by aging population, obesity, diabetes epidemic, conflict injuries" },
  { text: "Only 5-15% of people who need prostheses in low-income countries have access" },
], { note: "WHO Global Report on Assistive Technology | Gavin Publishers, 2025" });

// ── SECTION 2 BANNER ────────────────────────────────────────────────────────
sectionBanner(pres, 2, "Classification of Prostheses");

// ── SLIDE 6: Classification by Anatomic Location ────────────────────────────
contentSlide(pres, 6, "Classification: By Anatomic Location",
  [
    { text: "UPPER LIMB", bold: true },
    { text: "Shoulder disarticulation, transhumeral (above-elbow)" },
    { text: "Transradial (below-elbow), partial hand, finger" },
    { text: "LOWER LIMB", bold: true },
    { text: "Hip disarticulation, transfemoral (above-knee)" },
    { text: "Transtibial (below-knee), Syme's, partial foot" },
  ],
  {
    twoCol: true,
    col2: [
      { text: "INTERNAL IMPLANTS", bold: true },
      { text: "Joint: hip, knee, shoulder, elbow, ankle" },
      { text: "Cardiac: heart valves, ventricular assist devices" },
      { text: "Vascular: aortic grafts, stents" },
      { text: "Dental: endosseous implants, crowns" },
      { text: "Sensory: cochlear, retinal, ocular" },
      { text: "Urological: penile, testicular, urinary sphincter" },
    ]
  }
);

// ── SLIDE 7: Classification by Function ─────────────────────────────────────
contentSlide(pres, 7, "Classification: By Function & Control", [
  { text: "PASSIVE / COSMETIC", bold: true },
  { text: "Restore appearance; minimal active function; lightweight silicone gloves, ocular prostheses" },
  { text: "BODY-POWERED (Cable-actuated)", bold: true },
  { text: "Harness transmits force from residual limb movement; durable, low cost, tactile feedback" },
  { text: "EXTERNALLY POWERED (Myoelectric)", bold: true },
  { text: "EMG signals from residual muscles drive electric motors; multi-grip hands" },
  { text: "HYBRID", bold: true },
  { text: "Combines body-power and electric components for optimal function" },
  { text: "SMART / NEURAL INTERFACE", bold: true },
  { text: "Targeted muscle reinnervation (TMR), osseointegration, bidirectional sensory feedback" },
], { note: "PMC - Technological Advances in Prosthesis Design (2024)" });

// ── SLIDE 8: Classification by Material ─────────────────────────────────────
contentSlide(pres, 8, "Classification: By Material", [
  { text: "Metals: titanium (Ti-6Al-4V), cobalt-chrome, stainless steel - strength, biocompatibility" },
  { text: "Ceramics: alumina, zirconia, hydroxyapatite - wear resistance, osseointegration" },
  { text: "Polymers: UHMWPE, PEEK, polyurethane, silicone - flexibility, low friction" },
  { text: "Composites: carbon fiber reinforced polymer (CFRP) - high strength-to-weight ratio" },
  { text: "Biological/biologic mesh: processed human/animal tissue for soft tissue repair" },
  { text: "Smart materials: shape-memory alloys (NiTinol), piezoelectric polymers, hydrogels" },
  { text: "3D-printed scaffolds: titanium lattice, biodegradable polymer, patient-specific geometry" },
], { note: "Preprints.org - Future of Bone Prosthetic Design, 2026 | Schwartz's Surgery 11e" });

// ── SECTION 3 BANNER ────────────────────────────────────────────────────────
sectionBanner(pres, 3, "Indications for Prosthetic Use");

// ── SLIDE 9: General Indications ────────────────────────────────────────────
contentSlide(pres, 9, "General Indications for Prostheses", [
  { text: "AMPUTATION", bold: true },
  { text: "Peripheral vascular disease / diabetic foot (most common); trauma; malignancy; congenital limb deficiency; severe infection (gas gangrene, necrotizing fasciitis)" },
  { text: "JOINT DESTRUCTION", bold: true },
  { text: "End-stage osteoarthritis, rheumatoid arthritis, post-traumatic arthritis, avascular necrosis, failed prior arthroplasty" },
  { text: "ORGAN / TISSUE LOSS OR FAILURE", bold: true },
  { text: "Cardiac valve disease, aortic aneurysm, end-stage heart failure (VAD)" },
  { text: "SENSORY ORGAN LOSS OR IMPAIRMENT", bold: true },
  { text: "Profound sensorineural hearing loss (cochlear implant), blindness/enucleation (ocular prosthesis)" },
  { text: "RECONSTRUCTIVE NEEDS", bold: true },
  { text: "Post-cancer surgery (laryngectomy, maxillofacial resection), hernia, erectile dysfunction" },
]);

// ── SLIDE 10: Indications for Limb Amputation ───────────────────────────────
contentSlide(pres, 10, "Indications for Limb Amputation & Prosthetic Fitting", [
  { text: "Irreversible ischemia not amenable to revascularization" },
  { text: "Diabetic foot with osteomyelitis, gangrene, or non-healing ulcer" },
  { text: "Malignant bone or soft-tissue tumors (after failed limb-salvage)" },
  { text: "Severe crush injury or traumatic loss with non-viable distal limb" },
  { text: "Congenital limb deficiency - early fitting by age 6 months improves outcomes" },
  { text: "Electrical burns with full-thickness destruction" },
  { text: "~75% of vascular amputees can ambulate with a prosthesis (Mulholland, 2022)" },
  { text: "Patient selection: general health, motivation, residual limb condition, cognitive function" },
], { note: "Mulholland & Greenfield's Surgery 7e | Campbell's Operative Orthopaedics 15e" });

// ── SLIDE 11: Indications for Hip Replacement ───────────────────────────────
contentSlide(pres, 11, "Indications: Total Hip Arthroplasty", [
  { text: "PRIMARY INDICATIONS", bold: true },
  { text: "Severe hip pain with functional limitation unresponsive to conservative care (>6 months)" },
  { text: "End-stage osteoarthritis (Kellgren-Lawrence grade 3-4)" },
  { text: "Inflammatory arthritis (RA, ankylosing spondylitis) with joint destruction" },
  { text: "Avascular necrosis (osteonecrosis) of the femoral head - Stages III/IV" },
  { text: "Displaced femoral neck fracture in elderly patients" },
  { text: "RELATIVE CONTRAINDICATIONS", bold: true },
  { text: "Active joint infection, severe medical comorbidity, skeletal immaturity" },
  { text: "Obesity (BMI >40) - increased dislocation, infection, and revision risk" },
], { note: "Campbell's Operative Orthopaedics 15th Ed, 2026" });

// ── SLIDE 12: Indications for Knee Replacement ──────────────────────────────
contentSlide(pres, 12, "Indications: Total Knee Arthroplasty", [
  { text: "End-stage tibiofemoral or patellofemoral OA with severe pain and disability" },
  { text: "Rheumatoid or other inflammatory arthritis with joint destruction" },
  { text: "Post-traumatic arthritis (distal femur/proximal tibia fracture malunion)" },
  { text: "Chronic osteonecrosis of the femoral condyle" },
  { text: "Failed high tibial osteotomy or unicompartmental knee replacement" },
  { text: "DECISION CRITERIA: pain severity, functional limitation, radiographic grade, failed non-surgical treatment" },
  { text: "95%+ survivorship at 10 years; ~98.6% at 15-18 years for modern cementless designs" },
  { text: "Most common causes of revision: loosening (40%), infection (27%), instability (7.5%)" },
], { note: "Campbell's Operative Orthopaedics 15e - TKA Survivorship Data, 2026" });

// ── SLIDE 13: Indications - Cardiac / Vascular ──────────────────────────────
contentSlide(pres, 13, "Indications: Cardiac & Vascular Prostheses", [
  { text: "HEART VALVES", bold: true },
  { text: "Severe valvular aortic or mitral stenosis/regurgitation causing symptoms or LV dysfunction" },
  { text: "Mechanical prosthesis preferred in younger (<60 yrs) patients; bioprosthesis in older patients or those unable to anticoagulate" },
  { text: "Key selection: age, life expectancy, contraindication to warfarin, patient preference (Fuster's The Heart, 15e)" },
  { text: "VASCULAR GRAFTS", bold: true },
  { text: "Aortic aneurysm (>5.5 cm), occlusive disease (aortoiliac, femoro-popliteal), trauma" },
  { text: "Synthetic grafts (PTFE, Dacron) for large vessels; autologous vein preferred for infrainguinal" },
  { text: "VENTRICULAR ASSIST DEVICES (VADs)", bold: true },
  { text: "Bridge to transplant or destination therapy in NYHA IV heart failure" },
], { note: "Fuster & Hurst's The Heart 15e | Sabiston Textbook of Surgery" });

// ── SECTION 4 BANNER ────────────────────────────────────────────────────────
sectionBanner(pres, 4, "Biomaterials & Engineering Principles");

// ── SLIDE 14: Ideal Properties ───────────────────────────────────────────────
contentSlide(pres, 14, "Properties of an Ideal Prosthetic Material", [
  { text: "Biocompatible: non-toxic, non-immunogenic, non-carcinogenic" },
  { text: "Mechanically appropriate: sufficient tensile strength, stiffness, fatigue life" },
  { text: "Corrosion/wear resistant: withstands body fluids; minimal debris generation" },
  { text: "Infection resistant: anti-biofilm surface properties preferred" },
  { text: "Osseointegration or tissue ingrowth capability (for fixation)" },
  { text: "Radiolucent or MRI-compatible where needed" },
  { text: "Lightweight yet strong (high strength-to-weight ratio)" },
  { text: "Manufacturable: consistent quality, sterilizable, cost-effective" },
  { text: "An ideal mesh should be flexible, strong, inert, contraction-resistant, and inexpensive (Schwartz's 11e)" },
], { note: "Schwartz's Principles of Surgery 11e | Preprints.org 2026" });

// ── SLIDE 15: Metals ─────────────────────────────────────────────────────────
contentSlide(pres, 15, "Metallic Biomaterials",
  [
    { text: "TITANIUM (Ti-6Al-4V)", bold: true },
    { text: "Excellent biocompatibility, low modulus (closer to bone), superior osseointegration" },
    { text: "Used in hip/knee stems, dental implants, osseointegrated percutaneous posts" },
    { text: "COBALT-CHROME (CoCr)", bold: true },
    { text: "High wear resistance; used in femoral heads, knee condyles, shoulder stems" },
    { text: "Concern: elevated serum metal ion levels with metal-on-metal bearings" },
  ],
  {
    twoCol: true,
    col2: [
      { text: "STAINLESS STEEL (316L)", bold: true },
      { text: "Low cost; used in fracture fixation, some temporary implants; higher corrosion risk" },
      { text: "NITINOL (Ni-Ti)", bold: true },
      { text: "Shape-memory alloy; used in stents, orthodontic wires, self-crimping stapes pistons (Scott-Brown's 2022)" },
      { text: "TANTALUM", bold: true },
      { text: "Highly porous (Trabecular Metal); excellent bone ingrowth; revision acetabular cups" },
    ]
  }
);

// ── SLIDE 16: Polymers & Ceramics ───────────────────────────────────────────
contentSlide(pres, 16, "Polymers & Ceramics in Prosthetics",
  [
    { text: "UHMWPE (Ultra-High Molecular Weight Polyethylene)", bold: true },
    { text: "Tibial and acetabular bearings; cross-linked UHMWPE reduces wear by 80%" },
    { text: "PEEK (Polyether ether ketone)", bold: true },
    { text: "Radiolucent, bone-like modulus, MRI compatible; spinal, craniofacial implants" },
    { text: "SILICONE", bold: true },
    { text: "Socket liners, partial hand prostheses, ocular/facial prostheses; waterproof" },
  ],
  {
    twoCol: true,
    col2: [
      { text: "ALUMINA (Al2O3)", bold: true },
      { text: "Extremely hard, scratch-resistant; ceramic femoral heads - lowest wear rate" },
      { text: "ZIRCONIA (ZrO2)", bold: true },
      { text: "Toughened ceramic; alternative to alumina with improved fracture resistance" },
      { text: "HYDROXYAPATITE (HA)", bold: true },
      { text: "Calcium phosphate ceramic; osteoconductive coating on cementless stems to promote bone ingrowth" },
    ]
  }
);

// ── SLIDE 17: Carbon Fiber & Composites ─────────────────────────────────────
contentSlide(pres, 17, "Carbon Fiber & Smart Materials", [
  { text: "CARBON FIBER REINFORCED POLYMER (CFRP)", bold: true },
  { text: "10x stronger than steel at 1/5 the weight; used in energy-storing prosthetic feet (Cheetah blades, C-Legs)" },
  { text: "High fatigue resistance; variable stiffness by fiber orientation" },
  { text: "Running blades: Flex-Run, Proprio foot - normalized gait mechanics" },
  { text: "SMART MATERIALS", bold: true },
  { text: "Shape-memory alloys: self-crimping stapes pistons (Scott-Brown's Otolaryngology)" },
  { text: "Piezoelectric polymers: convert mechanical stress to electrical signal - sensory feedback potential" },
  { text: "Magnetorheological fluid (C-Leg knee): variable resistance in real-time" },
  { text: "Hydrogels: cartilage replacement, drug-eluting coatings" },
], { note: "Preprints.org - Future of Bone Prosthetic Design, 2026" });

// ── SECTION 5 BANNER ────────────────────────────────────────────────────────
sectionBanner(pres, 5, "Limb Prostheses");

// ── SLIDE 18: Lower Limb - Socket & Suspension ──────────────────────────────
contentSlide(pres, 18, "Lower Limb Prostheses: Socket & Suspension", [
  { text: "Socket is the most critical interface - transmits all forces between residual limb and prosthesis" },
  { text: "SOCKET DESIGNS", bold: true },
  { text: "Total-surface-bearing (TSB): distributes load over entire residual limb surface" },
  { text: "Patellar tendon-bearing (PTB): load on tibial flares and patellar tendon (below-knee)" },
  { text: "Ischial containment (IC): encloses ischium for transfemoral amputees - improved stability" },
  { text: "SUSPENSION SYSTEMS", bold: true },
  { text: "Suction socket (negative pressure), pin/lock system, sealing sleeve, elevated vacuum" },
  { text: "Silicone roll-on liner: standard - reduces shear, improves proprioception, skin protection" },
  { text: "3D-printed sockets: custom geometry, rapid iteration, reduced cost" },
], { note: "Campbell's Operative Orthopaedics 15e | PMC Advances Review 2024" });

// ── SLIDE 19: Lower Limb - Foot & Knee ──────────────────────────────────────
contentSlide(pres, 19, "Lower Limb Components: Foot & Knee Units",
  [
    { text: "PROSTHETIC FEET", bold: true },
    { text: "SACH (solid ankle cushion heel): basic, low activity" },
    { text: "Dynamic response / energy-storing: CFRP keel; returns 90-95% energy" },
    { text: "Microprocessor ankle (Proprio, Meridium): adjusts dorsiflexion automatically" },
    { text: "Bionic feet with powered push-off (Empower/IDEO) - near-normal gait" },
  ],
  {
    twoCol: true,
    col2: [
      { text: "PROSTHETIC KNEE UNITS", bold: true },
      { text: "Single-axis: basic hinge; manual lock" },
      { text: "Polycentric (4-bar): stable in stance, natural flexion arc" },
      { text: "Hydraulic/pneumatic: stance/swing phase resistance" },
      { text: "Microprocessor knee (C-Leg, Rheo Knee, Genium): real-time gait adaptation, stumble recovery" },
      { text: "Powered knee: active propulsion; improved stair climbing" },
    ]
  }
);

// ── SLIDE 20: Upper Limb ──────────────────────────────────────────────────────
contentSlide(pres, 20, "Upper Limb Prostheses", [
  { text: "Upper limb prostheses are used by ~200,000 amputees in the USA; rejection rate ~35-50%" },
  { text: "PASSIVE/COSMETIC: silicone gloves, passive hooks - for appearance and simple tasks" },
  { text: "BODY-POWERED: Bowden cable system; split hook terminal device (TD); reliable, low cost, excellent tactile feedback via harness tension" },
  { text: "MYOELECTRIC: EMG from biceps/triceps activates motorized hand (Otto Bock, Ottobock Michelangelo, LUKE arm)" },
  { text: "Multi-articulating hands (iLimb, Bebionic): up to 36 grip patterns via app/EMG" },
  { text: "HYBRID: cable elbow + myoelectric TD; common for transhumeral amputees" },
  { text: "Activity-specific TD: sports hooks, swim attachments, musical instrument adaptors" },
], { note: "PMC - Technological Advances in Prosthesis Design and Rehabilitation (2024)" });

// ── SECTION 6 BANNER ────────────────────────────────────────────────────────
sectionBanner(pres, 6, "Orthopedic Joint Prostheses");

// ── SLIDE 21: Hip Arthroplasty - Design ──────────────────────────────────────
contentSlide(pres, 21, "Total Hip Arthroplasty: Design Principles", [
  { text: "FEMORAL COMPONENT", bold: true },
  { text: "Stem: titanium alloy (cementless, porous ingrowth) or cobalt-chrome (cemented); varies by fixation philosophy" },
  { text: "Femoral head: cobalt-chrome or ceramic (alumina/zirconia); head size 28-36 mm" },
  { text: "ACETABULAR COMPONENT", bold: true },
  { text: "Metal shell with polyethylene, ceramic, or metal liner; press-fit with supplemental screws" },
  { text: "BEARING SURFACES", bold: true },
  { text: "Metal-on-polyethylene (most common), ceramic-on-ceramic (lowest wear), metal-on-metal (largely abandoned), ceramic-on-polyethylene" },
  { text: "Dual mobility cups: reduce dislocation risk in high-risk patients" },
], { note: "Campbell's Operative Orthopaedics 15e, 2026" });

// ── SLIDE 22: Total Knee - Design ────────────────────────────────────────────
contentSlide(pres, 22, "Total Knee Arthroplasty: Components & Design",
  [
    { text: "FEMORAL COMPONENT", bold: true },
    { text: "CoCr alloy; reproduces femoral condyle geometry; patellar groove" },
    { text: "TIBIAL COMPONENT", bold: true },
    { text: "Metal tray (Ti or CoCr) + UHMWPE insert; modular design" },
    { text: "PCL-retaining (CR) vs PCL-substituting (PS/posterior-stabilized) designs" },
  ],
  {
    twoCol: true,
    col2: [
      { text: "PATELLAR COMPONENT", bold: true },
      { text: "All-polyethylene button; controversial - selective resurfacing" },
      { text: "FIXATION", bold: true },
      { text: "Cemented: gold standard; predictable fixation" },
      { text: "Cementless: newer porous ingrowth surfaces (TM, Tritanium) - similar 15yr survival" },
      { text: "CONSTRAINT LEVELS", bold: true },
      { text: "CR < PS < constrained condylar < rotating hinge < custom" },
    ]
  }
);

// ── SLIDE 23: Shoulder Arthroplasty ──────────────────────────────────────────
contentSlide(pres, 23, "Shoulder Arthroplasty: Indications & Design", [
  { text: "ANATOMIC TSA (TSA): end-stage glenohumeral OA with intact rotator cuff" },
  { text: "REVERSE TSA (rTSA): rotator cuff arthropathy, massive irreparable cuff tear, complex proximal humerus fracture" },
  { text: "HEMIARTHROPLASTY: proximal humerus fracture (4-part), humeral head AVN, young patients with glenoid bone stock loss" },
  { text: "STEM DESIGN: cobalt-chrome or titanium alloy; proximal porous ingrowth; modular heads with concentric and offset options" },
  { text: "Neck-shaft angle 30-55 degrees; medial offset 4-14 mm; proximal humeral retroversion 0-55 degrees" },
  { text: "Eccentric Morse taper locking: allows fine anatomic positioning (Campbell's 2026)" },
], { note: "Campbell's Operative Orthopaedics 15th Ed, 2026 - Shoulder Prosthesis Design" });

// ── SLIDE 24: Tumor Prostheses (Oncologic) ───────────────────────────────────
contentSlide(pres, 24, "Oncologic / Tumor Endoprostheses", [
  { text: "Indication: malignant bone tumors (osteosarcoma, Ewing sarcoma, chondrosarcoma) requiring limb salvage" },
  { text: "Custom or modular segmental replacement systems (distal femur, proximal tibia, proximal femur, shoulder)" },
  { text: "Primary reconstruction method: endoprosthesis preferred when adequate host bone available for stem fixation" },
  { text: "Allograft-prosthesis composite (APC): used when host bone length is insufficient for stem fixation (Campbell's 2026)" },
  { text: "Growing prostheses: non-invasive magnetically expandable implants for skeletally immature patients" },
  { text: "Expandable stems avoid repeated surgeries; activated transcutaneously (PHENIX, MUTARS)" },
  { text: "5-year implant survival ~70-80%; infection and aseptic loosening are main failure modes" },
], { note: "Campbell's Operative Orthopaedics 15e | Current Surgical Therapy 14e" });

// ── SECTION 7 BANNER ────────────────────────────────────────────────────────
sectionBanner(pres, 7, "Cardiac & Vascular Prostheses");

// ── SLIDE 25: Heart Valves ─────────────────────────────────────────────────
contentSlide(pres, 25, "Prosthetic Heart Valves: Types & Selection",
  [
    { text: "MECHANICAL VALVES", bold: true },
    { text: "Bileaflet (St. Jude, CarboMedics): most durable; lifelong anticoagulation required" },
    { text: "Tilting disc (Bjork-Shiley) - largely replaced by bileaflet design" },
    { text: "Preferred in patients <60 years, already on anticoagulation" },
    { text: "Structural valve deterioration (SVD): rare but risk-free for lifetime" },
  ],
  {
    twoCol: true,
    col2: [
      { text: "BIOPROSTHETIC VALVES", bold: true },
      { text: "Pericardial (Carpentier-Edwards, Perimount): superior hemodynamics" },
      { text: "Stented vs stentless; porcine xenograft" },
      { text: "No permanent anticoagulation needed after 3 months" },
      { text: "SVD risk increases after 10-15 years; preferred >65-70 years" },
      { text: "TRANSCATHETER (TAVR/TMVR)", bold: true },
      { text: "Balloon-expandable (SAPIEN) or self-expanding (CoreValve); minimal invasive" },
    ]
  }
);

// ── SLIDE 26: Vascular Prostheses ───────────────────────────────────────────
contentSlide(pres, 26, "Vascular & Cardiac Support Prostheses", [
  { text: "SYNTHETIC VASCULAR GRAFTS", bold: true },
  { text: "Dacron (polyester): aortic grafts, aorto-iliac bypasses; excellent long-term patency" },
  { text: "PTFE (Polytetrafluoroethylene/Gore-Tex): peripheral bypasses; preferred for infrainguinal when vein unavailable" },
  { text: "Biological grafts: autologous saphenous vein (gold standard for below-knee bypass)" },
  { text: "Endovascular stent-grafts (EVAR): aortic aneurysm repair without open surgery" },
  { text: "VENTRICULAR ASSIST DEVICES (VADs)", bold: true },
  { text: "Continuous-flow LVADs (HeartMate 3, HVAD): bridge to transplant or destination therapy" },
  { text: "Total Artificial Heart (SynCardia): biventricular failure awaiting transplant" },
], { note: "Sabiston Textbook of Surgery | Fuster & Hurst's The Heart 15e" });

// ── SECTION 8 BANNER ────────────────────────────────────────────────────────
sectionBanner(pres, 8, "Sensory & Reconstructive Prostheses");

// ── SLIDE 27: Cochlear Implants ───────────────────────────────────────────
contentSlide(pres, 27, "Auditory Prostheses: Cochlear Implants", [
  { text: "Indication: severe-to-profound bilateral sensorineural hearing loss unresponsive to hearing aids" },
  { text: "Converts sound to electrical impulses - directly stimulates cochlear nerve fibers" },
  { text: "Components: external sound processor + microphone, transmitter coil, internal receiver/stimulator, electrode array" },
  { text: "22-channel electrode array; tonotopic frequency mapping in cochlea" },
  { text: "Outcomes: 80-90% open-set speech recognition; best results in post-lingual deafness" },
  { text: "Ossicular chain prostheses (TORP/PORP): stapes reconstruction in chronic otitis media/cholesteatoma" },
  { text: "TORP = total ossicular replacement prosthesis; PORP = partial ossicular replacement prosthesis" },
  { text: "Materials: Teflon, titanium, gold, Nitinol; piston diameter 0.4-0.8 mm (Scott-Brown's Vol 2, 2022)" },
], { note: "Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol 2" });

// ── SLIDE 28: Ocular & Facial Prostheses ────────────────────────────────────
contentSlide(pres, 28, "Ocular & Facial Prostheses", [
  { text: "OCULAR PROSTHESIS (artificial eye)", bold: true },
  { text: "Indication: enucleation (intraocular malignancy, endophthalmitis, severe trauma, blind painful eye)" },
  { text: "Integrated implant + custom acrylic shell; hand-painted to match fellow eye (Kanski's Ophthalmology 10e)" },
  { text: "Orbital implants: porous polyethylene (Medpor), hydroxyapatite - allow muscle attachment, natural motility" },
  { text: "FACIAL PROSTHESES", bold: true },
  { text: "Nasal, auricular, orbital prostheses following cancer resection or trauma" },
  { text: "Materials: medical-grade silicone (realistic skin tone, texture)" },
  { text: "Osseointegrated retention anchors (titanium implants) replace adhesive fixation" },
  { text: "Custom 3D-designed and manufactured using digital photography + CAD/CAM" },
], { note: "Kanski's Clinical Ophthalmology 10e | Scott-Brown's Vol 1 - Facial Prosthesis" });

// ── SLIDE 29: Voice Prostheses ──────────────────────────────────────────────
contentSlide(pres, 29, "Voice & Laryngeal Prostheses", [
  { text: "Indication: total laryngectomy (laryngeal/hypopharyngeal cancer)" },
  { text: "Tracheoesophageal puncture (TEP): surgically created fistula with one-way valve prosthesis" },
  { text: "Valve allows pulmonary air to vibrate pharyngoesophageal segment - producing voice" },
  { text: "Types: indwelling (placed by clinician, lasts months - Provox Vega, Blom-Singer Advantage) vs patient-changeable" },
  { text: "Voice quality superior to electrolarynx; 80-85% of patients achieve intelligible speech" },
  { text: "Prosthesis replacement: most common indication is Candida colonization causing leakage around valve" },
  { text: "Heat-moisture exchanger (HME): placed over stoma to humidify inspired air, compensating for lost nasal function" },
], { note: "Cummings Otolaryngology Head and Neck Surgery - Voice Prosthesis" });

// ── SLIDE 30: Penile & Urological ───────────────────────────────────────────
contentSlide(pres, 30, "Urological & Reconstructive Prostheses", [
  { text: "PENILE PROSTHESIS (IPP)", bold: true },
  { text: "Indication: organic erectile dysfunction refractory to medical/vacuum therapy; post-priapism fibrosis, Peyronie's disease" },
  { text: "Types: malleable (semi-rigid) rods vs 3-piece inflatable (AMS 700, Coloplast Titan)" },
  { text: "3-piece inflatable: most anatomically natural; cylinders + pump (scrotal) + reservoir (retropubic)" },
  { text: "Patient satisfaction >90%; mechanical reliability >90% at 5 years" },
  { text: "ARTIFICIAL URINARY SPHINCTER (AUS)", bold: true },
  { text: "Indication: stress urinary incontinence post-prostatectomy; neurogenic bladder" },
  { text: "AMS 800: fluid-filled cuff around bulbar urethra, pressure-regulating balloon, pump; continence rates ~80%" },
  { text: "TESTICULAR PROSTHESIS: saline-filled silicone; psychological benefit after orchiectomy" },
], { note: "Smith & Tanagho's General Urology 19e | Hinman's Atlas of Urologic Surgery | Campbell-Walsh 2019" });

// ── SECTION 9 BANNER ────────────────────────────────────────────────────────
sectionBanner(pres, 9, "Design Principles & Fixation");

// ── SLIDE 31: Fixation Methods ──────────────────────────────────────────────
contentSlide(pres, 31, "Prosthesis Fixation: Cemented vs Cementless",
  [
    { text: "CEMENTED FIXATION", bold: true },
    { text: "Polymethylmethacrylate (PMMA) bone cement; immediate rigid fixation" },
    { text: "Gold standard for TKA; used in elderly, osteoporotic bone" },
    { text: "Third-generation cementing technique: canal plug, pulsatile lavage, retrograde filling, pressurization" },
    { text: "Concern: cement-bone interface stress, particle disease, revision difficulty" },
  ],
  {
    twoCol: true,
    col2: [
      { text: "CEMENTLESS FIXATION", bold: true },
      { text: "Press-fit with porous surface for bone ingrowth (HA coating, sintered beads, fiber metal, TM)" },
      { text: "Requires good bone stock and initial stability" },
      { text: "Modern ingrowth surfaces: 98.6% TKA survival at 15-18 years" },
      { text: "OSSEOINTEGRATION", bold: true },
      { text: "Percutaneous titanium post anchored in bone - eliminates socket interface for amputees" },
      { text: "Branemark OPRA, OPL systems; transforms prosthetic use" },
    ]
  }
);

// ── SLIDE 32: Modularity & Custom Design ────────────────────────────────────
contentSlide(pres, 32, "Modularity, Patient-Specific & 3D-Printed Prostheses", [
  { text: "MODULAR SYSTEMS", bold: true },
  { text: "Allow intraoperative size selection without full stem revision; mix-and-match head/stem sizes" },
  { text: "Shoulder: independent sizing of head thickness and diameter for soft-tissue balancing (Campbell's 15e)" },
  { text: "PATIENT-SPECIFIC IMPLANTS (PSI)", bold: true },
  { text: "CT/MRI-based 3D planning; custom cutting guides or custom implants for complex deformity" },
  { text: "Especially useful in revision arthroplasty, oncology, craniofacial reconstruction" },
  { text: "3D PRINTING (Additive Manufacturing)", bold: true },
  { text: "Titanium lattice structures: high porosity (70-80%), biomimics cancellous bone for ingrowth" },
  { text: "Prosthetic sockets: rapid iteration, digital fitting, cost reduction for low-income settings" },
  { text: "CFRP structures printed with variable stiffness for dynamic response feet" },
], { note: "Preprints.org Future of Bone Prosthetic Design 2026 | Campbell's 15e" });

// ── SLIDE 33: Mesh Prostheses (Hernia) ──────────────────────────────────────
contentSlide(pres, 33, "Mesh Prostheses in Hernia Repair", [
  { text: "Most common: polypropylene (permanent, hydrophobic, induces scarring); polyester" },
  { text: "Lightweight mesh: beta-D-glucan, titanium-coated PP, PP-poliglecaprone" },
  { text: "Lightweight vs heavyweight: lower chronic pain risk (RR 0.61) with no difference in recurrence" },
  { text: "Biologic mesh: processed human/animal tissue; reserved for contaminated fields or infection risk" },
  { text: "High cost and higher recurrence than synthetic mesh" },
  { text: "Absorbable/hybrid mesh: provides short-term support during tissue healing, then degrades" },
  { text: "Laparoscopic approach (TEP/TAPP): lightweight mesh preferred - fewer 3-month mesh complications" },
  { text: "Sterilized mosquito net (resource-limited settings): similar short-term complication and recurrence rates" },
], { note: "Schwartz's Principles of Surgery 11e - Prosthesis Considerations in Hernia Repair" });

// ── SECTION 10 BANNER ───────────────────────────────────────────────────────
sectionBanner(pres, 10, "Complications & Management");

// ── SLIDE 34: General Complications ─────────────────────────────────────────
contentSlide(pres, 34, "Complications of Prosthetic Implants", [
  { text: "INFECTION (Periprosthetic Joint Infection - PJI)", bold: true },
  { text: "Most serious complication; 1-2% THA/TKA; Staph aureus most common pathogen" },
  { text: "Diagnosis: sinus tract with purulent discharge is pathognomonic for PJI (Firestein's Rheumatology)" },
  { text: "ASEPTIC LOOSENING", bold: true },
  { text: "Most common cause of revision (40%); polyethylene particle-induced osteolysis (wear debris)" },
  { text: "DISLOCATION", bold: true },
  { text: "THA: 1-3%; increased with poor component positioning, large head sizes reduce risk" },
  { text: "Shoulder prosthesis: rotator cuff failure; reverse TSA - 3-4% dislocation rate" },
  { text: "PERIPROSTHETIC FRACTURE: 4.7% revision TKA; increasing with aging population" },
], { note: "Firestein's Rheumatology | Campbell's Operative Orthopaedics 15e | Rockwood & Green's 10e" });

// ── SLIDE 35: PJI Diagnosis & Treatment ─────────────────────────────────────
contentSlide(pres, 35, "Periprosthetic Joint Infection: Diagnosis & Management", [
  { text: "DIAGNOSIS: MSIS/EBJIS criteria - serum CRP/ESR, synovial fluid analysis (WBC >3000/mL, PMN >80%), culture x2, histology" },
  { text: "Sinus tract = definitive PJI; absence of sinus tract requires combined criteria" },
  { text: "TREATMENT OPTIONS:", bold: true },
  { text: "DAIR (Debridement, Antibiotics, Implant Retention): early acute PJI (<4 weeks), stable implant, sensitive organism" },
  { text: "One-stage revision: selected cases with good soft tissue, low-virulence organism" },
  { text: "Two-stage revision: gold standard for chronic PJI; first stage: remove implant + spacer; 6-8 weeks IV antibiotics; second stage: reimplantation" },
  { text: "Salvage: resection arthroplasty, arthrodesis, amputation for untreatable PJI" },
], { note: "Firestein & Kelley's Textbook of Rheumatology 2-Volume Set" });

// ── SLIDE 36: Wear & Revision ───────────────────────────────────────────────
contentSlide(pres, 36, "Wear, Loosening & Revision Arthroplasty", [
  { text: "Wear particle generation (polyethylene, metal, ceramic debris) activates macrophages - osteolysis cascade" },
  { text: "Cross-linked polyethylene (XLPE): reduces linear wear rate from ~0.2mm/yr to <0.05mm/yr" },
  { text: "Ceramic-on-ceramic: lowest wear rate; risk of squeaking (~2%), stripe wear, catastrophic fracture (rare)" },
  { text: "Metal-on-metal (MoM): abandoned due to elevated Co/Cr ions, pseudotumor formation, ARMD" },
  { text: "Revision TKA: loosening (40%), infection (27%), instability (7.5%), periprosthetic fracture (4.7%), arthrofibrosis (4.5%)" },
  { text: "Revision complexity: requires offset stems, augments, cones/sleeves/tantalum metaphyseal constructs for bone loss" },
  { text: "Prosthesis dislocation management: closed reduction, brace, soft tissue repair, cup repositioning" },
], { note: "Campbell's Operative Orthopaedics 15e | Rockwood & Green's Fractures 10e, 2025" });

// ── SECTION 11 BANNER ───────────────────────────────────────────────────────
sectionBanner(pres, 11, "Recent Advances & Future Directions");

// ── SLIDE 37: Osseointegration (Percutaneous) ──────────────────────────────
contentSlide(pres, 37, "Osseointegration: Bone-Anchored Prostheses", [
  { text: "Concept: titanium implant surgically placed in residual femur/humerus - prosthesis attaches directly to bone" },
  { text: "Eliminates socket interface - no skin breakdown, pressure sores, or heat discomfort" },
  { text: "Two commercial systems: Branemark OPRA (2-stage surgical protocol); OPL (press-fit, 1-stage)" },
  { text: "Lower limb: improved osseoperception, better proprioception, longer walking distance, higher activity" },
  { text: "Upper limb: superior control, no harness, improved reach, body image satisfaction" },
  { text: "Recent advances (2026): dual-stage vs single-stage debated; robotically guided implant placement" },
  { text: "Limitations: infection at percutaneous site (soft tissue interface), falls, long rehabilitation protocol" },
  { text: "PMC systematic review 2026: comparative analysis of OPRA vs OPL - similar outcomes, evolving evidence" },
], { note: "PMC Lower Limb Osseointegrated Prosthetics 2026 | MDPI Robotic Prostheses 2025" });

// ── SLIDE 38: Myoelectric & Neural Interface ─────────────────────────────────
contentSlide(pres, 38, "Targeted Muscle Reinnervation & Neural Interfaces", [
  { text: "TARGETED MUSCLE REINNERVATION (TMR)", bold: true },
  { text: "Residual peripheral nerves rerouted to reinnervate spare muscle segments in residual limb" },
  { text: "Creates amplified EMG signals for improved myoelectric control (4-6 control sites)" },
  { text: "Also significantly reduces phantom limb pain (neuroma prevention)" },
  { text: "REGENERATIVE PERIPHERAL NERVE INTERFACE (RPNI)", bold: true },
  { text: "Peripheral nerve end implanted in free muscle graft; amplifies nerve signals for prosthetic control" },
  { text: "AGONIST-ANTAGONIST MYONEURAL INTERFACE (AMI)", bold: true },
  { text: "Pairs agonist-antagonist muscles at amputation site; preserves natural proprioceptive feedback" },
  { text: "Patients report sense of joint position in missing limb - paradigm shift in sensory restoration" },
], { note: "PMC Technological Advances in Prosthesis Design 2024 | MDPI 2025" });

// ── SLIDE 39: AI & Machine Learning ─────────────────────────────────────────
contentSlide(pres, 39, "Artificial Intelligence in Prosthetics", [
  { text: "AI-driven intent recognition: machine learning classifies EMG patterns for multi-grip control in real time" },
  { text: "Pattern recognition (PR) control: more intuitive than threshold control; adapts to muscle fatigue, posture changes" },
  { text: "Microprocessor knees (C-Leg, Genium): AI algorithms predict terrain, adapt resistance in <20ms" },
  { text: "Computer vision integration: camera on prosthetic hand identifies objects - auto-selects grip pattern" },
  { text: "Deep learning for socket fit optimization: pressure mapping + AI generates optimized socket geometry" },
  { text: "3D printing + AI design: generative algorithms create patient-specific lightweight lattice structures" },
  { text: "Wearable sensor fusion: IMU + EMG + pressure data combined for whole-body movement prediction" },
  { text: "ResearchGate 2025: AI-driven control and osseointegration enabling unprecedented upper limb function" },
], { note: "ResearchGate - Innovations in Finger Prostheses 2025 | MDPI Robotic Prostheses 2025" });

// ── SLIDE 40: Robotic & Powered Prostheses ────────────────────────────────
contentSlide(pres, 40, "Robotic & Powered Prosthetic Systems", [
  { text: "POWERED LOWER LIMB (Bionic leg)", bold: true },
  { text: "BiOM/Empower: powered push-off ankle; restores metabolic efficiency to near-normal" },
  { text: "IDEO brace + running blade: high-performance athletic use" },
  { text: "Luke Arm (DARPA): 7 degrees of freedom; fine motor tasks (picking up grapes, handling eggs)" },
  { text: "SENSORY FEEDBACK", bold: true },
  { text: "Haptic/tactile feedback via implanted electrodes - enables grip force modulation without visual cues" },
  { text: "Targeted sensory reinnervation (TSR): creates referred sensation on chest skin mapped to missing hand" },
  { text: "FULLY IMPLANTED SYSTEMS", bold: true },
  { text: "Implanted electrodes + wireless transcutaneous charging - eliminates external wires and skin electrode slip" },
], { note: "MDPI Robotic Prostheses and Neuromuscular Interfaces 2025" });

// ── SLIDE 41: Smart Biomaterials & Tissue Engineering ───────────────────────
contentSlide(pres, 41, "Smart Biomaterials & Tissue Engineering", [
  { text: "Shape-memory alloys (NiTinol): self-adjusting fixation; self-crimping stapes prostheses (Scott-Brown's)" },
  { text: "Piezoelectric polymers (PVDF): convert deformation to electricity for neural stimulation / sensory signals" },
  { text: "Bioactive coatings: antibiotic-eluting (rifampin + gentamicin) surfaces to prevent PJI" },
  { text: "Zwitterionic polymer coatings: anti-fouling; dramatically reduce bacterial adhesion" },
  { text: "Scaffolds seeded with stem cells: living cartilage implants growing in lab (tissue-engineered trachea, meniscus)" },
  { text: "Biohybrid prostheses: integrating living cells with mechanical components - bidirectional adaptation" },
  { text: "Biodegradable polymer scaffolds (PLGA, PLA): temporary support during host tissue regeneration" },
  { text: "Carbon nanotube composites: unprecedented tensile strength + electrical conductivity for neural interfaces" },
], { note: "Preprints.org - Future of Bone Prosthetic Design 2026 | Scott-Brown's Vol 2" });

// ── SLIDE 42: Retinal & Brain-Computer Interface ─────────────────────────────
contentSlide(pres, 42, "Retinal Prostheses & Brain-Computer Interfaces", [
  { text: "RETINAL PROSTHESES (Bionic Eye)", bold: true },
  { text: "Indication: retinitis pigmentosa, dry AMD with residual ganglion cells" },
  { text: "Argus II (Second Sight): 60-electrode epiretinal array; camera in glasses, wireless signal to implant" },
  { text: "Alpha IMS/AMS (Retina Implant AG): subretinal photovoltaic chip; 1500 photodiodes" },
  { text: "Enables light perception, motion detection, basic shape recognition" },
  { text: "BRAIN-COMPUTER INTERFACES (BCI)", bold: true },
  { text: "BrainGate: intracortical microelectrode arrays; tetraplegic patients control prosthetic arm by thought alone" },
  { text: "Neuralink N1 chip: 1024 electrodes; high-bandwidth bidirectional cortical interface" },
  { text: "Non-invasive EEG/fNIRS BCIs: lower bandwidth but no surgical risk" },
], { note: "Recent advances 2024-2026 - MDPI, PubMed" });

// ── SLIDE 43: 3D Printing & Personalized Prosthetics ────────────────────────
contentSlide(pres, 43, "3D Printing & Personalization", [
  { text: "Digital workflow: CT scan → segmentation → CAD → FEA analysis → additive manufacturing → fitting" },
  { text: "Titanium SLS printing: load-bearing implants with controlled porosity (60-80%) for osseointegration" },
  { text: "Gyroid lattice structures: biomimics trabecular bone; tunable stiffness gradient reducing stress shielding" },
  { text: "Prosthetic sockets: 3D-scanned residual limb → FDM printed socket in <24 hours; multiple iterations" },
  { text: "e-NABLE community: open-source hand prostheses 3D-printed for children (<$50 vs $10,000 myoelectric)" },
  { text: "Bioprinting: living tissues (cartilage, tracheal rings) for reconstructive surgery" },
  { text: "Digital inventory: on-demand manufacturing in conflict zones / remote areas replacing physical stockpiling" },
  { text: "AI + 3D printing: generative design creates optimized geometry automatically from performance specs" },
], { note: "Amputee Store 2025 | Preprints.org 2026 | Hopkins Medicine 2025" });

// ── SLIDE 44: Osseointegration & Microbiome ─────────────────────────────────
contentSlide(pres, 44, "Infection Prevention: Current Strategies", [
  { text: "Antibiotic-impregnated cement: gentamicin or tobramycin cement; reduces early PJI in cemented TJA" },
  { text: "Silver-ion coatings: broad-spectrum antimicrobial; used on tumor prostheses (40-50% infection reduction)" },
  { text: "Iodine-supported titanium (Iodophor): anti-infective titanium surface - used in Japan for tumor implants" },
  { text: "Copper-doped coatings: bactericidal by ROS generation; active against MRSA biofilm" },
  { text: "Bacteriophage therapy: experimental; targeted lysis of biofilm-forming organisms on implant surface" },
  { text: "Dual antibiotic local delivery (DAIR): rifampin-based regimen combined with fluoroquinolone for Staph biofilm" },
  { text: "Implant surface nanotopography: micro/nano-patterns reduce initial bacterial adhesion by 70-90%" },
  { text: "PEEK antibacterial modification: UV-grafted zwitterionic polymers show promise in spinal implants" },
]);

// ── SLIDE 45: Prosthetic Rehabilitation ─────────────────────────────────────
contentSlide(pres, 45, "Rehabilitation & Prosthetic Training", [
  { text: "Pre-prosthetic phase: residual limb shaping (stump bandaging/shrinker), strengthening, edema control" },
  { text: "Timing of fitting: immediate post-operative prosthesis (IPOP) in selected vascular amputees accelerates rehab" },
  { text: "Gait training: parallel bars → walker → cane → independent ambulation" },
  { text: "Occupational therapy: upper limb prosthetic training - use of hooks and hands for ADLs" },
  { text: "Mirror therapy and graded motor imagery: reduce phantom limb pain before/during prosthetic training" },
  { text: "Virtual reality (VR) rehabilitation: simulated environments for safe skill acquisition" },
  { text: "Multi-disciplinary team: physiatrist, prosthetist, physiotherapist, occupational therapist, psychologist" },
  { text: "Goal: maximize independence, return to work, sports participation, quality of life" },
], { note: "Mulholland & Greenfield's Surgery 7e | Campbell-Walsh Urology" });

// ── SLIDE 46: Pediatric Prosthetics ─────────────────────────────────────────
contentSlide(pres, 46, "Pediatric Prosthetics: Special Considerations", [
  { text: "Congenital limb deficiency: fitting as early as 4-6 months (upper limb) to match developmental milestones" },
  { text: "Rapid growth requires frequent socket replacement (every 6-18 months in children)" },
  { text: "Growing prostheses (non-invasive expandable): avoid repeated surgical lengthening in sarcoma patients" },
  { text: "MUTARS, PHENIX, JTS: transcutaneous magnetic expansion; 6-8 mm/expansion, multiple times" },
  { text: "Simple body-powered hooks accepted better than cosmetic hands in young children" },
  { text: "Myoelectric fitting feasible from ~2-3 years; pattern recognition from age ~8" },
  { text: "Psychological support: body image, school inclusion, peer interaction crucial" },
  { text: "3D-printed colorful/themed prostheses: improved acceptance in children (e-NABLE, Open Bionics)" },
], { note: "Campbell's Operative Orthopaedics 15e | PMC Upper Extremity Prosthetics Review 2024" });

// ── SLIDE 47: Global Access & Low-Cost Solutions ─────────────────────────────
contentSlide(pres, 47, "Global Access & Low-Cost Innovations", [
  { text: "Only 5-15% of people needing prostheses in LMIC have access (WHO)" },
  { text: "Jaipur Foot (India): polypropylene foot; waterproof, can squat, walk on uneven terrain; costs ~$45" },
  { text: "ICRC prosthetics program: >200,000 devices delivered in 20+ conflict-affected countries" },
  { text: "Mosquito net mesh for hernia repair: similar efficacy to commercial mesh at <1% of cost (Schwartz's 11e)" },
  { text: "3D-printed prosthetic hands: e-NABLE open-source designs; <$50 vs $10,000 commercial" },
  { text: "Locally sourced bamboo/carbon fiber composites: tested in sub-Saharan Africa" },
  { text: "Telerehabilitation: remote prosthetic fitting and training via smartphone camera + AI" },
  { text: "Regulatory pathways: WHO GATE initiative accelerating access to assistive technology globally" },
], { note: "Schwartz's Principles of Surgery 11e | WHO Global Assistive Technology Report" });

// ── SLIDE 48: Comparison Table ──────────────────────────────────────────────
tableSlide(pres, 48, "Comparison: Joint Prosthesis Fixation Methods",
  ["Parameter", "Cemented", "Cementless", "Hybrid"],
  [
    ["Material", "PMMA bone cement", "Porous metal / HA coating", "Cement tibial + cementless femoral"],
    ["Fixation Onset", "Immediate rigid", "Biological (6-12 weeks)", "Combination"],
    ["Bone Requirements", "Any (osteoporotic OK)", "Good bone stock needed", "Selective"],
    ["Revision Ease", "Moderate (cement removal)", "Easier (press-fit removal)", "Depends on component"],
    ["Long-term Data", "Gold standard >30 yr", "Similar 15-20 yr data", "Increasingly used"],
    ["Best For", "Elderly, osteoporosis, TKA", "Young active patients, THA", "TKA in younger patients"],
  ]
);

// ── SLIDE 49: Summary & Key Points ──────────────────────────────────────────
contentSlide(pres, 49, "Summary: Key Take-Home Points", [
  { text: "Prostheses span from limb replacements to heart valves, hearing implants, and hernia meshes - a broad, multidisciplinary field", bold: false },
  { text: "Indications are driven by disease severity, functional impact, patient factors, and failure of conservative treatment" },
  { text: "Material selection (titanium, CoCr, UHMWPE, ceramics, CFRP) is guided by required mechanical properties and biocompatibility" },
  { text: "Fixation: cemented remains gold standard in TKA/elderly; cementless preferred in younger patients and THA" },
  { text: "Infection (PJI) and aseptic loosening are the leading causes of prosthesis failure and revision" },
  { text: "Osseointegration, TMR, RPNI, and AI-driven control represent transformative advances in limb prosthetics" },
  { text: "3D printing is democratizing access and enabling patient-specific designs at scale" },
  { text: "Future: biohybrid/living prostheses, brain-computer interfaces, and closed-loop sensory feedback will redefine function" },
], { note: "Campbell's Operative Orthopaedics 15e | MDPI 2025 | PMC 2026 | Schwartz's 11e" });

// ── SLIDE 50: References ─────────────────────────────────────────────────────
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    "1. Campbell's Operative Orthopaedics, 15th Ed. Azar FM et al., 2026.",
    "2. Schwartz's Principles of Surgery, 11th Ed. Brunicardi FC et al.",
    "3. Mulholland & Greenfield's Surgery: Scientific Principles & Practice, 7th Ed.",
    "4. Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vols 1 & 2.",
    "5. Fuster & Hurst's The Heart, 15th Ed. Fuster V et al.",
    "6. Kanski's Clinical Ophthalmology, 10th Ed.",
    "7. Cummings Otolaryngology Head and Neck Surgery.",
    "8. Campbell-Walsh-Wein Urology, 12th Ed.",
    "9. Rockwood & Green's Fractures in Adults, 10th Ed. 2025.",
    "10. Firestein & Kelley's Textbook of Rheumatology, 2-Volume Set.",
    "11. Barootchi E, et al. Lower limb osseointegrated prosthetics. PMC 2026.",
    "12. Batista PG, et al. Robotic Prostheses and Neuromuscular Interfaces. MDPI 2025.",
    "13. Elmas ET. Prosthetics, Artificial Limbs, Implants. Gavin Publishers 2025.",
    "14. Future of Bone Prosthetic Design. Preprints.org, 2026.",
    "15. Hopkins Medicine. Prosthetic Hand Able to Differentiate Shapes/Textures. 2025.",
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// ── Write File ──────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/prosthesis-pptx/Prosthesis_Indications_Design_Advances.pptx" })
  .then(() => console.log("✅ Saved: Prosthesis_Indications_Design_Advances.pptx"))
  .catch(e => { console.error("❌ Error:", e); process.exit(1); });

cd /home/daytona/workspace/prosthesis-pptx && node build.js 2>&1

ls -lh /home/daytona/workspace/prosthesis-pptx/