3 20 187 https://staging.drfop.org/files/original/28274e1bdc8b1f42b700c9e81f28597f.pdf c98bd0663a677efb5cc36261b7c4cb7f https://staging.drfop.org/files/original/b6970149668330ce776434d9198152e3.jpeg 731206ce838388691e18855abcf7eb68 https://staging.drfop.org/files/original/a0bf70a49a9e3db596969c11b0c2c69c.jpg 23969c8fa88696d9a5addf89f363da7e https://staging.drfop.org/files/original/8a915c80bd9484bb8ab1b9a594fe6c66.jpg 7494d39a35704017937591467700f667 https://staging.drfop.org/files/original/f5da1243900128485bea8bd5f391499b.jpg beeee6ab4ded6b95b152fb192d126b8d https://staging.drfop.org/files/original/9ecbbc7b6c0294a18f4bb82b168db309.jpg a3cccb644afd639c1fbbc7860f03f802 https://staging.drfop.org/files/original/628b6e300a318be54667478bf7d69ef8.jpg 0ed7a62e1104b47e6adf43049a770bb2 https://staging.drfop.org/files/original/324715b55eb49ed8d385db9eef8fde73.jpg ef08536eda1fad5db1231816539fca86 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_02_009.pdf Text Any textual data included in the document <h2>Bivalved Spinal Orthoses for the Structurally Unstable Spine</h2> <h5>H.R. Lehneis, Ph.D., CPO <a style="text-decoration: none;">*</a> Roger Chin, CPO <a style="text-decoration: none;">*</a> Donald Fornuff, CP <a style="text-decoration: none;">*</a></h5> With the advent of plastics, particularly thermoplastics, and plastics technology, plastic molded spinal orthoses are increasingly used in the orthotics management of the structurally unstable spine for nearly all levels of involvement. Depending on the risk factor involved, they may be used in lieu of surgery, i.e. when the patient is not a candidate to undergo surgery for various physiological reasons, or they may be used in the post-surgical management of the structurally unstable spine. Because of the ability of modern plastics to be intimately contoured to the body, they provide for far safer orthotics management, particulary of the cervical spinal region, than conventional orthoses. Often they are a preferred substitute over casts since these bivalved orthoses can be readily removed, either fully or partially, for hygienic reasons and the orthosis can be kept clean much more easily than a cast. <h3>Orthotics Designs</h3> Two types of bivalved spinal orthoses are described below: <ol> <li> Cervico-thoracic orthosis (CTO) with forehead band. </li> <li> Thoraco-lumbo-sacral orthosis (TLSO). </li> </ol> With slight modifications, various combinations of the above can be designed. The area of injury or surgery usually determines the height and design of the orthosis. The contours of the orthosis aid in maintaining the proper position on the patient. Overlapping edges avoid pinching and allow for some weight gain or loss. The bivalved opening allows for fast removal in case of cardiac or respiratory problems, situations in which access has to be almost immediate. It is also a comfort to the patient, while lying in bed, that either half of the orthosis can easily be removed for short periods of time to give some relief from pressure and for ventilation. CTO with forehead band (<a href="/files/original/b6970149668330ce776434d9198152e3.jpeg">Fig. 1</a>) The cervical region is the most flexible of the spine. Rotation, flexion/extension, and lateral bending are difficult to control using just a cervical orthosis. Stabilization of the thoracic spine is necessary in order to provide the base, or foundation, for control of the cervical spine and head. It is extremely important to appreciate that without proper head control the cervical spine cannot be properly stabilized. Thus, the orthosis must extend posteriorly to cover the occipital area (<a href="/files/original/a0bf70a49a9e3db596969c11b0c2c69c.jpg">Fig. 2</a>), and anteriorly around the forehead, as well as the mandibular area (<a href="/files/original/8a915c80bd9484bb8ab1b9a594fe6c66.jpg">Fig. 3</a>). Inferiorly, it should be noted that the orthosis covers the entire rib cage, including the floating ribs (<a href="/files/original/f5da1243900128485bea8bd5f391499b.jpg">Fig. 4</a>). Thoraco-Lumbo-Sacral Orthosis (<a href="/files/original/9ecbbc7b6c0294a18f4bb82b168db309.jpg">Fig. 5</a>) Orthotics design for structural instability of the thoracic and lumbar spine requires the formation of a sound base inferiorly. In general, this is identical to the trimline used in the Milwaukee brace, or other orthoses for scoliosis. The superior trimlines depend on the level of involvement, but extend from at least the level of the xyphoid process to the inferior border of the clavicle (<a href="/files/original/628b6e300a318be54667478bf7d69ef8.jpg">Fig. 6</a>). The lateral Velcro® closures are of the cross-diagonal type described earlier by Ekus<a style="text-decoration: none;">*</a> to minimize relative vertical displacement between the bivalved sections. <h3>Indications</h3> The orthoses described are indicated either in lieu of surgery if the patient is not a surgical candidate for any physiologic reason, or post-surgically to maintain the desired position of the spine, instead of a plaster cast. Medical indications are: <ol> <li> Fracture and fracture-dislocations, including the odontoid process. </li> <li> Ligamentous rupture or laxity with resultant instability of the spine. </li> <li> Neoplastic disorders with concomitant degeneration of the vertebrae. </li> </ol> Physical indications are: <ol> <li> Lightweight. </li> <li> Hygiene, i.e. ability to clean the orthosis. </li> <li> Removability of either portion of the orthosis for patient hygiene and ventilation. </li> </ol> <h3>Casting Technique</h3> The casting method requires a Stryker frame. It is essential for accurate casting, and is the safest method for the patient. Body movement is limited to transfer in the supine position from bed to frame and back to bed, if the patient is not already in a Stryker frame and in skeletal traction. The patient can be turned from a supine to a prone position by turning the frame, which has been locked to prevent body movement. This method has proven to be the fastest, simplest, and cleanest. With the patient on the Stryker frame in the supine position, bony prominences and areas of relief are marked with an indelible pencil. The patient's anterior half is covered with a separative jelly (K-Y®, petrolatum), except the hair, which is covered with stockinette for casting for the CTO. Approximately 8-10 layers of plaster splints are applied in alternating vertical and horizontal layers to give the anterior shell added strength. With the patient in the supine position, abdominal pressure (which supports the spinal column internally) is built in at the time of casting. When the anterior half has hardened sufficiently to support the body without distortion, the patient is turned to the prone position. Again, bony prominences and areas of relief are marked with an indelible pencil on the posterior side which is then covered with a separative jelly. Approximately 4-6 layers of plaster splints are applied in alternating horizontal and vertical layers. The posterior half does not have to be as strong as the anterior half, as the patient will not be lying in it as in the anterior half. All casts are bi-valved with approximately 5 cm. overlap of the posterior half on the anterior half. A separative jelly is spread over the anterior areas to be covered by the posterior overlap. When the posterior half has hardened sufficiently to be removed, the sections will part easily because of the separative jelly under the overlap. They are then put back together with the overlap providing the key for proper position of the anterior and posterior halfs. The cast is then filled and modified. All bony prominences or areas of relief are built up approximately 2 to 3 cm. while in the soft tissue areas, e.g., abdomen, plaster is removed. <h3>Fabrication</h3> While any thermoplastic sheet material may be used for molding the orthosis, at this institution Subortholen® is preferred. It is a high strength polyethylene which is not only thermoplastic, but can be cold-formed as well. When heated, it can be drape-molded quite easily, and in a cold state, can be hammered similar to light alloy sheet material (e.g., hammered thin to form a hinge or channeled for rigidity or relief). Subortholen® is available in thicknesses of 1 to 6 mm. Sheets are cut to the size needed and placed in an oven heated to 150-160 degrees centigrade (350°F). The material is ready for molding when the sheet has lost its pink color and is almost translucent (<a href="/files/original/324715b55eb49ed8d385db9eef8fde73.jpg">Fig. 7</a>, right). When molding Subortholen®, a half hour oven dry cast or driest possible cast is recommended. The cast should be covered with stockinette to prevent moisture contact to the Subortholen® which, if not done, may cause rapid cooling, bubbling, and an uneven finish on the surface. The posterior half is molded first to extend approximately 5 cm. beyond the lateral midlines. When cooled, the posterior half is removed and cut to the desired trim lines and placed back on the cast. The anterior half is then molded to overlap the posterior half by approximately 5 cm. After the anterior half is cut to the desired trim lines, the orthosis is ready for fitting. <h3>Special Fitting Considerations</h3> Cervico-Thoracic Orthosis with Forehead Band : <ol> <li> Inferior trim line of forehead band should be approximately 1 cm. above the eyebrows. </li> <li> Circumferential pressure adjustability of head band is accomplished by means of a Velcro® strap. </li> <li> Mandibular pressure can be controlled by tightness of forehead band. </li> <li> Inferior trim lines need not extend below rib cage, as not to restrict lateral and posterior/anterior motion. </li> <li> Posterior/superior trim line should extend 3-4 cm. above the apex of the occiput. </li> </ol> Thoraco-Lumbo-Sacral Orthosis: <ol> <li> The orthosis must be keyed in the soft tissue area between the rib cage and iliac crests to prevent vertical displacement of the orthosis. </li> <li> The anterior inferior aspect must be trimmed to avoid sitting problems and pressure on the pubis. The posterior inferior trimline should allow sitting without the orthosis being pushed up from contact with the chair. </li> <li> Depending on the level of involvement, the anterior superior trimline should extend from a point somewhere between the xyphoid process to a level that follows the course of the inferior border of the clavicles. </li> </ol> <div style="width: 400px;">Footnote Ekus L., CO, Cross-Diagonal Closure of Pelvic and Spinal Appliances. Newsletter—Prosthetics and Orthotics Clinic, Vol. 5, No. 1, 2/1981 —Winter/Spring Issue *Donald Fornuff, CP Institute of Rehabilitation Medicine New York University Medical Center New York, NY *Roger Chin, CPO Institute of Rehabilitation Medicine New York University Medical Center New York, NY *H.R. Lehneis, Ph.D., CPO Institute of Rehabilitation Medicine New York University Medical Center New York, NY </div> Page Number(s) 9 - 11 Year 1983 Volume 7 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-6.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 7 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Bivalved Spinal Orthoses for the Structurally Unstable Spine Creator An entity primarily responsible for making the resource H.R. Lehneis, Ph.D., CPO * Roger Chin, CPO * Donald Fornuff, CP * https://staging.drfop.org/files/original/a4e24d04daaec423ee9b4e3a36bda7ea.pdf 1c53d4c491f0f059b170578f088b4157 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_02_006.pdf Text Any textual data included in the document <h2>Questionnaire: Extra-Ambulatory Prostheses</h2> The following analysis and comments were drawn from responses to a recent questionnaire on extra-ambulatory prostheses. The article, "Extra-Ambulatory Activities and Amputee/' by Drew A. Hittenberger, CP, appeared in the Autumn, 1982 issue of C.P.O. (Vol. 6, No. 4). As of January 25, 1983, five responses had been received to the questionnaire on extra-ambulatory prostheses. This is a very low response and of course no valid conclusions can be drawn from it. In response to question number one, "How many extra-ambulatory prostheses have you made?," four responses said six-15 and one said 16-25. On question number two, "What percent of your patients are involved in some form of physical exercise?," the average response was nine percent with a high of 20%, a low of five percent and one who said he had never thought to ask. When asked, "What percent of your patients ask you about extra-ambulatory prosthetics?," the average response was 11% with a low of two percent and a high of 25%. The respondees were asked to list, in order of occurrence, extra-ambulatory activities in which their patients participate. There were four mentions of swimming, although one was not the first activity listed; there was also one mention of scuba diving. Snow skiing was mentioned three times and water skiing once. Running and racquetball (a running sport) were both mentioned once, as were hunting, fishing, weight-lifting, and horseback riding. The respondees were asked what percentage of patients used their prosthesis for more than just daily activities and the average response was seven percent, with a high of ten percent, a low of five percent, and one who didn't know. As to how many of their patients had one prosthesis for daily activities and one for extra-ambulatory activities, the respondees on the average said four percent, with a low of one percent, to a high of ten percent. All the respondents said that they informed their patients of handicapped sports organizations. One said he had a directory posted, and another said that there were no such organizations in his area. Three of the respondents said that they were not satisfied with the level of prosthetics and its role in extra-ambulatory activities. One said yes, and the fifth said yes, but with reservations. Reasons given for amputees not being more involved were: <ul> <li> lack of interest </li> <li> not involved before amputation </li> <li> non-positive social conditioning </li> <li> fear of injury </li> <li> ignorance </li> <li> embarrassment </li> <li> rejection </li> <li> poor post-operative management </li> </ul> All five said that they would like to attend a seminar on the topic. Several additional comments were received and are listed below. In addition, Carl A. Caspers, CPO, of Minneapolis, Minnesota took the time to write a long, thoughtful letter in response. Parts of it are quoted below. Additional comments: <ol> <li> "Yes—we need better research on different designs of prostheses for different functional activities." </li> <li> "Technical reports detailing alignment and fabrication for these specialized devices [are needed]. I have had to research, design, and devise techniques to create extra-ambulatory prostheses. Also preprinted bulletins with photographs for the patients would offer greater understanding and perhaps desire for these devices." </li> </ol> Mr. Caspers writes, in part: "This letter is in response to Drew Hittenberger's article on extra-ambulatory activities and the amputee in the Autumn issue of Clinical Prosthetics & Orthotics—CPO. I was very pleased to see this article covering this subject as this has been a sadly neglected area for a long time. "Mr. Hittenberger brings up some very good questions regarding the rehabilitation team's capability of maximizing the patient's activity level and more importantly the resultant poor postoperative care and management of the amputee. The vast [majority] are suffering from diabetes or other vascular complications. Obviously, the level of activity and the requirements for these people are going to be considerably less strenuous than those of a younger amputee. I think the problem goes back one step further and does not start with the post-operative care but in the operative management of the amputee. To date, the physician's main concern has been with the medical needs of the patient at that time and very little thought is given to the patient's functional needs after amputation. Such things as myodesis procedures, tibia-fibula stabilization, and lengths of lever arms are all crucial in the long-range function of an amputee. . . . "In the area of limitation, I think Mr. Hittenberger covered this very well. There is an economic limitation that needs to be covered here also. The rehabilitation team's knowledge of extra-ambulatory activities and its awareness of the many extra-ambulatory prosthetic devices is somewhat limited. This thereby creates an economic factor that many amputees are unable to deal with. As has been well documented in the field of prosthetics, there is a need for extra-ambulatory devices and these should be considered in the total rehabilitation, physically, psychologically, and economically. "In the areas of prosthetic design, I think there are a number of things to provide [the patient] the capability of participating competitively or recreationally in extra-ambulatory activities. A sound pain-free residual limb is essential for good function in these areas. A good understanding of bio-mechanics as applied to the amputee is essential for the prosthetist to provide a well designed prosthetic device . . . "In this day and age we have available to us a very sophisticated armamentarium of component parts and space-age type materials that lend themselves extremely well to prosthetic device fabrication, particularly in the specialized limbs geared toward specific physical activities. "In recent times there has been much use of things such as rotational absorbers, Greissinger feet, and multi-axis type ankle joint foot complexes. All of these types of items offer capability to the amputee but should not be applied in a general fashion. There are many activities where a rotator or multi-axis type foot complex is extremely detrimental to the function-ability of an amputee. Any sport which requires rapid directional changes would be a good example where these items should not be used. A person making quick and rapid adjustments in dynamic balance requires immediate response from the floor through floor reaction with his foot. This cannot be accomplished adequately with such items. "In conclusion, I feel that extra-ambulatory activities of the amputee and the resultant prosthetic devices that may be required for his successful participation in these activities is a relatively untouched area. A great deal of input is needed, both from the amputees in this country and the individual prosthetic practitioner, along with the physician and rehabilitation team members. I, myself, have been an amputee for 23 years and have been involved in numerous competitive and recreational activities and sports. I have found there are many areas in which I can participate in a non-handicapped world, and can be very competitive either on a one to one basis or as a team member. I have found this to be extremely fulfilling for myself and feel this is one of the ultimate goals that any amputee would strive to achieve." As regards the question of torque absorbers and use of the more sophisticated ankle foot complexes, Mr. Caspers raises a very interesting question. Certainly many prosthetists hold decided views on the topic and it would be interesting to receive Letters to the Editor on the matter. The Editor Page Number(s) 6 - 7 Year 1983 Volume 7 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Questionnaire: Extra-Ambulatory Prostheses https://staging.drfop.org/files/original/dca562c934e6c03968ea74fbd3ff1f31.pdf 573718b9201606fcbfbf62993cef40b0 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_02_001.pdf Text Any textual data included in the document <h2>Cervical Orthoses</h2> <h5>Charles H. Pritham, CPO <a style="text-decoration: none;">*</a></h5> Orthoses are fit for the control of motion about a joint or joints. By extension, cervical orthoses are fit to control motion of the cervical spine. Such orthoses are provided to patients for a wide variety of conditions ranging from the merely inconvenient on one end of the spectrum to the life threatening at the other end. In response to this need, a plethora of devices have been described; a review of the literature and of manufacturers' catalogs will reveal a positive galaxy of orthoses, all described as being of great efficacy and many differing from others in matters of only minor detail. What seems to be lacking is any systematic and quantitative assessment of the various orthoses' merits and a rational scheme for their use. While it may be overstating the case, it seems that most individuals in various parts of the country rely on two rules of three: selecting from the panoply available three orthoses graded as minimally, moderately, and maximally immobilizing; and fit in terms of small, medium, and large. Which orthoses are selected is shaped by local preference, training, and experience among other factors. In contrast to other areas of orthotics, the topic of cervical orthotics can be described as a stepchild or plain shoe. Since the end of World War II, other areas of orthotics have been radically reshaped (lower limb orthotics and spinal orthotics for scoliosis and kyphosis) by the application of new knowledge, new technology, and new philosophies of treatment. Upper limb orthotics occupies the middle ground: it's not that the effort has not been made, just that the results have been less than totally successful. It would, of course, be fallacious to suggest that no effort at all has been made to elucidate in some rational fashion the prescription of cervical orthoses. James D. Harris, D.O., in his review of cervical orthoses in Orthotics Etcetera, 2nd Ed. <a></a> cites a variety of references which used such means of measuring cervical motion as goniometry, cineradiography, and still radiography to assess the immobilizing affects of various orthoses. He further used these references and descriptions of effectiveness in his comparisons of a variety of orthoses. Rollin M. Johnson and his coworkers <a></a> used their original studies for a similar purpose. The impression remains, however, that while useful work has been done, the effects of it have been relatively small scale, and much remains to be done. This point of view is endorsed by the results of a workshop panel convened in 1977 <a></a>. It would seem that there exists a genuine need for research to be conducted comparing the efficacy of various orthoses with an eye towards developing a rational basis for prescription and for the results to be widely disseminated. The contrary point of view can, of course, be argued. Those instances that are truly life threatening are relatively few, usually promptly recognized, and are best managed aggressively with immobilization, confinement to bed and even surgery. For the rest, cervical orthoses are generally prescribed for episodic and short term relief of pain. Even if prescribed with an orthosis that does not perfectly match the need, patients limit their activities in response to pain and if necessary a new orthosis can be prescribed. Under the circumstances a basic measure of common sense illuminated by experience will serve to assess the competing claims of similar orthoses and match a particular orthosis with a particular situation. It would also be fallacious to argue that no improvements in technology have been made. While such developments as the Philadelphia Collar and the S.O.M.I. can be cited, the foremost example is the Halo. Originally a specialized device applied in specialized centers for relatively few indications, it has, in the guise of the Halo-vest, come to be widely used in instances where maximal immobilization and possibly distraction are needed. While intimidating in appearance and implications, the evidence is that the technique is readily mastered, and that the device is well tolerated by patients. However, the possibility of such complications as pin-site infections, penetration of the skull, and loosening do exist. As a result of these reasons and the generally felt need for something less drastic, if equally effective, calls have been made for a non-invasive halo <a></a>. In response, Wilson, Hadjipavlou, and Berretta <a></a> described "A New Non-Invasive Halo Orthosis ..." in 1978. Fundamentally, this is a S.O.M.I. orthosis modified by the substitution of a low temperature thermoplastic skull-cap for the occipital piece. The authors cited experience treating 20 cases of unstable fractures and cineradiographic studies to support their contention that "this orthosis is almost the treatment of choice whenever rigid immobilization of the cervical spine is indicated." In a similar vein, Rubin, Dixon, and Bernkopf <a></a> described in 1978 another modification of the S.O.M.I. In this device the mandibular piece was removed and two pads pressing in under the zygomatic arches where substituted. In addition, a "cranial vertex pad" rigidly fixed to the occipital pad and flexibly connected to the zygomatic pads was added. The authors showed radiographic and photographic evidence of near rigid immobilization of the cervical spine of one subject. However, they cautioned that the device was intended for relatively brief use, specifically for the removal of trauma patients to a hospital by trained paramedics, and they further speculated as to the unknown effects of long-term pressure on the zygomatic arches. Interestingly enough, both Harris <a></a> and Rubin, et al <a></a> refer to a device described by Boldrey in 1945. It is described as a rigid cap encompassing the posterior and lateral aspects of the skull with a forehead strap and sub-zygomatic pads. It was connected by a posterior steel upright to padded thoracic and lumbar bands with over the shoulder extensions and straps. None of these variations are commercially available. One further point needs to be considered: Harris <a></a> cites evidence of Hartman, et. al. that the Guilford Orthosis is 90-95% effective in restricting motion. Therefore, does the need for a non-invasive halo really exist? In any event, it is apparent that the subject of cervical orthotics is one that has received scant attention. What is not so apparent is whether or not such attention is vitally needed. References: <ol> <li>Harris, James D., "Cervical Orthoses," Orthotics Etcetera 2nd Ed., edited by James B. Redford, M.D., Williams and Wilkins, Baltimore, MD, 1980, pp. 100-122.</li> <li>Johnson, R.M.,; Hart, D.L.; Simmons, E.F.; Ramsby, G.R.; and Southwick, W.O., "Cervical Orthoses, A Study Comparing Their Effectiveness in Restricting Cervical Motion in Normal Subjects," JBJS, Vol. 59-A, No. 3, April 1977, pp. 332-339.</li> <li>Johnson, R.M.; Owen, J.R.; Hart, D.L.; and Callahan, R.A., "Cervical Orthoses: a Guide to their Selection and Use," Clinical Orthopaedics and Related Research, No. 154, Jan.-Feb. 1981, pp. 34-35.</li> <li>Edmonson, A.S.; et al., "Report-Panel on Spinal Orthotics" Orthotics and Prosthetics, Vol. 31, No. 4, pp. 67-71, Dec. 1977.</li> <li>Wilson, C.L.; Hadjipavlou, A.G.; and Berretta, G., "A New Non-Invasive Halo Orthosis for Immobilization of the Cervical Spine," Orthotics and Prosthetics, Vol. 32, No. 1, March 1978, pp. 16-19.</li> <li>Rubin, G.; Dixon, M.; and Bernknopf, J., "An Occipito-Zygomatic Cervical Orthosis Designed for Emergency Use-A Preliminary Report," Bulletin of Prosthetics Research, BPR 10-29, Spring 1978, pp. 50-64.</li> </ol> <div style="width: 400px;">*Charles H. Pritham, CPO Durr-Fillauer Medical, Inc., Orthopedic Division, Chattanooga, TN. Editor, Clinical Prosthetics and Orthotics-C.P.O</div> <div style="width: 400px;"> </div> Page Number(s) 1 - 2 Year 1983 Volume 7 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Cervical Orthoses Creator An entity primarily responsible for making the resource Charles H. Pritham, CPO * https://staging.drfop.org/files/original/4e183acf56bb242b877abe71bad0c82c.pdf 2d5fb2193aba4c56fe7e72e3aa738711 https://staging.drfop.org/files/original/f35dbf1ec5058164a5372c266853ed58.jpeg b93e3a485fb5fa30970f58cb3c3f97b4 https://staging.drfop.org/files/original/84f9510431f05aafdee61cf4a63a6e60.jpg 815e14879134606d06e3dec6ad49473c https://staging.drfop.org/files/original/2bf778e75bd7f9b6cdd9a04374f57fee.jpg 0ce17c62d2456956432115616f913c64 https://staging.drfop.org/files/original/bf19e271aafb1c9ff9bb542af0b93338.jpg d3e8c2de5e80c1498f33a82414e7bcb3 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_01_011.pdf Text Any textual data included in the document <h2>A Modified Hemipelvectomy Socket</h2> <h5>Peter A. Ockenfels, CPO <a style="text-decoration: none;">*</a></h5> This paper is to demonstrate a modified design for a hemipelvectomy type of prosthetic socket, which was designed for an endoskeletal system prosthesis. The patient, a 28-year old white male, while involved in the operation of heavy equipment in May of 1978, experienced severe crushing type injuries. The injuries required a hemipelvectomy amputation on the right side, and due to peroneal nerve injuries, the function of the left lower limb was limited. For the purpose of this paper, however, only the hemipelvectomy socket design, which is different and special due to the presence of a colostomy, which needed to be fitted into the prosthetic receptacle, will be discussed. The patient's first prosthesis was designed in the usual fashion with the colostomy inside the prosthetic socket. This restricted drainage into the colostomy device. The patient needed to remove his prosthetic socket during the day in order to relieve pressure and dispose of the accumulated waste. In considering the design of a new prosthesis, it was felt that an anterior or a lateral opening on the opposite side was inadequate and non-functional since the colostomy opening could not be maintained in one particular area at all times. Thus, a lateral opening was provided on the amputated side. A flexible tongue allows the socket to expand as the patient dons his prosthesis (<a href="/files/original/f35dbf1ec5058164a5372c266853ed58.jpeg">Fig. 1</a>). A single Velcro strap (<a href="/files/original/84f9510431f05aafdee61cf4a63a6e60.jpg">Fig. 2</a>) secures the prosthesis, and the colostomy opening is maintained in a permanent position while standing (<a href="/files/original/2bf778e75bd7f9b6cdd9a04374f57fee.jpg">Fig. 3</a>), as well as sitting (<a href="/files/original/bf19e271aafb1c9ff9bb542af0b93338.jpg">Fig. 4</a>). *Peter A. Ockenfels, CPO American Orthotic &Prosthetic Laboratory, Inc., Columbus, OH Page Number(s) 11 - 11 Year 1983 Volume 7 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1983_01_011/1983_01_011-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1983_01_011/1983_01_011-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1983_01_011/1983_01_011-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 4 http://www.oandplibrary.org/cpo/images/1983_01_011/1983_01_011-4.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Modified Hemipelvectomy Socket Creator An entity primarily responsible for making the resource Peter A. Ockenfels, CPO * https://staging.drfop.org/files/original/760e13aa1dc8e1275a4a9976de2db4cb.pdf 71a8cfac282278de7ae518edde8b0333 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_01_004.pdf Text Any textual data included in the document <h2>Editorial: Metal vs. Plastic AFO - A Therapist's View</h2> <h5>Donald G. Shurr, LPT, MA <a style="text-decoration: none;">*</a></h5> Ankle foot orthoses are generally prescribed for patients who are able to ambulate without an orthosis, but for whom an orthosis allows a safer, and often more cosmetic, gait. Traditional "bracing" in these cases calls for a combination of metal and leather, often a spring-assisted ankle joint, and a so-called posterior stop, which simulates the motion of ankle dorsiflexion and prevents toe drag during swing phase. More recently, molded plastic ankle foot orthoses have become available. These lighter weight orthoses provide a nearly invisible option to the conventional metal, riveted to the shoe devices. Presently, little agreement exists as to the indications, the timing of the application, or the overall outcome anticipated with the use of plastic AFOs. The physical therapist plays an important function in the team approach to the care of patients with orthotic needs. Because the physical therapist spends considerable time working with these patients, he or she has an opportunity to continuously evaluate the patient's progress. This constancy is critical to the orthotic decision-making process as changes in patient symptoms may well alter orthotic needs. For this reason, it is often the responsibility of the physical therapist to recommend an appropriate orthotic device. In order to do this, the therapist must not only use the current physical findings, but must accurately predict future changes in these data. He/she must choose a device which will not only facilitate early ambulation, but will also meet the patient's future needs. Thus arise the dilemmas of when to fit which device, and whether to use temporary or longer-lasting orthotic devices. In the past, metal AFOs were considered more adjustable and more temporary. These devices were to act as the precursor to the more definitive, more cosmetic, lighter, and therefore "better" plastic AFOs. However, experience with plastic AFOs revealed problems with lack of adjustability, thus necessitating multiple fittings in order to accomodate the patient's changing clinical picture. The therapist must decide how to most effectively provide devices which not only meet the adjustability requirements demanded for early ambulation, but also provide a more cosmetically appealing, definitive device. Questions that need answering are: can an adjustable orthosis be fitted to allow for early ambulation? When should we recommend the more definitive (presumably plastic) devices? How can this be done with a minimum of dollars spent? In 1971, Lehneis and Sarno made the following statement: "It is clear in the function of our clinic that there is no longer any indication for prescription of the conventional double bar BKO." It would be interesting to know if the authors still feel this way despite evidence to indicate that the double bar device is still routinely being fit. The reason for the continued popularity of the bichannel, double upright AFO in our clinic is its adjustability. This allows for medial-lateral control in both swing and stance phase, as well as knee control during stance. The extension moment generated by an anterior pin stop and long foot plate allows good control of knee flexion. Similarly, knee hyperextension can be controlled by adjusting the posterior pin. The timing for the fitting of such a device should allow a sufficient training period so that the patient can be discharged with skills in the proper and safe use of the orthosis. Frequent return visits or home care sessions are necessary to continue to evaluate progress and provide necessary orthotic changes. In many situations, the cost of the orthotic care for the patient is the smallest total dollar amount spent during the rehabilitation phase, yet it seems to receive a disproportionate amount of discussion. In those cases where early ambulation is indicated and expected changes in condition dictate an adjustable orthosis, the device of choice would seem to be the conventional, double adjustable, double upright, metal AFO. Later, as the condition stabilizes and the need for adjustability subsides, a plastic, more cosmetically acceptable AFO may be fitted. Even with the fitting of two devices, the total dollars spent for orthotic care will remain a small part of the overall cost of rehabilitation. This discussion would be incomplete without specific mention of the polypropylene AFO. Since the arrival of the custom-made poly AFO, manufacturers have saturated the market with standard sized, stamped poly AFOs. Many therapists use such devices and compare them with other types of custom-fitted metal and plastic AFOs. If one inspects these devices, it is apparent that they fit very few patients. They do not provide the necessary dorsiflexion assist without a considerable amount of modification, and often never produce the desired effect. Additionally, they provide little knee extension assistance, which is often necessary for many early ambulators. The choice of plastic vs. metal AFOs should be considered with all aspects of the patient's present and expected future condition in mind. The type of orthotic device prescribed should meet all the needs of the patient, with cosmetics being only one element. Multiple plastic or a combination of metal and plastic orthotic fittings can be justified in order to attain early, safe, and independent ambulation. *Donald G. Shurr, LPT, MA Director of Physical Therapy University of Iowa Hospitals and Clinics Iowa City, IA Page Number(s) 4 - 4 Year 1983 Volume 7 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Editorial: Metal vs. Plastic AFO - A Therapist's View Creator An entity primarily responsible for making the resource Donald G. Shurr, LPT, MA * https://staging.drfop.org/files/original/b45df324d6e6eb3062561af4ba9ca31c.pdf fe6df163464ebb5485158fcdc77801d6 https://staging.drfop.org/files/original/42f3cf78c258ae2747437e3c837288cc.jpeg 2b66e681fb1e8c1d4ab08e11a80b7f95 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_01_001.pdf Text Any textual data included in the document <h2>Ankle Foot Orthoses: Metal vs. Plastic</h2> <h5>Joanne A. Klope Shamp, CPO <a style="text-decoration: none;">*</a></h5> Since the late 1960's, when Yates <a></a> and Lehneis <a></a> wrote the first articles pertaining to the use of plastics in orthotics, the debate has continued comparing conventional metal to thermoformed orthoses. But debate is no longer necessary as the well-informed clinic team finds that plastic orthotic systems have come of age and should be prescribed on a routine basis. The advantages of thermoformed orthoses are numerous, extending far beyond the obvious factors of improved cosmetic and weight considerations. These, however, have significant merit in themselves. American society is appearance-conscious and highly competitive, an atmosphere in which individuals with disabilities are finding their rightful place among the non-disabled. The influence that the appearance of a device has on the effective interrelationships at home and in the workplace cannot be ignored. Thermoplastic devices are form-fitting, fleshtone, hygienic, and noise-free, unlike the metal devices of yesterday, and assist the individual in breaking the stereotypes of disability set by society. Of particular importance to the patient is the ability to interchange shoes, as long as the heel height remains consistent. The devices' light weight means a decrease in energy expenditure and, in many cases, makes a marked difference in the patient's ability to perform hip and knee flexion adequate for a full day's activities. This also allows the patient to life the involved extremity for climbing stairs, getting into an automobile and other actions requiring flexibility. A recent study by Smith, Quigley, and Waters <a></a> concluded that the "lighter" polypropylene Ankle Foot Orthosis promotes more efficient advancement of the involved limb, allowing a greater percentage of the gait cycle to be devoted to the stance phase of gait." This accounted for the "more normal pattern of foot-floor contact at initial contact and at terminal stance" <a></a>, p. 54. Hygienic concerns are easily met with plastic orthoses that may be cleaned daily with soap and water, rubbing alcohol, or chemicals such as acetone. To incontinent children and adults this means an increased life for the orthosis, as well as cleanliness and an improved self-image. In the same manner that prosthetic practice was revolutionized by the concept of total contact, so too has orthotics experienced a renaissance. With the total contact features of thermoformed orthoses, increased force may be applied to the skeleton without discomfort and skin breakdown as the area receiving the force is multiplied. Prevention and correction of deformity is greatly enhanced as compared to the metal bands of conventional double upright orthoses with their small surface areas. The force-distributing properties of plastic orthoses are of particular benefit in the case of insensitive feet where decubitus ulcers must be aggressively prevented. The use of well-formed total contact orthoses may preclude the need for expensive custom shoes in these cases and allow healthy feet in affordable and attractive footwear. Although cosmesis, weight, hygiene, and total contact features are important assets of thermoformed orthotic systems, versatility is the major advantage to the prescribing physician and clinic team. Design potentials are unlimited and allow the customizing of the orthosis to the exact biomechanical needs of the patient, without excess bulk or "over-bracing." As von Werssowet stated ". . . a brace should be selected with the most simple design that will accomplish the purpose and mission" <a></a>, p. 364. At the knee and ankle joints, free motion and some degrees of limited motion are easily obtained with a total plastic orthotic system. When a specialized assist or stop is required, a hybrid system <a></a> utilizing metal joints within the plastic design may be more satisfactory in meeting the patient's needs. Where total immobilization is indicated, plastic orthoses may be fabricated with corrugations or carbon composite inserts <a></a> that afford rigidity. Ankle position may be altered to provide a stabilizing effect to the knee joint at midstance or to prevent recurvatum when posterior structures are compromised. <a href="/files/original/42f3cf78c258ae2747437e3c837288cc.jpeg">Fig. 1</a>: The controversy illustrated—metal double upright ankle-foot orthosis vs. plastic ankle foot orthosis. A striking advantage of plastic orthotic systems is their superior control at the ankle in the frontal plane. A result of both the total contact nature of the device, as well as the individuality of possible designs, this provides excellent control in cases presenting equi-novarus (hemiplegia secondary to CVA), clubfoot deformities, and other mediolateral instabilities. Varying the thickness of the plastic and the configuration of the trimlines creates an appropriate three point pressure system that will not require force application over boney prominences, as the ankle strap of a conventional double upright orthosis requires over the lateral malleolus. Plastic orthoses are beginning to play a role in work regarding inhibitive casting and the effect upon spasticity. Eberle, Jeffries, and Zachazewski <a></a> recently reported success with an inhibitive AFO, a concept that was not feasible with metal orthotics. Their report stated that "the technique of fabrication used for construction of a molded polypropylene AFO allows for all of the tone-inhibiting characteristics of casting ... to be built into the AFO. . . (including) hyperextension of the toes, pressure under the metatarsal heads, a stable ankle position, and deep tendon pressure along the tendo calcaneus" <a></a>, p. 454. The molded footplate offers excellent control as compared to conventional metal orthoses where "modification must be made to the shank of the shoe in cases of severe spasticity, lest it break at the anterior edge of the tongue and thus allow the foot to adopt a position of equinus" <a></a>, p. 1. The hydrostatic features of plastic fracture orthoses have, in many regions, radically changed the orthopaedic approach to fracture management. Their effective application has been well documented by Sarmiento <a></a> and others. Their light weight (6-10 oz.), excellent hygiene, and wear with street shoes <a></a>, allows the patient a safe and speedy return to a near-normal lifestyle that often includes employment, even in cases of delayed healing. Hybrid and total plastic systems are easily adjusted for volume change and progressive positional correction through the use of heat forming techniques. Longitudinal growth in children can be predicted and the appropriate length adjustability feature can be an integral part of the orthotic design. Some unique and exceptionally biomechanical designs have been made possible through the use of thermoplastics. The spiral and hemispiral AFO designs <a></a> employ the physical characteristics of the coiled configuration of plastic to store energy and serve as a functional assist to weakened dorsi- and plantar-flexor musculature, with little effect on knee stability. The prescription and use of thermoplastic orthotic systems is no longer confined to regions with specialized clinic teams. Although their use originated in the research of large medical centers in major cities, the private practice sector nationwide now has ten years experience in these management concepts. The professional literature of the prosthetic and orthotic profession abounds with information on all aspects of design rationale and fabrication techniques utilizing today's total plastic and hybrid systems. I challenge each of you to break through the stereotypes of your conventional metal orthotic prescription and management practices. The potentials of current thermoformed based orthotic design are limitless, and will provide the patient with an immeasurably improved functional outlook and self-image. References: <ol> <li>Yates, G. ,"A Method for Provision of Lightweight Aesthetic Orthopaedic Appliances," Orthopaedics: Oxford, 1:2, 153-162, 1968.</li> <li>Lehneis, H.R., Ph.D., CPO, "New Concepts in Lower Extremity Orthotics", Medical Clinics of North America, 53:3:3, pp.585-592, 1969.</li> <li>Lehneis, H.R., Frisina, W., Marx, H.W., "Bioengineering Design and Development of Lower Extremity Orthotic Devices. Final Report, Project #23-p-55029 2-03," Institute of Rehabilitation Medicine, New York University Medical Center, October, 1972.</li> <li>Smith, A.E., Quigley, M., Waters, R., "Kinematic Comparison of the BiCaal Orthosis and the Rigid Polypropylene Orthosis in Stroke Patients" Orthotics and Prosthetics, 36:2, pp.49-55,1982.</li> <li>von Werssowetz, O.F., "The Use and Abuse of Braces in Rehabilitation of Neuromuscular Disorders," Archives of Physical Medicine and Rehabilitation 35:1, pp. 363-368, 1954.</li> <li>Behsman, A.S., and Lossing, W.W., "A New Ankle-Foot Orthosis Combining the Advantages of Metal and Plastics," Orthotics and Prosthetics 33:1, pp. 3-10, 1979.</li> <li>Fillauer, C, "A New Ankle Foot Orthosis With a Moldable Carbon Composite Insert," Orthotics and Prosthetics, 35:3, pp. 13-16, 1981.</li> <li>Eberle, E.D., Jefferies, M., and Zachazewski, J.E., "Effect of Tone-Inhibiting Casts and Orthoses on Gait: A Case Report," Physical Therapy, 62:4, pp. 453-455, 1982.</li> <li>Rosenberger, R. and Pritham, C.H., "Instep Strap," Newsletter. . .Prosthetics and Orthotics Clinic, 3:1, pp. 1-3, 1979.</li> <li>Sarmiento, A., and Sinclair, W.F.,"Tibial and Femoral Fractures-Bracing Manegement," University of Miami School of Medicine, circa 1973.</li> <li>Stills, M., "Vacuum-Formed Orthoses for Fracture of the Tibia," Orthotics and Prosthetics, 3:2, pp. 43-55, 1976.</li> </ol> <div style="width: 400px;">*Joanne A. Klope Shamp, CPO Shamp Prosthetic Center, Inc. Norton, OH </div> Page Number(s) 1 - 3 Year 1983 Volume 7 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 1 http://www.oandplibrary.org/cpo/images/1983_01_001/1983_01_001-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Ankle Foot Orthoses: Metal vs. Plastic Creator An entity primarily responsible for making the resource Joanne A. Klope Shamp, CPO * https://staging.drfop.org/files/original/34801932f31180cf39fb42463e18ca64.pdf b4ff1b0359d2a02dba24114047c1044d https://staging.drfop.org/files/original/6809b2f2afa3773a2820029b18b49a0b.jpg b8e4c1286250c652a53ec2b688db1acb https://staging.drfop.org/files/original/57e50e2a54f0ed529988256cbb6dd943.jpg aaac9f8f9b8b2b5bf8bab18389269d28 https://staging.drfop.org/files/original/69330701385993f53424c16d9fd378d8.jpg 53eb4adca9de07365f0faacc7c1b2bfa https://staging.drfop.org/files/original/f4181d44fd6538734307d9ea8b28ee4d.jpg e62d56cac139627fc1c316f26e860671 https://staging.drfop.org/files/original/d486cbde489421e053211e9332e2c877.jpg 79345ea5bfda40249c1da95de22377db https://staging.drfop.org/files/original/e6f7827c015798b9284c3ad7bce99e38.jpg ff99b290faf944d9eebd1823beba3dee https://staging.drfop.org/files/original/5155ade9bfc40b5ca7f8f0ffd21b75b7.jpg 63ded18f1ee6bf58ba96d15ebbbd68a0 https://staging.drfop.org/files/original/c14fa38126fa67950a300f4f17a45399.jpg 03b0ad5b1d067e9071f0fa40d0d0fd4c https://staging.drfop.org/files/original/23b23cf47b748b0346de8afd3db7a6c1.jpg 50ec8dabc7e88784dc0fc29ba58bfb93 https://staging.drfop.org/files/original/5d0a16bddb915f4ed3e31d89b05da45e.jpg abb09ce6db620b6606f9e0aac650b94e https://staging.drfop.org/files/original/5ac7ebb70decd31ce91601a4ac4da9a3.jpg 04eb1f4faa9d34d5281ad3d69e9e9810 https://staging.drfop.org/files/original/3677c02db76680b30ae38c40228c41b5.jpg 75c09a73c1870f3807933653b49680d3 https://staging.drfop.org/files/original/07dd115ef89f6e6ef005fb07d990dd9a.jpg 7a6534119ecd4981b5a7fb1b7cf37739 https://staging.drfop.org/files/original/0a4c66d644160de8fd4f209c4af5be31.jpg c243901ecf8305a715c919c7ee9e9ca8 https://staging.drfop.org/files/original/284b966aa49d3e57ea60dffeb209a3f4.jpg 34a52cafac6420239a7e937c337dda16 https://staging.drfop.org/files/original/7a18444d44b13d13f4e58b5f7788a592.jpg 7a7490de4b0d6b9ce087c838b433bea6 https://staging.drfop.org/files/original/535a6901340cdd81ec7457c80224e031.jpg c5033dc23af49069a08349ed2d3ef192 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_04_035.pdf Text Any textual data included in the document <h2>New Concepts in Post-Operative Scoliosis Management</h2> <h5>Robert D. Fitch, M.D. <a style="text-decoration: none;">*</a> Carrie Louise Beets, CO. <a style="text-decoration: none;">*</a></h5> As improved surgical techniques and stronger spinal instrumentation are developed, the need for external stabilization post-operatively and the design of post-operative orthotics have also evolved. The purpose of this article is to review the many recent advances in the surgical technique and spinal instrumentation, and the early results of a new management protocol (both surgical and orthotic) in the treatment of selected spinal deformities. <h3>Evolution Of Spinal Stabilization</h3> The goal in the surgical treatment of scoliosis is to correct the deformity and maintain correction until fusion of the spine occurs. It is the surgical technique of fusion that provides long term spinal stability. Until the fusion mass matures, we must rely on stability provided through surgical instrumentation (internal support) and casts or orthoses (external support). If the spine is not stabilized sufficiently internally and externally, then a non-union of the spine will occur similar to that which occurs with inadequate immobilization of long bone fractures. Once a non-union develops, the deformity may gradually recur. Prior to the advent of the Harrington rod, correction of the spinal deformity was obtained through complicated casting techniques. Risser described the turnbuckle in 1927<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-01.jpg">Fig. 1</a>). Later he developed the localizer cast.<a></a> A cast technique similar to this was perfected by Dr. Cotrel of France<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-02.jpg">Fig. 2</a> and <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-03.jpg">Fig. 3</a>). These casting techniques allowed correction of the deformity in the cast. The spine was then operated upon in the corrected position through the cast and the patient was maintained in a cast postoperatively for a period of nine to 12 months. With this form of treatment, there was a high incidence of failure, primarily due to the development of cast complications, or pseudoarthroses.<a></a> Many surgeons advocated routine exploration of the fusion mass six months postoperatively to identify any areas of non-union. <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-01.jpg">Figure 1. Turnbuckle cast as devised by Risser. Patient had to remain in bed for six months. (Photo reproduced with permission from Scoliosis by J.I.P. James, Williams & Wilkins Publishers, 1967.)</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-02.jpg">Figure 2. Localizer cast which extends up over the occiput and mandible. (Photo reproduced with permission from Scoliosis, ibid.)</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-03.jpg">Figure 3. Posterior view of localizer cast showing window through which surgery was performed. (Photo reproduced with permission from Scoliosis, ibid.)</a> In 1960, Paul Harrington reported on the use of a stainless steel distraction rod for the correction and stabilization of spinal deformities.<a></a> The Harrington device has since become the mainstay of surgical treatment for scoliosis. It has shown to be of great benefit in experienced hands and has shortened hospitalization time, avoided the need for preoperative correction with casting, permitted early mobilization of the patient in a well-fitted cast or orthosis, and has markedly decreased the pseudoarthrosis rate following fusion. What it has not accomplished, however, is the ability to provide sufficient internal stabilization to allow the abandonment of external support either by cast or orthosis. There are many instances in which external immobilization is undesirable. These include patients with insensitive skin, spasticity, or respiratory compromise. During the early 1970's, Edwardo Luque, M.D. from Mexico City was faced with many complex spinal deformities similar to those just mentioned. This led him to develop a new form of spinal instrumentation called segmental spinal instrumentation.<a></a> Unlike the Harrington rod, which uses distraction forces and is fixed to the spine at the top and bottom so that all the forces are concentrated at the bone-hook interface superiorly and inferiorly, segmental instrumentation provides corrective forces in a transverse manner at each spinal segment and, therefore, the distribution of forces is spread out over the whole length of the instrumentation. This has been shown to be much stronger biomechanically than the Harrington system and is extremely stable<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-04.jpg">Fig. 4 </a>and <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-05.jpg">Fig. 5</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-04.jpg">Figure 4. X-ray showing Harrington rod system.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-05.jpg">Figure 5. X-ray showing Luque rod instrumentation.</a> Segmental spinal instrumentation has become the preferred method of treatment of complex spinal deformities, especially those associated with neuromuscular conditions such as muscular dystrophy, myelodysplasia and cerebral palsy. However, it has not replaced the Harrington rod for the management of idiopathic scoliosis. This is primarily because of the added neurologic risk that is involved when performing segmental spinal instrumentation. Wires must be passed sublaminarly within the spinal canal at every level to perform this technique. The potential for neurologic complications is related to invasion of the spinal canal with these wires and the potential for vascular compromise to the cord by correction of the deformity, which leads to elongation of the spinal canal and vascular stretch. It must be kept in mind that segmental spinal instrumentation does not take the place of a meticulous fusion, and if fusion does not occur, then instrumentation failure in inevitable. In general, patients who have been treated with segmental spinal instrumentation are not placed in any cast or orthosis post-operatively. This is based on the assumption that the Luque instrumentation is so strong that no external support is needed. However, recently some surgeons have questioned the requirement for external support even with Luque instrumentation. Although the early instrumentation failures have been solved with segmental spine instrumentation, some surgeons have found increased loss of correction over the first few months in patients not treated with orthoses, compared to those who have been treated with orthoses postoperatively. Also, the question of late pseudoarthroses must yet be resolved; and if there is a significant incidence of pseudoarthroses with Luque instrumentation, would post-operative orthotic support decrease this incidence? Because of the added neurologic risk, we have opted not to use segmental instrumentation in dealing with most idiopathic spinal deformities. Rather, we continue to use the Harrington rod with some recent modifications. The modified Harrington rod provides enough internal stability to allow us to use a post-operative orthosis that is comfortable, convenient, and cosmetic. Added stability to the Harrington system has been achieved by a simple modification of the Harrington hooks. This was devised by Dr. Bobechko of Toronto. The new hook has a cam placed inside a slot which allows two hooks, rather than one hook, to be utilized at the upper level. Since most of the early instrumentation failures with Harrington rods have been with the cut-out of the upper hook, two hooks allow the forces to be distributed over a larger surface area, and when the technique is properly performed, corrects that problem. At the bottom end, a specially designed hook with a longer shoe is used to prevent dislodgement of the hook in this area, which can occur when the patient flexes forward. With the degree of stability provided by this method, post-operative cast immobilization is unnecessary. In addition, currently available orthoses such as the Greenville spinal orthosis, the SOS modular orthosis, or the Milwaukee brace also provide more external support than we feel is necessary. This has led us to adopt the use of a posterior plastic shell with corset front and shoulder straps. <h3>Current Management Protocol</h3> This post-operative orthosis is used in two situations: (1) in the patient with idiopathic scoliosis who has undergone Harrington rod instrumentation with modified hooks as described above, and (2) in patients with more complex spinal deformities who have had segmental instrumentation and are at risk for loss of correction or late pseudoarthrosis. Our post-operative regimen consists of taking a mold at the time of surgery. The patient is then mobilized quickly beginning on the first post-operative day. The patient is allowed to stand at the bedside twice a day until the orthosis is ready and applied, usually on the third post-operative day. At that point, the patient is allowed to begin ambulation and sit with the orthosis on. Following discharge, the patient is allowed to doff the orthosis at night and once a day for showering. The orthosis is worn for four months post-operatively. <h3>Orthosis Design</h3> The posterior shell orthosis used at Duke University Medical Center is based on an orthosis design that was originally used at the Texas Scottish Rite Hospital for Crippled Children in Dallas, Texas. At the Scottish Rite Hospital a Surlyn® posterior shell, with a special order Camp corset front riveted to the shell, is used. It is cast and delivered post-operatively, or sometimes on an outpatient basis. At Duke, the design was modified by the addition of shoulder straps for provision of an anti-rotatory movement reminder. The shoulder straps and the corset front are removable for easy laundering. The Duke protocol is for its use as an immediate post-operative orthotic device. <h3>Casting</h3> The Department of Prosthetics and Orthotics at Duke University Medical Center has the advantage of being located on site. This permits close coordination with the physician and his operating room schedule. The dates for which an orthotist is needed in the operating room are known in advance, as well as the time and estimated length of surgery. The surgeon notifies the orthotist as the surgical team prepares to close the case. The orthotist arrives in the operating room while the case is being closed. Adequate time is available to set up splints and water, inspect operative x-rays, and confirm the length of the instrumentation (helpful in determining proximal trimline of orthosis). Following closure of the surgical site, a small temporary sterile dressing is placed over the suture line for protection. The orthotist places a split piece of cotton stockingette over the patient's back and buttocks. Using an indelible pencil, the axillary and proximal trimlines are marked, C-7 is marked for reference, the waist and the gluteal fold and a horizontal line across the top of the gluteal fold are also marked (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-06.jpg">Fig. 6</a>). Six inch wide plaster splints, three layers thick, are applied lengthwise starting with the center back and overlapping towards both sides. Attention is paid to apply the plaster splints as far anteriorly on the patient as possible to make sure the cast impression has been taken to midline or just beyond. If a patient appears large busted or overweight, the sides of the impression can be compressed while the plaster is setting up (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-07.jpg">Fig. 7</a>). This will afford a truer M-L measurement for the patient when standing and sitting. The cast impression is removed (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-08.jpg">Fig. 8</a>) and the post-operative bandages are applied. <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-06.jpg">Figure 6. With the patient still on the operating room table, a split piece of stockinette is placed over the patient's back and landmarks and trimlines are marked.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-07.jpg">Figure 7. If a patient is large busted, the sides of the cast impression can be compressed while the plaster is setting, allowing a truer M-L dimension for when the patient will be sitting and standing.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-08.jpg">Figure 8. Cast impression simply lifts off. Operating room nurses replace temporary bandage, protecting the suture site with a regular post-op dressing.</a> <h3>Fabrication</h3> Any number of thermoplastics can be used to fabricate this orthosis, however, we have found Surlyn® to be sufficiently rigid and cosmetic. The advantage of fabricating with Surlyn® is that the standard practice of pouring, stripping, and modifying a positive model can be completely eliminated. In the fabrication lab, the cast impression is allowed to dry 30 minutes to an hour. The stockinette is then powdered. The impression is placed into an adjustable support to prevent any M-L spreading during the plastic molding. A piece of 3/16" thick Suryln®, large enough to cover the inside of the impression, is placed in the oven and allowed to heat just until it is pliable (about five minutes). The heated plastic is placed in the impression and pressed into the contours of the cast impression (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-09.jpg">Fig. 9</a>). The plastic is then rapidly cooled by a wet towel or air (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-10.jpg">Fig. 10</a>). When completely cooled, the plastic shell is lifted off the cast impression and the stockinette is stripped, exposing trimlines and reference marks made at the time of casting. The plastic shell is set back on top of the cast impression and the trimlines are transferred to the shell (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-11.jpg">Fig. 11</a>). The shell is trimmed and the edges finished (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-12.jpg">Fig. 12</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-13.jpg">and 13</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-09.jpg">Figure 9. Surlyn®, heated just until pliable, is pressed into the contours of the cast impression.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-10.jpg">Figure 10. Surlyn® is rapidly cooled with a wet towel.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-11.jpg">Figure 11. Trimlines are transferred from the cast impression to the Surlyn® shell.</a> Figures 12 and 13. Drape forming the Surlyn® to the cast impression without pouring a positive mold gives excellent contour detail to the resulting posterior shell. The posterior shell is ready for the attachment of the corset front and shoulder straps. We use a standard corset front available from Truform in either a 9", 10", or 12" abdominal length, depending on the patient's stature. Holes corresponding to the corset eyelets are drilled in the lateral edges of the posterior shell and the corset front is laced onto the posterior shell (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-14.jpg">Fig. 14</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-14.jpg">Figure 14. Finished posterior shell with corset front laced in place and shoulder straps also removable for laundering.</a> The shoulder straps, which are also removable for laundering, are attached to the posterior shell via Velcro® on the ends which double back on themselves after slipping through loops permanently riveted to the posterior shell. The shoulder straps are attached to the shell just proximal to the interscapular level. They cross the shoulders and attach laterally several inches distal to the axillae via a standard corset style hook. Placement of the lateral hooks midway between the axillae and the waistline prevents binding in the axillae when the straps are tightened. Total fabrication time from casting to initial fit is approximately four hours. <h3>Fitting</h3> Though the fabrication of the posterior shell orthosis is fast enough to permit fitting the same day as the cast impression is taken, the orthosis is usually delivered on the third post-operative day. This is done to allow post-operative illeus with accompanying abdominal distention to resolve. If the orthosis is fit too soon, the corset front invariably needs to be altered or the size of the front changed altogether. By the third day, the patient is alert and tolerant of being log-rolled, and the majority of abdominal distention has subsided. The posterior shell is tried for initial fit in bed and the patient is measured for the corset front with the shell in place. The accuracy of the trimlines is noted and the shell is marked if any adjustments are needed. After the corset front is attached, the orthosis is delivered to the patient, along with two pieces of stockinette to serve as in-hospital t-shirts and a written information/instruction sheet which covers care of the orthosis and basic "do's and don'ts." When providing this orthosis for community physicians at nearby hospitals, rather than trying to coordinate with their operating room schedule since travel time is involved, we cast the patient several days post-operatively. The patient is log-rolled in bed to a prone position and the plaster impression is taken the same way as in the operating room. If thick bandages are still over the patient's surgical area, the impression will be slightly deeper than the final product. Trimlines must be adjusted accordingly. The community hospital patient is measured for the corset front at the same time as casting since he can be log-rolled back to a supine position for measuring. The M-L measurement for the corset front is taken midline to midline. The shell is then delivered in 24-48 hours. By either method, the patient is up and walking in the orthosis at four days postoperative and is usually discharged at 6-7 days post-operative. <h3>Summary</h3> As of this writing, the protocol described above had been utilized in 44 patients over a period of 18 months. Diagnoses include adolescent idiopathic scoliosis, myelodysplasia, adult scoliosis, and adult spinal tumor. There has been one occurrence of instrumentation failure in a patient with adolescent scoliosis who had dislodgement of the upper hooks as a result of improper hook placement at the time of surgery. We feel that with the increased internal support provided by the Bobechko hooks in the Harrington rod instrumentation that the modified bracing provided by the posterior shell (versus Milwaukee or Greenville orthosis) has provided satisfactory restriction of gross motions which might endanger the success of surgery. Forward bending and twisting are restricted and the shoulder straps add an upper torso anti-rotatory reminder for the patient. We have had no problems with lack of compliance in brace wearing, even though both the shoulder straps and the corset front are removable. The orthosis has been well received by the patients. It is cooler and more comfortable than many of its counterparts. It is also cosmetically acceptable and is easily donned and doffed. Hygienic maintenance requires minimal time and effort. Finally, it has been well received by both adolescent and adult patients (<a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-15.jpg">Fig. 15</a>, <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-16.jpg">Fig. 16</a>, <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-17.jpg">Fig. 17</a>, and <a href="http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-18.jpg">Fig. 18</a>). Figures 15(above) and 16(below). The orthosis is easily donned by the patient. Figures 17(above) and 18(below). Posterior shell orthosis is very cosmetic. *Carrie Louise Beets, CO. Carrie L. Beets, CO., is formerly of the Department of Prosthetics &Orthotics, Duke University Medical Center. She is presently with the University of Virginia, Department of Prosthetics and Orthotics, 1224 W. Main Street, Charlottesville, Virginia 22908. *Robert D. Fitch, M.D. Robert D. Fitch, M.D., is Assistant Professor at the Division of Orthopaedic Surgery, Duke University Medical Center. References: <ol> <li>Cotrel, Y., "Le corset de platic E.D.F. dass le treatment de la scoliose idiopathegirel," Med. Hyg., 28:1032, 1970.</li> <li>Harrington, P.R., "Correction and internai fixation by spine instrumentation," J. Bone Joint Surg., 42A:1448, 1960.</li> <li>Luque, E.R., "The anatomic basis and development of segmental spinal instrumentation," Spine, 7:256-259, 1982.</li> <li>Ponseti, E.V. and Friedman, B., "Changes in the scoliotic spine after fusion," J. Bone Joint Surg., 32A:751-766, 1950.</li> <li>Risser, J.C., "The application of body casts for the correction scoliosis," Am. Acad. Orthop. Surg., Instructional Course Lect., 12:255-259, 1955.</li> <li>Risser, J.C.; Lauder, CH.; Norquist, D.M.; and Craig, W.A., "Three types of body casts," Am. Acad. Orthop. Surg., Instructional Course Lect., 10:131-142, 1953.</li> <li>Wenger, D.R.; Eurollo, J.J.; Wilkerson, J.A.; Wau-ters, K.; and Herring, J.A., "Laboratory testing of segmental spine instrumentation versus traditional Harrington instrumentation for scoliosis treatment," Spine, 7:265-269, 1982.</li> </ol> Page Number(s) 35 - 42 Year 1985 Volume 9 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-14.jpg Figure 15 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-15.jpg Figure 16 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-16.jpg Figure 17 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-17.jpg Figure 18 http://www.oandplibrary.org/cpo/images/1985_04_035/1985_04_035-18.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource New Concepts in Post-Operative Scoliosis Management Creator An entity primarily responsible for making the resource Robert D. Fitch, M.D. * Carrie Louise Beets, CO. * https://staging.drfop.org/files/original/901b570f7984e7d4389bd77bc8b49ab7.pdf 4dc89f03888f81781cc820b1c4281db2 https://staging.drfop.org/files/original/70079561438f68ead76f52fc65dd8527.jpg 9f295a4e4335c10beed8e204bd3902b4 https://staging.drfop.org/files/original/178ecd5991ed2ffe397316d0a4dd0546.jpg 843b4338dc78f6e9769246fa79846425 https://staging.drfop.org/files/original/2b7b51bf9cad86f7ce11a1660d52b387.jpg b0271f700b8d4901edf91d2082d01352 https://staging.drfop.org/files/original/ffaa35ca7b5ac23a6a947d2d3ad255f2.jpg 2fe8351da1a1e6155fb684e2e76de872 https://staging.drfop.org/files/original/f7c3b167230622c735630542cfdca207.jpg 3c649879a171c5ff0e0d93e99308eb76 https://staging.drfop.org/files/original/c4a610256e9b758a37d3623694e2271b.jpg 50f7124cde5cc7ce984f2315ba51fa73 https://staging.drfop.org/files/original/804efb442220a760c2ad6db87361ab61.jpg 373e078a4bb07aaf2eae6726bd391ff6 https://staging.drfop.org/files/original/1e7fab041130f301f034215e0e5b357d.jpg ecae0c1212323fe32a9a5b842bcf28b2 https://staging.drfop.org/files/original/ef3813f645bf9a4a4dd8188a6de82361.jpg 3a0b706d106a04ea3b6e27dcc9b84af6 https://staging.drfop.org/files/original/bb68eabedc0b65835c332efcf81f8201.jpg d34e1f0f082d9b6183dc2c8cee20fa2c https://staging.drfop.org/files/original/ccf65b3120d8051f16e304b8d2ef8f53.jpg 3ef8653b23290da3062586d399ca498b https://staging.drfop.org/files/original/1e94e8303e2979d8bbc043ee1a0e6ee8.jpg abc1ec3d3045264621578c7b7baf7e6e https://staging.drfop.org/files/original/b6daf9f8f83efde86777545189ff48f7.jpg dd96d853a981be0539a39293ad96b1d4 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_04_031.pdf Text Any textual data included in the document <h2>Flex-Frame Sockets in Upper Extremity Prosthetics</h2> <h5>Donald L. Fornuff, CP. <a style="text-decoration: none;">*</a></h5> The development of various new plastic materials has brought about a rapid change in the design and fabrication of lower extremity prosthetic sockets. We can now expect most of these revolutionary developments to overflow into other areas of prosthetics and orthotics. The most natural area next to be influenced is upper limb prosthetics. We at Rusk Institute of Rehabilitation Medicine have been trying various socket frame configurations with all levels of upper limb amputees, from wrist disarticulations to above elbows, including the humeral neck amputation. The following is a brief "technical note" describing the technique we use for fabricating the flex-frame socket for the upper limb prosthesis and a sampling of various socket designs. <h3>Below Elbow Socket</h3> When the below elbow socket model has been modified and smoothed, a flexible socket is made by vacuum molding, using Surlyn or Ethalux polypropylene (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-01.jpg">Fig. 1</a>). A thin socket is then laminated in the conventional fashion, over the flexible socket (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-02.jpg">Fig. 2</a>). This socket will act as a frame for the flexible socket and will allow for the secure attachment of the forearm extension and wrist unit. Upon completion of the thin laminated socket, the P. V. A. sleeve is removed. The socket is then covered, using strips of 1" masking tape (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-03.jpg">Fig. 3</a>). The forearm extension form, or mold, holding the wrist unit is mounted to the below elbow socket in the correct alignment, position, and length (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-04.jpg">Fig. 4</a>). The wrist unit is taped over to prevent foam from clogging various screw holes. A hole is cut in the forearm extension piece just proximal to the wrist unit. Foam is poured into this hole to form the forearm extension piece. Additional foam may be required to ensure proper shaping of the forearm section. When shaping is completed, the wrist unit is heated slightly and removed. Vaseline® is applied to the remaining foam and socket, and a P.V.A. sleeve is pulled on and tied at both ends (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-05.jpg">Fig. 5</a>). The wrist unit is replaced over the P.V.A. sleeve, held in place by the layers of material to be used in the second lamination. The material is tied off in the usual manner. When the forearm has been laminated, it should be completely removed from the below elbow socket and foam extension (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-06.jpg">Fig. 6</a>). This removal is relatively easy because of the P.V.A. sleeve applied over the shaped foam forearm section. After the laminated forearm is removed, the foamed forearm section and tape are completely removed from the laminated socket. The laminated and vacuum molded flexible sockets are removed from the model (the model must be broken many times) and the laminated socket frame is cut to its desired shape to allow maximum flexibility of the flexible socket (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-07.jpg">Fig. 7</a> and <a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-08.jpg">Fig. 8</a>). The frame socket is placed into the forearm section and trim lines are established. Both sections are then sealed together. The flexible socket is placed in the frame socket and the trim line is established: 1/8" to 1/4" above the edge of the laminated frame socket to minimize the stiffness gradient and to allow a gradual transition from the flexible socket to the rigid frame (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-09.jpg">Fig. 9</a>). Socket designs are many and quite variable (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-10.jpg">Fig. 10</a> and <a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-11.jpg">Fig. 11</a>). <h3>Above Elbow Socket</h3> All previous steps used in the below elbow prosthesis apply to the above elbow prosthesis until removal of the laminated humeral section with the attached elbow turntable. When the humeral section is removed from the foamed humeral extension, it is set aside (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-12.jpg">Fig. 12</a>), while the laminated above elbow socket is cut out to allow maximum flexibility of the flexible socket. The laminated humeral extension holding the turntable is then re-attached to the flex-frame socket with a rigid plastic resin (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-13.jpg">Fig. 13</a>). Easy removal of the flexible socket will allow for easy access to the elbow friction and attachment nut at the elbow turntable. Again, configurations of both below and above elbow flex-frame sockets are many in design, but must provide attachment areas for harnessing and base plates for proper transition of the cable control system. <h3>Acknowledgments</h3> The author wishes to acknowledge Mr. Steve Szabo's technical assistance. *Donald L. Fornuff, CP. Donald L. Fornuff, CP., was formerly Assistant Director of Orthotics and Prosthetics at Rusk Institute of Rehabilitation Medicine, New York, New York. He is presently Director of Medishare Orthotics and Prosthetics Laboratories, Fords, New Jersey. Page Number(s) 31 - 34 Year 1985 Volume 9 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-13.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Flex-Frame Sockets in Upper Extremity Prosthetics Creator An entity primarily responsible for making the resource Donald L. Fornuff, CP. * https://staging.drfop.org/files/original/9fce2f56ec56ccbbaff5166e0706b01f.pdf 5548abda79aee7e1363a542a22e37550 https://staging.drfop.org/files/original/1cc44d2e04b139d764a73a5ec808af6f.jpg 0222f4152435fc260955f32524bbb711 https://staging.drfop.org/files/original/fed0e95cfabfb6b0189e6da15c916a6f.jpg d1dbb049869929f1473972725498c986 https://staging.drfop.org/files/original/9345c2d14d824a077fd7b1f96c118c14.jpg 3bafaaab01346b31406d8d2d21b0be9c https://staging.drfop.org/files/original/de4e477cd3382de1d4516750b81da61d.jpg abf27e1e5360c4d5dfa6da2f7932a611 https://staging.drfop.org/files/original/5ac2dc8211dc6bd0f9079857dd3ca586.jpg 7bc8b46ef73d497018dceb1b1133d3c5 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_04_027.pdf Text Any textual data included in the document <h2>Flexible Socket Systems</h2> <h5>David J. Jendrzejczyk, CP. <a style="text-decoration: none;">*</a></h5> Over the past two years there has been impetus towards the use of the flexible socket interface in above knee prosthetics. For our purposes here, it is widely accepted that the flexible socket is of multiple benefit to the patient. We will concentrate on discussing the different systems available. The history of flexible sockets dates back a number of years. The article by Charles Pritham, C.P.O., et. al. "Experience with the Scandinavian Flexible Socket"<a></a> provides a concise summary of this train of development. At the present time, there are numerous flexible socket systems being used in the United States and throughout the world. These sockets differ in design in two major areas: flexible socket interface and the outer hard socket. The flexible socket is currently being used with three types of support mechanisms: <ol> <li> Total hard socket as the support </li> <li> Hard socket with strategic fenestrations </li> <li> True frame design </li> </ol> The prosthesis discussed by R. Volkert in the article, "Frame type Socket for Lower Limb Prosthesis"<a></a> is constructed with a frame outer socket and an elastic stocking interface. This system can accommodate stump volume changes, therefore, it appears to be most useful with early amputees. The TC Couple Socket<a></a> above-knee prosthesis used a polyethylene flexible interface and an external polypropylene socket. There are no fenestrations in the outer socket, so it doesn't have some of the benefits of sensory feedback as a fenestrated outer socket would. The advantage of this system is its light weight polypropylene outer socket. Work done at the Institute of Rehabilitation Medicine, New York University Medical Center, is detailed in "Flexible Prosthetic Socket Technique."<a></a> Two systems are described in the article, both have a hard outer socket with windows cut out in strategic locations (<a href="/files/original/1cc44d2e04b139d764a73a5ec808af6f.jpg">Fig. 1</a>). The interface is either of thermo-formed polyethylene or of silicone elastomer lamination. <a href="/files/original/1cc44d2e04b139d764a73a5ec808af6f.jpg">Figure 1</a>. Prosthesis incorporating a flexible Polyethylene socket in a support with fenestrations in selected areas as fitted at the Rusk Institute of Rehabilitation Medicine (Photo courtesy RIRM). Currently, in the United States, the external frame with the thermoplastic interface seems to be the most commonly used. There are three major fabrication techniques for the frame system described. They are the IPOS System (<a href="/files/original/fed0e95cfabfb6b0189e6da15c916a6f.jpg">Fig. 2</a>),<a></a> the ISNY (<a href="/files/original/9345c2d14d824a077fd7b1f96c118c14.jpg">Fig. 3</a>),<a></a> and the SFS System (<a href="/files/original/de4e477cd3382de1d4516750b81da61d.jpg">Fig. 4</a>)<a></a> (Fillauer Technique).<a></a><a style="text-decoration: none;">*</a> <a href="/files/original/fed0e95cfabfb6b0189e6da15c916a6f.jpg">Figure 2</a>. Flexible AK socket as fabricated by IPOS (Photo courtesy IPOS). <a href="/files/original/9345c2d14d824a077fd7b1f96c118c14.jpg">Figure 3</a>. Icelandic Swedish New York (ISNY) flexible socket (Photo courtesy NYU). <a href="/files/original/de4e477cd3382de1d4516750b81da61d.jpg">Figure 4</a>. Scandinavian Flexible Socket (SFS) (Photo courtesy Durr-Fillauer Medical, Inc.). The intention of this article is to describe the differences and similarities of the above three systems. <h3>Socket Interface</h3> All three systems use a thermoplastic material for their inner socket. IPOS uses ipolen,<a></a> which is a specially formulated polyethylene and which reportedly provides a uniform socket thickness and has little shrinkage. The resulting socket is translucent. The ISNY system prefers polyethylene which has a tendency to shrink. NYU reports that the shrinkage is not a problem. This socket is also translucent. The SFS system recommends Surlyn®, but polyethylene can be used. Surlyn® is a thermo-formable plastic which shrinks little and provides a transparent socket. The thermo-forming method for the interface is basically the same for all three systems. The only difference is that IPOS recommends that you preheat the vacuum forming frame, and they prefer a dry cast. If a wet cast is used, they recommend that an IPOS sheath be pulled over the cast before the thermo-forming. The SFS system recommends a warm, wet mold for Surlyn®. ISNY states no preference. <h3>Frame (Structural Element)</h3> The most variation occurs in the fabrication of the frame. Materials and lay-up have a wide range of variation (<a href="/files/original/5ac2dc8211dc6bd0f9079857dd3ca586.jpg">Table I</a>). <img src="/files/original/5ac2dc8211dc6bd0f9079857dd3ca586.jpg" /> IPOS laminates on the positive model with the flexible socket in place. Carbonacryl, which has been specially formulated to use with carbon fibers (13-1), is laminated over the appropriate layers of nylon stockinette, carbon-glass stockinette, fiberglass matting, and fiberglass stockinette. Total lay-up is seven layers for the average size patient of 120 to 180 pounds. The ISNY system laminates on the positive model with the flexible socket in place. Their recommendation is for 100 percent rigid polyester, acrylics if desired. A polyester lamination is done over the appropriate layers of nylon stockinette, fiberglass stockinette, and 1" and 2" unidirectional carbon tape. The total layup is 26 layers in both directions. In addition, they recommend adding dacron felt "to insure sufficient thickness in strategic areas."<a></a> SFS laminates their frame over the positive model, which has been built up with varying layers of stockinette used as a filler in place of the flexible socket. An acrylic lamination is done over the appropriate layers of nylon stockinette, fiberglass stockinette, and 1" unidirectional carbon tape. Total lay-up at the proximal brim is 25 layers, and 26 layers at the medial brim. In the ISNY and SFS systems care must be taken in the lay-up of the medial/proximal brim where the materials overlay to avoid excessive thickness. <h3>Frame Dimensions</h3> There are some variations in the final trim-lines of the frame. The medial strut on the SFS and ISNY are approximately 2 1/2" and 2 3/4" wide. The medial strut on the IPOS frame extends around the anterior and posterior medial edge by one centimeter. The proximal trimlines on the SFS, anteriorly and posteriorly, are 2/3 the medial/lateral width. The proximal trimlines of the ISNY extend to the anterior and posterior lateral socket corners. The proximal trimlines of the IPOS extend around the anterior and posterior lateral corner by 2 centimeters. In the SFS and IPOS systems, the distal trim-line cups around the lateral distal femur. The ISNY does not. All systems tell you to take care to have an adequate radius on connecting edges between the medial strut and the proximal and distal trimlines. <h3>Comments and Conclusions</h3> The afore-mentioned indicated that there are many questions still unanswered. The varying lay-up design makes for varying flexibility and weight difference in the frames. At Newington, we question why the severe differences in build-up exist and as a result are undertaking a research project with some students at the Engineering Department at the University of Hartford. As a senior research project, they are planning an evaluation of the mechanics and structure of the three strut designs as well as the flexible socket material. It should be noted that if there are severe undercuts on the positive model, removal of the finished strut from the model can cause stress cracks in the frame. Problems have been noted by Newington and others of the flexible socket breaking after delivery to the patient. Care must be taken in fabrication of the socket that all flares are built into the positive mold. This will help reduce the stress in the molding process. Another recommendation to remove the stress from the finished flexible socket is an annealing process. We have yet to evaluate its effectiveness. In conclusion, there has been some confusion as to the different systems. Our purpose here has been to clarify the systems and their differences. As with any new system, questions and confusion are to be expected. It is still a subjective evaluation. As long as the patient benefits, use the system (or combination of systems) with which you are the most comfortable. Footnote Further reference to the SFS system will be as it is fabricated by Durr Fillauer Medical, Inc. *David J. Jendrzejczyk, CP. David J. Jendrzejczyk, CP. is with Newington Children's Hospital, 181 East Cedar Street, Newington, Connecticut 06111. References: <ol> <li>Berry, Dale, CP., "Flexible above knee socket made from low-density polyethylene suspended by a weight transmitting frame," IPOS-Composite Materials for Prosthetic Orthotic Application, April 10, 1985.</li> <li>Berry, Dale, CP., IPOS-Flexible Socket, Case Study and Overview, April 10, 1985.</li> <li>Davis, Roy B., Ill, Ph.D., "Comparison of Inter-face Pressure Distributions, Soft Socket (ISNY/SFS) vs. Hard Socket," presented at an American Academy Orthotics and Prosthetics-New England Chapter Meeting, March, 1985.</li> <li>Giannini, Margaret, M.D., "Transfer of Rehabilitation Research and Development Results into Clinical Practice," Clinical Prosthetics and Orthotics, Volume 8, Number 1.</li> <li>Kay, Hector W. and Newman, June D., "Report of workshop on below-knee and above-knee Prostheses," Orthotics and Prosthetics, Volume 27, Number 4, pp. 9-12, 21, December, 1973.</li> <li><a href="poi/1981_03_129.asp">Koike, K.; Ishikura, Y.; Kakurai, S.; Imamura, T., "The TC double socket above-knee prosthesis," Prosthetics and Orthotics International, 1981, pp. 129-134.</a></li> <li>Kristinsson, Ossur, "Flexible Above Knee Socket made from Low Density Polyethylene, Supported by a Weight Transmitting Frame," Orthotics and Prosthetics, Volume 37, Number 2, pp. 22-27.</li> <li>Lehneis, H.R., Ph.D., CPO; Chu, Don Sung, M.D.; Adelglass, Howard, M.D., "Flexible Prosthetic Socket Techniques," Clinical Prosthetics and Orthotics, Volume 8, Number 1, pp. 6-11.</li> <li><a href="al/1968_02_028.asp">McCollough, Newton, C, III, M.D.; Sarmiento, Augusta, M.D.; Williams, Edward M., M.D.; Sinclair, William F., CP., "Some considerations in Management of the Above-Knee Geriatric Amputee," Artificial Limbs, Volume 12, Number 2, pp. 28-35, Autumn, 1968.</a></li> <li>Pritham, Charles H., C.P.O.; Fillauer, Carlton, C.P.O.; Fillauer, Karl, C.P.O., "Experience with the Scandinavian Flexible Socket," Orthotics and Prosthetics, Volume 39, Number 2, July, 1985.</li> <li>Technical Notes, Artificial Limbs, Volume 13, Number 1, pp. 69-71.</li> <li><a href="poi/1982_02_088.asp">Volkert, R., "Frame type socket for lower limb prostheses," Prosthetics and Orthotics International, pp. 6, 88-92, 1982.</a></li> <li>"A Revolutionary Technique in Fitting AK Amputees," IPOS Flexible Socket Fabrication Manual.</li> <li>"Prosthetic and Sensory Aids Service," Department of Medicine and Surgery, Veterans Administration, Washington, D.C., Bulletin of Prosthetics Research, pp. 227-229, Fall, 1972.</li> <li>"Fabrication Procedures for the ISN Y Above Knee Flexible Socket," January, 1984.</li> </ol> Page Number(s) 27 - 31 Year 1985 Volume 9 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1985_04_027/1985_04_027-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_027/1985_04_027-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_027/1985_04_027-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_027/1985_04_027-4.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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Jendrzejczyk, CP. * https://staging.drfop.org/files/original/da38b7a72d5f0f1d6ac21325f1e039c0.pdf edff63be99e2d8d729cbef998b406a52 https://staging.drfop.org/files/original/d2651974fba7f87f92cd366e455eb4c5.jpg 0f355eb01031549a7c829b5af0d3f97f https://staging.drfop.org/files/original/3cfe30bd191e924a3452548f324e3ab5.jpg 47d785dd2b06ea09755b1fc2db9ef7db https://staging.drfop.org/files/original/4b1a2b96b627fa58481925790ad1945d.jpg bc16cafb9de766ae75e4542da415a35e https://staging.drfop.org/files/original/6ce24c5ca94ed61c1f0b3605e1ea6609.jpg f33c04d0c9047f47f04324fda1775b97 https://staging.drfop.org/files/original/fc25931e137ae824d29d27f46056a337.jpg 14c2a7ea1bf14353dd93b0c7e0608750 https://staging.drfop.org/files/original/1db4cd12acf584900a88521b27b26e22.jpg 23a84ca687819185cd051e2b72a42df3 https://staging.drfop.org/files/original/c3b1f79a3aaf3398396bb240f223b4de.jpg 9d5cd10084e101a37287eb8a11b4dca5 https://staging.drfop.org/files/original/469379a388c74aff071a488496e54792.jpg 17f0c07a2d134591296da907616f4734 https://staging.drfop.org/files/original/d1b3a3a68b94f6ca40969ed5ddbfc33d.jpg c6317785d951bc3b1b237c59ba182c51 https://staging.drfop.org/files/original/18fc4dd5386650d70edc02d759d56432.jpg 482a6131207eda8a57c2ad534f20a1ee https://staging.drfop.org/files/original/1d28451c642c56ef2e891b7eb76b1000.jpg 9dc47a9c6572d79510690e5ca31ff324 https://staging.drfop.org/files/original/020cd4e30afb76ef85d5f9af5a444a4b.jpg 687f1e7b639a806faa83626517e263d3 https://staging.drfop.org/files/original/f5f456fe9b7abda81bee843c15ee1a12.jpg 5d3d1d2068fe0eaa7339520b499663f8 https://staging.drfop.org/files/original/10b792b285121de0002ec3efd54edc8b.jpg 1b42f34eeda78a19f81c150ffa6edd06 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_04_015.pdf Text Any textual data included in the document <h2>Contoured Adducted Trochanteric-Controlled Alignment Method (CAT-CAM): Introduction and Basic Principles</h2> <h5>John Sabolich, C.P.O. <a style="text-decoration: none;">*</a></h5> Since 1969, it has become increasingly evident that quadrilateral sockets have serious bio-mechanical problems. Even my old-timer above-knee prosthetic patients seem to be more comfortable in their ancient plug sockets, although transverse rotational stability was not as good. Fundamental to these objections is the lack of adequate stabilization in the frontal plane, which results in the gluteus medius gait most AK amputees demonstrate. In order to stabilize the upper trunk and pelvis in normal gait, the gluteus medius and abductors on the stance side must fire vigorously when the contralateral side is in swing phase. However, we are dealing with a patho-mechanical situation when we consider the case of the above-knee amputee. No longer are bones and ligaments positively connecting the hip to the floor. There is an intervening pseudo-joint, "the patient socket interface." We now have part of the femur inside a gelatinous semifluid mass, the human thigh. When the abductors fire, what is most likely to occur in a rectangular socket with a wide M-L dimension and no bony areas for the socket to lock against medially? The answer we have discovered, is that the femur tends to abduct. In quadrilateral sockets, the ischial tuberosity is sitting on top of the ischial seat and is free to shift about (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-01.jpg">Fig. 1</a>). As the gluteus medius pulls the femur into abduction, the pelvic slides medially on the ischial seat and makes the abduction worse. The unsupported femur has little choice than to drift into an abducted attitude within the wide M-L quadrilateral container. Pain at the distal femur and at the proximal medial area is due to this abducted position and excessive soft tissue pressure medially. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-01.jpg">Figure 1. No bone block and no real force system to prevent femoral or ischial drift. Ischial tuberosity acts as a fulcrum. Pelvis can rotate as well as the femur abduct.</a> We now have a perfect set-up for the classical above-knee "lateral trunk leaning" gait familiar to prosthetists. The patient has to lean to the side to position his upper torso over the base of support (the abducted distal femur) during stance phase, since the prosthesis is falsely placed under him (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-02.jpg">Fig. 2</a>). The patient executes this maneuver to prevent excessive pressure on the lateral distal femur and the medial proximal soft tissue. In essence, the patient must walk in a fashion similar to a person who has two sound legs with one leg out to the side in abduction. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-02.jpg">Figure 2. Patient must lean lateral over distal abducted femur, use inertia, or muscular tightening to prevent pain on lateral distal femur.</a> To the best of my recollection, I began questioning the validity of the quadrilateral socket theory in 1969 when I was a student at New York University. Dr. H. Richard Lehneis, C.P.O., of that institution taught that it is not necessary to put most of the patient's weight on the ischial tuberosity and, if the truth were known, most of the weight is probably borne by the peripheral tissue and gluteal mascula-ture. Moreover, at heel strike, when the largest inertial forces are placed on the above-knee residual limb, the ischial tuberosity is not on the ischial seat due to the flexed hip.<a style="text-decoration: none;">*</a> This concept was reinforced in my mind by the idea that if the majority of the amputee's weight was borne by the ischial tuberosity on the quadrilateral socket's flat ischial seat, one would only be able to obtain a tangental force at best, which would bring to bear tremendous force on a very small part of that bony prominence, and consequently cause great discomfort. Placing extra force in the neurovascular bundle anteriorly, Scarpa's triangle, with the purpose of pushing the ischial tuberosity up onto the ischial seat, has never made much sense to me. This seems to be the worst place to apply pressure and can not have a positive effect on circulation. These thoughts confirmed my concern that the quad socket theory had serious biomechanical problems and spurred my subsequent efforts. We began to close the M-L dimension of the socket by adding material to the lateral and medial sides to try to force the femur into adduction. We also began opening up the A-P dimension, not only to reduce the pressure on the neurovascular structures of the Scarpa's triangle, but also to compensate for the reduced diameter in the M-L dimension, and thus to maintain the original circumference. (Prosthetists naturally tend to be fearful of such modifications since they have been taught to tighten the A-P to keep the ischial tuberosity on the ischial seat.) In addition, I began to slant the ischial seat in the frontal plane upward laterally at about a 30° angle, rather than leaving it horizontal, so as to increase the weight bearing of the gluteal muscles, and thus rely less on the ischial tuberosity. These are some examples of early attempts to change the quadrilateral design and may be considered as our first generation efforts. In early 1981, the Sabolich Prosthetics Center sponsored a seminar to investigate non-quadrilateral alternatives for A.K. management. Participating in this seminar, among others, was Ivan Long, CP., developer of the concept of Long's Line and an associated socket design.<a></a> The information learned from Mr. Long was of the greatest benefit in advancing our efforts. However, for reasons that will become apparent in this article, we found it essential to proceed on a different track that experience has shown was necessary to make this program work for us. After this seminar, the Sabolich Center continued research study of non-quadrilateral above-knee designs. Over 900 non-quadrilateral sockets have been fit on a documented basis in Oklahoma City to patients ranging from six months to 103 years of age. X-rays (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-03.jpg">Fig. 3</a>) and Xerography have been impressive, showing the femur to be in a much improved adduction attitude. We have made major changes in shape and contour, especially in the last three years. We have coined the acronym CAT-CAM, which stands for Contoured Adducted Trochanteric-Con-trolled Alignment Method, to describe the second generation design which is covered in the remainder of this article. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-03.jpg">Figure 3. Weight bearing x-rays comparing CAT-CAM and quadrilateral sockets.</a> This design includes undercutting of the trochanter and a special fossa in which the ischial tuberosity and descending ramus can rest, giving this bony prominence three-dimensional support within the socket. No more consideration is given to the transverse angle of the posterior wall relative to the medial wall (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-04.jpg">Fig. 4</a>). The Scarpa's triangle is virtually eliminated, as are the adductor longus and rectus channels, and the ischial seat. The ischial tuberosity still bears some measure of vertical loading since it rests on an angled surface. The old principles of the quadrilateral design simply do not function, since we are dealing with a completely different design in shape, contour, and biome-chanical principles. The socket is so different that it looks somewhat like a quadrilateral socket turned sideways with a large A-P and narrowed M-L. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-04.jpg">Figure 4. Comparison of CAT-CAM and quadrilateral sockets in a transverse view. Since the femur and ischial tuberosity are fixed in position, the adductor longus tendon has to shift a small amount. Note mild O.K.C. (Oklahoma City) channel about the femur.</a> A number of prosthetists have come to our facility to learn these techniques on a one-on-one basis. We have gained much information and feedback from the other prosthetists who have participated in these informal educational efforts. However, this process is not altogether appropriate and has come to be tremendously time consuming. We feel that in the future, education should be administered to several prosthetists at once in an organized and structured course by one or another of the schools. In March, 1985, a preliminary course was taught at UCLA after two years preparation and the writing of a manual. This effort confirmed, in the minds of those involved, the necessity of such a course, and also the necessity of further efforts upon the part of the teaching staff involved to perfect techniques and teaching material. Moreover, it should be borne in mind that the acronym CAT-CAM embraces a number of varying concepts advanced by a number of prosthetists working in common directions and these differences must be reconciled into one technique to be taught. In the strongest possible terms, and in view of the problems some prosthetists have had, we can not recommend using the CAT-CAM method without a hands-on instructional course. <h3>CAT-CAM Theory</h3> The CAT-CAM holds the femur in adduction primarily by two means. First, the ischial tuberosity and part of the inferior ramus of the ischium rest inside the socket proper, and bear laterally directed forces which work in conjunction with medially directed forces borne by the femur (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-05.jpg">Fig. 5</a>). Medially directed forces bearing on the proximal portion of the femur in the trochanteric and sub-trochanteric region act to hold the ischial tuberosity on an inclined medial-posterior surface within the socket, while forces on the mid and distal portion of the femur act to maintain the proper adduction angle. Actually, it could be described as a wedging or "locking effect." (Imagine yourself holding the ischial tuberosity of a skeleton in the cupped palm of your hand and pushing the femur into adduction with your opposing hand; thus, the "locking effect.") The lateral surface of the socket proximal to the greater trochanter is contoured intimately into the soft tissue distal of the iliac crest. It is hypothesized that medially directed forces in this area, working in conjunction with the medially directed forces on the lateral surface of the femur and laterally directed forces borne by the ischial tuberosity, create a three-point pressure system to lock the femur into adduction and reduce motion that can occur when the ischium is free to shift about. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-05.jpg">Figure 5. Ischial tuberosity is locked in the socket to provide a counter force against femoral shift.</a> Second, the narrow socket means that the pressure bearing areas of the socket bear directly against the skeletal elements, thus reducing motion lost through intervening soft tissues. A wide socket M-L cannot provide this locking phenomenon since the femur can fall away from the supporting surfaces. In the transverse plane, the medially directed force of the ischial tuberosity is posterior to the laterally directed force of the trochanter and femoral shaft. One might assume, therefore, that the socket would twist or whip about its long axis. This does not happen, and apparently the adductor longus tendon and other medial proximal tissues anteriorly generate enough counter force to resist this tendency. Also, the ischial tuberosity creates a posteriorly directed force (since it is nestled in the posterior medial corner of the socket), resisting this tendency. Last, this tendency is checked by a new medial trimline (described later) which captures the medial portions, or the inferior ramus of the ischium, which are almost exactly opposite the trochanter. The exact weight bearing mechanism of the CAT-CAM socket with its wide A-P diameter and decreased emphasis on ischial tuberosity weight bearing is unclear. However, it is assumed that the femur is capable of bearing some measure of the patient's weight due to the increased adduction angle. It is also assumed that hydrostatic weight bearing plays an important role and that the ischial tuberosity still bears a measure of weight. In general, we have discovered that the prosthetic foot should be placed considerably lateral of a plumb line through the ischial tuberosity, but not always under the center of the hip joint or distal femur as with "Long's Line." This line changes position with how well the ischial tuberosity is locked in the socket and how narrow the mid and distal M-L dimensions can be molded. This alignment line also changes from patient to patient and depends on gluteal muscle strength, ischial ramus shape, femoral length, and subcutaneus tissue thickness. The prosthetist is now able to align the prosthesis in a normal physiological and anatomical fashion because the femur is no longer in abduction. The Berkeley Adjustable Shank is very useful in determining this critical relationship. By outsetting the foot more than with quadrilateral designs, the patient must adduct his femur to get his feet close together again. With the femur in abduction, as in the quadrilateral socket, a patient would be standing with his prosthesis scissored over his sound leg if he tried to stand with his femur in normal adduction angle. One cannot use a standard unchangeable line and always obtain the same adduction angle as with the contra-lateral femur, since the shorter the femur, the greater the adduction angle must be in order to place the distal femur under the center of the hip joint resulting in hyper-adduction. This was the reason I abandoned this line in favor of an adjustable line utilizing the Berkeley Adjustable Shank. This has resulted in much better alignment. One may ask, "If everything is stabilized in the M-L direction, then what about in the A-P plane?" Afer all, this is of the utmost importance at heel strike in order to stabilize the prosthetic knee and to help propel the patient over the foot. Our experience has not shown this to be a problem. In fact, if anything, an increase in A-P stability has been noted. We hypothesize two ways by which this might be explained. First, the majority of the muscle activity about the hip is in the A-P direction. The flexors and extensors are allowed to expand naturally, filling the socket quickly, and thus firmly stabilizing it (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-06.jpg">Fig. 6</a>). Also, this change in contour allows the A-P muscles to function naturally, increasing their size and strength. We have noted many cases of hypertrophy of the A-P muscle groups rather than atrophy. No longer are these muscles being squeezed, stifling their motion and effectiveness. Even suction sockets seem to hold on better since the tissues are not being deformed in an unnatural fashion, causing air pockets and channels to form. Second, the ischial bone is inside the socket, creating a solid posterior stop as opposed to simple soft tissue pressure, aiding A-P control at heel strike (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-07.jpg">Fig. 7</a>). Distally, CAT-CAM's become more round, again aiding A-P control. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-06.jpg">Figure 6. Most muscles function in the A-P plane. The CAT-CAM socket gives these muscles room for their normal dynamics.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-07.jpg">Figure 7. The ischial tuberosity is free to shift about in the A-P plane as well as the M-L plane when sitting on top of the ischial seat.</a> We have noted several interesting phenom-enons during this research effort. The first I have dubbed the "lateral pylon lean syndrome." Sometimes during dynamic alignment on the adjustable shank, the pylon has to lean laterally in order for the patient to be comfortable. The pylon can be brought vertical by increasing the socket adduction. This turns out to be a temporary solution and does not solve the real problem. This eventually results in pain in the perineum. What is actually happening is that the ischial tuberosity is slipping out of the socket proper and migrating medially on the proximal brim. As a result, the femur falls into abduction, or more realistically, the superior lateral portion of the socket drifts laterally on the patient, the medial superior brim digs in, the pylon leans laterally, and the proximal lateral brim gaps. The problem is not one of alignment at all, but of ischial containment (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-08.jpg">Fig. 8</a>). This happens when the socket is too tight in the M-L plane. This happened with sockets fitted after the 1981 seminar when circumference charts were used to determine socket M-L. These resulted in the ischial tuberosity being on top of the medial brim and that is why the brims of such sockets were so wide and thick. The intention was to get the ischium in the socket, but in actual practice it invariably ended up on top. This is no longer necessary due to improved measurement techniques used to determine true M-L. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-08.jpg">Figure 8. When the CAT-CAM socket is too tight, the ischial tuberosity shifts medially, the femur abducts and the lateral superior brim gaps.</a> Secondly, it seems that the shorter the femur and the greater the volume of the residual leg, the more noticeable is the "CAT-CAM effect." This is due to the favorable comparison of the CAT-CAM sockets versus quadrilateral sockets. The shorter the femur and the greater the relative amount of soft tissue in which it can move, the more obvious the problems of the quadrilateral socket become. However, even with long and lean residual legs, patients still notice the difference in comfort and adduction associated with the CAT-CAM method. A common statement is "it feels more solid," "it feels like its under me again," or "my leg goes where I want it to go." Also, the short residual limbs simply have much more peripheral tissue containment in which to bear vertical and horizontal loading, since the CAT-CAM extends much higher and contains more tissue, especially gluteal. Third, we have virtually eliminated use of hip joints even on very short sub-trochanteric above-knee patients. The adducted femur and the high lateral wall, snugly pressing into the intraillio-trochanteric region, help stabilize the M-L and tend to reduce the need for external support. Fourth, to the question of sitting: will there be a lot of gapping anteriorly? Not if the socket is dimensionally correct. Bending forward at the hip is actually enhanced due to increased room anteriorly, and with the new flexible brim described next, the problem is completely eliminated. Fifth, both the modified version of the Swedish Flexible design, with medial and lateral framing, and the new Total Flexible Brim (T.F.B.) mesh with CAT-CAM principles perfectly as both allow increased function of the A-P muscle groups (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-09.jpg">Fig. 9</a>). The CAT-CAM with T.F.B., is preferred because of its superior sitting comfort, adaptability, and dynamic comfort without sacrifice of A-P muscle freedom. The T.F.B., which allows the entire upper three-fourths of the posterior wall and the entire proximal portion of the socket to be flexible and allows a flexible anterior window, is actually opposite of the Swedish Flexible design, which has its greatest measure of flexibility concentrated in the mid-thigh. The T.F.B. is possible because the ischial bone is no longer on top of the posterior or medial seat, but down in the socket, so it does not tend to collapse or push the flexible seat distally. Instead, the tuberosity forces out against the side of the socket as does the trochanter, adductor longus tendon, and peripheral tissues. This can be thought of as one trying to hold his body in place in a V-shaped vertical tunnel or shaft by pushing out on the walls of the tunnel with one's hands and feet. The residual leg pushes out in all directions at once, thus there is no collapse of the flexible posterior brim. For the first time in prosthetics, the proximal thigh is actually allowed to deform naturally during sitting and to change contour dynamically while ambulating. I feel this is important since a great deal of pain complaints are related to the proximal areas. This flexible brim has also allowed us to become much more aggressive and make a major change by extending the posterior and posterior-medial brims higher to capture the ramus and ischial tuberosity more effectively. It has also allowed us to actually slant the medial brim superiorly to better capture the ischium and ramus while relieving the pubis. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-09.jpg">Figure 9. Three views of the Total Flexible Brim (T.F.B.) CAT-CAM.</a> Sixth, bilateral above-knee patients gain additional benefit from the CAT-CAM design. Our bilateral patients who rejected their quadrilateral socket accept the CAT-CAM enthusiastically. They benefit from the extra space provided in the perineal area by the narrowed M-L (especially with male patients). Even the old round plug sockets gave more room in the perineal area (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-10.jpg">Fig. 10</a>). The shaded area in <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-10.jpg">Fig. 10</a> demonstrates the extra area available for the genitalia from plug sockets over the quadrilateral socket represented by the rectangles. The CAT-CAM, of course, allows even more room in this area due to its opposite shape and contour. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-10.jpg">Figure 10. Graphical representation of the amount of room afforded in the perineum by a non-quadrilateral socket.</a> Seventh, the CAT-CAM has great advantages for the geriatric patient for several reasons. We have had our worst difficulties with quadrilateral socket on people with poor muscle tone. The shortcomings of the quadrilateral design become more obvious in the older population. The sharp angles of the adductor longus channel, the posterior medial corner, the medial brim, and the Scarpa's triangle of the quadrilateral socket were almost never really comfortable. With the CAT-CAM, these patients seem to have improved vascular flow; their residual limbs feel warmer after removing the prosthesis. This seems reasonable since the neurovascular bundle is not being choked off with a large bulge in the Scarpa's triangle. The A-P is not being choked but opened up. We hope to conduct comparative temperature and later Doppler blood flow analysis of this phenomenon. For the extremely large geriatric patient population, this alone might be one of the single greatest benefits of research with CAT-CAM design. When the Total Flexible Brim is added, we have not only greater comfort, but further increase in circulation. Eighth, we have noted that a large percentage of patients who were switched to CAT-CAM comment about energy savings. They do not seem nearly as tired after walking the same distance in the CAT-CAM as with their old prosthesis. This is probably first due to less lateral displacement of the center gravity. Second, patients do not have to fight to keep the femur from hitting painfully against the socket distally by tightening their musculature. Third, with more boney contact inside the socket and thus a more solid purchase, the prosthesis moves quickly without delay from false motion. Ninth, we have found that by undercutting the greater trochanter, a much better purchase and counter force to the ramus and tuberosity can be generated with less M-L play and, I suspect, some vertical component of weight can be borne on the flare of the trochanter much like that of the medial tibial shelf in the below knee. Also, now that the femur is actually adducted, we are now probably picking up a vertical component of force on the lateral shaft of the femur. Tenth and most important, after the 1981 seminar, we used a chart that related circumference of soft peripheral tissue to the desired medial lateral dimension of the socket. We found many fallacies with this method. The reason for this is that one cannot rely on circumference measurements to indicate the proper diameters between the ischial tuberosity and sub-trochanter, or the ramus and sub-tro-chanter. In our work, we found that it was absolutely necessary to obtain both of these measurements to obtain consistent results. A patient may be very fleshy and obese, but that in no way changes the anatomical dimension of the bony structures. The reverse is true with a thin patient. This was one of the most difficult stumbling blocks to obtaining truly good results. It seemed that when using this chart, the tuberosity was usually up on top of the medial superior shelf, which acted as an ischial seat, and this explained why the medial brims at the 1981 seminar were flat and 1 1/2" to 2" wide. In effect, the medial brim became an ischial seat. The sockets fabricated at the 1981 seminar still had the ischial tuberosity out of the socket proper and superior medial lateral diameters that were too narrow, resulting in M-L socket shift. True, the ischial tuberosity was no longer on the posterior shelf, but we had simply moved the tuberosity to the top of the medial shelf. The narrow M-L did provide better adduction of the femur, but not as good as when the ischial tuberosity and ramus are totally locked in the socket, providing a medial stop. The reason for this was discovered with more research. Namely, that it is incorrect to rely on what a patient measures in circumference at the perineal or ischial level, and to expect to extrapolate the medial-lateral dimension of the socket. I had two years of severe problems in this area until we dropped the circumference chart and adopted methods to determine exact measurements through xerography, x-rays, and anatomical measurements. Only then was I able to obtain consistent results, symmetrical adduction of the femur, and stabilization of the proximal socket to prevent lateral socket shift. Eleventh, through the course of our research, we have defined three ischial tuberosity-ramus types. We call these different configurations: alpha, beta, and gamma types (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-11.jpg">Fig. 11</a>). These classifications are valuable since they can be used to predict to what extent we will be able to control femoral adduction comfortably. The more purchase one can obtain by locking against the medial border of the ischial-ramus, the less the pressure that comes to bear on the soft medial proximal tissues, and the less the M-L shift of the socket. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-11.jpg">Figure 11. The well defined high slope of the alpha type usually results in improved femoral adduction and M-L control. At the other extreme is the gamma type which is more difficult to grasp properly with the socket.</a> The alpha type is the most desirable, since it has a medial side which slants up at a sharp angle, making it more appropriate for good M-L purchase, and also making it easier to slip into the socket. The beta type has more sloping sides, making purchase somewhat more difficult. The gamma is the poorest type for purchase. We tend to have some pressure problems in the medial proximal area with the gamma types due to M-L socket shift. It is difficult to get this wide bone inside the socket proper. This necessitates widening the medial lateral dimensions of the socket so the wide gamma tuberosity will slip into the socket. With the gamma types, we usually have to settle for a less ad-ducted femur than the patient exhibits on the contralateral side. Another very important point that finally emerged as research continued was that, not only ischial tuberosity, but medial inferior ramus containment was very important to stabilize the socket from lateral shift. The reason for this is that, while the ischial tuberosity is more posterior, and thus helps prevent anterior shift of the socket at heel strike, the ramus is a greater asset when it comes to prevention of M-L shift of the socket and is in a much better anatomical and mechanical position to provide a true medially directed force to the socket, since it is more diametrically opposite the trochanter and sub-trochanteric regions than is the ischial tuberosity. We have had some problems in the beginning with CAT-CAM due to inexperience. However, these have fallen below the one percent range. I find this one percent figure extremely interesting since most patients, especially older people, tend to reject new designs. We found almost none of this phenomenon, however, in switching from quadrilateral to CAT-CAM. We did experience problems due to low back pain in two very old patients. This problem is probably due to the fact that the quadrilateral sockets worn for years and associated with an abducted femur, allowed the lumbar spines to drift to one side. Apparently, fitting the CAT-CAM sockets suddenly pulled the lumbar spines in the opposite directions, inducing low pack pain. During the early years, we sometimes had to fit many transparent check sockets to the same patient before we had successful outcomes. With increased experience and the formulation of rational guidelines and more exacting anatomical measurements, this necessity has been greatly reduced. However, one should expect to spend a great deal more time fitting CAT-CAM design sockets due to the intimate bony contouring. A comprehensive CAT-CAM program should include use of comparative x-rays, which aid in modification and establishment of the angle of correction, as well as transparent diagnostic sockets, video gait analysis, and biofeedback as described in the next paragraph. We also recommend that previous quadrilateral patients undergo an intensive program of abductor strengthening with a prosthetically knowledgeable physical therapist, who will also later teach them not to laterally trunk bend from habit. The full benefit of the CAT-CAM socket is not achieved if the patient has been using a quadrilateral socket long enough to weaken his gluteus medius and abductor mechanism. If the femur tends to be in abduction (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-12.jpg">Fig. 12</a>), the gluteus medius is slack and not under normal tension, causing it to have a poor mechanical advantage and makes this muscle effectively weak. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-12.jpg">Figure 12. The gluteus medius is not effective when the femur is in abduction.</a> We have developed a CAT-CAM program to strengthen the gluteus medius muscle through the use of myoelectric biofeedback during gait training. Pressure sensitive electrodes are mounted to the patient over the gluteus medius, and the biofeedback unit emits an audible signal proportional to the electrical activity generated by the muscle when it fires. Using this method, the patient can actually listen to the muscles fire and begin to force himself to use the abductors more. The stronger this abductor mechanism becomes and the more training the patient receives, the less the classical A.K. "lateral trunk lean" during stance phase is observed. This is an important phase of the program and a very effective way to not only strengthen the gluteus medius, but to do so dynamically while the patient is ambulating. We also explain to the patients the reason why they must trunk lean laterally in a quadrilateral socket and use a video system to provide visual feedback to enable them to see themselves walk. This works very well since people seem to react better to watching themselves walk incorrectly and correcting it voluntarily, than to have a practitioner telling them what they are doing wrong. With former quadrilateral patients, do not expect this lean to go away completely because the habit is so well entrenched; however, it can be greatly reduced if not eliminated. <h3>Future Plans</h3> In late 1985 or early 1986, we will introduce the SCAT-CAM, or Skeletal CAT-CAM, which is a highly bone and muscle contoured design. We have been working on this design for three years and it looks considerably different than CAT-CAM (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-13.jpg">Fig. 13</a>). We feel this approach is the next logical step with the evolution of CAT-CAM and are very pleased with the results. SCAT-CAM is actually a third generation CAT-CAM exhibiting, among other refinements, a highly relieved lateral wall with Oklahoma City channel (O.K.C.), which is actually a trough for the entire femoral shaft along with full length of the lateral wall (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-14.jpg">Fig. 14</a>). I feel this is a major advance, since it attempts to capture the femur in the A-P direction and to prevent A-P and transverse pseudo movement. <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-13.jpg">Figure 13. Evolution in shape from the quadrilateral socket (right) to the SCAT-CAM socket (left).</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-14.jpg">Figure 14. Cross-sectional view of the SCAT-CAM socket.</a> The O.K.C. fossa is provided in a SCAT-CAM to place the ischial tuberosity in a hollowed out relief as opposed to the angular shelf of the second generation CAT-CAM. This fossa enhances the locking effect A-P and M-L. A transparent diagnostic socket is very helpful to properly locate this fossa placement. Also, the medial superior wall has undergone drastic changes to allow relief for the pubis, but still quickly slant superiorally posterior of the pubis to trap even more of the inferior ramus of the ischium and tuberosity. This gives a much improved medial superior locking counter force than a horizontal medial brim. It takes on the shape of a letter "V." With the SCAT-CAM, the pubis can be relieved in the vortex of the "V," while the medial border of all but the inferior apex of the ramus and all of the ischial tuberosity are caught in the arms of the "V." The use of direct anatomical measurements instead of the circumference chart has resulted in a drastic change in general contour where the superior medial-lateral dimension is wider to catch the bony areas, then quickly reduces in M-L dimension and becomes very narrow distal to the sub-trochanteric area, resulting in superior adduction control of the femur. Another important change was with the radius of the superior medial brim. We have changed from a 90° to a gentle upward sloping brim, which prevents the ramus and tuberosity from sliding or shifting out of the socket. With the SCAT-CAM, even more vertical loads are possible on the ischium than with quads sockets since the forces can be wrapped around this complex and curved ischial-ramus bone, which in essence can now be used for vertical posterior and medial loading. We are planning a research program which we hope will contain the following studies: Quantitative <ol> <li> X-ray with comparative study of femur adduction-abduction angles. </li> <li> Digitally timed video comparison of gait A-P and lateral analysis. </li> <li> Myoelectric measurements of major muscle groups, especially the abductors. </li> <li> Dynamic oxygen consumption rates to monitor energy expenditure. </li> <li> Relative Doppler blood flow in distal residual leg. </li> <li> Temperature of skin in both sockets after controlled time factor. </li> <li> Data on acceptance rates. </li> <li> Atrophy data or hypertrophy comparisons. </li> <li> Determination of the weight bearing mechanism. </li> </ol> Qualitative <ol> <li> Video comparisons. </li> <li> Patient comments. </li> </ol> <h3>Conclusion</h3> Even though the CAT-CAM and SCAT-CAM are diametrically opposite to the quadrilateral in design and precept, I believe these new principles will eventually be widely accepted and deeply penetrate the prosthetic field. I encourage practitioners to insist on weight bearing x-rays as part of a comprehensive prosthetic program, which lend credibility to our premise by exposing internal problems which result in external manifestations. My sincere hope is that the prosthetic community will not take this article to be controversial, but as a statement of what we have discovered and felt compelled to share. <h3>Acknowledgments</h3> The main source of strength in perpetuating my interest in CAT-CAM has come from the support of my father, Lester J. Sabolich, C.P.O., Thomas Guth, CP., Mike Wilson, C.P.O., and Dr. Ernest Burgess. These people have supported this project from early on and deserve much credit. I would also like to credit Ivan Long, C.P. who defined his alignment principles in 1975 and thus started us on the right track. Enough credit cannot be given this man! Also I thank my wife Lee, who has not complained about many lonely evenings during this research project. I thank the entire staff of Sabolich Prosthetics Orthotic Center. Without these people, none of this research could have been achieved. Only they understand the grit of many failures and garbled plastic in the trash. I thank all of the prosthetists who have worked with us and tried this method. Their feedback has been invaluable. Last, special credit goes to Chuck Childs, C.P.O., who could see the profound effect of this method and was in hot pursuit of it when he was taken from us. Footnote Dr. Lehneis states that the first person to indicate that the ischial tuberosity was more efficient biomechanically if it was in the socket proper was a German man by the name of Schnur in the early 1950's. *John Sabolich, C.P.O. John Sabolich, C.P.O., is Vice-President of Sabolich, Inc., 1017 N.W. 10th Street, Oklahoma City, Oklahoma 73106. References: <ol> <li>Long, I., "Allowing Normal Adduction of Femur in Above-Knee Amputations," Orthotics and Prosthetics, Vol. 29, No. 4, pp. 53-54, December, 1975.</li> </ol> Page Number(s) 15 - 26 Year 1985 Volume 9 Issue 4 Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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Title A name given to the resource Contoured Adducted Trochanteric-Controlled Alignment Method (CAT-CAM): Introduction and Basic Principles Creator An entity primarily responsible for making the resource John Sabolich, C.P.O. * https://staging.drfop.org/files/original/6d1bdbfb3822612ccf70563fefbb4019.pdf 356c1ebffaaa95283031c39e033f657c https://staging.drfop.org/files/original/9b3dbfd47f4e205b3f3566f5c2598ac8.jpg 5a1fa0e5452223577fc6c6f63fe3d92d https://staging.drfop.org/files/original/98ee1f01a6ef29370ac9ad0bbfb94469.jpg d73980b5e63ccd830a91b081fe43edd0 https://staging.drfop.org/files/original/0fecb05ac19dc561124c48611c56a93a.jpg 623b7bf0044a88b7d34c77709fa54bb5 https://staging.drfop.org/files/original/95e006b3a425afa6d9f016bd69c3c4be.jpg 2e7e56d1bb7cdaf6bf13a8ff13e075d3 https://staging.drfop.org/files/original/1a32f54d3357fabb1ad9960c341aebf1.jpg d7abfc1d599e85de9900579f35a25034 https://staging.drfop.org/files/original/ef60e5343c1d3795a8af570b62a2645d.jpg 4fee5b46777df4d2048fd04943f125a5 https://staging.drfop.org/files/original/96be9b456a559b47dc97d6b1d8762776.jpg 6138c8980b24c30dd059ffc8d4a80251 https://staging.drfop.org/files/original/36c9b2abea8e6ce94e65566293c465a1.jpg c83e90321948696244f77976e48ff66a https://staging.drfop.org/files/original/6ae2fccc79bd5e8aa4f65fb1aaf2e51f.jpg 5159bf1873b503d8f3054c3182d51ff4 https://staging.drfop.org/files/original/9354bdc5ff2a0e6de61afdf78f664d83.jpg 8c50f7c6f65863d52a9dc7a767d3cd9d https://staging.drfop.org/files/original/852b96d874c1c25e67850af48b8d494d.jpg e0747089b4f52509b68a3e938ee55bd6 https://staging.drfop.org/files/original/a8a745290d743a87ddf6cd43e7f4d514.jpg d4510cc8170aed8908dbcbc660b26231 https://staging.drfop.org/files/original/854bb6844fef8050def39efea9a8447c.jpg 78018016d2195bca56aa7ca163f91998 https://staging.drfop.org/files/original/20bc29a508bf9a567e95fb90f7016bb0.jpg 4ee050bd695563984ed8ed14ca0ab801 https://staging.drfop.org/files/original/f92594d34b7d0d92262b30e6614a5fd5.jpg ed668351f5e0faad932ac687328a3385 https://staging.drfop.org/files/original/34ba0a161c273f2936d369676640a72f.jpg 61e794fe0c4f3caa10ce7fee4e05e438 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_04_009.pdf Text Any textual data included in the document <h2>Normal Shape-Normal Alignment (NSNA) Above-Knee Prosthesis</h2> <h5>Ivan A. Long, CP. <a style="text-decoration: none;">*</a></h5> On March 13, 1974, I saw the first x-ray of an amputee standing with his prosthesis, equal weight on both feet, heels 2" apart and toes 3" apart. (See <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-01.jpg">Fig. 1</a>. Notice the two zippers on the boots.) After seeing the amputated femur in such abduction, I realized that the quadrilateral socket and standard alignment procedures were not adequate for an above-knee limb. In December 1975, Orthotics and Prosthetics, the journal of the American Orthotic and Prosthetic Association, published my article, "Allowing Normal Adduction of Femur in Above-Knee Amputations." <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-01.jpg">Figure 1. X-ray of standing patient showing relative abduction of amputated femur as compared to normal side.</a> On February 2 and 3, 1981, I presented a demonstration and the booklet "Fabricating the 'Long's Line' Above-Knee Prosthesis" at Sabolich, Inc. in Oklahoma City. Shortly thereafter, news of a CAT-CAM socket available through Sabolich was announced. For the last 11 years, I have been fabricating only above-knee limbs and all have "Long's Line." The following article is presented so that prosthetists can provide the above-knee amputee with a limb that has a comfortable socket and alignment that allows him to walk in a normal fashion without drawing attention. Recently, it has been decided to call this work "Normal Shape-Normal Alignment" (NSNA) above knee prosthesis. <h3>What Is Wrong With Our Present A/K Prostheses?</h3> Most above-knee amputees walk with a wide base and a lurch to the amputated side. Only 100 percent concentration can change that pattern. We looked at 100 x-rays of above-knee amputees standing in their prostheses and found 92 out of 100 to have a difference in angle of the femur. In 91 to 92, the difference was towards abduction. (In this article, the angle of the sound femur is considered normal and movement away from the midline will be called abduction.) Most amputees would have to cross their legs to put the amputated femur in normal position while wearing the standard quadrilateral socket made all over the United States. Abduction was caused by the quadrilateral socket being entirely too large in the M-L dimension and too tight in the A-P. The ischium sits on top of the seat at best and a couple of inches above it in most fittings. The x-rays show the lateral wall to be several inches away from the femur except at the most distal point. When the femur exerts force against the lateral wall in weight bearing, the quadrilateral socket moves laterally immediately, because the ischium has no effect on stopping this shift. With the more narrow socket and increased A-P, the ischium is inside the socket, preventing lateral shifting of the socket during weight bearing. To insure proper angle of the femur, the distal femur is brought directly under the head of the femur. This allows hip musculature to work in a normal fashion. The narrow socket with a well shaped lateral wall will support this angle, and the ischium will secure the socket from shifting laterally, which destroys femoral support. Balance is dramatically improved when the foot is placed directly under the head of the femur rather than under the ischium. The amputee will immediately bring his feet closer together when he starts to walk, as opposed to a widened position when the foot is placed under the ischium. Long's Line is a straight line from the head of the femur (located approximately at the center of a narrow socket), through the distal femur, and down to the center of the heel. This line is not always vertical because it constantly shifts when changing from a standing position to a walking position. In order to support the femur, it is necessary to narrow the M-L dimension of the socket. The resulting greater A-P allows muscular function which is not possible with the crowded effect of a narrow A-P. <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-02.jpg">Table I</a> is used as a guide in establishing the width of the finished positive model. The figures were taken from approximately 500 sockets made in this facility, and may of these sockets have now been worn eight years. Very few, if any, sockets have been replaced because of shrinkage. Many sockets have been replaced as muscles return to normal and the thigh takes on its original shape and size increases. Most of the increase in size will take place in the A-P dimension, with very little change in M-L. Increasing the M-L dimension by anything more than 1/4" will result in a lateral gap at the top of the socket. <h3>Technique</h3> Thigh is measured as to length and circumference as high as possible and every two inches. Taking a cast: Take two pieces of 6" wide cotton stockinette, 32" long. Cut 17" into each piece and sew together to make undergarment for casting (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-03.jpg">Fig. 2</a>). Measure length of thigh and sew one leg of garment to fit thigh. Cut small holes in front and back of top of garment and insert cord to tie up over amputee's shoulder to help hold garment securely in place. With a snug fitting undergarment on the patient, and with the seam as near center as possible, the prosthetist will work from the side and completely circle the pelvis above the trochanter with a single wrap of 4" non-elastic plaster bandage. Pull it snug, for this wrap is to prevent downward slippage of the cast as more wraps of plaster are applied around the thigh. Work quickly so your finger can be placed around the ischium to mark its location and proper depth of cast before the plaster sets. This spot will be used to measure length to floor, pelvis level. The hand should be held to indicate the medial and posterior surfaces of ischium. Do not push forward of ischium. Ask the amputee to bring his knees together as tightly as possible and to extend his thigh to tighten the hamstrings. Hold this position until the plaster sets. Now place a vertical mark on lateral surface, with muscles tightened in extension (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-04.jpg">Fig. 3</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-03.jpg">Figure 2. Casting garment.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-04.jpg">Figure 3. Lateral view of cast ready to pour.</a> Tear the single wrap of plaster than encircles the pelvis. The cast will drop away. Immediately check depth of cast and location of ischium. Prepare cast for filling by adding duct tape around top to make top level. Pipe must be parallel with lateral mark, and tipped to medial to approximate Long's Line angle (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-05.jpg">Fig. 4</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-05.jpg">Figure 4. Anterior view of cast.</a> Now pour the cast full of plaster and let it set. When the plaster bandage and stockinette are peeled away, we now have a grossly oversided model (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-06.jpg">Fig. 5</a> and <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-07.jpg">Fig. 6</a>) that must be reduced in size. Practically all the reduction will take place on the lateral wall. <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-06.jpg">Figure 5. Posterior view of unaltered model.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-07.jpg">Figure 6. Lateral view of unaltered model.</a> Referring to <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-02.jpg">Table I</a>, the socket M-L will be 4.5" for a 19", 0 circumference level measurement of the amputee. <h3>Socket Modification</h3> <ol> <li> Lateral wall is to be shaped to give support over a wide area, and particularly the lateral posterior aspect of socket. </li> <li> The medial wall will be lower than seat level, and the cast will be the guide as to how low (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-08.jpg">Fig. 7</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-08.jpg">Figure 7. Medial view of modified model.</a></li> <li> Depth of the socket will be the same as measured length of the thigh. </li> <li> The seat will be at right angle to Long's Line. </li> <li> Long's Line is drawn from center of M-L (see chart) to center of distal femur (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg">Fig. 8</a>). (Distal femur will be very close to lateral surface, probably covered only by skin.) <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg">Figure 8. Posterior view of modified model.</a></li> <li> Top 1" of medial wall will flare outward at 45° (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg">Fig. 9</a>, point Y). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg">Figure 9. Anterior view showing relationship of medial brim (point X) to ischium and of lateral wall (point Y) to greater trochanter.</a></li> <li> Lateral wall is higher than usual. Do go above the trochanter (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg">Fig. 9</a>, point Y). </li> <li> Seat need not be wide, but sharp edges must be avoided (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-11.jpg">Fig. 10</a>). The ischium will bear on flare of socket, both medial and posterior. <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-11.jpg">Figure 10. Lateral view.</a></li> <li> Do not worry about the socket touching the greater trochanter. Take the cast down as though the trochanter does not exist. Practically all sockets gap in this area. In order to achieve the desired M-L, many casts will be reduced 2" or more (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-13.jpg">Fig. 11</a>, <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-12.jpg">Table II</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-13.jpg">Figure 11. Proximal view of socket and socket pattern for thigh measuring 19". Actual measurement of the pattern is 18".</a></li> <li> Many sockets require fill added distally on medial side, only because I failed to remove enough material in this area when modifying the model. </li> <li> Laminate socket using two layers of 1 oz. dacron felt plus extra felt around top. </li> <li> Remove socket from cast and trim excess plastic. </li> <li> Mark the center of the lateral wall at seat level for TKA. TKA should be parallel to lateral cast mark lines (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg">Fig. 12</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg">Figure 12. Lateral view of bench aligned prosthesis.</a></li> <li> Mark Long's Line on posterior of socket (Center of M-L through distal femur) (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg">Fig. 13</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg">Figure 13. Posterior view of bench aligned prosthesis.</a></li> <li> When using a standard wood set-up, knee bolt should be 4° higher on lateral side when Long's Line is vertical. Long's Line will thus not be in center, but towards lateral side. </li> <li> Mount socket on set-up so that lines are straight (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg">Fig. 12</a> and <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg">Fig. 13</a>) and medial wall checks out for height. </li> <li> Install valve and walk amputee. </li> </ol> DO NOT change the alignment. Allow the amputee to take a few steps and watch the foot come in to a narrow base normal gait pattern. Notice level knee bolt while walking. DO expect the amputee to have much more difficulty in readjusting to his old prosthesis. He will need to widen his base and may experience vertigo at first due to lack of support and extreme inward location of the foot. To finish shaping of the thigh, material is added to the knee block to widen the knee block in front of medial joint. This must not limit full extension (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-16.jpg">Fig. 14</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-16.jpg">Figure 14. Anterior view of prosthesis following completion of shaping.</a> *Ivan A. Long, CP. Ivan Long, CP., is President of Polycadence, 6080 West 55th Place, Arvada, California 80002. Page Number(s) 9 - 14 Year 1985 Volume 9 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-02.jpg THIS IS TABLE I Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-03.jpg THIS IS FIGURE 2 Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-04.jpg THIS IS FIGURE 3 Figure 5 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-05.jpg THIS IS FIGURE 4 Figure 6 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-06.jpg THIS IS FIGURE 5 Figure 7 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-07.jpg THIS IS FIGURE 6 Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 16 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-16.jpg THIS IS FIGURE 14 Figure 8 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-08.jpg THIS IS FIGURE 7 Figure 9 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg THIS IS FIGURE 8 Figure 10 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-10.jpg THIS IS FIGURE 9 Figure 11 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-11.jpg THIS IS FIGURE 10 Figure 12 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-13.jpg THIS IS FIGURE 11 Figure 13 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-12.jpg THIS IS TABLE II Figure 14 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg THIS IS FIGURE 12 Figure 15 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg THIS IS FIGURE 13 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Normal Shape-Normal Alignment (NSNA) Above-Knee Prosthesis Creator An entity primarily responsible for making the resource Ivan A. Long, CP. * https://staging.drfop.org/files/original/bd46617c235c4772e936e7d1a60ba734.pdf 579389d66872bebcf4e498a65ae678ea https://staging.drfop.org/files/original/455ecf115629123392857fe8469670c3.jpg 83423844a564fec85ce56c817a3f5ec7 https://staging.drfop.org/files/original/741a3625b8142c75ec6b345c5bfffc5d.jpg 03abbdb99e38076f14d95a0e59f913a2 https://staging.drfop.org/files/original/1138499b4a4ed059bcd0c8b24e6f8680.jpg 710defbe06f6ae092234a49207f4415e https://staging.drfop.org/files/original/0c94fac2ea4e7c0aacd0c52cbcb94002.jpg 95ae51859297d017d7d6e2924646f528 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_04_006.pdf Text Any textual data included in the document <h2>Beyond the Quadrilateral</h2> <h5>Hans Richard Lehneis, Ph.D., C.P.O. <a style="text-decoration: none;">*</a></h5> Earlier this year I had the pleasure to be invited to the Academy Midwest Chapter Symposium entitled, "AK Design Principles: Beyond the Quadrilateral." I found the latter half of the title so intriguing and expressive of contemporary thinking and rethinking in AK socket prosthetics that I chose it as the title of this commentary. I hope that the organizers of the Chicago Symposium do not mind my borrowing this title. One of the earliest and major break throughs in AK socket design in this century was the concept of ischial weight bearing. At first glance this appears to be a sound approach and certainly one that has improved general comfort over other sockets. If, however, one analyzes that concept more closely, i.e., biomechanically, it becomes clear that ischial weight bearing is not a reality through all phases of gait. It must be appreciated that the socket and, thus, the prosthesis as a whole during walking is controlled by movement emanating from the center of rotation of the residual hip joint. At heel strike, when the hip is flexed, the distance from the ischial tuberosity to the ischial seat of the socket increases with the angle of hip flexion (<a href="http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-1.jpg">Fig. 1</a>). Obviously, at this point in the gait cycle, there cannot be any ischial weight bearing. Yet, the need to support weight is greater than at any other point during locomotion. Body weight, plus the force of impact must be transmitted. How is this possible without direct skeletal support? I believe that, by what in German is called "verspannung" of the musculature, a stable interface is achieved. This is a phenomenon which every AK amputee must learn to prevent the prosthetic knee from buckling. Unlike normal locomotion in which there is phasic interaction of the musculature to produce controlled hip and knee flexion (eccentric contraction), the AK amputee must learn out-of-phase contraction of the hip musculature, i.e., the hip joint must produce an extension moment prior to heel strike so that the knee joint is in full extension at heel strike. Such muscular activity causes "verspannung," an increase in cross sectional volume, which in turn increases the tangential forces in the socket to equal the vertical forces generated at this point in the gait cycle. While it is clear that reasonably comfortable ischial weight bearing is indeed possible in the midstance phase, ischial weight bearing cannot be comfortably maintained at heel off. When the hip joint is extended, the perpendicular distance between the axis of rotation of the hip and the ischial seat of the socket is less than in the mid-stance phase (<a href="http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-2.jpg">Fig. 2</a>), yet the distance from the hip joint to the ischium remains constant throughout all phases. Thus, hip extension causes increasing pressure on the ischial tuberosity, which now becomes the fulcrum about which the prosthesis tends to rotate. This results in the stump being pulled out of the socket, gapping of the anterior brim, elevation of the body on the involved side, and discomfort. Clinically, prosthetists have relieved this problem by increasing the radius of the anterior portion of the ischial seat. This maneuver allows the socket and seat to move posterior to the ischium as the hip is extended. Personally, I have always advocated that the ischial seat is sloped forward and downward such that it is tangent to a radius from the hip joint to the ischium (<a href="http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-3.jpg">Fig. 3</a>). This not only increases comfort at heel strike, since it reduces the sharpness of the anterior portion of the ischial seat, but at heel off, it allows the ischial tuberosity to be inside the socket and pressure to be transferred to the much larger part of the ischium and gluteus maximus. Placing the ischial tuberosity on the anterior portion of the ischial seat also results in greater comfort, since it reduces skin tension in that area. While one might argue that placing the ischial tuberosity squarely on the seat was a necessity with open-end sockets; it is amazing that this theory continued to persist past the advent of total contact sockets. Under certain conditions, Pascal's law may be applied to total contact sockets, i.e., a hydrostatic condition exists which would eliminate the need for ischial weight bearing. In other words, the quadrilateral shape of AK sockets has remained unchanged despite the fact that total contact has resulted in a different application of the laws of physics which makes ischial weight bearing less important than originally conceived. Practitioners familiar with the fitting of prostheses to patients with Proximal Femoral Focal Deficiency (PFFD) know that the quadrilateral socket is inappropriate for these patients. A more appropriate socket shape resembles that of a flower pot in which the ischium is contained within the socket. In addition, the largest patient population for which the quadrilateral shape must be revised is the geriatric AK amputee. These patients, as a rule, become amputees due to Peripheral Vascular Disease (PVD), often compounded by diabetes. They usually present diminished sensation, reduced muscle tone, poor skin quality, and sometimes senility. Generally, they suffer from great discomfort when fitted with a prosthesis. Although most of this can be ascribed to the problems presented, it appears that some of this discomfort is due to the quadrilateral socket shape, particularly when the patient is provided with a manual knee lock. Unlike amputees who are fitted with an open knee and who must, and are able to, contract the residual muscles prior to heel strike, the geriatric amputee with a manual knee lock simply steps on the prosthesis. This simulates the effect of stepping on a rake (<a href="http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-4.jpg">Fig. 4</a>). As a result, the tissue below the ischium is compressed (poor muscle tone), resulting in excessive skin tension, anterior proximal gapping of the socket, and the ischium to be far posterior to the socket. In summary, it seems to me that in light of the change in patient population (overwhelmingly geriatrics) with all the physical problems they present, one should, indeed, think beyond the quadrilateral. One should also note that with the advent of total contact, the concept of ischial weight bearing needs to be re-visited and re-assessed. Designs such as CAT-CAM and work supported by the Veterans Administration at the Rusk Institute of Rehabilitation Medicine hold promise to go beyond the quadrilateral to improve patient comfort. <h3>Acknowledgments</h3> This is to acknowledge that certain concepts presented in this paper are based on, Schnur, J., DAS KUNSTBEIN- Messen und Bauen. Kothen-Anhalt: Buchdruckekel Hans Greiner. I am also grateful to Robert Wilson, M.S., research scientist, designer and medical illustrator, Orthotics & Prosthetics Research for the illustrations in this text. *Hans Richard Lehneis, Ph.D., C.P.O. Hans Richard Lehneis, Ph.D., C.P.O., is with the Rusk Institute of Rehabilitation Medicine, 400 East 34th Street, New York, New York 10016. Page Number(s) 6 - 8 Year 1985 Volume 9 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-4.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Beyond the Quadrilateral Creator An entity primarily responsible for making the resource Hans Richard Lehneis, Ph.D., C.P.O. * https://staging.drfop.org/files/original/ba789f483ace72e6c0f63c6846e6c081.pdf 519c0ffb1b60b8ec2558c4682b78c1b1 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_04_005.pdf Text Any textual data included in the document <h2>Basic Changes in Lower Limb Prosthetics</h2> <h5>Alvin L. Muilenburg, C.P.O. </h5> After several years of very little change in above knee amputee fitting, we now have a C.P.O. issue with four papers on current advanced clinical practice in lower limb prosthetics. Some of these advances can be brought into use without too much difficulty while others require much more training and careful follow-up. The techniques that involve materials and fabrication are usually not too difficult to try, but changes in these techniques can give us problems that we didn't expectand require extra caution during initial use. Alterations of socket shape to adapt to more difficult amputations or congenital deficiencies is something where we also look for improvements. Papers that are written giving experience and suggestions on how to solve these problems give us help that is needed in our day to day fitting. This usually does not alter our basic method of alignment and cast model alterations. The discussions concerning basic changes in socket shape and alignment cause us much more concern by whatever name they may be given. There is a new way to fit an AK amputation, that is certain. I cannot question the results; patient acceptance has been proven. New information, however, does not always come easily. These new methods have been brought to the public view only through a considerable amount of publicity, which then stimulates us to get more information. Traditionally, information and results have been passed on from one prosthetist to the other; usually by visiting the developers and exchanging new ideas. Educational institutions have provided a valuable learning ground. U.C.L.A. had a one week course in March and a few seminars have been held elsewhere. However, many details on how to teach the new methods have created controversy. We must support our educational institutions and help them to determine what should be taught. I believe we need a working group of a few prosthetists who are already involved in the new methods to develop guidelines for teaching. Perhaps the Academy could organize this. Clinical evaluation programs have been discussed but communication between prosthetists involved seems to have adequately covered that area. I want to express my appreciation to the publishers in this issue for all the work that has been done. Having this information published enables us to sort it out and make better decisions on improving our own care of the AK amputees. Page Number(s) 5 - 5 Year 1985 Volume 9 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Basic Changes in Lower Limb Prosthetics Creator An entity primarily responsible for making the resource Alvin L. Muilenburg, C.P.O. https://staging.drfop.org/files/original/7cf119166ad87eb06c27bf19aa14601f.pdf 1c96a3b3328679e9ce5c00a407f461c9 https://staging.drfop.org/files/original/7a03de2fa3abd6434dbf35ea90f8a24f.jpg 9a3b91d6d25d0ea128bd129f72052d5c https://staging.drfop.org/files/original/41d2e99ef2712e6bf37fd90b99884729.jpg e365f90de9bf9d37b3e930728b987afe https://staging.drfop.org/files/original/45f9ecdd3583fca4a9b40e43d40b8fcb.jpg a3a4b242703db91a587f408c2738acdf https://staging.drfop.org/files/original/f25d2a79d7de53b2ee49b4c388895c22.jpg 792d3c81e1d5d48a515061f80fe3204a https://staging.drfop.org/files/original/c8ecb78314e07610c4b41af0358a23f4.jpg 68b404353e59f1a8fcdfd73e57d06d44 https://staging.drfop.org/files/original/e0db5f9e5fb35400f61e401dd85599b9.jpg e0b92835fd4de23f0c8bb8fb5d1635fa https://staging.drfop.org/files/original/7aa1f8cbe0e245431055b7fe9d6d2d6f.jpg 4bdf0fe2fee9272b3e8bb7c7a4fd1960 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_023.pdf Text Any textual data included in the document <h2>Evaluation of a Prosthetic Shank with Variable Inertial Properties</h2> <h5>Scott Tashman, M. Eng. <a style="text-decoration: none;">*</a> Ramona Hicks, R.P.T., M.A. <a style="text-decoration: none;">*</a> David J. Jendrzejczyk, CP. <a style="text-decoration: none;">*</a></h5> Above-knee amputees walk slower than the normal population. This has been documented in adults<a></a> and children.<a></a> It has been suggested that the prolonged swing phase of the prosthesis forces a slower cadence and, therefore, a slower walking speed.<a></a> Since children rely on a fast cadence to obtain an adequate walking speed,<a></a> a prolonged swing phase can be a major obstacle to comfortable, efficient normal-speed walking. To date, most efforts to reduce prosthetic swing phase time have been directed towards the prosthetic knee joint.<a></a> Various mechanisms have been designed to accelerate the extension of the prosthetic knee. Mechanical, hydraulic, and pneumatic systems have been developed in an effort to provide a more favorable gait.<a></a> Hydraulic knee units have been shown to provide a more normal cadence and walking speed for adults than simple constant friction knee units.<a></a> Most of the prosthetic knee unit research has been directed towards the adult amputee population. Pediatric hydraulic knee units have been considered impractical because of size and weight limitations. Pediatric above-knee amputees are generally fitted with constant friction knee units because they are simple, light in weight, low in cost, easy to install and adjust, and require little maintenance.<a></a> It has often been presumed that adjustments in the knee joint friction could be used to provide an optimum cadence for the amputee with a constant friction knee joint. A study was performed at the Newington Children's Hospital Kinesiology Laboratory to test this assumption.<a></a> When subjects were asked to walk at a comfortable speed, no significant changes were observed in cadence or actual prosthetic shank swing time as the knee joint friction was varied over a wide range. In all cases, the swing period of the prosthetic shank was close to the natural swing period of the shank measured off the patient. This indicates that the physical properties of the prosthetic shank play a significant role in determining the natural cadence of the above-knee amputee with a constant-friction knee joint. To force the shank to move at a frequency different from its natural frequency requires significant input of energy in the form of applied torque at the knee joint (from hip or pelvic muscle force). The test subjects, when asked to walk at a comfortable speed, did not supply the extra energy needed for a faster cadence; they instead aligned their cadence with the natural frequency of the shank. <h3>Purpose</h3> The above results led to the current project: the design and testing of a prosthetic shank with variable physical properties. The purpose of this study was to test the following hypotheses: <ol> <li> If the physical properties of the shank section of an above-knee prosthesis with a constant friction knee unit are changed in such a way as to alter the natural swing period, the swing period of the shank during gait will also be altered. </li> <li> Reducing the swing period of the shank will increase natural cadence and walking speed. </li> </ol> <h3>Methods</h3> Design The principal design goal for the shank was to reduce the natural swing period as much as possible. If the shank/foot is considered as a physical pendulum, it has a period T equal to: T = 2pi(I/Mgd)^(1/2), I is proportional to Md2. Where: <blockquote> T = natural swing period of shank as a pendulum I = rotational inertia of shank/foot above knee pivot g = acceleration due to gravity d = distance from knee pivot to center of mass M = mass of shank/foot </blockquote> These equations indicate that changes in mass alone will not reduce the swing period of the shank; the center of mass must be shifted proximally (towards the knee joint) to significantly reduce the period. With reducing distal weight as the primary goal, an experimental shank was constructed for the test subject, a 13 year old male knee disarticulation patient with a "good" amputee gait pattern. Since the limb was to be used for laboratory testing purposes only, some strength was sacrificed in order to obtain the maximum possible reduction in distal weight while still using readily available materials. The shank was thin and hollow, with layers of polyester resin and one layer of carbon filter cloth laminated over a plaster mold. Excess material was ground away wherever possible. In addition, the prosthesis was set in correct alignment using a heel build-up on an ultra-light SACH foot to eliminate shoes and further reduce distal weight. To enable changes in the natural swing period, a lead mass which attached to a metal rod could be placed proximally or distally inside the shank. The additional mass was chosen so that the experimental shank/foot would weigh the same as the patient's standard prosthesis. The completed prosthesis is shown in <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-1.jpg">Fig. 1.</a> With the moveable mass placed distally, the shank had a center of mass positioned similarly to the patient's original shank. Shifting the mass proximally caused the center of mass to move proximally by 13 centimeters. To determine the effect of changing the mass position, the pendulum swing period of the shank was measured by timing the swing of the shank, which was suspended by a metal rod through the knee joint axis. The light weight shank, with the mass placed distally, exhibited inertial properties very close to those of the patient's original shank. Shifting the mass to the proximal position reduced the pendulum swing period by 0.20 seconds or 15 percent (<a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-2.jpg">Table 1</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-1.jpg">Figure 1. Completed experimental prosthesis; shown during testing in the Kinesiology laboratory.</a> Evaluation The Newington Children's Hospital Kinesiology Laboratory measured the effect on the gait of the changes made in the position of the center of mass of the experimental prosthesis. An automated video system was used to acquire three-dimensional kinematic data from 26 retro-reflective markers placed at designated positions on the body.<a></a> The kinematic data were used to determine the motions of all major body segments and calculate dynamic lower extremity joint angles in three planes. Linear movement and temporal measurements, such as stride length, single stance time, swing phase time, cadence, and walking speed were also determined. Swing time was determined by measuring the time from toe-off to heel strike. The shank pendulum time was determined by measuring the time required for the prosthesis to go from full extension into flexion and back to full extension; this is equivalent to one half of the period of the shank measured as a free-swinging pendulum. Kinematic data were acquired for two walks with the subject walking at: <ol> <li> normal speed, weight proximal </li> <li> fast speed, weight proximal </li> <li> normal speed, weight distal </li> <li> fast speed, weight distal </li> </ol> For the normal speed walks, the subject was asked to walk at a speed that was comfortable; no further prompting was given. For the faster speed walks, the subject was instructed to walk as fast as was comfortable; again, no further instructions were given. For each mass position, the knee joint friction was set to "clinically optimal" by matching the prosthetic side heel rise to the normal side heel rise at normal speed, and the patient was allowed to walk around for a while until he seemed reasonably comfortable with the altered characteristics of the limb. <h3>Results</h3> Stride Parameters Stride parameters measured during the four different conditions are shown in <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-3.jpg">Table 2</a>. This data represents the first walk acquired for each condition; the variation between the first and second trials for all conditions was less than five percent. Cadence, stride length, and walking speed were all essentially the same at the "normal" walking speed with the mass placed proximally or distally. At the "fast" walking speed, the subject walked seven percent faster with the mass placed distally than with the mass placed proximally, due to both a faster cadence and a longer stride length. Shank Swing Dynamics At the normal walking speed, the shank pendulum time was reduced by eight percent with the weight placed proximally, resulting in an eight percent reduction in the swing phase time for the prosthetic limb (<a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-4.jpg">Table 3</a>). Since the swing phase time for the normal side stayed the same, the swing asymmetry (prosthetic side vs. normal side) was reduced from 19.5 percent to 9.1 percent. A similar reduction in swing asymmetry was seen during the fast walk (from 32.4 percent to 19.6 percent). During fast walking with the proximal weight placement, the swing phase time was increased by five percent for the normal limb and reduced by eight percent for the prosthetic limb. The reduction in pendulum swing time was much greater (16 percent). <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-5.jpg">Table 4</a> The dynamic knee joint motion is shown for both weight positions (<a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-6.jpg">Figure 2</a> and <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-7.jpg">Fig. 3</a>). The peak knee flexion was reduced from 64 degrees to 54 degrees at the normal walking speed and from 84 degrees to 62 degrees at the fast walking speed with the weight placed proximally. The plots also indicate delayed initiation of knee flexion and faster motion of the limb with the proximal weight placement. <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-6.jpg">Figure 2. Knee flexion-extension angle vs. percent of gait cycle: normal walking speed, proximal and distal weight placement.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-7.jpg">Figure 3. Knee flexion-extension angle vs. percent of gait cycle: fast walking speed, proximal and distal weight placement.</a> <h3>Discussion</h3> As expected, proximal weight placement in the shank produced a shorter shank swing time during gait. This subsequently resulted in a shorter swing phase (toe-off to heel-strike) for the prosthetic limb. At normal speed, the decrease in swing phase was equal in time to the decrease in shank swing time (eight percent). At a faster walking speed, the same eight percent decrease in swing phase was observed, but the shank swing period was reduced by a much greater amount.<a href="http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-7.jpg"> Fig. 3</a> illustrates the effect of this discrepancy: the limb reaches full extension well before heel strike. One explanation for this is that the subject did not have sufficient time to fully adjust to the new limb; further use should enable the subject to reduce swing phase as much as the shank swing period was reduced. A less expected outcome was the similarity in walking speed and cadence between the two different weight placements. The reduced swing phase did not result in a reduced gait cycle time; the subject instead lengthened his stance phase to balance the decrease in swing phase. This resulted in a smoother, more symmetric gait. <h3>Conclusions</h3> Limited conclusions can be made based on this single-subject study. However, it appears that decreasing the natural swing period of the shank by shifting the center of mass proximally results in a faster swing phase during gait. In one subject this led to an increase in stance phase for the prosthetic side towards normal values, and considerably reduced left-right asymmetry for this subject. Improved symmetry should lead to a more energy efficient, natural appearing gait. No increase in cadence or walking speed was observed. It is possible that longer wear of the limb might have permitted the subject to naturally increase his cadence; this could not be evaluated with the present limb design. The outcome of this study indicates that weight distribution in the prosthetic shank/foot has a significant impact on gait. This suggests that future prostheses should be designed to minimize distal shank/foot weight. *David J. Jendrzejczyk, CP. Kinesiology Department and Department of Orthotics and Prosthetics at Newington Children's Hospital, Newington, Connecticut, 06111. *Ramona Hicks, R.P.T., M.A. Kinesiology Department and Department of Orthotics and Prosthetics at Newington Children's Hospital, Newington, Connecticut, 06111. *Scott Tashman, M. Eng. Kinesiology Department and Department of Orthotics and Prosthetics at Newington Children's Hospital, Newington, Connecticut, 06111. References: <ol> <li>James, U., and Oberg, K., "Prosthetic gait pattern in unilateral above-knee amputees," Scand J Rehab Med, 5:35-50, 1973.</li> <li>Godfry, C. M.; Jousee, A. T.; Brett, R.; and Butler, J. F., "A comparison of some gait characteristics with six knee joints," Orthotics and Prosthetics, 29(3):33-38, 1975.</li> <li>Murry, M. P., "Gait patterns of above-knee amputees using constant-friction knee components," Bull Prosthet Res, 17(2):35-45, 1980.</li> <li>Hoy, M. G.; Wiring, W. C; and Zernicke, R.F., "Stride kinematics and knee joint kinetics of child amputee gait," Arch Phys Med Rehabil, 63:74-81, Feb 1982.</li> <li>Drillis, R., "Objective recording and biomechanics of pathological gait," Ann NY Acad Sci, 74:86-109, Sept 1958.</li> <li>Sutherland, D. H.; Olshen, R.; Cooper, L.; and Woo, S., "The development of mature gait," J Bone Joint Surgery, 62A:336-353, April, 1980.</li> <li>Zarrugh, M. Y., and Radcliffe, C. W., "Simulation of swing phase dynamics in above-knee prosthesis," J Bio-mech, 9:283-292, 1976.</li> <li>Wallach, J., and Saibel, E., "Control mechanism performance criteria for an above-knee leg prosthesis," J Bio-mech, 3:87-97, 1970.</li> <li>NYU Medical Center, Lower-Limb Prosthetics, pp. 145-163. Prosthetics and Orthotics, New York University Post-Graduate Medical School, 1980 revision.</li> <li>Murray, M. P.; Mollinger, L. A.; Sepic, S. B.; Gardner, G. M., and Linder, M. T., "Gait patterns in above-knee amputee patients: Hydraulic swing control vs. constant-friction knee components," Arch Phys Med Re-habil, 64:339-345, 1983.</li> <li>New York University Medical Center, "The ISNY PTB Socket," Lower-Limb Prosthetics, 1980 revision, pp. 107-108.</li> <li>Hicks, R.; Tashman, S.; Cary, J. M.; Altman, R. F.; and Gage, J. R., "Swing Phase Control with knee friction in juvenile amputees," In press, J Orthop Res.</li> <li>Gage, J. R., "Gait Analysis for decision-making in cerebral palsy," Bull Hosp Joint Des, 43:147-163, 1983.</li> <li>Gage, J. R.; Fabian, D.; Hicks, R.; and Tashman, S., "Pre- and postoperative gait analysis in patients with spastic diplegia-a preliminary report," J Ped Orthop, 4:715-724, 1984.</li> </ol> Page Number(s) 23 - 28 Year 1985 Volume 9 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-6.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 7 http://www.oandplibrary.org/cpo/images/1985_03_023/1985_03_023-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Evaluation of a Prosthetic Shank with Variable Inertial Properties Creator An entity primarily responsible for making the resource Scott Tashman, M. Eng. * Ramona Hicks, R.P.T., M.A. * David J. Jendrzejczyk, CP. * https://staging.drfop.org/files/original/681729931d4cfc067bfb635d350a0038.pdf 08c883182b90889c54a46553cb7eb012 https://staging.drfop.org/files/original/e3d52b0be7f8bf314487219accc7c636.jpg 533dd7911eac0f2103f63f55a2974f2e https://staging.drfop.org/files/original/88d35e0e098d1d592a33914182995d15.jpg 01b25278628c187bfd931c739f3f8d09 https://staging.drfop.org/files/original/7ea94c7033aad3284d8cc18bffbb2567.jpg 0e95b44fd8762f309bc14b7344472c45 https://staging.drfop.org/files/original/504357506176edb60a65b7ae82059220.jpg 0a53764bf308ba3a7a6cb38844c982d5 https://staging.drfop.org/files/original/4e0d9e4dfe99d6747445d53d6087df2b.jpg d6f074b0d9ad6cb75e44c3c67e36f961 https://staging.drfop.org/files/original/525c5f37bce1e329faedbb78c8ff8a2d.jpg 79827f16dc5d8ac8a0d99d9def75de42 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_018.pdf Text Any textual data included in the document <h2>Gait Analysis in Prosthetics</h2> <h5>James R. Gage, M.D. <a style="text-decoration: none;">*</a> Ramona Hicks, R.P.T., M.A. <a style="text-decoration: none;">*</a></h5> <h3>Review</h3> Objective measurement systems which quantify locomotion have been in use for the past century. But not until World War II, when thousands of men returned home to the United States with amputations, was technology really applied to the understanding of prosthetic gait. Inman and colleagues<a></a> founded the Biomechanics Laboratory at the University of California to establish fundamental principles of human walking, particularly in relation to problems faced by lower limb amputees. Inman's measurement techniques included motion pictures of coronal and sagittal views, as well as transverse rotations from below using a glass walkway. Using interrupted light photography, the Biomechanics Laboratory team studied the motion of body segments during gait. Force plates measured the subject's ground reaction forces, and muscle activity was recorded using electromyography (EMG), which measures the electrical signals associated with contraction of a muscle. Prior to Inman's fundamental studies prostheses were customized for the individual amputee, without any particular regard to rational structural design. Inman's goal was to provide fundamental data essential for the design of prosthetic limbs. By analyzing normal human walking, he and his colleagues laid the groundwork for biomechanical analysis of amputee gait.<a></a> Since that time, numerous techniques have been developed to study human locomotion,<a></a> and numerous studies have been undertaken to evaluate prosthetic gait. <h3>Research Applications</h3> Eberhart, et al.<a></a> described the locomotor mechanism of the above-knee amputee from kinematic and kinetic data. They compared lateral stick figures of amputees to normal subjects as a means to objectively identify gait deviations in the sagittal plane. Force plate data were used to compare the weight-bearing characteristics of the prosthetic limb and the sound limb. From these comparisons, the authors identified amputees who walked well with their prostheses and those who were less adept. Eberhart believed that ultimately "optimal" patterns of gait could be determined for amputees and used as a reference for evaluating prosthetic gait. Zuniga, et al.<a></a> studied gait in 20 above-knee amputees by using electrogoniometers attached to the knee and foot switches. Their data documented asymmetry in the stance and swing phase times between the prosthetic and sound limb. In similar investigations, James and Oberg<a></a> and Murray, et al.<a></a> studied temporal stride parameters and knee flexion-extension angles, and also examined above-knee gait at various speeds. They confirmed the stance and swing phase asymmetry between the prosthetic and sound limb. They also showed that the asymmetry was present regardless of the speed of walking. The collection of baseline data in above-knee amputees clearly demonstrated some shortcomings in prosthetic gait. One of these, the longer swing time which is required on the prosthetic side, has led to the development of dozens of prosthetic knees. Gait analysis laboratories have been used to evaluate some of these prosthetic designs. Godfrey, et al.,<a></a> in a limited study that compared gait with six cadence-responsive knee units, found no significant differences among them. Murray, et al.<a></a> compared the gait of above-knee amputees with hydraulic knee units versus constant friction knee units. Temporal and kinematic data, which were collected at slow, free, and fast speeds, showed that the hydraulic knees improved the symmetry between the prosthetic limb and the sound limb, especially at the fast and free speeds. This finding was true for both cadence and the amount of knee-flexion at swing phase. Hoy and colleagues,<a></a> in one of the few studies on gait in juvenile amputees, collected kinematic data at various speeds to compare the solid ankle cushioned heel (SACH) foot to a Child Amputee Prosthetic Project (CAPP) experimental foot. The authors found hip range of motion to be closer to normal and significantly less with the CAPP foot than the SACH foot. Hannah and Morrison<a></a> studied the effect of alignment of the below-knee prosthesis on gait. Using electrogoniometers to measure hip and knee joint rotations in the coronal, sagittal, and transverse planes, they found that malalignment of the prosthetic foot was the most crucial for gait symmetry. Grevsten and Stalberg<a></a> used electromyography to compare muscle activity in below-knee amputees walking with patellar tendon-bearing (PTB) and PTB-suction prostheses. Surface electrodes were placed over the tibialis anterior and gastrocnemius muscles which, in normal gait, usually fire at opposite phases. The data showed that these muscles contracted for longer periods when the PTB prosthesis was used than with the PTB-suction prosthesis, suggesting that the suction mechanism improved the adaptation to the prosthesis. Thiele, et al.<a></a> investigated possible neuro-physiological reasons for weakness in above-knee amputees by recording electromyographic activity of the quadriceps during gait. They did not find abnormal recordings and concluded that muscle weakness was secondary to biomechanical, rather than neurophysiological, factors. <h3>Clinical Applications</h3> Until the present, gait analysis has been applied to prosthetics only for research purposes. Routine prosthetic fitting and checkout are still done by means of observational gait analysis. However, observational gait analysis has many disadvantages. In the first place, even normal human walking is extremely complex. With each step, more than 30 major muscles have to contract and/or relax synchronously in each lower extremity. Also, normal human gait is rapid (approximately 105 steps per minute), and the human eye is not fast enough to separate the various components of gait at this speed. Krebs, et al.<a></a> have shown that data vary widely when different examiners have observed a person's gait and that observational analysis is only a moderately reliable technique. The variations between observers may be due to the preconceptions of individual observers, to limitations of human perception, or to problems in transmitting the information or data to colleagues. In light of these findings, it is not surprising that the fit and quality of the limbs fabricated by different prosthetists vary greatly. Technology has now progressed to the point where automated gait laboratories can be built. Their capabilities vary, but most labs monitor one or more of the following parameters: <ol> <li> kinematics or movement measurements through a motion analysis system, </li> <li> evaluation of ground reaction forces via force plates or pressure sensitive switches, and </li> <li> dynamic electromyography (monitoring the electrical activity of contracting muscles). </li> </ol> The advantage of an automated motion measurement system is that automated data entry and rapid processing allow routine clinical use at a reasonable cost. Since the sampling rate of most automated motion systems is in excess of 50 Hz (50 samples/second), all movement in the lower extremities during walking can be examined in detail and with excellent reproducibility. Thus, the analysis of walking becomes objective, rather than subjective, and a record of this objective analysis is produced by the computer in such a fashion that preconceived biases and communication errors between observers are minimized. Furthermore, some of the more modern gait analysis facilities have the ability to compare records, for example, of a patient's gait pre- and post-operatively, or of an amputee's gait with two different prosthetic devices or components. Through comparisons like these, the presence or absence of benefit can be determined objectively. <h3>Kinesiology</h3> The field of prosthetics can make use of the new science of kinesiology, or the study of movement. Kinesiology consists of two major fields: <ol> <li> kinematics, the study of motion exclusive of the influences of mass or forces, i.e., without regard to the underlying cause of the motion; and </li> <li> kinetics, which deals with the forces that produce motion. </li> </ol> Kinematic Data Kinematic data can be gathered in a variety of ways—through interrupted light photography, cinefilm, video systems, and/or electro-goniometers—and it can be displayed in many ways. Stick figures provide a visual display of the subject walking. <a href="/files/original/e3d52b0be7f8bf314487219accc7c636.jpg">Fig. 1</a> is a stick figure representation of an 11 year old girl with a right knee disarticulation. The stick figures facilitate the identification of gait deviations, e.g., knee hyperextension on the prosthetic side at stance phase. With observational gait analysis, this gait deviation might be missed, or two examiners might argue about its presence. With objective gait analysis, we can prove the deviation's existence by viewing the stick figures, and we can identify the cause of the deviation by reviewing the graphs that depict motion. These graphs display motions of each joint of the lower extremities in all three planes during a representative gait cycle. <a href="/files/original/e3d52b0be7f8bf314487219accc7c636.jpg">Figure 1.</a> Lateral stick figures of the right gait cycle of an 11-year-old-girl with a right knee disarticulation. <a href="/files/original/88d35e0e098d1d592a33914182995d15.jpg">Fig. 2</a> is a graph showing knee flexion-extension of the same child with a knee disarticulation. The child's sagittal knee motion is compared with the mean or average flexion-extension of seven other above-knee amputees. <a href="/files/original/88d35e0e098d1d592a33914182995d15.jpg">Figure 2</a>. Comparison of knee flexion-extension motion in one above-knee amputee with an average composite of knee flexion-extension in seven above-knee amputees. Although all above-knee amputees hyperextend their knees slightly during stance phase, this patient has 10 degrees more hyperextension than average. Following the gait analysis, it was discovered that the knee extension bumper was too soft, and it was replaced with a suffer one. Kinematic data can also be used to compute temporal data, such as stride length, cadence, and walking velocity. <a href="/files/original/7ea94c7033aad3284d8cc18bffbb2567.jpg">Fig. 3</a> compares the temporal data of the child with knee disarticulation with "normal" children the same age. Notice that the stride length is normal but that the walking velocity and cadence are less than normal. <a href="/files/original/7ea94c7033aad3284d8cc18bffbb2567.jpg">Figure 3.</a> Linear measurements of an 11-year-old girl with a knee disarticulation compared with a composite of linear measurements of normal children. Kinetic Data The forces that cause movement are usually collected through pressure sensitive switches or paper, or with commercial force plates, which are designed to break down the ground reaction forces into their components (X,Y,Z force, and X,Y,Z moment). The software of a modern gait analysis laboratory is able to combine force plate data with motion analysis data to produce meaningful graphic outputs. <a href="/files/original/504357506176edb60a65b7ae82059220.jpg">Fig. 4</a> shows the vertical ground reaction force (Z force) for walking barefoot compared with walking with shoes in a 9 year old boy with a Symes prosthesis. Notice the improved symmetry at push-off between the prosthetic and sound limb when shoes are worn. <a href="/files/original/504357506176edb60a65b7ae82059220.jpg">Figure 4.</a> Graphic display of the vertical ground reaction forces in a 9-year-old boy with and without shoes. Force plates can also be used to compute the location of the center of pressure on the foot. <a href="/files/original/4e0d9e4dfe99d6747445d53d6087df2b.jpg">Fig. 5</a> compares the foot force progression pattern of a SACH foot to a multi-axis foot in a 27 year old male with a below-knee amputation. From these data, one can see that the foot force progression pattern is more lateral with the multi-axis foot than with the SACH foot. Also, notice with the SACH foot how the initial forces move from an anterior to posterior direction as the heel compresses. This pattern is not seen in the multi-axis foot. <a href="/files/original/4e0d9e4dfe99d6747445d53d6087df2b.jpg">Figure 5</a>. Path of the center of pressure on the foot in a 27-year-old below-knee amputee with a SACH foot and with a multi-axis foot. <h3>Dynamic Electromyography</h3> Dynamic electromyography is a valuable tool for measuring the time duration of muscle activity, which is recorded through electrodes, either surface or indwelling. However, since voluntary muscle activity results in an electromyographic recording that increases in magnitude with the tension, other variables can also influence the signal, limiting the accuracy of EMG as a predictor of muscle tension. Electromyographic data can be displayed in several ways. When used to analyze a gait cycle, the data show which muscles are active during each phase of gait. <a href="/files/original/525c5f37bce1e329faedbb78c8ff8a2d.jpg">Fig. 6</a> compares muscle activity during gait of the subject walking with the SACH foot compared with the multi-axis foot. The hamstrings and quadriceps muscle groups were sampled and show the same firing patterns regardless of the type of foot that is worn. What is interesting is that the hamstrings are firing just before toe-off when they are usually silent and the quadriceps are inactive at this time when normally they fire to restrain knee flexion and prevent excessive heel rise. As might be expected, this patient walks with exaggerated knee flexion at swing phase. <a href="/files/original/525c5f37bce1e329faedbb78c8ff8a2d.jpg">Figure 6.</a> EMG activity of the hamstrings and quadriceps muscles during gait in a 27-year-old patient with a SACH foot and with a multi-axis foot. <h3>Summary</h3> Gait analysis is useful in evaluating an amputee's prosthesis by providing objective measurements and a permanent record of the patient's status. Kinematic, kinetic, and EMG data assist the clinician and prosthetist in identifying specific problems encountered by the amputee and in identifying the causes. Gait analysis also allows comparison of different prosthetic designs or different alignments of the same prothesis. Most importantly, however, the record provided allows examiners to objectively discuss the problems and their potential solutions. <h3>Future Applications</h3> The field of prosthetics will begin to change rapidly with the application of kinesiology. Soon, optimal standards of gait will be established for each prosthetic level. With the widespread availability of low-cost motion analysis, kinematic analysis will be routinely incorporated into dynamic alignment of each new prosthesis, helping to insure appropriate alignment and fit. Finally, prosthetic research, using both kinematics and kinetics, will continue as we seek to identify and rectify the problems created by loss of the body's normal limb. The ultimate outcome of this research will be the development of components that will be stronger, lighter in weight, and much more functional than those used now. <div style="width: 400px;"> <div style="width: 400px;">*Ramona Hicks, R.P.T., M.A. Kinesiology Laboratory at Newington Children's Hospital in Newington, Connecticut 06111. *James R. Gage, M.D. Kinesiology Laboratory at Newington Children's Hospital in Newington, Connecticut 06111.</div> </div> <div style="width: 400px;"></div> References: <ol> <li>Fundamental Studies of Human Locomotion and Other Information Relating to Design of Artificial Limbs. Subcontractor's Report to the Committee on Artificial Limbs. National Research Council. Prosthetic Devices Research Project, College of Engineering, University of California, Berkeley. Serial No. CAL 5. 2 vols. The Project, Berkeley, 1947.</li> <li>Radcliffe, C.W., "Functional considerations in the fitting of above-knee prostheses," Selected Articles From Artificial Limbs, Huntington, NY, Kreiger Publishing Co, Inc, 1970, p.p. 5-30.</li> <li>Winter, D.A., Biomechanics of Human Movement, New York, John Wiley & Sons, 1979, p.p. 9-46.</li> <li>Eberhart, H.D.; Elftman, H.; and Inman, V.T., "The locomotor mechanism of the amputee," Klopsteg PE, Wilson PD, et al (eds): Human Limbs and Their Substitutes, New York, Hafner Publishing Co, 1968, p.p. 472-480.</li> <li>Zuniga, E.N.; Leavitt, L.A.; Calvert, J.C.; Canzoneri, J.; and Peterson, C.R., "Gait patterns in above-knee amputees," Arch Phys Med Rehabilitation, 53:373-382, 1972.</li> <li>James, U. and Oberg, K., "Prosthetic gait pattern in unilateral above-knee amputees," Scand J Rehabil Med, 5:35-50, 1973.</li> <li>Murrary, M.P.; Sepic, S.B.; Gardner, G.M.; and Mollinger, L.A., "Gait patterns of above-knee amputees using constant-friction knee components," Bull Prosthet Res, 17(2):35-45, 1980.</li> <li>Godfrey, C.M.; Jousse, A.T.; Brett, R.; and Butler, J.F., "A comparison of some gait characteristics with six knee joints," Orthotics and Prosthetics, 29(3):33-38, 1975.</li> <li>Murray, M.P.; Mollinger, L.A.; Sepic, S.B.; Gardner, G.M.; and Linder, M.T., "Gait patterns in above-knee amputee patients: Hydraulic swing control vs constant-friction knee components," Arch Phys Med Rehabil, 64:339-345, 1983.</li> <li>Hoy, M.G.; Whiting, W.C.; and Zernicke, R.F., "Stride kinematics and knee joint kinetics of child amputee gait," Arch Phys Med Rehabilitation, 63:74-82, 1982.</li> <li>Hannah, R.E. and Morrison, J.B., "Prostheses alignment: Effect on gait of persons with below-knee amputations," Arch Phys Med Rehabil 65:159-162, 1984.</li> <li>Grevsten, S. and Stalberg, E., "Electromyographic study of muscular activity in the amputation stump while walking with PTB- and PTB-suction prosthesis," Ups J Med Sci, 80:103-112, 1975.</li> <li>Thiele, B.; James, U.; and Stalberg, E., "Neuro-physiological studies on muscle function in the stump of above-knee amputees," Scand J Rehabil Med, 5:67-70, 1973.</li> <li>Krebs, D.E.; Edelstein, J.E.; and Fishman, S., "Reliability of observational kinematic gait analysis," Accepted for publication in J Phys Ther, 1985.</li> </ol> <div style="width: 400px;"></div> Page Number(s) 18 - 23 Year 1985 Volume 9 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-6.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Gait Analysis in Prosthetics Creator An entity primarily responsible for making the resource James R. Gage, M.D. * Ramona Hicks, R.P.T., M.A. * https://staging.drfop.org/files/original/02b69054e99fc08b4b12033c4c735d90.pdf a11820a4a41bad505f07eb0c2b9d0fc9 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_017.pdf Text Any textual data included in the document <h2>Gait Analysis</h2> <h5>Ronald F. Altman, C.P.O. <a style="text-decoration: none;">*</a></h5> The following series of articles on Gait Analysis were based on a project which was supported by the Newington Children's Hospital Research Fund. The following series of articles all have to do with using gait analysis, in orthotics as well as prosthetics, to improve function. The Gage/Hicks study traces gait analysis in prosthetics from Inman forward, and the individual articles illustrate contemporary laboratory approaches to the objective assessment of gait. Fundamental to optimal lower-extremity prosthetic/orthotic service is an analysis of the gait of the patient. To the extent the method of analysis fails to provide adequate objective or useful information about gait, it allows for the possibility and probability that a less than optimum fit and/or alignment configuration has been or will be achieved. While gait analysis has long been an established procedure of varying objectivity in prosthetics, in orthotics the use of gait analysis has been rather ineffectual in assisting to optimize gait, a process which for the most part fails to go beyond a most rudimentary observation. This is due in part to the rudimentary functional characteristics of most orthoses. Advances in our profession as well as technology and materials can and do result in more functional orthoses. If we are going to provide the optimal orthotic design configuration for any given patient, it is essential that we define gait characteristics more precisely and reliably. Though not yet universally available, the increasing number of gait analysis facilities will soon benefit us all—patients and practitioners alike—as we gain access to the resulting information flow in formats readily usable by orthotists and prosthetists. *Ronald F. Altman, C.P.O. Director of Orthotics/Prosthetics Department at Newington Children's Hospital in Newington, Connecticut. Page Number(s) 17 - 17 Year 1985 Volume 9 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Gait Analysis Creator An entity primarily responsible for making the resource Ronald F. Altman, C.P.O. * https://staging.drfop.org/files/original/3c4ac589e8903780aa0da08c35aaeb58.pdf c97b050714fb3e489b9de161df583e40 https://staging.drfop.org/files/original/e764f2e58593ada37005d3d671580fcc.jpg e1b3b3b57afea255233eea6635c36111 https://staging.drfop.org/files/original/8d7c38e3e14f7ff5264b9dc030615015.jpg 6fcb2c844c796a0566c819a3ec665430 https://staging.drfop.org/files/original/3f65a33756d243d9afabd2712fe9240b.jpg 7e2a8536aa8f9635302e070c9e7f99ca https://staging.drfop.org/files/original/c0094ee66e32340329fd3c14ab5fdbf2.jpg 95b1799693489eae13885500343e64d2 https://staging.drfop.org/files/original/11c6bea9e74d7b47e03c2f589c5f3dcc.jpg c17a38b68b4a2e9a28ba4bfc88b46ab0 https://staging.drfop.org/files/original/a9f74838bb3d260e38168c79e38c620a.jpg c910911d2c29aac18ef5344138533538 https://staging.drfop.org/files/original/6c3b995cb38a1514af6eaf680994ddd0.jpg 29990018762f14ec45b71e8106effaaf https://staging.drfop.org/files/original/4efea2cf8a0ab176b2e02167045bf2c0.jpg f505f6705bbc9e93d3772e72f9a5b118 https://staging.drfop.org/files/original/f88f0a978929d9669ad1e8001308498d.jpg 2ed82df089dc35c181a50d43ec37a98e https://staging.drfop.org/files/original/e1c24db93cdb2a299cab3af1da2f2dc9.jpg 560f2db154b03d37f12eb9b6d864e7d2 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_013.pdf Text Any textual data included in the document <h2>A Below-Knee Weight-Bearing Pressure-Formed Socket Technique</h2> <h5>Robert F. Hayes, CP. <a style="text-decoration: none;">*</a></h5> I'm pleased that the Academy has requested that I update and rewrite the Below-Knee Weight-Bearing, Pressure-Formed Socket Technique article I originally wrote in 1975. It's hard to believe that ten years have passed since the original publication of this paper. I haven't made any significant changes regarding the principles or application of this procedure, but let's go back to some of the reasons this concept was developed. <a href="/files/original/e764f2e58593ada37005d3d671580fcc.jpg">Fig. 1.</a> Place a sheet of plastic wrap, such as Saran, over the patient's stump to keep it clean and to ease removal of the cast. As I explained in the original article, my son was being fitted for ski boots and it occurred to me that we might make use of some of the techniques used by ski boot designers. The ski boot had an inflatable inner bladder. With the foot under weight-bearing, a conforming material similar to certain silicone compounds was injected into the bladder to give a perfect form-fitting in the attitude of weight-bearing. The incentive to apply this technique to limb prosthetics was reinforced while I was casting a below-knee patient who was a dentist. We exchanged thoughts on molds and changes when pressures are applied. Dentists take one mold for a cast which is filled with dental impression cream (similar to alginate). This is applied to the patient under pressure to give a more accurate impression, and then this is filled to form the definitive positive mold. The standard method of fitting a below-knee amputee involves taking a negative cast in a non-weight-bearing condition, forming a positive model, modifying it in size to present dimensions by removing material to create pressure, and applying material to relieve pressure on the stump as appropriate. A socket is then molded over this model with the hope that, with small adjustments, it will fit the patient. Wouldn't it be wiser to develop a socket under pressure that will adjust to and fit the patient, rather than fit the patient to the socket? In trying to answer this question, the procedure described here was developed. <a href="/files/original/8d7c38e3e14f7ff5264b9dc030615015.jpg">Fig. 2</a>. Apply cast sock and felt relief pads. <a href="/files/original/3f65a33756d243d9afabd2712fe9240b.jpg">Fig. 3.</a> Using Plaster-of-Paris, wrap the residual limb in the usual manner. <a href="/files/original/c0094ee66e32340329fd3c14ab5fdbf2.jpg">Fig. 4</a>. Remove the tube gauze and felt buildup from the negative cast. <a href="/files/original/11c6bea9e74d7b47e03c2f589c5f3dcc.jpg">Fig. 5.</a> Pour and modify the positive model. <a href="/files/original/a9f74838bb3d260e38168c79e38c620a.jpg">Fig. 6</a>. Build up the distal end of the positive model at least 1". <h3>The Procedure</h3> Measure the patient in the usual manner. Place a sheet of plastic wrap material, such as Saran, over the patient's stump to keep it clean of indelible pencil, and to make removal of the cast easy. If a wool sock is to be used, apply it, and then apply the plastic wrap. Apply a cast sock or tube gauze over the stump. Bond 1/4" felt over all pressure-sensitive areas: the crest of the tibia and the head of the fibula. Keep in mind that all areas being built up will be filled with alginate to give contact, yet minimizing pressure. There are some prosthetists who have adopted this technique and claim they apply direct pressure over the crest of the tibia. My experiences do not agree with that. In particular, since many of our patients are diabetic with very thin skin, extra caution should be taken to reduce pressure and especially friction over all bony prominences. Using elastic Plaster-of-Paris bandage 4" wide, wrap the stump in the usual manner, and reinforce with 3" or 4" wide regular plaster bandage. Remove the cast and remove the tube gauze and felt buildup from the negative cast. Pour the positive model, remove the negative cast, and modify in the usual manner, but do not touch areas that were covered with felt. Build up the distal end of the positive model at least 1". <a href="/files/original/6c3b995cb38a1514af6eaf680994ddd0.jpg">Fig. 7.</a> Set up the transparent check socket for dynamic alignment. <a href="/files/original/4efea2cf8a0ab176b2e02167045bf2c0.jpg">Fig. 8.</a> Pour the alginate and let it escape through the distal holes until the patient is lowered into the socket to the proper level at which time the holes are blocked. The alginate will then escape along the proximal brim of the socket. Make a check socket. This is a perfect application for vacuum-forming. Plaster bandages or laminates can, of course, be used. Drill two holes 1/4" in diameter in the distal end and rough up the inside surface of the socket. For the first fitting, apply the stump sock of choice, and place plastic "wrap" over the stump sock to act as a separator. An invaginated balloon will not work because it adheres to the alginate that is to be used later. Some prosthetists apply the check socket to the patient's bare stump (no socks) for visual inspection. It bothers me to think what happens to the fit of this socket when the prosthesis is finished from this exact mold and the patient applies the usual stump sock of 3-ply or 5-ply. When the check socket is applied on new patients, I recommend using a thin-fitting sock in anticipation of stump atrophy. On seasoned, well-shaped stumps, I use the same sock that the patient usually wears. When using inserts that tend to compress, i.e. Pelite®, you may use a 3-ply and, after several weeks of prosthetic use, the socket should accommodate a 5-ply sock. Of course, there are many factors to be considered, and this is the area where the prosthetist's knowledge and experience will play the major role as to how well his or her patient does. Mix about 1/2 pint of dental impression cream or alginate (which is more economical). Pour about 1/3 of the total amount in the distal part of the socket and, with a spatula, spread the rest around the remaining surface of the socket. It is necessary to work quickly at this point. Place the socket on a fitting stool adjusted for height. Use some sort of pad to prevent slipping and cover the drilled holes in the socket with your thumb and forefinger. Have the patient place his stump in the socket. Let the alginate escape through the distal holes until the patient is lowered into the socket to the proper level, at which time the holes are blocked. Alginate will now escape along the proximal brim of the socket. <a href="/files/original/f88f0a978929d9669ad1e8001308498d.jpg">Fig. 9.</a> The completed socket. <a href="/files/original/e1c24db93cdb2a299cab3af1da2f2dc9.jpg">Fig. 10</a>. The completed socket. As soon as the alginate has set up, remove the stump from the socket and immediately fill the socket with plaster. The rigid socket and alginate are removed by using a cast cutter. The mold resulting is a perfectly smooth, pressure-formed, positive mold that can be used in any method of fabrication desired. When this technique is used, patients can be fit with sockets without soft liners. Only a minimal amount of additional time is required. I feel that the technique allows better fitting of "problem" stumps and that it may be used as a routine procedure to advantage, especially in central fabrication systems. Vacuum-forming procedures recently introduced make this approach to fitting even more attractive. We have since switched to clear plastic check sockets for the obvious advantage of visual inspection and also the ability to adjust check socket pressure areas with a heat gun on some plastics. We also now fit the check socket on the adjustable leg, rather than the fitting stool. This better simulates the pressures exerted on the stump by the definitive prosthesis, since we all agree that socket alignment greatly affects the application of pressure. I know that this procedure has been used by many prosthetists in various parts of the country, and I have received many favorable comments about the benefits to the patient. This pleases me because this is the goal of the process. I'm sure that in the future new devices and innovations will continue to add to and improve this concept to even greater benefit of the patient. *Robert F. Hayes, CP.President of Hayes Prosthetics, Inc., 1309 Riverdale Street, West Springfield, Massachusetts 01089. Page Number(s) 13 - 16 Year 1985 Volume 9 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Below-Knee Weight-Bearing Pressure-Formed Socket Technique Creator An entity primarily responsible for making the resource Robert F. Hayes, CP. * https://staging.drfop.org/files/original/ff3340abee0b201874784eb994f1540f.pdf c2e3cc34fa9285809d54831e90850af8 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_011.pdf Text Any textual data included in the document <h2>The Role of Test Socket Procedures in Today's Prosthetic Practices</h2> <h5>Michael J. Quigley, C.P.O. <a style="text-decoration: none;">*</a></h5> The proper role of a test socket procedure is a controversial topic in today's practice of prosthetics. A test socket procedure can be defined as that stage in the design of a prosthesis when a socket is fabricated solely for the purpose of determining proper socket fit. Although test sockets were originally used for upper limb prostheses, the true advent of the test socket was in 1972 when Mooney and Snelson<a></a> described the polycarbonate clear test socket as developed at Rancho Los Amigos Hospital. During the 13 years since that article, the proper role of the test socket procedure has still not been defined. There are several reasons for the controversy over test sockets. First, when a test socket procedure is done, there is an implication that the mold, mold modifications, and socket design principles instilled in the prosthetist may not be correct. After all, if the prosthetist's techniques were perfect, the socket would fit perfectly and the need for a test socket would be obviated. However, any time a clear test socket is used, the prosthetist immediately notices a few things he would like to change in the definitive socket or, in some cases, the next test socket. It is safe to say that the majority of United States prosthetists believe in the value of test sockets and use them on a regular basis. Indeed, insurance companies and most other third party reimbursers, including Medicare, pay for test sockets, thereby recognizing twin values. A test socket procedure makes good sense, and there is no question that it improves prosthetic fitting. However, it is also true that many prosthetists do not use these sockets, or use them only rarely. The group that does not use test sockets feels that they can fit nearly all prostheses well without test sockets and do not want to spend the additional effort that test sockets require, or they simply do not want to change the methods they learned many years ago. The present Veterans Administration's (VA) procedure for obtaining approval for test sockets seems to favor this latter group, since it is an intentionally cumbersome system that, in effect, discourages test socket procedures on VA patients. Test socket users also include prosthetists who routinely use multiple test sockets on every patient, with the principle that each successive socket brings you one step closer to the perfect fit. If one test socket procedure is good, shouldn't two be better? Or three? Or more? This is a major area of controversy that could be discussed here but not resolved. Probably the best example of this use of test sockets is at the Institute for the Advancement of Prosthetics (IAP) in Lansing, Michigan (although a number of other prosthetic practices are also using multiple test sockets, or featuring them as a type of "first class" service). An average of six test socket procedures are done on each patient in Lansing: beginning with static fittings in clear sockets with the patient wearing no prosthetic socks, going on to clear socket dynamic (walking) fittings, and progressing to a definitive socket with a gel liner for below knee amputees. The patient is seen every day for two to three weeks until the socket fit is perfected, and only then is the prosthesis finished. This, of course, is an expensive undertaking, but it seems logical to assume that with so much time and energy spent, the patient would end up with a better fit. The multiple test socket users lead an Utopian existence, seeking the perfect fit, and see only one or two patients every week or continue fittings for many months if they are seen only on a weekly basis. For the average prosthetist who fits 100 or more patients alone each year, the sheer logistics of using multiple test sockets on every patient is staggering. Another area of controversy regarding test sockets is that they provide an incentive for prosthetists to delay being satisfied with the socket fit if they are paid separately for every test socket used. If they fit six test sockets, they are paid six times more than if they fit one test socket. The only response to this problem is that there are a few difficult cases where the only way a good fitting can be achieved is with multiple sockets, and the prosthetist should be reimbursed for his effort. On the other hand, there are always the few people who will abuse the system. In practice, less than five percent of all prosthetists have the time or inclination to routinely use multiple test sockets. After all, there are also very few patients or insurers who want to bear the expense, are able to make all the appointments necessary, and are willing to wait the many months for a finished prosthesis when multiple test sockets are used. Before summarizing, one final comment is necessary. Having test socket procedures available and using test sockets properly are two different things. There are no standardized, recommended, or documented procedures for the proper use of a test socket. Some people use clear sockets, some do not. Some use "wet fit" procedures with no prosthetics socks; others use prosthetic socks. Some test sockets are used statically, others dynamically. Alginate procedures are used in some areas. Even when a clear socket is used directly against the skin, how do we interpret what we are seeing? The result of the confusion over the proper use of a test socket is that the prosthetist converts one of the few objective tools he has available (a clear socket) into a subjective one by having to use educated guesses to determine the modifications needed to improve socket fit. The whole area concerning the optimum use of test socket procedures is in great need of study and documentation. In summary, test socket procedures are good procedures. When a prosthetist knows that the socket he is fitting is not the final product, he is more likely to make major socket modifications and, therefore, less likely to provide a poor fitting prostheses. Multiple or successive test sockets will always be required on a few difficult cases. In some areas, the patient and prosthetist will afford the luxury to use successive test sockets to try to achieve the perfect fit, but this will probably include less than one percent of the patient population. It is obvious that these socket procedures are here to stay and that the use of test sockets will increase as new materials and techniques are introduced. Hopefully, some meaningful documentation will be developed to enable prosthetists to obtain as much information as possible from a test socket procedure. Without a true understanding of how to properly use a test socket, each prosthetist is left to practice and develop his own technique, and the art of prosthetics again overwhelms the science. References: <ol> <li>Mooney, V. and Snelson, R., "Fabrications and Applications of Transparent Polycarbonate Sockets," Orthotics and Prosthetics, 26 (1), p.p. 1-13, March 1972.</li> <li>Personal communication, Jan Stokosa, CP., May 6, 1985, Lansing, Michigan.</li> </ol> *Michael J. Quigley, C.P.O. Michael J. Quigley, C.P.O. is President of Oakbrook Orthopedic Services, Ltd. 1 South 132 Summit Ave, Ste 102, Oakbrook Terrace, IL 60181.   Page Number(s) 11 - 12 Year 1985 Volume 9 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Role of Test Socket Procedures in Today's Prosthetic Practices Creator An entity primarily responsible for making the resource Michael J. Quigley, C.P.O. * https://staging.drfop.org/files/original/cc46ad414ca9f0d932c9c1bd427dabc4.pdf 497441a68e5f2a4eef555521963106c4 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_010.pdf Text Any textual data included in the document <h2>The New Revolution</h2> <h5>Timothy B. Staats M.A., C.P. <a style="text-decoration: none;">*</a></h5> The recent development and proliferation of advanced and precision fitting techniques in prosthetics have caused many prosthetists to reevaluate those principles which were held sacred for the past twenty years. In the last three years in particular, both below-knee and above-knee prosthetics have undergone tremendous changes. Many progressive practitioners recognize that the term "Patellar Tendon Bearing (PTB)" is no longer considered descriptive of a well designed below-knee socket and use the term only in a historical sense. The term Total Surface Bearing better describes what has superseded PTB philosophy. In above-knee prosthetics, a greater revolution is in the offing. Now the CATCAM (Contour-Adducted-Trochanteric-Controlled Alignment Method) socket is shaking the underpinnings of the Quadrilateral above-knee socket design. For those of us who are "dyed-in-blue-and-gold-UCLA-Quad-socket" prosthetists, it is both difficult and exciting to see the development and confusion a rival design causes throughout the profession. I am sure that thirty years ago the "wood-socket-plug-fit" prosthetists shared a similar feeling when the quadrilateral socket and later the introduction of plastics caused their world to turn upside down. The point is that change and improvement are inevitable. You can fight it and it will flow over you like a river, or you can go with the flow and learn to adapt to new techniques. I have been asked repeatedly what I think about the use of multiple check socket fittings, CATCAM, alginated check sockets, and the Flex-Foot. The list goes on and on. American prosthetists in particular must understand that we are in the midst of a full blown revolution and the results of this revolution will set the path we follow for the next couple of decades. Rather than question what is right or wrong without really having proof of either, I have chosen a path as the director of a prosthetics education program of "pouring fuel on the fire." What better time or place for controversy than at UCLA, where the first school was started over thirty years ago. Is all this extra precision and care really necessary to accurately fit an artificial limb? The answer is quite simple, and if you are an amputee the question is repulsive. If superior techniques that can improve the quality of the care provided to amputees are available but are not used, it is nothing less than criminal. There are those who would question: how much of a good thing is enough? That is a question that the patient must answer and the prosthetist must decide based on knowledge and education. The fact that many of the newer techniques and fitting regimes demand more time and effort than methods which have been in use for twenty years is entirely a separate issue. While it may not be possible to provide these services for the reimbursements, which are now received from payment sources, this does not mean that the techniques do not work or are wrong. It only means that the third party payers are ignorant of changes which have occurred in our profession and must be introduced to the benefits of new procedures. This same principle applies to prescribing physicians. It is totally fair to say that a physician who took his prosthetics-orthotics training over five years ago is now out of date. The same is true for practitioners who have not upgraded their practices through educational opportunities during this period. It is always uncomfortable when you begin to wonder whether you are doing the best you can for your patient. It is even more uncomfortable when you know you are not. We should never be satisfied with our work and never doubt that a better job can be done. With such a philosophical upheaval running rampant through our profession, the time for learning is now. Are you satisfied with application of outdated techniques, or are you willing to enter a new era of prosthetic and orthotic practice? The choice is yours. *Timothy B. Staats M.A., C.P. Timothy Staats, M.A., CP., is Adjunct Assistant Professor and Director of the Prosthetics &Orthotics Education Program at UCLA, Rehabilitation Center, 1000 Veteran Avenue, Rm 22-41, Los Angeles, CA 90024. <div style="width: 400px;"></div> Page Number(s) 10 - 11 Year 1985 Volume 9 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The New Revolution Creator An entity primarily responsible for making the resource Timothy B. Staats M.A., C.P. * https://staging.drfop.org/files/original/b3a2c7a0584c7b41faa78f8463cf4268.pdf f252ffd28bf2d19a88c0995299dca5af Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_004.pdf Text Any textual data included in the document <h2>An Advanced Approach Toward Improved Prosthetic Fittings</h2> <h5>David F.M. Cooney, R.P.T., C.P.O. <a style="text-decoration: none;">*</a> Keith E. Vinnecour, C.P.O. <a style="text-decoration: none;">*</a></h5> The importance of amputation surgery and dedicated follow-up cannot be underestimated by those clinicians who deal with the amputee population. A prosthetist who receives a patient with a residual limb that is of the optimum configuration to receive a prosthesis and permits the lowest energy cost with maximum unilateral weight bearing comfort, is too often the exception. A concerted effort by all professionals involved—physicians, nurses, physical and occupational therapists, psychologists, social workers, and prosthetists—is required for truly successful rehabilitation. <h3>Delineation Of Level</h3> Successful primary healing in patients who have experienced a trauma related amputation is not as great a concern since the average age of this group is much younger than the dysvascular amputee. For the majority of patients who require prosthetic care due to vascular insufficiency, predictions for successful healing, and therefore level of amputation, is a critical consideration and of primary address here. The following discussion and techniques employed, however, can apply to all prosthetic fittings. In the dysvascular patient, the correct assessment of tissue viability and level of limb amputation is paramount to successful rehabilitation. Correct assessment also serves to reduce the length of the hospital stay and, therefore, costs. Patient morbidity and mortality are also reduced.<a></a> A number of methods are employed to determine amputation level. Absolute determinants include ischemia and necrosis. Skin temperatures, absence of hair, sensory deficits, and peripheral pulses are also clinical tools of relative, though unreliable, demarcation. A less direct way of determining level of amputation is the condition of the underlying tissues and skin bleeding during surgery.<a></a> Objectively defined methods are being used to more accurately determine surgical level. Doppler pressure measurements use systolic pressure differentials between the level of concern and brachial pressure. The literature cited offers relative values for prediction of successful healing,<a></a> but also points out the Doppler method's fallibility.<a></a> Two other non-invasive tests, segmental systolic pressure readings and pulse-volume recordings, can provide a reasonably valid prediction of primary wound healing, but should not be used as the sole indicators for amputation site.<a></a> Thermography has been used to estimate the optimal site of amputation. Infrared emissions from the involved extremity are displayed on a screen to show temperature differentials. One study claimed a 96 percent success rate with amputation levels recommended via thermography<a></a>. Skin blood flow by the Xenon-133 clearance techniques to predict primary healing levels in amputation surgery have shown positive results. A 100 percent primary amputation healing is claimed by these authors for surgeries where recommendations according to their standards were followed.<a></a> The choice of any of the above methods rests with the abilities of the institution. Though most non-invasive means are available throughout the medical community, invasive techniques using radioactive isotopes, like Xenon-133, require the availability of a nuclear medicine department. Clearly, not all facilities have this capability. Once the level of tissue viability and surgical healing have been determined, operative procedures commence. A residual limb offering optimal function should be a "well muscled, durable stump of effective length with a pliable skin cover that has adequate sensation." The means to this end requires careful attention to the handling of the bone, nerves, and soft tissues.<a></a> <h3>Surgery</h3> Subsequent to determining the amputation level is the actual surgical technique, which is an important adjunct to successful rehabilitation of the amputee. Handling of the bone requires close attention to the residual cortical shaping, and in standard practice it should be beveled to prevent sharp margins and potential socket problems.<a></a> The reaction of the bone to surgical handling of the periosteum is not fully understood, but when dealing with tissues that are compromised initially, one cannot fault a "kid-glove" approach to dissection and ligation. Delicate handling may avoid subsequent spurring along the bony margins.<a></a> It has generally been considered that fibular length should be less (approximately 2.0 cm.) than the length of the tibia.<a></a> The authors feel that fibular length should be equal to or no more than 5 mm. shorter than the cut tibia. It is felt that this improves prosthetic medio-lateral stability, provides greater distal bulk, and serves to prevent mature conical shaping and increase total tissue contact and weight-bearing. In the procedure described by Ertl,<a></a> the lengths of the two bones are equal. A bony bridge, or periosteal flap, is then created to afford an end bearing residual limb. This synostosis also prevents any relative motion of the two bones. The tibiofibular osteoplasty closes the open medullary canals and can recreate the normal conditions of direct weight bearing pressures and circulation in the long axis of the bone. This can help prevent degeneration in the joints proximal to the amputation.<a></a> It would seem that this procedure should warrant greater attention in appropriately selected patients (especially in light of the much improved fitting techniques now available). Establishing stabilization in the distal musculature at the selected site of amputation is important to provide a more physiologically effective residual limb. Where surgically feasible, the muscles should be sutured to each other as well as to the periosteum and/or bone without excessive tension or laxity. This allows for a well contoured and generally less prosthetically troublesome limb.<a></a> Nerve tissue should be handled meticulously to avoid residual problems once prosthetic wear is initiated. Each nerve should be individually dissected and have adequate traction applied. Severing of the nerve with traction maintained will cause it to retract far enough up into the soft tissue so as to be well protected and less threatened by weight bearing pressures.<a></a> Prosthetically crucial are the smaller sural and saphenous nerves, as they are sometimes neglected in lieu of the more major posterior tibial, deep and superficial peroneal nerves.<a></a> Redundancy of soft tissues should be avoided, but adequate coverage of the remaining structures is a must in order to provide a good limb for weight bearing. Closure of the wound should include careful suturing and handling of the already compromised tissues and care should be taken to avoid traction at the suture line so as to prevent contractures of the joint.<a></a> It has been shown again and again that immediate post-surgical fitting procedures can improve residual limb viability, reduce pain and edema, and prevent contractures.<a></a> Rigid dressings are common practice in immediate post-surgical fittings, but variations on this theme include the use of pneumatic devices that can also afford the advantages of their more rigid counterparts.<a></a> More tenuous situations that may not allow for early weight bearing and ambulation, secondary to healing problems, can be approached through the use of Una boot dressings<a></a> and an innovative removable rigid dressing technique.<a></a> Invariably, the independent and/or conjunctive use of any one of these methods can enhance the post-operative management of even the most difficult rehabilitation patient. By improving a patient's physical and mental status and by providing mobility through this approach, the clinical team can increase a patient's rehabilitation potential.<a></a> <h3>Prosthetic Evaluation</h3> Little has changed in the physical aspects of evaluation. Standard anthropometric measures are still used to provide an objective record for modifications and fabrication, and for comparative purposes related to future changes. Accurately determining the anatomical joint range of motion (both in the involved and uninvolved limb) and strength/stability can provide criteria for prescription and serve to mediate problems during fitting. One new tool in the evaluative process is Xeroradiography®. Xeroradiography® is a process that yields an x-ray image on an opaque background. The picture records are easier to store than their x-ray counterparts and provide a clear definition of both the bony anatomy and soft tissue. Evidence of bone spurring, vessel calcification, and presence of vascular surgery staples is readily observed. Measurements are also easy to glean. The use of this information in the treatment of the amputee is obvious and can significantly improve and objectify the prosthetist's skills and, ultimately, improve patient management.<a></a> <h3>Casting</h3> Adopting a "hands-on" technique in the quest of obtaining an anatomical replica of the residual limb should be the goal of the prosthetist. A careful volume study of the involved limb can serve to optimize the definitive results. The growing use of static and dynamic test sockets, and the information provided by them, has yielded a twist on the time tested practices utilized by many prosthetists. The technique of automatic build-ups over sensitive areas has been found to be less than necessary. Reversing this thought process to promote negative model modifications over areas of weight bearing can provide better total-contact, total-weight bearing sockets. Doing this in the molding process can reduce the amount of relatively educated guesswork necessary in cast modification by producing better initial cast molds. Methods which have been developed to aid in this pursuit include vacuum casting<a></a> or a three to four stage alginate casting technique.<a></a> Another method to improve fit from the initial casting is to work toward a more dynamic casting method. As the casting is predominantly done under non-weight bearing conditions, working toward more "dynamic" casting methods which equalize the weight bearing pressures is warranted consideration. Where an Ertl procedure has been performed, distal weight bearing casting is preferred to achieve maximum results. The same intent should be attempted with the non-Ertl distal end as well. Ultimately, the better the quality of the cast and the less initial modification guesswork, the better the test socket fitting. <h3>Test Socket</h3> Use of clear test sockets for improving fit is well documented in the literature cited. Though the technology for transparent test sockets has been available since the 1950's, the current practice of direct weight bearing modifications to the socket are relatively new.<a></a> During the initial static weight bearing period, areas of the residual limb are demarcated according to weight distribution and, therefore, load. This is evidenced by varying degrees of blanching or redness. The goal of a total tissue bearing socket is then pursued to decrease areas of excessive pressure (blanching) and to increase areas of inadequate loading (redness). This goal can be met through either static or dynamic test socket volume changes, or cast model modifications. Under weight bearing conditions, loose areas are marked by redness, and tension analysis is accomplished via "poking" the tissue through holes made in the socket. Various injectable materials (glycerine, alginate, pour-a-pad) are then added to equalize weight bearing pressures. Areas of excessive weight bearing, if not relieved by the weight borne by the newly injected materials, are either relieved in the socket or modified on the master mold. By achieving a careful stump-socket interface tension analysis as described, greater confidence in he ultimate result and an optimum fit is possible. Difficulty of fit dictates the number of check socket fittings. Unfortunately, fittings are also affected by the reimbursement source. The fact is undeniable, however, that a transition to the use of transparent test socket fittings can increase the level of prosthetic expertise and elevate the profession to a higher plateau of fitting success. <h3>Dynamics</h3> Advancements in prosthetic componentry and gait analysis techniques, when used in conjunction with improved evaluation tools and fitting methods, provides a greater arsenal for the prosthetist seeking to optimize his patient's abilities. An exciting variety of new techniques are surfacing throughout the country which not only render prosthetics more professionally demanding to the practitioner, but also challenging to the patient. Different socket styles and theoretical bends are adding to current thought and practice. The above-knee amputee now has a variety of alternatives in not only socket material and construction, but in functional design as well. The Swedish flexible socket offers a lighter weight, more "natural" feeling socket to the AK amputee. It also allows for greater transmission of heat via the polyethylene or Surlyn® material, and therefore a cooler feeling. The flexibility of the socket also encourages physiological muscle activity and provides sensory feedback through the thin material.<a></a> Contoured Adducted Trochanteric Controlled Alignment Method (CATCAM) is an exciting new above-knee socket design. Proponents claim it increases comfort secondary to total soft tissue weight bearing, because the ischial tuberosity is no longer on the "seat" of the conventional quadrilateral design, but contained within the socket. The CATCAM also allows for more natural muscle activity by virtue of both the flexible design (a la Swedish flexible socket) and inherent socket mechanics. By improving the socket's purchase on the femur, whereby the ischium, trochanter, and adductor longus tendon are in essence "locked-in," stabilization increases, which then decreases the Trendelenberg tendencies experienced by many above-knee amputees. By obtaining a definite position of adduction of the femur, one can take advantage of the muscle stretch of the gluteus medius and therefore increase pelvic control with unilateral weight bearing.<a></a> Ultralight weight components continue to be preferred in the above-knee prosthesis. The availability of titanium, carbon graphite, and higher density plastics in the manufacturing of the pylons, joints, and attachment plates allow for lighter weight limbs and, ultimately, decreased energy costs for the amputee. The below-knee amputee has a varied repertoire of options. A greater array of suspension methods—latex rubber, neoprene sleeves, total suction prostheses—are now available. The Flex-foot prosthesis<a></a> utilizes a sleeve suspension and is comprised of a carbon graphite and fiberglass pylon and a heel that is very strong, light weight, waterproof, and energy cost effective. The Flex-foot design provides "stored energy" upon weight bearing that "propels" the amputee forward, mimicking "normal" muscle activity in gait. This can also be used for the above-knee amputee. The Flex-foot is proving to be a great advance toward increasing the abilities of the athletic amputee and shows great promise for the elderly and less physically challenged. New liner materials have also provided alternatives for the below-knee amputee, with greater comfort as a result. Silicone gel and leather liners,<a></a> Ipocon gel,<a></a> and injection molded silicone gel liners<a></a> offer the amputee who has minimal tissue coverage and/or scarring the benefit of shock absorption and a "new skin" type feel. The active, athletic below-knee amputee also captures the benefit of the gel system and suffers less trauma as a result. Prosthetic feet, such as the Seattle<a></a> foot and S.A.F.E.<a></a> foot, appear to offer better gait characteristics and function, and also allow for increased activity by virtue of their functional, flexible designs. Ancillary methods of evaluating and improving gait performance are making their way into the more aggressive practices. John Sabolich, C.P.O.<a style="text-decoration: none;">*</a> in Oklahoma City has been utilizing a bio-feedback device with his above-knee patients in an attempt to re-educate the gluteus medius muscle during gait training. Utilizing the system in a dynamic fashion, i.e. patient ambulating with the electrodes over the targeted muscle, provides the patient audible feedback of muscle activity. Use of a video tape camera also provides patients with optimum benefits during the alignment and gait training period.<a></a> Careful analysis of the saggital and frontal views provides the practitioner with a better opportunity to critically analyze and improve his patient's gait. Improved problem-solving subsequent to delivery is also a benefit of this technique. The film serves as a learning tool for the new amputee and the practitioner, and also serves as a record of a patient's progress and delivery status for ironing out future fitting problems relative to gait induced complaints. The Computer Aided Design, Computer Aided Manufacturing (CADCAM) technique<a></a> is presently available for use in designing below-knee prosthetic sockets and will soon be available for design of above-knee prosthetic sockets as well. Measurements are taken from the residual limb and entered into the program. A screen display then allows for modifications to be made relative to the entered data and design scheme. Once the design is created, the information is transmitted to a computerized milling device that then carves out a model of the residual limb. From this model a socket is fabricated from polypropylene. In the future, "shape-sensing" will allow for modifications from the sensed data rather than the standard methodology. The ability to draw from the digitalized information of Computerized Axial Tomography (CATSCAN) or x-rays is also in the offing. This system is also an excellent, accurate record keeping tool. The potential to "sense" size and shape, store the information, recall, modify, or duplicate as desired is an enticing prospect. Further research is both warranted and forthcoming. <h3>Conclusion</h3> With the advent of better technology and methods, a concomitant increase in prosthetic professionalism occurs. Improved education must also follow. Industry-wide attention to continuing the trend will help prevent our field from lapsing into the mundane. The practice of this increased professionalism and improved techniques also commands a higher cost. Jan Stakosa, C.P.'s<a style="text-decoration: none;">*</a> method of using a wide variety of componentry per patient during the fitting and alignment phases in order to optimize function not only serves to improve the patient's quality of life, but carries with it an increased time commitment and cost. Due to this increased input and component variability, thorough education of the public and professionals per the costs involved is required. Ultimately, third party payers and the government will also have to be addressed. Until such time as these practices and advancements become standard, there will not be reimbursement for them.<a></a> How do you value human needs in a marketplace in which the trend is toward price reduction? The reality is that all these advances will increase the cost of prosthetic care. Prosthetists, the public, third party payers, and the government will need to be willing to improve the quality of life for this sector of the population, who deserve to be rehabilitated to the maximum and be allowed to perform as well as any able-bodied individual. It is our hope that the prosthetic industry will take up the challenge to advance the profession and invest the time in testing preferred methods and improvements. Equally important is the quest to participate in their creation. Through improved knowledge of the mechanics of amputation surgery and the variables of follow-up care, combined with mutual professional dialogue, we can better serve the amputee population. 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University of California, Los Angeles, April 5-9, 1982.</li> <li>Staats, T.B., "Advanced prosthetic techniques for below knee amputations," Orthopedics, 8(2):249-258, 1985.</li> <li>Stakosa, J.J., "Prosthetics for lower limb amputees," Vascular Surgery: Principles and Techniques, Norwalk, CT, Appleton-Century-Crofts, p.p. 1143-1162, 1984.</li> <li>Sterescu, L.E., "Semirigid (Una) dressing of amputations," Archives of Physical Medicine and Rehabilitation, 55:433-434, September, 1974.</li> <li>Varnau, D.; Vinnecour, K.E.; Luth, M.; and Cooney, D.F., "The enhancement of prosthetics through Xerora-diography," Orthotics and Prosthetics, 39( 1): 14-18, 1985.</li> <li>Whipple, L. and Stakosa, J., "The not so simple ABC's of high technology," Disabled USA, Washington, D.C., July, 1983.</li> <li>Wu, Y.; Keagy, R.D.; Krick, H.J.; et al., "An innovative removable rigid dressing technique for below-the-knee amputation," Journal of Bone and Joint Surgery, 61-A(5):724-729, 1979.</li> </ol> <div style="width: 400px;">Footnote Jan Stakosa, C.P. is Director of the Institute for the Advancement of Prosthetics, Lansing, Michigan. John Sabolich, C.P.O., is Vice-President of Sabolich Orthotics-Prosthetics Center, Oklahoma City, Oklahoma. </div> <div style="width: 400px;">*Keith E. Vinnecour, C.P.O. Keith E. Vinnecour, C.P.O., is owner and president of Beverly Hills Prosthetics Orthotics, Inc., Beverly Hills, California. *David F.M. Cooney, R.P.T., C.P.O. David F.M. Conney, R.P.T., C.P.O., is a senior vice-president at Beverly Hills Prosthetics and Orthotics, Inc. </div> Page Number(s) 4 - 9 Year 1985 Volume 9 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource An Advanced Approach Toward Improved Prosthetic Fittings Creator An entity primarily responsible for making the resource David F.M. Cooney, R.P.T., C.P.O. * Keith E. Vinnecour, C.P.O. *