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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/1986_02_066.pdf Text Any textual data included in the document <h2>Upper Limb Powered Components and Controls: Current Concepts</h2> <h5>John W. Michael, M.Ed., C.P.O. <a style="text-decoration: none;">*</a></h5> In order to review the current offerings in powered upper limb components, it is necessary to agree upon certain standardized terms. The following suggestions, based upon a survey of the existing literature, are intended to help insure we are all speaking a common language. Practitioners with strong opinions regarding alternate definitions are encouraged to publish their views as well. It is critical that we agree upon some definition; which particular version is of much less importance. The focus of this paper will be on externally powered prostheses—specifically, those that are electrical in nature. The opposite concept is the familiar body powered prosthesis, which is powered by muscular action and transmitted from remote body locations. Many prosthetists have some experience at the below-elbow level with the components produced by Otto Bock, and assume they have fitted myoelectric devices. Technically, that is not completely correct. The MyoBock system is most accurately termed "Myoswitch" control. This is a much simpler version than true myoelectric control. In the Otto Bock system, the residual myoelectric signal does not directly control the terminal device. Instead, the patient must generate a sufficiently strong signal to cross a threshold, which triggers an electronic switch. A good analogy would be that of sound-activated devices which can be installed in lieu of a standard light switch. Clapping one's hands turns the light on. If the clap is too faint, nothing will happen, but an extremely loud clap has no more effect than one just loud enough to trigger the switch. This is sometimes described as "digital control." This approach does not allow proportional control. That is, the light is either all on, or all off. There is no in-between. Proportional control is provided by a rheostat, which allows one to gradually dim or brighten the lights as the mood dictates. Proportional control is, in this author's opinion, the key distinction in true myoelectric systems. The below-elbow system marketed by Fidelity Electronics is an example of such a design. In this version, a mild myoelectric impulse causes a slow, gentle movement of the hand, while a strong impulse creates a rapid, powerful movement of the hand. Many authorities feel this is the most physiologically natural control, and offers the greatest degree of prehension control as well.<a></a> A good analogy is the accelerator in an automobile, which allows proportional control of the speed of the vehicle. Imagine a switch-controlled car with the throttle either at idle or wide open! Otto Bock has a very clever solution to this dilemma: the automatic transmission. The MyoBock prosthesis has two speeds: a quick, gentle motion when opening and closing, and a slow, powerful motion once the fingers grip an object. This might not be a reasonable solution for the auto industry, but it has proved to be clinically acceptable in prosthetics. The third available control mode is pure Switch Control. This is the least expensive approach and generally requires less bulky electronics. For these reasons, it is often used in juvenile below-elbow designs (for example, Variety Village). It also does not require any myoelectric signals, which can be helpful when control sites are limited or unavailable. Switch controls come in three basic varieties. <ol> <li> Rocker Switches are similar to the on-off control for stereo equipment, and are sometimes used where a mobile acromion is present. </li> <li> Button Switches are also adaptable for acromion control, for use with phoco-melic digits, and any other mobile body parts. They are the electronic analogue of mechanical nudge control. </li> <li> Pull Switches are useful when harness control is desired. Most are multiposi-tional, where initial excursion will cause one motion, and further excursion the opposite motion. These are somewhat analogous to the alternating lock used in the conventional elbows with one motion controlling two or more functions. </li> </ol> These are simply the most common types; literally hundreds of variations can be obtained from electronic supply stores. On rare occasions, they can be arranged in a piano keyboard array, allowing several degrees of freedom to be controlled from one location.<a></a> Another set of related concepts are "site and state."12 Site refers to the number of distinct muscle signals required. Thus, the original Myobock system was a "two site" version, requiring one myosignal for hand opening and a separate signal for hand closing. The University of New Brunswick (UNB) was one of the first groups to develop a commercial system that required only one myosignal. This is particularly advantageous when dealing with young congenital below-elbow patients. Very often they can only generate one mass contraction in the residual limb, and space considerations alone may preclude more than one electrode. UNB termed their system "Single Site/Three State" control. The term "Three State" means that the myopulse both opens and closes the hand; the "third" state is "off." In the last couple of years, Otto Bock has introduced their version of this concept. As in the UNB design, it is a digital "Myoswitch." A quick, hard myopulse causes the hand to open, while a slow, gentle myopulse causes closure. Bock calls this "Double Channel Single Site" control. "Double Channel" accurately identifies the capabilities: one channel opens and the other closes. Unfortunately, the word "channel" has established meanings in other fields that may be a source of confusion. For maximum clarity, the term "Function" is probably preferable.<a></a> This has a clear intuitive meaning. Thus, the system just described would be termed a "One Site-Two Function" system. With suitable changes in the terminal device electronics, Otto Bock can offer what they term "Grip Force" control which is a kind of psuedo-proportional control. In this application, the patient can use the quick, strong pulse to automatically downshift the transmission, thereby increasing the grip strength. A logical extension of this approach is Bock's "Four Channel" design. One electrode controls terminal device opening and closing while the other controls electric wrist pronation and supination—four distinct functions. Clearly, if suitable sites could be found, additional degrees of freedom could be controlled using existing technology. Experience has shown, however, that this is rarely feasible. In the above-elbow realm, the developers at Motion Control argue strongly that proportional control is the ideal. Therefore, they avoid the digital control mentioned thus far. Yet, they have developed a system permitting only two muscle sites to operate elbow raising and lowering, as well as terminal device opening and closing. Thus far, their solution is unique in the field of powered components. The Motion Control design uses a very clever method of electronic switching to separate elbow and terminal device functions. When the arm is first powered on, the two muscle sites proportionally control elbow flexion and extension. (In an ideal candidate, biceps and triceps are the remnant muscles yielding physiologically normal control as well.) Whenever the elbow is in motion, things remain in this mode. However, if the elbow is stopped in a flexed position and held steady for a moment, the arm "senses" that one intends to perform a grasping function. It then locks the elbow and automatically switches itself into a "grasping" mode. The same two sites now control proportional, bidirectional grasp. To return to the "elbow" mode, the patient co-contracts in a specific fashion. The co-contractures cancel each other out so that no motion of the TD occurs, and the electronic switch senses this and changes modes. This strategy can be termed "Sequential Control", and is directly analogous to the familiar mechanical elbow joint where the same shoulder motion moves first the elbow and then the terminal device. The most sophisticated control for a high level amputee would be Simultaneous Proportional Control. Northwestern has done some fascinating work in this area,<a></a> as has the Illinois Institute of Technology and others.<a></a> This would be the most natural-appearing motion, since our biological arms move through multiple degrees of freedom simultaneously with every gesture. However, there are numerous technical and control difficulties with this approach, and all seem to be far from commercial production right now. One major issue is control site availability. Even if one conceives of an arm offering twenty simultaneous degrees of freedom, where on the high-level amputee are twenty independent controlable sites to be found? Much of the current research involves reading data from a few sites and using computer algorithms to simulate multi-degree control.<a></a> Most currently require a mainframe computer to process the data in real time, but perhaps the future will see microchip processors with these capabilities built into upper limb devices. But, for now there are less spectacular components to choose from. What follows is an overview of currently available hardware. Specific details change almost weekly; contact the manufacturer for the latest updates. The final caveat is: the ideal system does not exist. All the components have strengths and weaknesses. When prescribed correctly, one can achieve very satisfying results. When used inappropriately, failure is the inevitable result. As prosthetists gain more collective experience and confidence in the realm of powered upper limb prosthetics, perhaps we can learn to "mix and match," as we do in body powered fittings, to maximize the benefits for our patients. <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-01.jpg">Fig. 1. Otto Bock electric hand and electric hook (Greifer). Bilateral powered fittings can be successful in carefully selected cases. (Courtesy of Otto Bock Industries.)</a> <h3>Otto Bock</h3> In the United States, Otto Bock is viewed as the "father" of electrically controlled prostheses. Although all their current designs are digital controls, they offer one of the largest arrays of interchangeable electric components of any manufacturer. At this time, all Otto Bock components are designed for below-elbow use, although they are equally adaptable for higher levels. One ramification of this is that since 1976, they have been using six volts as their standard. (Twelve volt terminal devices can be obtained for use with other manufacturers' systems.) Six volts offers lower battery weights while still providing adequate power for terminal device operation. Otto Bock's battery is a relatively small package, easily interchangeable, but for slow recharge only. Their "Griefer" is the only adult-sized powered hook currently on the market, and it readily interchanges with their adult hands. They also have the only electric wrist rotator currently available. They currently offer four hand sizes, for older children, teens and ladies, standard adult, and large adult males. These have become the de facto standard in the industry; virtually every other company can interface their system with a MyoBock hand. An assortment of wrists are also available. All their electrodes are digital, myoswitch types, as already discussed. They offer optional floating electrode mounts for cases where a change in residual limb volume is anticipated. Since their terminal devices are set up for myoswitch control, it is relatively easy to use regular switch control as well. Otto Bock offers both a rocker switch and a harness pull switch version. With their typical attention to detail, a complete set of Technical Information Bulletins, courses, and specialized tools are available. Otto Bock also offers a variety of well thought out accessories, such as a tweezer (pincer) for the hands, blank Griefer tips for machining custom gripping surfaces, and so on. <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-02.jpg">Fig. 2. Variety Village VV2-6 electric hand: the smallest and lightest powered hand commercially available. (Courtesy of Variety Village Electrolimb Production Centre.)</a> <h3>Variety Village</h3> Variety Village components complement Otto Bock's nicely, as they are targeted for smaller children, and include a powered elbow. All their components are switch controlled. They market three switch types: a toggle for phocomelics, a button type, and a pull strap version. In addition, their elbow can have the pull switch built in, or be ordered for use with remote switches. Their elbow is available in either 6 or 12 volts; their hands are 6 volts exclusively. Their smallest hand (for 2-6 year olds) has just been redesigned. Although similar to the Swedish hand, it is three ounces lighter. Their original hands (Models 105 and 106) have been discontinued. Research is currently underway to create the smallest electric hand yet available: thirty percent smaller than their VV2-6. Only prototypes exist at this time, however. They market several battery configurations, including a "Battery Saver Circuit" designed to prevent children from draining the electrical charge by stalling the motor. None are of the quick-charge variety, however. <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-03.jpg">Fig. 3. Electric hands imported by Liberty Mutual. The smallest is the System-Teknik from Sweden; balance are Steeper hands from England. (Courtesy of Liberty Mutual Research Center.)</a> <h3>Hugh Steeper Limited</h3> Steeper is the British corporation responsible for upper limb prosthetics in the United Kingdom. They have recently announced the availability of powered hands for small children. These are now being distributed by Liberty Mutual in the United States. The sizes complement the Swedish hand, in that the Steeper hands are a bit larger than either Swedish version. Sometime in 1986, they will probably offer a larger hand for the early teen. These are 6 volt, switch controlled devices for the most part. However, Steeper also offers a "Servo-Control" option. This is a unique kind of proportional switch control: the harder the child pulls on the switch cable, the stronger the grasp. With minor adaptations (which Liberty Mutual will make), they can also be controlled by Otto Bock or UNB myos witches. <h3>System-Teknik</h3> System-Teknik is a Swedish company with two children's hands on the American market. Production rights for these hands have just been aquired by Steeper, so design changes can be expected. Liberty Mutual is the American distributer. At the present time, two Swedish hands are available: one for 2-6 year olds and another for 5-9 year olds. Both are 6 volts, and they use the same size forearm laminating ring for easy interchange. They can be controlled by either the UNB or Otto Bock myoswitches and switch controls. UNB designed its batteries to be mounted within the forearm shell. If space permitted, Otto Bock's could be used as well. To simplify the fitting procedure, Liberty Mutual plans to offer a special wrist unit option, containing all necessary electronics. Planned for use with both the System Teknik and Steeper hands, it will come in one version containing the battery supply, and a shorter version for longer residual limbs with remote battery mounting. <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-04.jpg">Fig. 4. Variety of powered components supplied by Liberty Mutual, including the UNB Toy Controller. (Courtesy of Liberty Mutual Research Center.)</a> <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-05.jpg">Fig. 5. Fidelity components, including harness pull switch, electric elbow, and VANU hand. (Courtesy of Fidelity Biomedical Products.)</a> <h3>University Of New Brunswick</h3> All UNB products are available through Liberty Mutual in the United States. When ordering their "Single Site" system, there are three options for battery placement: built-in to the electronics package, mounted inside the forearm section, or mounted externally. As is the case with all manufacturers, you must purchase their particular myotester/trainer to properly adjust their system. In addition, UNB offers a unique single site system with built-in sensory feedback. To aid in myotraining small children, they also market a "Toy Controller," which can be adapted to run with Otto Bock electrodes as well. <h3>Fidelity Electronics</h3> Fidelity Electronics distributes the proportional below-elbow system originally developed at Northwestern University. At one time the United States Manufacturing Company also carried these components, but Fidelity is currently the sole source. This is sometimes referred to as the "VANU" hand. Several things are unique about this product. First, it is a 12 volt system. Secondly, all the electronics are located in a "wrist module," including the battery. Therefore, it is self-contained with minimal risk of wire damage. However, this also prevents fitting very long residual limbs and concentrates all the weight at the distal portion of the prosthesis. Long residual limbs require the use of a switch-controlled version, thus eliminating the wrist module. This hand is sized for adult males only (7 3/4). Fidelity also offers a switch-controlled elbow (again, in adult size only). This is an 8.75 volt system, with its own built-in battery pack. It utilizes an exoskeletal soft foam forearm set-up. <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-06.jpg">Fig. 6. The Prehension Actuator provides powered opening for a variety of conventional hooks. Closing force is controlled by the number of rubber bands applied. (Courtesy of Hosmer Dorrance Corporation.)</a> <h3>Hosmer Dorrance</h3> As the "grandfather" of upper limb prosthetics in North America, Hosmer is in a unique position to develop a system of powered components. Their basic philosophy has been to focus on light-weight, straightforward, relatively inexpensive designs. For years, they have offered the "Michigan Hook," which is the familiar child's hook, closed by a rubber band, but opened with a small motor winding a string. Last year, they announced an adult version of this concept, called the "NYU Prehension Actuator." This is a conventional forearm set-up with an electric "winder" included. It can be mated with a variety of voluntary opening hooks, using up to five rubber bands or so. Although it is currently switch-controlled, a single-site "MyoPack" will soon be available, offering the option to convert both the Michigan Hook and the Prehension Actuator to myoswitch control. Hosmer has also released the "NYU Hush" elbow. This is unique in several respects. First, it is designed to permit the familiar mechanical elbow to be substituted for the electric one, even in a finished prosthesis. Secondly, they elected to use standard "grocery store" nickel cadmium batteries to power the system. This dramatically reduces the cost to the consumer. Four AA NiCad cells yield a 5 volt system; if desired, five can be used for 6.25 volts. Either version is rechargable with an inexpensive "dimestore" trickle charger. Hosmer hopes to offer in 1986 a "Free Swing" option for their elbow, which could be retro-fitted to existing units in the field. Once the elbow attains full extension, it would automatically enter the free-swing mode. In addition to enhancing the dynamic cosmesis during ambulation, this may offer some special benefits to bilateral patients. Those who depend on the prosthesis for feeding would then have the option of resting the forearm against the table and using "body English" for elbow flexion. Finally, it can be used with either an endo-skeletal or exoskeletal forearm, as desired. This is a switch-controlled elbow, again keeping the costs lower, which is currently available in a large and medium size, corresponding to the familiar E-400 and E-200 mechanical elbows. Thus, it is suitable for many older children as well as adult men and women. Hosmer's switches have recently been redesigned to increase reliability. In addition to the familiar button and harness switches, they also offer a "Three-Position Harness Switch," permitting one control motion to operate both elbow flexion-extension and the NYU Prehension Actuator. The latest addition to the Hosmer line is an adult male (7 3/4) switch-controlled hand to complement their elbow. This also uses readily available NiCads for 5 or 6.25 volt operation. The "Synergetic Hook" designed by Dr. Dudley Childress at Northwestern University<a></a> should be available sometime in 1986. Beyond that, work is ongoing for a myoelectric elbow and hand, but neither is presently available. <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-07.jpg">Fig. 7. Boston elbow, combined with a Hosmer mechanical shoulder joint and Otto Bock electric hand. Combining various international components can enhance prosthetic restoration. (Prosthetic Design by John C. Hodgins, C.P.O.; (Courtesy of Liberty Mutual Research Center.)</a> <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-8.jpg">Fig. 8. Exploded view of the Utah elbow. Highly modular construction facilitates servicing in the field. (Courtesy of Motion Control, Inc.)</a> <h3>Liberty Mutual</h3> Liberty Mutual is the world's largest workmen's compensation insurer. In the United States, one in fifteen workers is insured by this company. Thus, they have a dual motivation in offering sophisticated prosthetic components: both to help the clients they insure, and also to enable the clients to return to work, thus reducing the company's liability. The 12 volt Liberty Mutual "Boston Elbow" can be categorized as a working man's device. And, in fact, it is one of the most durable electric elbows on the market. Although the original version was widely criticized because of the noise it made when operating, the current generation is markedly improved. This is the only elbow offering dual battery chargers. Although Liberty Mutual recommends overnight "trickle" charging for longer battery life, they offer a "quick charge" option, in case the internal battery becomes discharged before the day is over. This is also the only elbow designed to easily convert from proportional myoelectric control to switch control. Simply altering one wire makes the conversion. This can be very useful, for example, in fitting patients early with switch control, then later upgrading to myo-control as their residual limb matures. As mentioned elsewhere, Liberty Mutual also distributes the UNB, System-Technik, and Steeper components. <h3>Motion Control</h3> Motion Control is marketing the powered elbow system originally developed by the University of Utah. In contrast to Hosmer's strategy, this group sought to offer the most technologically advanced components possible. Undoubtedly, they have succeeded in this goal. However, most sophisticated does not necessarily mean best; simpler technology is often more reliable than state-of-the-art. Nevertheless, Motion Control has a unique addition to the prosthetic armamentarium. Their electronic locking mechanism and Sequential Proportional Control have already been discussed. Originally designed for mechanical terminal device operation, this 12 volt elbow can also be ordered with an Otto Bock hand. In this case, however, Motion Control discards the electronics and substitutes their own, thus offering true proportional myoelectric control of the Otto Bock hand. Of all the systems on the market, particularly above-elbow systems, this is the most "pros-thetist friendly." All the inner components are modular and easily exchangeable in the field. The quick-change battery pack is built into the humeral section, but below the elbow axis. This permits fitting longer residual limbs than is possible with other systems, and means there are no external wires to fray and fail. Further, this version offers by far the most adjustments to "fine tune" the elbow for a particular patient. There is a price to pay for this degree of technology, of course. In addition to being the most sophisticated, the Utah Arm is also by far the most expensive powered device available today. It is now possible to add an Otto Bock powered wrist rotator to the Utah Arm, using a variety of control strategies, including UNB or Otto Bock's single-site electrodes, two-site electrodes, and assorted switches. If a mechanical terminal device has been used, the Utah Arm mechanism can be modified to provide dedicated proportional control of the wrist unit. Also, their highly sensitive myotester is finally a commercial reality. Beyond that, Motion Control has just announced the availability, to prosthetists trained in the elbow fitting procedures, of a proportionally controlled below-elbow system, using Motion Control electronics to power an Otto Bock hand with 12 volts in a below-elbow prosthesis. Currently, this requires mounting two Otto Bock batteries, which can present some difficulties, although other battery sources can be utilized in selective cases. Finally, and perhaps most significantly, Motion Control has become the first supplier to offer a rental program for myoelectric components. In marginal cases, if funding has been conditionally approved, the components can be rented on a monthly basis for about ten percent of the total cost. Most of the rental is applied toward purchase of the arm if the fitting proves successful; if not, the parts are returned to Motion Control. <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-09.jpg">Table 1</a>, <a href="http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-10.jpg">Table 2</a> Summary Our powered upper limb armamentarium is now surprisingly complete. Although one must select components from all over the world, it is possible to fit virtually any patient from two years old to adulthood with an externally powered prosthesis. Otto Bock components remain the most widely utilized, and their hands and connectors are becoming the de facto standards in the field. Their own components are designed for below-elbow use, but are routinely adapted to higher levels. Otto Bock has chosen to develop a variety of myoswitch controls, but does not offer true proportional control. Although several voltages are used, a general trend toward 12 volts for above-elbow systems and 6 volts for below-elbow is apparent. And, switch control is used almost exclusively for very small children, progressing to myoswitch control as they mature; proportional control is most commonly reserved for adults. The children's components are all from outside the United States: Sweden, England, and Canada currently offer toddler hands. American designs are often targeted to adults: the Hosmer and VANU hands and Boston Elbow toward males, in particular. Hosmer is aggressively pursuing the inexpensive, low-tech end of the market, emphasizing interchangeability with the familiar mechanical counterparts. Motion Control is equally aggressive in pursuing the high tech, high cost end. Lack of funding is probably the major factor limiting the number of powered fittings currently undertaken. With the ready availability of various switch, myoswitch, and proportional controls, virtually any patient could operate an electric prosthesis. Questions about who is a suitable candidate for powered fittings are still largely unanswered. The evidence suggests that the highest failure rate is with bilateral fittings.<a></a> Perhaps the simplicity and resultant reliability of body powered prostheses makes mechanical solutions more succcessful here. The best system cannot be found, and few practitioners are brave enough or experienced enough to freely mix these international components. The issues of proportional vs. digital control, high tech vs. low tech design, hybrid vs. purely mechanical vs. purely powered fittings are all open to debate. And some very provocative data is emerging suggesting that the issue of when to fit is at least as significant as the issue of what to fit.<a></a> It is beyond the scope of this paper to resolve these complex issues. Rather, the intent is simply to bring into focus the basic concepts, components, and controversies in the field of powered upper limb fittings. It is hoped that clarifying these issues will encourage prosthetic practitioners to deepen their involvement and understanding in this rapidly evolving area. As we struggle collectively with these problems, our patients and our profession will ultimately reap the benefits. <h3>Appendix</h3> V.A.N.U. Products Fidelity Biomedical Products 6000 N.W. 153 Street Miami Lakes, Florida 33014 (800) 327-7939 Hush Elbow; Prehension Actuator Hosmer-Dorrance Corporation 561 Division Street P.O. Box 37 Campbell, California 95008 (800) 538-7748 Boston, UNB, Steeper, Systek Products Liberty Mutual Research Center 71 Frankland Road Hopkinton, Massachusetts 01748 (617) 435-9061 Utah Elbow, BE System Motion Control, Inc. 1005 South 300 West Salt Lake City, Utah 84101 (800) 621-3347 MyoBock Products Otto Bock Industry 4130 Highway 55 Minneapolis, Minnesota 55422 (800) 328-4058 Variety Village Products Variety Village Electrolimb Production Centre 3701 Danforth Avenue Scarborough, Toronto CANADA MIN 2G2 (416) 698-1415 *John W. Michael, M.Ed., C.P.O. John W. Michael is Director of Prosthetics and Orthotics, Duke University Medical Center, Box 3885, Durham, North Carolina 27710. References: <ol> <li><a href="poi/1981_02_092.asp">Agnew, J.P., "Functional Effectiveness of a Myo-Electric Prosthesis Compared with a Functional Split-Hook Prosthesis: A Single Subject Experiment," Prosthetics and Orthotics International, 5(2), pp. 92-96, 1981.</a></li> <li><a href="cpo/1985_01_023.asp">Billock, John N., "Upper Limb Prosthetic Management-Hybrid Design Approaches," Clinical Prosthetics and Orthotics, 9(1), pp. 23-25, 1985.</a></li> <li>Childress, D.S., "An Approach To Powered Grasp," Proceedings of the Fourth International Symposium on External Control of Human Extremities, Dubrovnik, Yugoslavia; pp. 159-167, 1973.</li> <li>Doubler and Childress (1984), "Design and Evaluation of a Prosthesis Control System Based on the Concept of Extended Physiological Proprioception," Journal of Rehabilitation Research and Development, 10(39), pp. 19-31.</li> <li><a href="http://www.acpoc.org/library/1983_04_001.asp">Ferguson, Shirley, "Electric Power In Upper Limb Prosthetics: The Michigan Experience," Inter-Clinic Information Bulletin, 18(4), pp. 1-8, 1983.</a></li> <li>Graupe, et al., "A Multifunctional Prosthesis Control System Based on Time Series Identification of EMG Signals Using Microprocessors," Bulletin of Prosthetics Research, 10(27), pp. 4-16, 1977.</li> <li>Jacobsen, et al., "Development of the Utah Artificial Arm," IEEE Transactions on Biomedical Engineering, BME-29, (4), pp. 249-269, 1982.</li> <li>Malone, et al., "Immediate, Early, and Late Post-surgical Management of Upper-Limb Amputation," Journal of Rehabilitation Research and Development, 21(1), pp. 33-42, 1984.</li> <li>Millstein, Heger, and Hunter, "A Review of Failures in Use of the Below-Elbow Myoelectric Prosthesis," Orthotics and Prosthetics, 36(2), pp. 29-34, 1982.</li> <li>Murphy and Horn, "Myoelectric Control Systems- A Selected Bibliography," Orthotics and Prosthetics, 35(1), pp. 34-47, 1981.</li> <li>Northmore-Ball, et. al., "The Below-Elbow Myo-Electric Prosthesis: A Comparison of the Otto Bock Myo-Electric Prosthesis with the Hook and Functional Hand," Journal of Bone and Joint Surgery, 42-B(3), pp. 363-367, 1980.</li> <li>Scott, Robert NL, "My?-Electric Control of Prostheses," Archives Of Physical Medicine and Rehabilitation, 47(3), pp. 174-181, 1966.</li> <li>Scott, R.N., An Introduction to Myoelectric Prostheses. Bio-Engineering Institute, University of New Brunswick, Fredricton, N.B., pp. 37, 1984.</li> <li>Spaeth and Klotz, Handbook of Externally Powered Prostheses for the Upper Extremity Amputee, C. Thomas, Springfield, IL, p. 107, 1981.</li> <li>Wirta, Taylor, and Finley, "Pattern-Recognition Arm Prosthesis: A Historical Perspective-A Final Report," Bulletin of Prosthetics Research, 10(30), pp. 8-35, 1978.</li> </ol> Page Number(s) 66 - 77 Year 1986 Volume 10 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-8.jpg Figure 9 TABLE I http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-09.jpg Figure 10 TABLE II http://www.oandplibrary.org/cpo/images/1986_02_066/1986_02_066-10.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 Upper Limb Powered Components and Controls: Current Concepts Creator An entity primarily responsible for making the resource John W. Michael, M.Ed., C.P.O. * https://staging.drfop.org/files/original/74c6246acf34d3fe13807d14ce98dc43.pdf 6441dedb6d6cc9c3408c00c008e17f34 https://staging.drfop.org/files/original/5fad73a9eef3f2a1ab53ce2f213efece.jpg 087d0de996c5b8aedb032fcd6c2b18af https://staging.drfop.org/files/original/46e79972c3cbe07d3d9a3bf9ee340543.jpg ed3a48b7a53ce8a61cd8625552177b7e https://staging.drfop.org/files/original/e6c3404c22e5309a73c20747e6ed1a13.jpg 9272df686c0c19c8ad1dda4d9c346ec6 https://staging.drfop.org/files/original/281142d97946d38fc471de221b5faf8f.jpg bf1e5c9c2e488ceb7a1e4cfe23204140 https://staging.drfop.org/files/original/c47ee86296fe96d24d9bd4f980c48f92.jpg b3b28bcd274b720de45e627bfb56fb30 https://staging.drfop.org/files/original/6428da51018c9c2b4e7abbee2e25edb7.png 1647605a0dec60c4196c094faf88d769 https://staging.drfop.org/files/original/68cd1ff085e2984407091e0d7a6c5d37.png 9904eb51a9b616c598335dfad75c4a5e https://staging.drfop.org/files/original/0615e189294ec61bfdf16988f8a7b884.png c338f0114ebb1696a89da2d560ae081c https://staging.drfop.org/files/original/7ec5171e3138ef5823db95a0fc0c969c.png b27d019d267f9fe4bf3c8a2e1dcbf8f3 https://staging.drfop.org/files/original/371c70ccf0c7354316fbbb481fe93334.png 66509ce03e3cd337dcfb9ff45cd414eb 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/1986_02_057.pdf Text Any textual data included in the document <h2>Upper Limb Prosthetic Terminal Devices: Hands Versus Hooks</h2> <h5>John N. Billock, C.P.O. <a style="text-decoration: none;">*</a></h5> No one would argue that the human hand is the most complex and challenging structure of the human anatomy to replace and restore. The hand is an extremely complex structure which moves with a precision and dexterity that has long challenged the minds of researchers in medicine and engineering. Beyond its kinematic capabilities, the hand is also one of the most intricate sensory mechanisms of the human body-with unequaled proprioceptive and sensory feedback capabilities. With this in mind, it is easy to understand why prosthetic terminal devices today (hand and/or hook) offer very little in the way of true functional restoration to individuals with upper limb deficiencies. This is not meant to be critical of past developments, but puts into proper perspective the complexities and challenges of duplicating the human hand. Further emphasis of this is found in a commentary by Murphy<a></a> in which he stated, "Though engineers and prosthetists have made substantial contributions, they need perspective and humility to inspire and guide the very long, sustained efforts required to replace even a few of the roles of the hand." This challenge will doubtlessly keep researchers in prosthetics, and now those involved in robotics, busy with the task of trying to duplicate the kinematic and sensory capabilities of the human hand for years to come. <h3>Prosthetic Terminal Devices Today</h3> There exists today a significant number of prosthetic terminal devices for treating both adult and juvenile complete hand deficiencies. These terminal devices are designed as either mechanical or electromechanical systems and, as such, are either body-powered or electric powered. The body powered terminal devices function by utilizing forces generated by body movement as described by Taylor.<a></a> An electric powered terminal device functions by utilizing the electrical force stored within and generated from a battery. Further, these sources of power can activate or control a terminal device in different ways. The three most commonly used control systems are the Bowden cable control, myoelectric control, and switch control. In order to fully understand the functional potential of a particular terminal device, it is important to understand the control approach or system being used to actuate the device. <h3>Prosthetic Control Systems</h3> Professional opinions vary considerably regarding the most appropriate terminal device and control system to utilize in the design and development of a functional upper limb prosthesis. Bowden cable control systems harness the motions and forces generated by gross body movement to actuate and control, primarily, a mechanical terminal device. They require an adequate degree of force and excursion to actuate and control an upper/limb mechanical terminal device.<a></a> The most common example of this would be the Bowden cable control system of a totally mechanical below-elbow prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-01.jpg">Fig. 1</a>). This type of control system harnesses the body motion and forces generated by flexion-abduction movements at the glenohumeral joint to actuate and control the terminal device. It is important to note that this form of control does produce a certain degree of sensory feedback related to force and position.<a></a> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-01.jpg">Figure 1. Illustration of a typical conventional body powered Bowden cable controlled below-elbow prosthesis with a mechanical hook terminal device actuated by "gross" body movements.</a> Myoelectric control systems utilize the existing neuro-muscular system for actuation and control of an electromechanical terminal device (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-02.jpg">Fig. 2</a>). EMG potentials are monitored with surface electrodes placed over appropriate muscle or muscle groups within the residual limb and are used for either digital or proportional control of the terminal device. This type of control is considered to be quite natural since it utilizes the existing residual neuromuscular system for control.<a></a> This is especially true with synergistic muscle contractions, particularly related to natural hand functions, which can be selected for actuation and control of the terminal device. The use of myoelectric control enhances the feasibility of designing a totally self-contained and self-suspended prosthesis which has proven to be an acceptable and reliable design approach.<a></a> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-02.jpg">Figure 2. Illustration of a typical electric powered, myoelectrically controlled below-elbow prothesis with an electromechanical hand terminal device actuated by EMG potentials.</a> Switch control systems are those which utilize the motions and forces generated by "fine" body movements to actuate and control an electromechanical terminal device (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-03.jpg">Fig. 3</a>). They require considerably less force and excursion than a Bowden cable controlled system to actuate and control a terminal device. Switch control systems can incorporate a variety of different types of switches, such as, pull, rocker, push-button or toggle type switch for activation of the terminal device (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-04.jpg">Fig. 4</a>). This type of control is typically indicated in situations when limited body motion and forces are available for Bowden cable control and/or when EMG potentials are inadequate or inappropriate for control of the terminal device. <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-03.jpg">Figure 3. Illustration of a typical electric powered switch controlled below-elbow prosthesis with electromechanical hand terminal device actuated by "fine" body movements.</a> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-04.jpg">Figure 4. The actuation characteristics of a typical pull, rocker, push button and toggle switch are illustrated. Switches are generally designed to produce one or more functions such as opening and/or closing of an electromechanical terminal device, (a) Pull (sliding) switch for actuation of two functions; (b) Rocker switch for actuation of two functions; (c) Push Button switch for actuation of one function; (d) Toggle switch for actuation of two functions.</a> <h3>Mechanical Hooks And Hands</h3> Following World War II and especially since the development of the APRL Voluntary Closing Hand and Hook in 1945, considerable controversy has existed regarding the functional aspects of hands versus hooks as terminal devices. Prior to the introduction and clinical use of electric hands in the early 1960's, this controversy only related to mechanical hands and hooks. Mechanical hands, although certainly more aesthetic, were felt by many professionals to be too heavy and awkward for fine prehension activities. Mechanical hooks, by way of contrast, weigh approximately one third the weight of a mechanical hand and provide dexterity comparable to a pair of tweezers. Mechanical hooks were also considered to be more durable because of their simple mechanical design, and the fact that a cover to protect internal mechanisms or provide aesthetics is unnecessary. Because of these mechanical advantages, very little regard was given to the social-psychological advantage and need for a prosthetic hand versus the hook terminal device. In fact, it became common practice within prosthetic clinics and teaching institutions to encourage use of a hook terminal device first before providing the individual with a hand terminal device. The purpose of this practice, which continues today, is to develop the individual's appreciation for the functional advantage of the mechanical hook over the mechanical hand. Further, it was the opinion and experience of many clinics and prosthetists that many individuals, if provided a hand and hook terminal device simultaneously, tended to reject the hook for aesthetic reasons and not develop an appreciation for its functional advantage. Conservative estimates indicate, however, that approximately only fifty percent of those individuals provided with conventional type mechanical prostheses are wearing their prosthesis as reported by LeBlanc.<a></a> This estimate does not distinguish between actual functional use versus simple wearing of the prosthesis. It is the author's opinion and experience that the introduction of a hook terminal device in the early stages of the prosthetic rehabilitation process may in fact be the primary cause of the high incidence of total prosthetic rejection since little, if any, attention is given to the social-psychological aspects of the individual's limb deficiency. The social-psychological aspects of an acquired or congenital upper limb deficiency should be regarded as the first and most significant problem which has to be understood and dealt with appropriately if successful prosthetic rehabilitation and functional use of a prosthesis is to be achieved. Dembo, Leviton, and Wright<a></a> clearly identified the social-psychological problems individuals, as well as those around them, have to deal with in accepting limb loss as part of the total rehabilitation process. If an individual has not accepted a limb loss, or in the case of a congenital limb deficiency, the parents have not accepted the limb loss, it is unlikely that successful prosthetic rehabilitation and functional use of a prosthesis will be achieved. Dr. Howard A. Rusk, recognized by many as the "father of physical medicine and rehabilitation," has identified motivation and timely rehabilitation services as the key elements to achieving successful rehabilitation of an individual's disability.<a></a> An individual can receive the best rehabilitation services available and be provided with the best prosthesis today's technology has to offer. However, if they are not motivated to overcome their disability or adjust to it, acceptable rehabilitation is unlikely. Likewise, the child born with a congenital limb deficiency will not be encouraged to adapt to or functionally utilize a prosthesis if the parents have not accepted their child's disability. <h3>Electric Powered Hooks And Hands</h3> The introduction of electric powered hands into clinical practice in the early 1960's brought about a new era in prosthetics. Acceptance of these "electric hands" by the American prosthetics profession was much slower than in the European countries where they were initially developed. They are, moreover, still considered by many to be not as functional as mechanical hook terminal devices. It is felt that much of this belief can be traced to the attitude that regards mechanical hands as being less functional than mechanical hooks. Electric powered hands, however, have one primary major functional advantage over mechanical hooks and hands. Electric hands can produce finger prehension force which is equal to, and in some cases greater than, that of an adult or juvenile human hand. The average adult male, for instance, can produce an average of 20 to 24 lbs. of finger prehension. The average tolerable amount of prehension that an adult male can generate with a Bowden cable controlled prosthesis and the more commonly used voluntary opening mechanical hook terminal device is approximately 8 to 10 lbs. Voluntary closing mechanical hands and hooks obviously are able to provide greater finger prehension than voluntary opening hooks or hands; however, they have not been widely accepted or used. Another key advantage of an electric powered hand is that it provides forceful "3 jaw chuck" palmar type prehension. This type of prehension has been identified as early as 1919 by Schlesinger,<a></a> to be the most commonly utilized hand-finger prehension pattern for picking up and holding objects in activities of daily living (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-05.jpg">Fig. 5</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-01.jpg">Fig. 1</a> shows the percentage of use to pick up and hold objects with an electric powered hand. The predominance of "3 jaw chuck" palmar prehension in our activities of daily living accounts for the reason all mechanical and electric powered hands of today are designed with the thumb in opposition to the second and third fingers. The forceful palmar prehension of the electric powered hand, therefore, enhances its overall functional value as a prosthetic terminal device. <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-05.jpg">Figure 5. Of the six commonly used hand/finger prehension patterns, described by Schlesinger, "3 jaw chuck" palmar type, tip type and lateral type prehension are considered to be the most frequently used during activities of daily living.</a> The only electric powered hook available for clinical use at this time is the Otto Bock "Griefer"<a></a> which was introduced in the U.S. in the late 1970's. As an electric powered terminal device, it has the quality of providing "forceful" prehension. Along with this, it is uniquely designed with multi-axis fingers to keep the grasping surfaces parallel during the entire range of opening and closing (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-07.jpg">Fig. 6</a>). This design feature allows for even pressure throughout its range of opening and closing which enhances its grasping ability over mechanical hooks. The grasping surfaces of a mechanical hook angle away from one another as the active finger moves in relationship to the stationary finger (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-08.jpg">Fig. 7</a>). Therefore the larger the object to be held in the mechanical hook terminal device, the less contact with the object and, consequently, the more force required to stabilize the object, dependent upon its shape. The "Griefer," on the other hand, is heavier than the heaviest stainless steel mechanical hook and is not as durable, primarily because its design is more complex than the single axis mechanical hooks. <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-06.jpg">Table 1</a> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-07.jpg">Figure 6. This diagram illustrates the angular relationship of the prehension surfaces and the object being held, utilizing a multi-axis prehension design approach, such as in the Otto Bock "Griefer."</a> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-08.jpg">Figure 7. This diagram illustrates the angular relationship of the prehension surfaces and the object being held, utilizing a single-axis prehension design approach, such as in the Hosmer/Dor-rance</a><a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-08.jpg"> mechanical hook series.</a> Clinical Experience The terminal device of the prosthesis plays an important key role in developing the motivation which will, hopefully, lead to successful prosthetic rehabilitation. It has been the author's experience, in over 300 cases involving individuals with congenital and acquired limb deficiencies from the wrist to the shoulder, that 95 percent or better of those individuals preferred to have a prosthetic hand rather than a hook terminal device (<a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-09.jpg">Table 2</a> and <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-09.jpg">Table 3</a>). In all cases involving juvenile subjects (which represents approximately ten percent of the total case load), the parents and children over the age of five years preferred hand terminal devices to hooks. Forty percent of the total juvenile case load involved children under the age of five years, and in all cases, the parents preferred hand terminal devices. Parents were also found to prefer a passive nonfunctional hand as opposed to the more typically used passive type nonfunctional mitten for children up to 1 1/2 years of age. <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-09.jpg">Table 2</a> <a href="http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-10.jpg">Table 3</a> One might quickly draw the conclusion that this preference was specifically related to the aesthetics of the hand and not necessarily related to function. There is no doubt that the aesthetics of the hand played a key role in the decision. However, this preference also emphasizes the strong social-psychological need for individuals, as well as the parents of children with limb deficiencies, to visually feel as normal as possible within our society. The aesthetics of a hand terminal device obviously satisfies this need more appropriately than a hook terminal device. Beyond this, it is also interesting to note that approximately only one percent of those provided a prosthesis with hand are utilizing a mechanical hand terminal device. Therefore, 99 percent utilize electric powered hands in their prostheses; eighty percent of these are controlled myoelectrically. It is estimated that total rejection of an electric powered hand prosthesis has been approximately 15-20 percent. Actual percentages of rejection have been difficult to verify because of lack of follow-up by the patients, and it is felt that 5-10 percent of the patients are now being followed-up elsewhere. Nevertheless, total prosthetic rejection is considerably less than those provided with conventional upper limb prostheses.<a></a> It is not felt that the acceptance rate of electrically powered hand prostheses is specifically related to aesthetics of the hand. If this were the case, one would expect more individuals to have been utilizing mechanical or passive hands prior to the development of electric powered hands. <h3>Conclusion</h3> Clinical experience has definitely proven, in the author's experience, that an electrically powered prosthetic hand terminal device which is proportionally controlled, utilizing myoelectrical EMG potentials from synergistically related muscles within the residual limb, is the most acceptable and functional upper limb prosthetic design for individuals with complete hand deficiencies. It is further felt that the terminal device is the most important component of the prosthesis; just as the hand is to the normal upper limb. Whenever possible, a prosthetic hand should be preferred to a hook terminal device, in consideration of the individual's social-psychological needs. The individual's social-psychological needs must be of primary concern initially and must be considered before vocational needs can be effectively addressed. This is also true when managing children and is especially important in addressing the social-psychological needs of parents of children born with congenital upper limb complete hand deficiencies. If the vocational or avocational needs clearly indicate the need for a hook terminal device, this must be clinically tested and proven, or the individual must personally desire the hook terminal device. This has been found to be true for all levels of upper limb deficiencies involving the hand, wrist, elbow, and shoulder. This criteria is obviously not the case for everyone with an upper limb deficiency; however, it is felt to be true for the majority and especially those with unilateral upper limb involvement. The prosthetic hand should be thought of as an assistive device to the sound limb, just as the nondominant normal hand is to the dominant normal hand. Many have felt it is important to be able to perform fine motor prehension activities with a prosthetic terminal device and this has been a major argument in favor of hook terminal devices. The fact is, the majority of those individuals with upper limb deficiencies are unilaterally involved and do not use their prosthesis for fine motor prehension activities; just as a non-involved individual does not typically utilize the nondominant hand for such activities. The prosthetic terminal device is most important for gross prehension activities, to hold and stabilize objects while the sound limb performs the fine motor prehension activities. An electrically powered hand terminal device, with adequately controlled functional prehension, best serves this need for the majority of an individual's activities of daily living. It is important to remember that we live in a world made for hands, and most everything we encounter in our activities of daily living is made to be hand held. <h3>Acknowledgments</h3> The author is deeply indebted to those individuals who have sought and benefited from the research which made this paper possible. Special appreciation is given to my wife, Dottie, Jean Ann Pasini, and Gordon L. Grimm for their editorial input and assistance in preparation of this paper, and to the other staff members of the Orthotics and Prosthetics Centre of Warren for their continued understanding and support of the author's professional interests. The illustrations and art work of Jean Ann Pasini are particularly appreciated. *John N. Billock, C.P.O. John N. Billock, C.P.O. is Clinical Director at the Orthotics and Prosthetics Centre of Warren in Warren, Ohio. He is also Chairman of the Research and Evaluation Committee of the American Academy of Orthotists and Prosthetists. References: <ol> <li>Billock, J.N., "The Northwestern University Supracondylar Suspension Technique for Below Elbow Amputations," Orthotics and Prosthetics, Vol. 26, No. 4, pp. 16-23, 1972.</li> <li>Billock, J.N., "Upper Limb Prosthetic Management: Hybrid Design Approaches," Clinical Prosthetics and Orthotics, Vol. 9, No. 1, pp. 23-25, 1985.</li> <li>Childress, D.S. and Billock, J.N., "Self-containment and Self-suspension of Externally Powered Prostheses for the Forearm," Bulletin of Prosthetics Research, Vol. 10, No. 14, pp. 4-21, 1970</li> <li>Childress, D.S., "Powered Limb Prostheses: Their Clinical Significance," IEEE Transactions on Biomedical Engineering, Vol. BME-20, No. 3, pp. 200-207, May, 1973.</li> <li>Childress, D.S.; Holmes, D.W.; and Billock, J.N., "Ideas on Myoelectric Prosthetics Systems for Upper-Extremity Amputees," The Control of Upper-Extremity Prostheses and Orthoses, pp. 86-106, 1974.</li> <li>Dembo, T.; Leviton, G.L.; and Wright, B.A., "Adjustment to Misfortune: A Problem of Social-Psychological Rehabilitation," Selected Articles from Artificial Limbs, pp. 117-175, New York, July, 1970.</li> <li>Gwynne, G., "Mechanical Components," Manual of Upper Extremity Prosthetics, Department of Engineering, University of Southern California at Los Angeles, Second Edition, pp. 33-68, 1958.</li> <li>Le Blanc, M.A., "Patient Population and Other Estimates of Prosthetics and Orthotics in the USA," Orthotics and Prosthetics, Vol. 27, No. 3, p. 38-44, 1973.</li> <li>Murphy, E.F., "Commentary," Selected Articles from Artificial Limbs, New York pp. vii-xii, July, 1970.</li> <li>Rusk, H.A., "Rehabilitation," Journal of the American Medical Association, Vol. 140, pp. 286-292, 1949.</li> <li>Rusk, H.A., "Advances in Rehabilitation," Practitioner, Vol. 183, pp. 505-512, 1959.</li> <li>Schlesinger, G., "Der Mechanische Aufbau der kunstlichen Glieder," Ersatzglieder und Arbeitshilfen, Vol. 3, Berlin, 1919.</li> <li>Taylor, C.L., Schwarz, R.J., "The Anatomy and Mechanics of the Human Hand," Selected Articles from Artificial Limbs, New York, pp. 49-62, 1970.</li> <li>Taylor, C.L., "Biomechanics of Control," Selected Articles from Artificial Limbs, New York, pp. 63-84, July, 1970.</li> <li>Otto Bock "Griefer" is a registered trade mark of the Otto Bock Orthopedic Industry, Inc., Duterstat, West Germany/Minneapolis, Minnesota.</li> <li>Hosmer Dorrance is a registered trade mark of the Hosmer Dorrance Corporation, Campbell, California.</li> </ol> Page Number(s) 57 - 65 Year 1986 Volume 10 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 TABLE I http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-06.jpg Figure 7 FIGURE 6 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-07.jpg Figure 8 FIGURE 7 http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-08.jpg Figure 9 TABLE II http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-09.jpg Figure 10 TABLE III http://www.oandplibrary.org/cpo/images/1986_02_057/1986_02_057-10.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 Upper Limb Prosthetic Terminal Devices: Hands Versus Hooks Creator An entity primarily responsible for making the resource John N. Billock, C.P.O. * https://staging.drfop.org/files/original/c9a1d6e7671d63f3fcd52fc82276041f.pdf 7dc5a6a86a368317cbf6867d2a17b66e 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/1986_02_055.pdf Text Any textual data included in the document <h2>Rehabilitation: Goals or Shoals?</h2> <h5>Samuel A. Weiss, Ph.D. <a style="text-decoration: none;">*</a></h5> In the pre-1960 period, the dominant aim of rehabilitation personnel working with amputees was the restoration of the amputee to maximum pre-morbid functioning. Lower-extremity amputees had little choice. A degree of prosthetic restoration consonant with some ambulation was necessary in order to provide some independence and self-sufficiency. Upper-extremity amputees were also presented with the goal of maximum functional restoration. While comfort and cosmesis were given their due, the explicit dogma was restoration to as much premorbid functioning as was mechanically feasible. The writer remembers the dictum of one expert, "a hook for work and a functional, cosmetically acceptable hand for recreation." An upper-extremity amputee might plead that he had learned to "manage" with his intact hand and was, therefore, interested only in an acceptable, passive appendage to fill a sleeve and allow him to mix in society inconspicuously. All in vain. He was regarded virtually as a self-denigrating quitter who was undermining his own livelihood, as well as a heretic in our work ethic society. To an appreciable extent this pejorative judgment was then true because in the pre-60's period there were, as yet, no "Great Society" programs which were to introduce alternative means of financial support. To a worker in the pre-60's period, functional restoration was the life raft which prevented him from sinking unless he was content to gasp through life on the dole and undergo the psychological angina pains of conscience. When the "Great Society" programs were introduced, the work ethic, for better or worse, was to a considerable extent attenuated. Moreover, improvements in technology, reduction in the need for manual labor, and the proliferation of new types of jobs allowed amputees better viability because an entirely intact body was no longer necessary for self-support. Yet the dogma of total, functional restoration hovered in the consciousness of rehabilitation personnel. While society in the 60's became more interested in immediate self-gratification, rehabilitation experts, who had been trained to make men and things "work," retained their pure work ethic consciousness. Physicians desired that body functioning become normal; physical and occupational therapists knew that somatic improvement required vigorous exercise; psychologists believed in maximum self-realization; and engineers and prosthetists yearned for more powerful mechanisms to provide normality. The old-fashioned work ethic had, to a considerable extent, been replaced by a new pay ethic—more pay for less work and poorer service for higher fares. We rehabilitation workers, however, remained aloof on Mt. Sinai, in our pristine innocence, proclaiming the Ten Commandments to stiff-necked and stiff-limbed rehabilitants who preferred to dance around the golden calf of entitlements. While recent political changes are striving to restore the work ethic to its former glory, the average person does not readily relinquish the desire to be presented with a set of options from which to choose. Attempts to enforce one set of standards or goals equally on all rehabilitants are doomed to fail. Perhaps some examples of individual personality types I have encountered among amputees seen at NYU Medical Center and in private practice will illustrate the distinctive rehabilitation goals of different people. <h3>Case Studies</h3> "A" applied as a volunteer experimental prosthesis wearer. He had lost his non-dominant hand in an accident. During the interview, he impressed the writer with his stability. His psychological test profile was exceptional. The writer remembered "A's" well-executed and orderly Bender-Gestalt drawings and recommended him for a position at an agency where he is still employed. I never saw "A" wear anything but a hook when I visited the agency. He never attempted to emphasize his functional restoration goal. His good-natured and efficient performance with his hook spoke for itself. In my conversations with him on various topics, both vocational and personal, he would often become enthusiastic and wave his hook in front of my eyes to emphasize a point. I never "saw" the hook. His efficiency and personality preempted his amputation. All I saw was the person, not the disability. "B" was a double hand amputee volunteer. He was gainfully employed and wished to contribute to amputee rehabilitation. "B" underscored his conviction of absolute normality. He wished to demonstrate this to the staff by maneuvering his two prostheses and a sheet of paper to pick up a dime. He failed a number of times before succeeding, but the note of triumph in his eye compensated for the failures. "B" had convinced himself that he was normal and who were we to question him? He was gainfully employed, easy to deal with, and adjusted to his environment. His "super normality" was irrelevant since this illusion did not interfere with his various roles as a human being. "C" did not require functional restoration for his work. He wore an active, cosmetic hand because of his desire not to attract attention to his disability, and his prosthesis was useful for minor tasks. He refused to wear a hook for more inclusive manual functioning. His goal was mainly cosmetic. The limited function of the type of prosthetic hand then available was satisfactory to him. "D" wore a passive hand with no function. His main goal was to appear normal to the casual observer. To some work ethicists on our staff "D" was regarded as an unactualized individual, but "D's" goals were not the attainment of complete self-actualization, but merely a wish to blend with the crowds on the trains and street. "E" was a prosthesis wearer interviewed for phantom limb experience. Our explanation as to the potential value of the study was misinterpreted by him. He somehow gained the impression that further knowledge about phantom limb sensation and neurological functioning would enable scientists to grow a new, natural limb on his amputation stump (as is the case with some lower animals). He nervously inquired "Will I lose my pension?" This veteran was so satisfied with his prosthesis (and disability pension) that he seemingly rejected the ultimate restoration, a reborn limb! "F" lost his left hand in an accident. He absolutely refused to wear his prosthesis because of discomfort and because he functioned adequately with his intact limb. His empty sleeve was virtually "filled" by his outgoing and warm personality. His interpersonal behavior was the best camouflage for his amputation. He was an amputee who had the best prosthesis of all—his total personality. Unfortunately, he later died, following a disease unrelated to his amputation. The large funeral chapel was packed with people from numerous walks of life. Each of these individuals represents a different personality type with distinctly different goals and levels of achievement, satisfactory to each if not to rehabilitation personnel. My experience as a psychologist has convinced me that different patients are ready for varying levels of growth. Some patients who have made appreciable, but not optimal gains in psychotherapy will leave. A percentage of these will return months or years later, after they have assimilated their original gains, to strive for a higher level of achievement. The choice must be voluntary. *Samuel A. Weiss, Ph.D. Dr. Samuel A. Weiss can be contacted at 7 Park Avenue, Suite 66, New York, New York 10016; tel. 212-686-8324. Page Number(s) 55 - 56 Year 1986 Volume 10 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 Rehabilitation: Goals or Shoals? Creator An entity primarily responsible for making the resource Samuel A. Weiss, Ph.D. * https://staging.drfop.org/files/original/dd8db7616001226c18971be2d8fcd283.pdf 1ad480aad4abe8298ef123b76f395b42 https://staging.drfop.org/files/original/d5b8d44b32ee77a3f0a1323a80a9afcc.jpg 2d03a3805b271567b07dc8e3a894f760 https://staging.drfop.org/files/original/beabbcc10d39750ad0df0029737fbb9a.jpg 2c4cecf0a116c3038089460eeeb1656d https://staging.drfop.org/files/original/eab5312062924db051a8886268065332.jpg 9a0e042d67cb98394cd3911b39aa9ef8 https://staging.drfop.org/files/original/6a6cd46dbbb7e7a257b0eb28b50d3729.jpg d75170a96119542a41e69cf1cdd9e7c9 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/1986_01_038.pdf Text Any textual data included in the document <h2>Use of a Bivalved Thoracic Suspension Jacket in the Orthotic Seating Management of Severe Arthrogryposis Multiplex Congenita</h2> <h5>Carrie L. Beets, CO. <a style="text-decoration: none;">*</a> Louis Whitfield, R.T. (O) <a style="text-decoration: none;">*</a> Jan Minnich, L.P.T. <a style="text-decoration: none;">*</a> J. Leonard Goldner, M.D. <a style="text-decoration: none;">*</a></h5> <h3> Introduction</h3> The thoracic suspension orthosis<a></a> was developed to aid in the management of patients with neuromuscular disease and has been used primarily in individuals with myelodysplasia. The principle of the device is to use the rib cage as a weight bearing structure and thus provide improved seating posture for the patient while attempting to limit spinal deformity and relieve excess ischial pressure. Additional benefits include improvement of balance and mobility and freeing of the hands and arms for feeding and other activities of daily living. The body image of the patient is improved while seated in a wheelchair, and the patient may interact better with the environment. The thoracic suspension orthosis should be considered for those patients who cannot tolerate surgery or when surgery should be delayed until they reach maturity. The patient presented in this paper does not fit the usual criteria for use of a thoracic suspension orthosis. The needs of this patient went beyond those provided by usual orthotic seating devices and led to the adaptation of established techniques and development of a different design to provide a functional seating arrangement for a severely involved child who had failed with other custom seating devices. This seven year old girl with severe generalized arthrogryposis multiplex congenita had functional limitation in the upper extremities and no voluntary action in the lower extremities. Surgical releases of soft tissue contractures and proximal and distal femoral osteotomies had been performed to adapt the patient to a sitting position. Past attempts to provide molded seating inserts to allow a comfortable sitting position had failed. She was most functional supine in a custom designed and portable bed-like seating insert which permitted feeding. Examination of the child revealed severe muscle atrophy of both upper extremities. There was active elbow extension but no active flexion. She was able to get her left hand to within several inches of her mouth by abducting and forward flexing her shoulder and then allowing gravity to bring her hand to the mouth. The spine revealed right thoraco-lumbar scoliosis, thoracic kyphosis, fixed lumbar lordosis, and a fixed pelvic obliquity in which the left pelvic brim was higher than the right. The left hip had a range of motion from 30 degrees flexion to about 90 degrees for a total of 60 degrees of flexion, with an external rotation deformity. The right hip was fixed in +20 degrees flexion. Both knees had flexion contractures of 70 degrees with 10 degrees motion. In order to flex the right femur for sitting, a subtrochanteric osteotomy had been performed with creation of a silicone capped pseudoarthrosis. While this was relatively successful, pain occurred when the patient was placed in a sitting position with any weight bearing occurring on the right ischium. For this reason, she was evaluated for use of a thoracic suspension orthosis. The patient was initially placed in a plaster cast thoracic suspension jacket for a three week trial. During this time, the periods of suspension were gradually increased. Her skin was not accessible for monitoring; however, since she had normal sensation and was cooperative, we depended on her complaints of pain to assess the support. She tolerated the three week trial period and experienced no skin breakdown or abrasion. At that time, a cast impression was taken for the fabrication and fitting of a thoracic suspension orthosis. <h3>Fabrication And Fitting</h3> Due to the lack of spinal flexibility, the need for easy and accurate application of the orthosis, and the need to make the device as simple as possible for the parents; a bivalved design was chosen rather than the traditional single anterior opening. The bivalved design (<a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-1.jpg">Fig. 1</a>) necessitated fabrication of two plastazote™ linings complete with conventional additional plastazote™ layers over the inferior costal margins. Special attention was needed to insure that the anterior and posterior halves of the two linings matched up accurately during the vacuum forming process (<a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-2.jpg">Fig. 2</a>). <a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-1.jpg">Figure 1.</a> Lateral view of bivalved thoracic suspension orthosis showing anterior shell trimlines. <a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-2.jpg">Figure 2.</a> View from above, the anterior and posterior linings match up to provide an even pressure just distal to the lateral and anterolateral inferior costal margins. The suspension spools were incorporated into the posterior shell, which was fabricated of low density polyethylene. High density polyethylene was chosen for the anterior shell, as it was felt that the additional rigidity provided by this material would be needed to maintain the integrity of the circumferential containment of the jacket under weight bearing. A large abdominal opening was provided in the anterior shell because the patient had experienced some distress in the plaster jacket, especially following meals, which had been relieved by the addition of an opening in the plaster cast (<a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-3.jpg">Fig. 3</a>). The two half shells were held in place as a unit with Velcro® closures. <a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-3.jpg">Figure 3.</a> Anterior view of bivalved thoracic orthosis showing abdominal opening. Fitting of the orthosis was followed by an in-hospital program of gradually increasing wearing time both in the nonsuspended and suspended states. Her original supine positioning device was modified to permit her to lie in this with the thoracic suspension jacket on, eliminating the need to take off the jacket between periods of suspension. Since she could not tolerate any weight bearing on her right hip, the suspension brackets on the wheelchair were positioned for full weight bearing suspension. She tolerated the conditioning program well. At the time of discharge, she was wearing the jacket all day long and was tolerating uninterrupted suspension for periods of two and one-half hours. Her electric wheelchair was outfitted with a chin operated joy stick control (<a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-4.jpg">Fig. 4</a>). While suspended, she could operate the wheelchair well. However, at the end of two and one-half hours in suspension, the patient would begin to complain of discomfort and would be transferred to her supine positioning device. <a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-4.jpg">Figure 4.</a> Patient sitting in suspension in wheelchair. <h3>Conclusion</h3> The application of a thoracic suspension jacket is a way of successfully providing a functional sitting position for a patient with severe arthrogryposis. In conjunction with a modified electric wheelchair, the patient was given an opportunity to interact actively with her environment, including a vertical position for eating. The bivalved design not only affords easy application and removal, but also permits visual monitoring of the skin. The crucial circumferential containment in the area of and just distal to the inferior costal margin was maintained satisfactorily with a bivalved design. *J. Leonard Goldner, M.D. J. Leonard Goldner, M.D., was former Chief of Orthopedics, Division of Orthopedic Surgery, Duke University Medical Center. *Jan Minnich, L.P.T. Jan Minnich, L.P.T., is with Lenox Baker Children's Hospital, Durham, North Carolina. *Louis Whitfield, R.T. (O) Louis Whitfield, R.T.(O), is with the Department of Prosthetics and Orthotics at Duke University Medical Center. *Carrie L. Beets, CO. Carrie L. Beets, CO., is with the University of Virginia. She was formerly with the Duke University Medical Center at the time of submission of this article. References: <ol> <li>Drennan, J.C.; Renshaw, T.S., and Curtis, B.H., "The Thoracic Suspension Orthosis," Clinical Orthopaedics and Related Research, No. 139, March/April, 1979, pp. 33-39.</li> <li>Drennan, J.C., Orthopedic Management of Neuromuscular Disorders, J.B. Lippincott Co., Philadelphia, p.83.</li> <li>Fillauer, C.E.; and Pritham, CH., "The Thoracic Suspension Jacket-Review of Principles and Fabrication, Orthotics and Prosthetics, Vol. 38, No. 1. Spring, 1984, pp. 36-44.</li> </ol> Page Number(s) 38 - 41 Year 1986 Volume 10 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-4.jpg 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 Use of a Bivalved Thoracic Suspension Jacket in the Orthotic Seating Management of Severe Arthrogryposis Multiplex Congenita Creator An entity primarily responsible for making the resource Carrie L. Beets, CO. * Louis Whitfield, R.T. (O) * Jan Minnich, L.P.T. * J. Leonard Goldner, M.D. * https://staging.drfop.org/files/original/d7b675b0378cee1912a8d5e84687921d.pdf 9d96407f8c68159964c5da7b9a38bd7f https://staging.drfop.org/files/original/3d9d7c0b41f15695d1d34ad758690f2a.png 69bc94cb8f542767a5c7ce6a7afa1b4a https://staging.drfop.org/files/original/d65d1661f0886e3d968a3606ff3a6a5c.jpg 87ff5e2a3fe1a34b03c0c39672002824 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/1986_01_033.pdf Text Any textual data included in the document <h2>Immediate Post-Operative Orthotic Impression Technique for Thermoplastic Spinal Orthoses Following Spinal Surgery</h2> <h5>James T. Lehner, M.D. <a style="text-decoration: none;">*</a> Wilbur A. Haines, C.P.O. <a style="text-decoration: none;">*</a> Mark E. Horwitz, CO. <a style="text-decoration: none;">*</a> Cynthia J. King, CO. <a style="text-decoration: none;">*</a></h5> Spinal surgery has been revolutionized in recent years by advances in surgical approaches, surgical techniques, and forms of internal fixation. Post-operative management has progressed from bed rest with log rolling, to mobilization in plaster casts, to modern technology orthoses. Co-polymer plastic composite orthoses have been used by the authors during the last few years. The orthoses have been easy to apply and have been comfortable for our patients. There have been no associated complications which would jeopardize the outcome of the operative procedure. <h3>Patient Selection</h3> The original patient the authors selected for management using a thermo-plastic orthosis was a retarded child with cerebral palsy who had previously been intolerant of casting, developing pressure sores within the cast. Molding for the co-polymer orthosis had to be done while the patient was anesthetized, since this patient was combative and otherwise difficult to work with. While the impression for this patient was being made, it became apparent that this molding technique would be easy to do in the operating room at the conclusion of operative spinal procedures. Initially, this postoperative molding technique was used for "special cases." These included patients with cerebral palsy, myelomeningocele, severe osteoporosis, and patients with severe respiratory problems. Eventually, the older adult idiopathic population which seemed very intolerant of rigid metallic orthoses or casting, was included. Things have gradually evolved to a point where most patients, other than teenage idiopathics, are candidates for this type of orthosis. The authors still prefer using a Kosair metallic axillary crutch style orthosis postoperatively for adolescent idiopathic scoliosis patients, since they seem to tolerate the rigidity of this system well.<a></a> The first 80 patients fitted with the co-polymer postoperative spinal orthotic system are reviewed in this study. Diagnoses include all the aforementioned, plus other types of muscular dystrophy, congenital scoliosis, tumors, post-menopausal deformities, and degenerative spinal deformities. All orthoses were applied after long (minimum of six vertebral levels) spinal fusions. All surgical cases, except those of congenital scoliosis, were routinely done with instrumentation. <h3>Orthosis Impression Technique</h3> The orthotic impression is taken immediately after the spinal surgery while the patient is still asleep. The technique is: <ol> <li> After the skin incision is closed, a light layer of Adaptic® and one layer of sterile four-by-fours are placed over the wound. </li> <li> The skin is bilaterally marked longitudinally along the mid-axilla (mid-coronal line) using a wet indelible pencil. Perpendicular hash marks are randomly made across the mid-axillary line to be used as "key" reference marks later. </li> <li> Sterile Vidrape® is placed across the patient's back to establish an impermeable membrane. </li> <li> The Vidrape® is marked by superimposing onto it the marks made previously on the patient's skin. </li> <li> Plaster splints are draped across the required area of the patient's torso, making sure that the plaster crosses the mid-axillary lines on both sides of the patient. The first layer is applied using two or three thicknesses of plaster. Subsequent reinforcing layers are applied, using about six layers of plaster. Finally, a few strips are applied to help prevent distortion of the mold. These are placed across the mold at two or three locations in the shape of an inverted "V." </li> <li> At this point, the posterior section of the impression is removed from the patient when hard (<a href="http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-1.jpg">Fig. 1</a>). Figure 1. Orthotist removing posterior mold. Note Vidrape® and markings in mid-axillary line.</li> <li> The Vidrape® is then removed in a manner which keeps plaster or water from touching the wound. </li> <li> Sterile dressings are applied by the scrub nurse, who has remained sterile to this point. </li> <li> The patient is placed on the post-operative bed that has been prepared using one extra sheet. </li> <li> Vidrape® is then applied to the patient anteriorly in preparation for the anterior section molding. (Cover breast and groin areas with four-by-fours or diapers.) </li> <li> The indelible pencil marks are again superimposed onto the Vidrape® along the mid-axillary lines, and appropriate relief markings are made on the rib cage and iliac crests. </li> <li> The anterior mold is made using the technique described in step five. When set, the plaster is removed. </li> <li> Finally, the Vidrape® is carefully removed and the patient is ready to go to the post-operative recovery room. </li> </ol> After the impression has hardened sufficiently, a cast cutter may be used to cut along the mid-axillary indelible lines, visible on the inner surfaces of each half of the impression. Using the "key" hash marks established previously, the two impression halves are joined together with plaster strips. The impression is now ready for orthotic fabrication using the method of choice. Since the impression has been made with the patient in the prone and supine positions, the orthotist must take this into account when fabricating the orthosis. The medial-lateral dimension of the patient is distorted normally about one inch due to the flattening effect created by the patient's weight against the operating and post-operative bed. The time required for the impression procedure adds 15 to 20 minutes of extra anesthesia and operating room time. There have been no infections in any of these cases. <h3>Results</h3> The orthosis described has been applied to 80 post-spinal surgery patients between January 1980 and October 1984. There were no cases of rod dislodgement or pseudoarthrosis. Fifty-eight patients had instrumentation done using segmental spinal wiring with either L-Rod or Harrington Rod fixation. One Mongoloid boy broke a wire in his L-Rod fixation, but over a subsequent 24 month follow-up, has shown no further wire or rod breakage. No other incident of internal fixation failure while wearing the orthosis has been encountered to date. Early in the series, one orthosis had to be remade due to pressure problems. No other orthosis has required anything except routine minimal corrections of trim lines. In the beginning, the average time of orthotic application was the eighth post-operative day. Later in the series, this dropped to the fifth post-operative day. Orthotic application varied from the second to the thirteenth day post-op and was determined by the patient's medical condition in all but one case. The patients were placed upright immediately upon application of the orthosis (<a href="http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-2.jpg">Fig. 2</a>). They were dismissed from the hospital an average of four days after the orthosis was applied. <a href="http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-2.jpg">Figure 2.</a> Post-op Spina Bifida child two days after brace application and four days post-operatively. Note colostomy site on right lower quadrant. Orthoses were worn about six and one half months post-operatively (the first 25 patients wore theirs for eight months post-op; all subsequent patients have worn theirs for six months post-operatively). Compliance has been monitored by the parents or guardians of the patients. They have reported 100 percent compliance. The parents are instructed that the orthosis may be removed when the patients are supine, for bathing, skin care, and pulmonary toilet as needed. Patients are never allowed up in the sitting position without wearing the orthosis during the six month post-operative period. One-half of the patients were non-ambulatory. <h3>Discussion</h3> This is an easy, quick, and accurate way to measure and apply post-operative thermoplastic orthoses after spinal surgery. It has been possible to eliminate patient discomfort during the molding process and no manipulation of the patient was required during the procedure. While this technique requires a close working relationship between physician, hospital personnel, and orthotist, it has virtually eliminated time delays in orthotic delivery. Historically, orthotic impressions were taken "when the patient was ready post-operative-ly." This left the impression making process in a nebulous time frame. Typically, patients were delayed in the application of their orthosis by a few days. This added additional patient time in the hospital with little benefit. Also, the orthotist had to schedule the impression making process at a time convenient to appropriate hospital personnel. The technique described gives the orthotist and his/her staff adequate time to properly design and fabricate the orthosis. Although none of the patients were felt to be ready to ambulate or sit on the first post-operative day, it would be possible to apply the orthosis, if necessary, within 24 hours. Many of the severe respiratory cases (spinal muscular atrophy) were fitted with their orthoses and sat up while still on a respirator in intensive care. There was only one case where orthotic application delayed patient mobility (orthosis revision was necessary). Usually, comfort was the deciding factor in-getting patients up. Later in this study group, when indications were broadened to include healthier patients, the time frame post-op of ambulation decreased significantly. It is believed that molding for a spinal orthosis while the patient is awake, several days after surgery, is unnecessarily painful. It also places the patient in some jeopardy of dislodging the instrumentation while having the impression made. It is also considered irrational to mold patients for an orthosis at a time when they are actually ready to be up and around. The authors do not trust segmental spinal instrumentation without external bracing, and reports now indicate this conservative approach, including the use of an orthosis, in this group of patients is warranted.<a></a> Retarded children and patients with anesthetic skin easily get into trouble with body casts and non-removable orthoses. The orthotic system described certainly helps to alleviate many of the problems previously encountered with post-operative spinal orthoses. This technique is still not used for the standard adolescent idiopathic patient, who in our judgment currently does well with Harrington Instrumentation fixation and post-operative bracing using a rigid metallic Kosair type orthotic system. <h3>Advantages</h3> The co-polymer post-operative orthotic spinal system has many advantages: <ol> <li> Minimal patient discomfort; </li> <li> Expedient spinal orthosis application; </li> <li> Maximum utility for patient care (skin cleansing, checking anesthetic skin, respiratory therapy, etc.); </li> <li> Taking an accurate impression with minimal post-operative movement of the patient; and </li> <li> Excellent wearing compliance by patients. </li> </ol> <h3>Disadvantages</h3> While there are disadvantages to most anything, the negative points of this technique and system are few. They would include: <ol> <li> Increased anesthesia and operating room time (15-20 min.); </li> <li>Tight post-op scheduling of the orthotist's time (Requires a close working relationship with physician, hospital personnel, and orthotist).</li> </ol> *James T. Lehner, M.D. James T. Lehner, M.D. is from the Wright State University College of Medicine, Division of Orthopedics. *Wilbur A. Haines, C.P.O. Wilbur A. Haines, CO. is President of LaForsch Orthopedic Laboratories, 536 Valley Street, Dayton, Ohio *Mark E. Horwitz, CO. Mark E. Horwitz, CO. is Director of Orthopedic Services for LaForsch Orthopedic Laboratories. *Cynthia J. King, CO. Cynthia L. King, CO. is with the Clinical Orthotic Services at LaForsch Orthopedic Laboratories References: <ol> <li>Benson, S.; McKinley, L.M.; Martin, T., Delto-Pec-toral Axillary Lumbar Thoracic Support. Kosair Orthotic Laboratory, Louisville, Kentucky (Unpublished Data).</li> <li>Broadstone, P.; Johnson, J.R.; Holt, R.T.; Leath-erman, K.D., "Consider Post-operative Immobilization of Double-L Rod S.S.I. Patients," Orthopedic Transactions, 8(1):171-172, 1984.</li> <li>Taddonio, R.F.; Weller, K.; Appel, M., "A Comparison of Patients With Idiopathic Scoliosis Managed With and Without Post-operative Immobilization Following Segmental Spinal Instrumentation With Luque Rods," Orthopedic Transactions, 8(1): 172, 1984.</li> <li>Wallace, S.L.; Fillauer, K., "Thermoplastic Body Jackets for Control of Spine after Fusion in Patients with Scoliosis," Orthotics and Prosthetics, Vol. 33, No. 3, pp. 20-24, September, 1979.</li> </ol> Page Number(s) 33 - 37 Year 1986 Volume 10 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 2 http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-2.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 Immediate Post-Operative Orthotic Impression Technique for Thermoplastic Spinal Orthoses Following Spinal Surgery Creator An entity primarily responsible for making the resource James T. Lehner, M.D. * Wilbur A. Haines, C.P.O. * Mark E. Horwitz, CO. * Cynthia J. King, CO. * https://staging.drfop.org/files/original/5fbec4052a52f2f96c332992054740bd.pdf 20e1c68a1e68c26c17ebe0dcbed427db https://staging.drfop.org/files/original/1aa501ac55eba1dc5a0b97d8b3391563.jpg 1c3a60d6625ab486da03f8e2fc2f4e77 https://staging.drfop.org/files/original/16e17501c3eb200567a45563f807c9bd.jpg a2e25a04633c58de9d3fe329ed8a47d6 https://staging.drfop.org/files/original/6dc1d516628f4acd9f6a74eea19e37e0.jpg d80207c27684f55a49e165cd49c6f76a https://staging.drfop.org/files/original/f8ee04e92547ecb0cde7b37fab8d661f.jpg ecad7b10960f167cd183869d747a981e 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/1986_01_024.pdf Text Any textual data included in the document <h2>The Use of the AFO and PTB Orthoses for Severe Pes Planus</h2> <h5>Gustav Rubin, M.D., F.A.C.S. <a style="text-decoration: none;">*</a> Malcolm Dixon, M.A., R.P.T. <a style="text-decoration: none;">*</a></h5> When the severely deformed pes planus foot is rigid, the deformity fixed, and the arch totally dropped, to provide the patient with a conventional molded arch "support" is an exercise in futility. Placement of a shoe insert under the non-existent long arch cannot prevent further dropping on weight-bearing if the talar head is already in contact with the floor and the intertarsal joints are immobile. It is the purpose of this paper to report the use of the Ankle Foot Orthosis and Patellar Tendon Bearing Orthosis for such a situation. Because it would not be feasible to attempt to raise the arch of a rigid foot with an orthosis, the authors decided to employ an orthosis to decrease stresses on the foot and ankle by transferring push-off forces to an AFO.<a></a> This was to be accomplished by fabricating the orthosis with a solid ankle and modifying the shoe to incorporate a long steel spring and a rocker bar. Since it was anticipated that this approach might not provide adequate relief, it was considered that the next procedure would be to introduce partial unweighting with a Patellar Tendon Bearing Orthosis.<a></a> This would also be fabricated with a solid ankle and include a shoe with a long steel spring and a rocker bar. <h3>Case Report</h3> B.L., age 62, was initially referred to the VA Prosthetic Center on June 14, 1982, with a history of painful feet since World War II, which had become worse in recent years. The patient stated that "my feet are going to collapse and I can hardly walk and barely make it when I stand and walk." He had a cerebral vascular accident on January 18, 1982, but had made an almost complete recovery. There was also a history of aortic valve insufficiency and gout. The patient was receiving Coumadin, in-deral, digoxin, and allopurinal for his medical problems. He had not had relief of his foot pain from arch supports in the past. On examination there was noted medial downward dislocation of the talar heads, abduction of the forefeet, absence of the long arches, marked restriction of joint motion, marked splaying of the forefeet and severe hallux valgus, bilaterally (<a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-1.jpg">Fig. 1</a>). The dorsalis pedis and posterior tibial arteries were palpable. <a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-1.jpg">Figure 1.</a> The severe bilateral pes planus noted when patient was first seen at VAPC. X-Rays confirmed the clinical findings of severe pes planus and hallux valgus bilaterally. The patient's private orthopedic surgeon had fit him with short AFOs (<a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-2.jpg">Fig. 2</a>). These were a significant improvement over previous arch supports, but were bio-mechanically inefficient. Bilateral solid ankle AFOs and shoes with long steel springs and rocker bars were prescribed (<a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-3.jpg">Fig. 3)</a>. <a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-2.jpg">Figure 2.</a> Orthosis prescribed by patient's private orthopedic surgeon. <a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-3.jpg">Figure 3.</a> Bilateral AFOs and shoe corrections prescribed at the VAPC. On July 16, 1982 the patient reported that he was much more comfortable. When re-evaluated on October 21, 1982 it was indicated that the left side was subjectively worse than the right. He was experiencing very painful weight-bearing directly on the talar head. The "comfort" that he had reported in the previous note was relative. A PTB orthosis was prescribed for the left side (<a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-4.jpg">Fig. 4</a>), in accordance with the originally outlined plan of procedure. <a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-4.jpg">Figure 4.</a> The final prescription included an AFO on the less symptomatic right side and a PTB orthosis for the left side. On April 19, 1983 the patient stated that the PTB was an improvement over the AFO. On August 7, 1984 he returned for a new orthosis because of loss of fit. The patient had lost weight following cardiac surgery for aortic valve replacement and triple bypass in March, 1984. On October 4, 1984 he reported that the new orthoses were "comfortable, that he feels much better with them, and is able to ambulate." He and his wife both stated that he "would not be able to walk" without these orthoses. <h3>Discussion</h3> Severe pes planus of the type described in this report can only be helped to a limited degree by orthoses. However, if a maximally efficient approach is employed, the limited degree of relief can be significant and allow an almost non-ambulatory patient to achieve a useful degree of ambulation. A solid ankle AFO not only functions to stabilize the ankle and foot, but when combined with shoe corrections (rocker bar and long steel spring), it acts to diminish the stresses on the foot and ankle. The PTB provides, in addition, partial unweighting while retaining the features that permit transfer of forces to the orthosis. We have employed the AFO in other similar instances, but this was the first occasion in which we employed the PTB for severe pes planus. *Malcolm Dixon, M.A., R.P.T. Malcolm Dixon, M.A., R.P.T., is Chief of Clinical Services at the Veterans Administration Prosthetics Center. *Gustav Rubin, M.D., F.A.C.S. Gustav Rubin, M.D. F.A.C.S., is Chief of Special Clinics at the Veterans Administration Prosthetics Center, 252 7th Avenue, New York City, New York 10001. References: <ol> <li>Rubin, Gustav; Dixon, Malcolm; and Danisi, Michael, "VAPC Prescription Procedures for Knee Orthoses," Orthotics and Prosthetics, 31:3: pp. 9-25, September, 1977.</li> <li>Rubin, Gustav, "Patellar-Tendon-Bearing (PTB) Orthosis," The Bulletin of the Hospital for Joint Diseases, XXXIII:2: pp. 155-172, October, 1972.</li> </ol> Page Number(s) 24 - 26 Year 1986 Volume 10 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-4.jpg 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 Use of the AFO and PTB Orthoses for Severe Pes Planus Creator An entity primarily responsible for making the resource Gustav Rubin, M.D., F.A.C.S. * Malcolm Dixon, M.A., R.P.T. * https://staging.drfop.org/files/original/c54eb7124de515dfb5a2c80a171d7287.pdf c059ad161633dad45eeca0934c909cad https://staging.drfop.org/files/original/31133865c8e9557260f8bd1f96b35cb4.jpg debb2dccb15037ed716833a862676f55 https://staging.drfop.org/files/original/76ab2bdb3b1f40392d5acf2a80fd81b4.png 43a51d537ade33c716726c11122de9c4 https://staging.drfop.org/files/original/4f846be89dcfbaec03b8dad30b643b65.png a0c333594d20ee22e61d648d3bcfae4b https://staging.drfop.org/files/original/7f0bb6d12c337d84a73004ac18796aa1.png b48ad1593888f726b2a0bc79a21b203d https://staging.drfop.org/files/original/5cc591632bd5f7625f8e45a5a49a36d0.png 705de92b431b5f51242ae9f39ef3ec60 https://staging.drfop.org/files/original/69ad968f9a2cf740fdc8d5b581168b3b.png 790de1d7c9a6efb98b1d02b364e0b307 https://staging.drfop.org/files/original/ae253c60ad9d64d58dbfac9c47ee01be.png d30b4e0de83279aeb3e762423c9857a8 https://staging.drfop.org/files/original/19126cd2ef8d8d5083aab77f1085e37c.png 2dabbcdddb43512de496ab4f5f6f14a4 https://staging.drfop.org/files/original/14a35a5f66f2ee538c1c2434c44c25fc.jpg 67623f61c98ef625125a37b8d0a7539d https://staging.drfop.org/files/original/465e3d5de18530598f0969d467274b98.jpg e3e0205c514936cf914a9b702fe72d87 https://staging.drfop.org/files/original/8fa0ab62291904e82c034570067739ed.jpg 867595c1ead00d2fe609177aaf7bd6dc https://staging.drfop.org/files/original/c0ddbdde7e6e9da54ea514b9702bae66.png 5d25185ae8749e550c43a5b995c176e3 https://staging.drfop.org/files/original/62674ecfd2487303bd0f2c43e4c2e95e.png 13289e1e860786dd87e5194224b9e186 https://staging.drfop.org/files/original/868b64230ca00759e385e4755b5bee47.png 3733a698ebcfc317708a7b1648e9f896 https://staging.drfop.org/files/original/3356a9cd35710355b95159bc4e956f25.jpg bf4173cccdb9cf33f8b446708fbf620b https://staging.drfop.org/files/original/08d2efb1cecdfedd9f6a8f4094ecc9a0.png c75fc32703b813d98a800c9a737e9b33 https://staging.drfop.org/files/original/ecc985ed9b93d29a2d75ef7106a21396.png 6e62f348e8e431c5a12a450ced56ca13 https://staging.drfop.org/files/original/0f9b75065ce897d36a34c7c0444ef436.png 3cae37b94c333a15216e53e37622c513 https://staging.drfop.org/files/original/9ae4112185463778c8c98562034a2871.png 8fde75e930c09bb4580e61964646f969 https://staging.drfop.org/files/original/961e4683cecdfaaaa686708364eadb39.png 5bd393a1040e8dea23f11dc5c1094db5 https://staging.drfop.org/files/original/383857a30168ede26d54ea4707277586.png b633443e6489d214a32313536803e427 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/1986_01_015.pdf Text Any textual data included in the document <h2>The Neurophysiological Ankle-Foot Orthosis</h2> <h5>Cyndi Ford, P.T. <a style="text-decoration: none;">*</a> Robert C. Grotz, M.D. <a style="text-decoration: none;">*</a> Joanne Klope Shamp, C.P.O. <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, orthotic practice has been revolutionized by the design possibilities afforded by total contact devices. However, prescription of lower extremity orthoses for neuro-logically involved patients has traditionally depended solely upon biomechanical principles even as neurophysiological approaches to treatment gained recognition and acceptance. Neur-odevelopmental Techniques (NDT) were developed as a theory of Karl and Berta Bobath and evolved to "a sensorimotor approach to control motor output and in doing so change sensory input."<a></a> Handling techniques which counteract patterns of abnormal tonic reflex activity reduce spasticity and allow facilitation (activation) of normal postural reactions through stimulation of key points of control, which include points on the foot and ankle. Recent advances incorporating neurophysiological principles of inhibition and facilitation into the design of ankle-foot orthoses make possible tone-reducing devices with specific areas of pressure or contact to inhibit abnormal hypertonicity. 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 the construction of a molded polypropylene AFO allows for all of the tone-inhibiting characteristics of casting ... to be built into the AFO." Although tone-reducing AFO inhibit abnormal hypertonicity in the affected lower extremity, the disadvantages inherent in traditional AFO persist. Limited ankle dorsi-flexion and plantar flexion, create a negative influence upon independent knee and hip function. Floor reaction forces intended to prevent the typical hemiplegic knee recurvatum during stance phase also contribute to increased effort and decreased smoothness in gait. Tonic foot reflexes elicited by contact on the plantar surface of the foot as a means to facilitate normal movement are disregarded. In an effort to address these gait concerns, an orthosis was designed based upon the neurode-velopmental concepts as described by Bobath<a></a> and Utley<a></a>, and the foot reflexes as described by Duncan and Mott<a></a> with the following considerations in mind: <ol> <li> A design configuration intended to utilize both biomechanical principles to limit calcaneal varus and neurophysiological principles (of facilitation and inhibition) to obtain dynamic ankle dorsiflexion and plantar flexion. </li> <li> Selection of a material with adequate flexibility, durability, and shape retention under conditions of continual deformation during ambulation. </li> <li> Ease of donning for the one-handed patient. </li> </ol> <h3>Design Rationale</h3> The Neurophysiological Ankle-Foot Orthosis (NP-AFO) is a custom polypropylene device, vacuum-formed over a plaster model of the patient's affected lower extremity (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-01.jpg">Fig. 1</a>). Within the total contact design are incorporated the following forces: <ol> <li> A three-point pressure system to biomechanically control calcaneal varus (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-02.jpg">Fig. 2</a>). </li> <li> A biomechanical force medial to the achilles tendon to counterbalance and prevent excessive pronation and rotation of the orthosis in the shoe (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-03.jpg">Fig. 3</a>). </li> <li> A neurophysiological force on the medial aspect of the calcaneus, extending to the plantar surface of the longitudinal arch without creating pressure under the navicular itself (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-03.jpg">Fig. 3</a>). This facilitates straight plane dorsiflexion. </li> <li> A neurophysiological force on the lateral aspect of the plantar surface of the foot (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-04.jpg">Fig. 4 </a>and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-05.jpg">Fig. 5</a>) to facilitate the eversion reflex (peroneals) and recruit more proximal controls (vastus lateralis and gluteus medius) for knee and hip stability as discussed by Duncan<a></a>. The amount of dorsiflexion assist may be graded by adjusting the width of the segment joining the heel-cup and the metatarsal arch (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-05.jpg">Fig. 5</a>). </li> <li> A neurophysiological force to inhibit the toe grasp reflex (toe flexors and gastroc-nemius-soleus) by unweighting of the metatarsal heads through use of a metatarsal arch (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-06.jpg">Fig. 6</a>). </li> <li>Biomechanical function through flexibility of the foot and ankle due to the trimlines and configuration of the plastic NP-AFO (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-07.jpg">Fig. 7</a> and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-08.jpg">Fig. 8</a>).</li> </ol> <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-07.jpg">Figure 7.</a> Medial view, left foot <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-08.jpg">Figure 8.</a> Lateral view, left foot <h3>Prescription Rationale</h3> The NP-AFO is designed for use in the treatment of the patient with a central nervous system disorder, such as a cerebral vascular accident or closed head injury. Assessment should include analysis of the individual's tone or spasticity, range of motion, and the availability of follow-up by members of the clinic team familiar with a neurophysiological approach to care. Spasticity has been classified as minimal, moderate, or severe in terms of function of the foot and ankle during gait.<a></a> Minimal spasticity allows the patient to land on a stable calcaneus without excessive supination of the forefoot and then shift the body weight over the heads of the metatarsals, although during swing phase the foot assumes a varus or supinated posture. Moderate spasticity causes the calcaneus to assume a position of varus with excessive supination at initial contact; however, during midstance some pronation occurs and the body weight can again be transferred normally across the forefoot. Severe spasticity is characterized by the foot and ankle being held rigidly in a position of equinovarus throughout stance so that the body weight remains on the lateral aspect of the forefoot with little or no weightbearing through the heel or medial metatarsal heads. This varus position persists throughout swing phase also. Patients exhibiting minimal or moderate spasticity are excellent candidates for the NP-AFO. Patients with severe spasticity are candidates only if their tone can be modified through handling techniques and/or inhibitive casting. The use of toe separators (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-09.jpg">Fig. 9</a>, <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-10.jpg">Fig. 10</a>, and<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-11.jpg"> Fig. 11</a>) as an adjunct treatment is also effective in patients with a separate toe grasp reflex to inhibit excess tone and reduce pain.<a></a> In order for the NP-AFO to function appropriately, the patient must have at least 15 degrees of passive dorsiflexion with the knee in flexion. <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-09.jpg">Figure 9.</a> Toe separators fabricated from Plastazote® with a Moleskin® cover and toe extension. <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-10.jpg">Figure 10.</a> Toe separators in place under the toes <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-11.jpg">Figure 11.</a> Superior view showing tabs to hold in place under sock. Follow-up by a clinic team familiar with the device is important to monitor the continued fit and function. With most AFO the major concern may be skin breakdown. However, with the NP-AFO the change in fit due to edema, weight loss, or tone variations may require modifications to maintain the critical areas of contact. Contraindications for this device are severe spasticity which cannot be modified through inhibitive casting or handling techniques, and early excessive pronation or calcaneal valgus with the foot pronated at initial contact of stance. <h3>Clinical Experience</h3> The NP-AFO has been prescribed for 35 patients with the following diagnoses: 29 Cerebral Vascular Accidents (CVA), 4 Closed Head Injuries (CHI), 1 Cauda Equina Injury, and 1 undiagnosed Demyelinating Disease. Although three patients were lost to follow-up, the NP-AFO has continued to be worn by the remaining 32 with overwhelming acceptance which seems to be attributed to the comfort and function of the device. Of the four patients converted from traditionally designed orthoses (2 metal, 2 plastic AFO), three have improved gait patterns and prefer the NP-AFO to their previous device. The fourth has rejected orthotic care due to refusal to adapt footwear from inappropriate styles with 2 1/2" heels. Four patients became independent ambulators without the use of any orthotic device. <h3>Fabrication</h3> Polypropylene was chosen as the thermoplastic currently exhibiting the best conformance to the desired qualities, when used in the fabrication process described. <h3>Casting Procedure</h3> The casting technique is similar to that described in Lower Limb Orthotics, A Manual<a></a> and is a procedure commonly used by certified orthotists. The cast must be taken in a position of maximal dorsiflexion, preferably 20 degrees. The calcaneus, midfoot, and forefoot should be in a neutral position. It has been our experience that tone-reducing handling activi-. ties performed by a physical therapist just prior to casting will help assure an optimal position. These activities include forefoot, midfoot, and hindfoot mobilizations as taught by Jan Utley.<a></a> The cast is removed upon hardening and filled with plaster to create a positive model for use in vacuum-forming of the orthosis. The positive model is now ready for modifications to create the necessary biomechanical and neurophysiological forces. <h3>Modification Of The Positive Model</h3> As the key to function of the orthosis is selective inhibitive and facultative forces, accurate cast modification is essential. Plaster removal is performed in the following areas to a depth of 0.5 to 1 cm. depending upon the compressibility of the patient's extremity. These modifications must be sufficient to provide a very firm force to the skin as designated. <ol> <li> Medial and lateral to the achilles tendon using a Scarpa's knife to deeply groove the modification (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-12.jpg">Fig. 12</a>). </li> <li> Medial aspect of the calcaneus extending to the plantar surface of the longitudinal arch without creating pressure under the navicular itself that would stimulate mid and forefoot supination (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-13.jpg">Fig. 13</a>). </li> <li> Along the lateral plantar surface of the mid- and forefoot, excluding the base and head of the fifth metatarsal (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-14.jpg">Fig. 14</a>). </li> <li> Create a metatarsal arch 6mm. proximal of the metatarsal heads for the inhibitive function of unweighting the metatarsal heads and thereby reduce tone (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-06.jpg">Fig. 6</a>). </li> <li> Smooth entire cast. </li> </ol> If an accurate negative cast and positive model were created, no further modifications are necessary. <h3>Vacuum-Forming Process</h3> Leather, nylon, or rope cording is applied to the cast (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-15.jpg">Fig. 15</a>, <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-16.jpg">Fig. 16</a>, and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-17.jpg">Fig. 17</a>) to create strengthening corrugations in the orthosis after molding. A separating agent or material is used between the positive model and the hot plastic to create adequate vacuum and to leave a smooth inner surface. For our drape-forming process one layer of perlon with one layer of ladies' nylon knee-high stockings are applied and smoothed with talc. Stress-relieved 3/16" polypropylene is then drape-formed under vacuum to the positive model and allowed to cool for 24 hours. <h3>Trimlines</h3> The orthosis is removed from the positive model using a cast cutter and is sanded to finish according to the following trimlines: <ol> <li> Overall height of the orthosis is equal to the distance from the plantar surface of the calcaneus to the flare of the achilles tendon as it meets the gastrocnemius-soleus group, multiplied by 2. An average overall length for a 175cm. (5'9") adult is 25.5cm. (10"). </li> <li> Length of the plantar extension is terminated 6mm. proximal to the metatarsal heads for comfort. </li> <li> The lateral trimlines (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-18.jpg">Fig. 18</a>) come as far anterior as possible and still allow passage of the leg into the orthosis. The posterior trimline (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-18.jpg">Fig. 18 </a>and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-19.jpg">Fig. 19</a>) approaches the lateral margin of the achilles tendon, but may require modification to prevent a bowstring effect by the heel counter of the shoe against the NP-AFO. Note that flexibility is enhanced by the narrowing anteriorly and posteriorly as the lateral side meets the heelcup. </li> <li> The achilles tendon is left exposed to the point of flare with the gastronemius-soleus (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-19.jpg">Fig. 19</a>). </li> <li> The medial margin is trimmed so as to provide the appropriate forces and yet avoid contact on the medial malleolus and under the navicular. The open area provides for lack of resistance to dorsiflexion and plantar flexion (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-20.jpg">Fig. 20 </a>and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-21.jpg">Fig. 21</a>). The plantar extension (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-21.jpg">Fig. 21</a>) may be varied in width depending upon the size of the patient and flexibility desired, but as it serves only to join the metatarsal arch to the heelcup, it should remain as flexible as possible. The distal aspect, including the metatarsal pad, should span the distance between the shaft of the first metatarsal and the extreme lateral margin of the foot to allow maximum facilitation of the eversion reflex.</li> </ol> A full 1/8" Plastazote® liner is glued to the inner surface of the orthosis, with the exception of the areas contained by the patient's shoe to allow ease of donning the same size shoe previously worn by the patient. A Velcro® strap of 2" width is applied to the proximal anterior calf. A lace-tied or Velcro®-closed shoe is recommended to maintain the critical fit of the NP-AFO. <h3>Discussion</h3> The movement allowed by the NP-AFO encourages dynamic control of the entire lower extremity. When sitting, normal weight-bearing attitude can occur with the foot remaining in full contact with the floor throughout a full range of knee flexion. Analysis of the normal movements of the ankle during elevation from a chair has revealed to us that the ankle begins in dorsiflexion and continues to dorsiflex during the initial phase of the elevation before plantar flexing to a relatively neutral position. Devices which eliminate this normal range of dorsiflexion necessarily require a patient to work over an abnormal base and make difficult active weight-bearing during elevation. The ability to assume a normal weight-bearing surface in a position of power as allowed by the NP-AFO encourages weight-bearing on the affected extremity throughout all activities of daily living. Further, dynamic control of the pelvis and knees are encouraged during ambulation by eliminating floor reaction forces inherent in other AFO. Without these abnormal forces, the patient experiences the normal movement of the pelvis and knee over the foot, allowing development of a propulsive toe-off with the NP-AFO. Progressing from use of the NP-AFO to being independent of assistive devices is more feasible, as the patient has the opportunity to gain control of muscles through the normal range of movement. <h3>Summary</h3> The adequacy of traditional AFO to provide a safe, functional gait pattern is irrefutable. However, experience with patients who sustained a CVA five to fifteen years ago and received a traditional metal or plastic AFO reveals they now present problems related to overuse of the sound side: the pathomechanics resulting from a rigid ankle and/or increasing hypertonicity from abnormal weightbearing patterns. As more patients have increased lifespans following a CVA, treatments and orthotic care which assure prolonged quality of life become increasingly important. Neurophysiological treatment attempts to do this through emphasis upon normal movement patterns and integration of the affected and unaffected sides. The NP-AFO is a biomechanically and neurophysiologically effective ankle-foot orthosis that is appropriate for creating a functional gait in the patient with a central nervous system disorder. The design allows for independent motion at the ankle, knee, and hip joints in a lightweight and cosmetic custom-made orthosis. The NP-AFO joins the inhibitive cast and other neurophysiological armamentarium in new approaches to the rehabilitation of the spastic or hypertonic patient. *Joanne Klope Shamp, C.P.O. Joanne Klope Shamp, C.P.O., is with the Shamp Pros-thetic-Orthotic Center in Norton, Ohio. *Robert C. Grotz, M.D. Robert C. Grotz, M.D., is Medical Director for Edwin Shaw Hospital in Akron, Ohio *Cyndi Ford, P.T. Cyndi Ford, P.T., is with the Edwin Shaw Hospital in Akron, Ohio. <h3>Additional Reading</h3> <ol> <li> Bobath, B. "The Application of Physiological Principles to Stroke Rehabilitation—A Special Report," The Practitioner, December, 1979, Vol. 223, 793-4. </li> <li> Ibid, "The Treatment of Neuromuscular Disorders by Improving Patterns of Coordination," Psychotherapy. </li> <li> Bobath, B. and Bobath, K., "The Importance of Memory Traces of Motor Efferent Discharges for Learning Skilled Movement," Developmental Medicine and Child Neurology, 1974, p. 16, pp. 837-8. </li> <li> Cherry, D.B., "Review of Physical Therapy Alternatives for Reducing Muscle Contracture," Physical Therapy, Volume 60, Number 7, p. 877, July, 1980. </li> <li> Effgen, S., "Integration of the Plantar Grasp Reflex as an Indicator of Ambulation Potential in Developmentally Disabled Infants," Physical Therapy, Volume 62, Number 4, pp. 433-35, April, 1982. </li> <li> Freedman and Herman, "Inhibition of EMG Activity in Human Triceps Surae Muscles During Sinusoidal Rotation of the Foot," Journal of Neurology, Neurosurgery and Psychiatry, 1975:38, pp. 336-45. </li> <li> Knutsson, E. et al., "Different Types of Disturbed Motor Control in the Gait of Hemiparetic Patients," Brain, 1979:102, p. 405. </li> <li> Lehmann, J.F., "Biomechanics of Ankle-Foot Orthoses: Prescription and Design," Archives of Physical Medicine and Rehabilitation, Volume 60, May, 1979, p. 200. </li> <li> Ibid, "Plastic Ankle-Foot Orthoses: Evaluation of Function", Archives of Physical Medicine and Rehabilitation, p. 402. </li> <li> Ibid, "A Biomechanical Evaluation of Knee Stability in Below-Knee Braces," Archives of Physical Medicine and Rehabilitation, p. 688, December, 1970. </li> <li> Manfredi, Sacco and Sideri, "The Tonic Ambulatory Foot Response," Brain, 1975: 98, pp. 167-80. </li> <li> Perry, et al., "Determinates of Muscle Action in Hemiparetic Lower Extremity," Clinical Orthopaedics and Related Research: p. 131, March-April, 1978. </li> <li> Walters, R.L., "The Enigma of 'Carry Over'," International Rehabilitation Medicine, 1984:6, pp. 9-12. </li> <li> Watemabe, I. and Obubo, J., "The Role of Plantar Mechanoreceptor in Equilibrium Control," Ann-NY-ACAD-Science, 1981: 374, pp. 855-64. </li> <li> Weiz, S., "Studies in Equilibrium Reaction," Journal of Nervous and Mental Disorders: 88, 1938, p. 150. </li> </ol> References: <ol> <li>Yates, G., "A Method for Provision of Lightweight Aesthetic Orthopaedic Appliances," Orthopaedics: Oxford, 1:2, pp 153-162, 1968.</li> <li>Lehneis, H.R., "New Concepts in Lower Extremity Orthotics," Medical Clinics of North America, 53:3:3, pp. 585-592, 1969.</li> <li>Bobath, K., "The Problem of Spasticity in the Treatment of Patients With Lesions of the Upper Motor Neurone," The Western Cerebral Palsy Centre, London, England.</li> <li>Eberle, E.D.; Jeffries, 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>Bobath, B. and Bobath, K., Motor Development in Different Types of Cerebral Palsy, Heinman, London, 1975.</li> <li>Utley, J., NDT Adult Hemiplegia and Closed Head Injury Certification Course, Columbus, Ohio, July, 1982.</li> <li>Duncan, W. and Mott, D., "Foot Reflexes and the Use of the Inhibitive Cast," Foot and Ankle, p. 145, 1983.</li> <li>Duncan, W., "Tonic Reflexes of the Foot," Journal of Bone and Joint Surgery, July, 1960.</li> <li>Sarno, J.E. and Lehneis, H.R., "Below-Knee Orthoses: A System for Prescription," Archives of Physical Medicine and Rehabilitation, Vol. 54, p. 548, December, 1975.</li> <li>Rehabilitation Engineering Center, Moss Rehabilitation Hospital. Lower Limb Orthotics: A Manual, First Edition, Philadelphia, 1978.</li> </ol> Page Number(s) 15 - 23 Year 1986 Volume 10 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Neurophysiological Ankle-Foot Orthosis Creator An entity primarily responsible for making the resource Cyndi Ford, P.T. * Robert C. 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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/1986_01_008.pdf Text Any textual data included in the document <h2>The Biomechanics of the Foot</h2> <h5>André Bähler <a style="text-decoration: none;">*</a></h5> "The human foot is one of nature's works of art and as such, it has not yet been fully recognized and explained. It will require a deal of scientific investigation before this structure is fully understood." These words of the old master of orthopaedics, Georg Hohmann, from his book "Fuss und Bein" are still applicable today. Thirty years later, the biomechanics of the foot have still not been completely explained, and there are many questions yet unanswered. The many, more or less articulated connections of the foot allow a variety of changes which make it difficult to understand the movement as a homogeneous process. Too many factors can only be qualified, but not quantified. Nor may we forget the reciprocal influence of the position of the foot, knee, and hip joints. Each change in the position of one of these joints automatically involves a change in the position of the other two joints. For example, in the upright position, the neck of the femur forms a posteriorly open angle of approximately 20 degrees. This is determined by the anatomical factors in relation to the frontal plane of the body. The direction of the axis of the hip joint corresponds fairly accurately to the connection inner-malleolus/ outer-malleolus, which have an exterior rotation of approximately 20 to 30 degrees in relation to the frontal plane. Consequently, there is a conformity between the ankle axis and the hip axis. In the upright position, the knee is practically locked due to the automatic rotation, so the position of this axis is of minor importance. When walking, the pelvis rotates approximately 20 degrees forward. As the lower leg also rotates inwardly in relation to the upper leg during flexion, the ankle axis rotates inwardly and the foot takes up a straight position in the swing phase. <h3>Characteristics Of The Foot</h3> The foot has the characteristics of a triple axial joint which allows it to assume any position. The three main axes of movement converge in the talus area (<a href="staging.drfop.org/files/original/557b90124720a7da30c19930ed30060d.jpg">Fig. 1</a>). Particularly during rotational movements to adapt the foot to an uneven surface, all the joints are involved to some extent; nevertheless, the ankle joint, although formed as a hinge joint, forms the main joint for locomotion. According to Kapandji, the foot can be compared architectonically to a vault, which is supported by three arches. Other authors criticize this vault-concept on the basis that it is too static. However, the vault-structure is very meaningful as an aid to analyzing the foot in general (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-02.jpg">Fig. 2</a>). The arrow shows the direction and position of the main weight, which is first taken by the calcaneus (A) and then transferred to the forefoot: inside on metatarsal I (B) and outside on metatarsal V (C). The front transversal vault can also be understood as a supporting construction: on the one side the two corner stones (metatarsal I and metatarsal V) and on the other side, the transverse vault (metatarsal II, III, and IV). This construction enables the forefoot to take a great amount of weight and at the same time allows the foot to adapt to uneven surfaces. Furthermore, it can be seen that when the feet are put together, the position of both cal-canei can be regarded as a vault structure. The position of the calcaneus together with a slight valgus position serves to stabilize the body, particularly during the walking motion of the leg (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-03.jpg">Fig. 3</a>). <h3>The Joints</h3> The joints themselves pose some problems. Let us take for example the development of the inclination of the trochlea of the talus, and the distal tibial epiphyseal cartilage to the longitudinal axis of the lower leg in the frontal plane as described by Lanz Wachsmuth. Left in the infant and right in a two year old (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-04.jpg">Fig. 4</a>), it can be seen that the axes of the ankle joint and the talocalcaneonavicular joint and that of the epiphyseal cartilage are developing. In the 12 year old, left, and in the adult, right, the axis becomes horizontal during normal growth process, stabilizing the support system of the foot (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-05.jpg">Fig. 5</a>). The changes in the various process-, movement-, and development-axes of the ankle during the development of the child are probably one reason for the controversial views over the biomechanics of the foot. Biomechanically we are interested in the joints, and in particular, those used when walking. The Ankle Joint The ankle joint (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-06.jpg">Fig. 6</a>) is of particular importance, because in at least one direction it secures a movement without which it would be impossible to walk. This joint could also be described as a hinge joint with a diagonal axis of rotation, which allows a movement of about 20 degrees up and down. This inclination of the ankle joint certainly contributes to stability when carrying weight and can only be fully understood when considered in connection with the talocalcaneonavicular joint. The Talo-Calcaneonavicular Joint The movement of the talocalcaneonavicular joint is decidedly more difficult to understand. Whereas the axis of the ankle joint can easily be defined, the axis of the talocalcaneonavicular joint is drawn obliquely from lateral posterior to medial anterior. It is surprising that both articular surfaces of the talocalcaneonavicular joint are congruent only in the mid-position. An incongruence develops between the two articular surfaces by both eversion and inversion. This incongruence cannot be maintained for long periods when carrying weight. The ankle joint and the talocalcaneonavicular joint must be regarded as a functional unit. The possible movements of these two joints can be compared to a spheroid joint which can be moved freely within its range of motion: flexion, supination, pronation, abduction and adduction which in some respects corresponds to a rotation. Chopart's Joint The talocalcaneonavicular joint, comprising the talus and the navicular, and the joint which is formed from the calcaneus and the cuboid, together all form a sort of working unit. These two joints comprise Chopart's joint which allows a rotational movement of the fore-foot. Lisfranc's Joint The Lisfranc joint is a collective joint where the three cuneiform bones and the cuboid bone on the one side, and the five metatarsal bones on the other side, are united to form an articular connection. The small deflectionary movement can be described as in an obliquely situated hinge exhibiting dorsal and plantarflexion. The Chopart and the Lisfranc joints are connected by taut ligaments so that there is hardly any friction between them. They serve primarily to give elasticity to the foot during pressure and allow it to adapt better to uneven surfaces. The Transversal Anterior Vault of the Foot From metatarsal I to metatarsal V, the metatarsal bones form an oblique arch (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-07.jpg">Fig. 7</a>). This arch tends to drop due to excessive pressure, which can partly be attributed to walking on level ground. This "even" walking, which always puts pressure on the same points of the foot, leads to over-exertion of the individual metatarsal heads. The Toe Joints The toe joints are limited spheroid joints. That is, they are capable of sideways movement within certain limits, but are primarily intended as hinge joints with movement upwards and downwards. <h3>The Ligaments</h3> It is known that the structure of the foot is held together with muscles and ligaments. These ligaments are so constructed as to be able to withstand the extreme pressures exerted on the foot (long jump and high jump). <h3>The Muscles</h3> Long and short muscles hold and move the foot. If one of the muscles gives way, it is immediately visible from the gait how important the interaction of each muscle group is for locomotion. However, descriptive anatomy is not the theme here and so a further discussion of this aspect must be omitted. <h3>The Mechanics Of Depression Of The Foot</h3> Experience has shown that not every valgus of the calcaneus results in an equivalent drop of the longitudinal vault. The talipes valgoplanus is a collective term for different inadequacies which arise when the foot is under pressure. These can be classified according to different characteristics: (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-08.jpg">Fig. 8</a>) <ol> <li> The pronation position of the calcaneus; </li> <li> Inward rotation of the ankle joint; </li> <li> A forward and inward drop of the talus; </li> <li> Abduction of the fore-foot; and </li> <li> Supination, i.e., a turning upwards of the first metatarsal. </li> </ol> These five basic characteristics of the talipes valgoplanus lead to a variety of outward manifestations, which must be taken into consideration when deciding on a course of action. This wide variety is one reason why the kinematics of the foot eludes an exact biomechanical and mathematical analysis. When pressure is applied in valgoplanus, the calcaneum gives way but the fore-foot remains flat on the ground, regardless of the extent of the flexion. Congenital and ischaemic valgoplanus are exceptions to this but they are not included in the discussion here (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-09.jpg">Fig. 9</a>). Between the calcaneus, rear-, and fore-foot there is a distortion or rotation. If pressure is removed from the foot, the calcaneus falls into a vertical position, but the fore-foot then rotates to the same degree. Consequently the position of the rear-foot relative to the fore-foot remains a constant deformity (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-10.jpg">Fig. 10</a>). What then is the role of the shoe in the standing position and swing-phase? In the standing position, more pressure is exerted medially on the rear part of the shoe (the counter and the heel), depending on the extent of the valgoplanus. However, the front of the shoe remains flat on the ground regardless of the extent of the deformity. In the swing-phase, the distortion between the fore- and rear-foot influences the alignment of the shoe. If the heel is too big or badly fitting, the fore-foot dictates the position of the shoe and as a result there is an unwanted deflection of the heel of the shoe from the heel of the foot. This means that the heel-strike is lateral and as pressure is exerted, it then turns inwards and adapts to the surface whereby it has returned to the original standing position. The distortion between the fore- and rear-foot, combined with an inadequate heel counter, produces a potential risk of injury. A stone on an inclined surface can easily lead to a strained joint (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-11.jpg">Fig. 11</a>). This phenomenon is particularly significant for sportsmen and joggers who train in open country. After suffering such strains, the fear of further injury can hinder training. <h3>Deformity Of The Fore-Foot (Talipes Transversoplanus)</h3> During growth, there is a slight biomechanical change in the lateral metatarsal arch. The first metatarsal rotates pronatorally and this leads to a greater arching in adults. Congenital ligament or tissue weakness can cause this lateral arch to flatten under pressure and so result in a broadening of the fore-foot. Here, the length of the various metatarsal bones compared to the different patterns of pressure exerted on the fore-foot is of significant importance. Depending on the type of foot, the first or second metatarsal will be under greater pressure depending on which is the longer of the two. Instability between the fore- and rear-foot can also result if the inclination between metatarsal one and metatarsal five is too great. This type of foot tends to tilt sideways during the propulsion process of walking. In the case of the high-arched foot, the angle between the metatarsal and the ground increases, resulting in a greater load to the individual metatarsal heads. <h3>The Shoe</h3> From a biomechanical point of view, the shoe plays a significant part in the process of walking and standing. The height of the heel as well as the thickness of the sole greatly influence the conveyance of the weight and consequently influence locomotion itself. This sphere of influence must be duly considered, particularly in cases of static deformity. A build-up of the shoe, i.e., constructing a rocker bottom must be compensated for at the heel, otherwise the relationship between the heel-height and sole-thickness in the front of the shoe will be disturbed, thus having a negative effect on the roll-over process (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-12.jpg">Fig. 12</a>). <h3>Cushion-Heel</h3> The attachment of a cushion-heel also changes the roll-over process in that it acts as a shock absorber at heel strike and at the same time increases the roll-over (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-13.jpg">Fig. 13</a>). <h3>Heel-To-Toe-Roll For The Whole Sole</h3> A heel-to-toe roll sole can be attached to the shoe to protect the ankle joint and Chopart's joint. Measured radially from the knee, this allows a complete roll of the foot (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-14.jpg">Fig. 14</a>). <h3>The Use Of Insoles</h3> The insole and the shoe must form a unit with the level ground. Whether the foot is neutral, in pronation or supination, is of no significance. When insoles are made of solid material, their length and shape are important. It is of particular importance with handicapped patients that the insoles are kept somewhat longer in order to reduce the risk of tilting sideways. This pronatory support, especially in the forefoot region, gives the patient a feeling of security. The correction of the talipes valgus should be differentiated from the correction of the talipes varus. With talipes valgus, the rear of the foot should be supinated and the fore-foot pronated in order to achieve a rotation of the foot. With talipes varus, this is not possible. Here, the whole foot must be pronated, i.e., the rear- and fore-foot must be included in an homogenous correction. *André Bähler André Bähler is an Orthotist/Prosthetist from Zurich, Switzerland. References: <ol> <li>G. Hohmann, Fuss und Bein, ihre Erkrankungen und deren Behandlung, Verlag von J.F. Bergmann 1951.</li> <li>J. Lang, W. Wachsmuth, Praktische Anatomie, Bein und Statik, Springer-Verlag AG.</li> <li>I.A. Kapandji, The Physiology of the Joints, Churchill Livingstone.</li> </ol> Page Number(s) 8 - 14 Year 1986 Volume 10 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-05.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/1986_01_008/1986_01_008-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-14.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 The Biomechanics of the Foot Creator An entity primarily responsible for making the resource André Bähler * https://staging.drfop.org/files/original/5a1dda96e4178cd06649ab215cbbe0d5.pdf 916f9e9ed1caca96356f3a227150715d https://staging.drfop.org/files/original/8636aa4e4c5c07d52b8abe2b11b37b34.jpg d84ef6ba41e554dcba230d9df535077a https://staging.drfop.org/files/original/5b4a9dbd8c695c2a35af0d77111fe2c1.jpg 8fbbd755ed8145a65a43809e70417f90 https://staging.drfop.org/files/original/8487fa7a9496454abdd425b5a0d7785f.jpg f87e785df8826fce7f9b25bbfa02d214 https://staging.drfop.org/files/original/6d91bb58231e3290cbcf8e2dd6de2830.jpg 8c72ee75f68585c21747347b7c6d1307 https://staging.drfop.org/files/original/1b17acd6b2b5de624697430d6894d59e.jpg a0c575e50cf69d22a6c74b5be9757d31 https://staging.drfop.org/files/original/07792a7c6f21b09b088faf9389ca2610.jpg da7f539b8006bf431baa7e3e5b8122f7 https://staging.drfop.org/files/original/11eb68ee39aa5ebeb200cda4a27eeebc.jpg 20f231014dcb6fa69b27864fb3ffa898 https://staging.drfop.org/files/original/197c2d8a6200d52ac28aef88fcc77fdd.jpg 801b1962726d6ad8ef106424aca27645 https://staging.drfop.org/files/original/afdc0eb1a348faf2d0c27285bcbb337e.jpg fd18d6f8a478bd70ef313e66aa24f6d3 https://staging.drfop.org/files/original/2250f8e6296a64f9cab5e169d1c2b241.jpg 516066b6193dbe1c2a6b992facb1be90 https://staging.drfop.org/files/original/6a4612dbdc98238350b49fd1d433b615.jpg 198d5a4e6535b9269b942902bc83a6d6 https://staging.drfop.org/files/original/013bbfd894737f6f6987e68067760431.jpg f272ceb4a5cfc69133ef0090cd118908 https://staging.drfop.org/files/original/6b60e9da47923de26b69a07869eb13ed.jpg 889d26201fbd7450b4346f43c42da7ee https://staging.drfop.org/files/original/b6a47343d2d4db601a1452d432a910bb.jpg d57c642323cf7ae5fe5d51d3c25f34e0 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/1988_03_128.pdf Text Any textual data included in the document <h2>With a Spring in One's Step</h2> <h5>D.D. Murray, M.D. <a style="text-decoration: none;">*</a> W.J. Hartvikson <a style="text-decoration: none;">*</a> H. Anton <a style="text-decoration: none;">*</a> E. Hommonay, C.P.O.(C) <a style="text-decoration: none;">*</a> N. Russell, C.P.(C) <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> In recent years, there has been a significant number of new developments in prosthetics in both North America and Europe. New concepts for socket molding, knee control, dynamic foot action, and the utilization of space-age materials have expanded prosthetic development and performance. The traditional prosthetic foot had a keel and an articulated ankle. This concept has modern derivatives with multi-axis ankles, but the principle remains the same. The S.A.C.H. foot design is that of the solid ankle and cushioned heel. By virtue of a compressible heel of a selected rubber density, the wearer achieves a simulated ankle motion at heel strike.<a></a> This design has been a mainstay in prosthetic fabrication for several decades. These feet are both essentially passive and accommodating. The Seattle foot, with its cushioned heel and keel spring action, stores energy through the stance phase of gait and releases it at toe-off, thus imparting a dynamic component to gait.<a></a> An added feature of this foot is that of cosmetic molding. The principle of dynamic toe-off to improve the mechanical efficiency of the prosthesis is an attractive one, and it forms the basis for the design of the Seattle foot. The purpose of this study is to evaluate the performance of the Seattle foot and subjectively and objectively determine whether or not it improves prosthetic gait. <h3>Clinical Investigation</h3> A questionnaire was designed to gather general demographic data and review foot function in general living situations. Thirty-three patients were identified in the last two years as having been fit with a Seattle foot, and 31 (94%) responded to the questionnaire. There were 27 males and four females. The age range was from 24 years to 72 years (Fig. 1). <a href="/files/original/8636aa4e4c5c07d52b8abe2b11b37b34.jpg" target="_blank" rel="noopener">Figure 1</a>. The age range was from 24 to 72 years. The weight of the patients ranged from 95 pounds to 195 pounds and their height ranged from 5'1" to 6'4". Amputation dates ranged from 1930 to 1986, with over half of the respondents having been injured since 1975. On average, each patient had 3.75 surgical procedures, with a range from 1 to 24. The length of time from amputation to prosthetic fitting was, for the most part, under one year (Fig. 2). <a href="https://staging.drfop.org/files/original/5b4a9dbd8c695c2a35af0d77111fe2c1.jpg" target="_blank" rel="noopener">Figure 2.</a> The length of time from amputation to prosthetic fitting was, for the most part, under one year. The original foot supplied in most cases was a S.A.C.H. foot. The next most frequent, in order, was a single axis ankle with a keel foot. The remainder are unknown. A significant number of the candidates had been using their original foot an average of 14 years before having it changed to a Seattle foot. For the most part, people were attracted to the Seattle foot because of a better design and newer technology. They wished for added spring, flexibility, and mobility in the foot. Some simply tried it because it was recommended by staff, or because they liked the cosmetic appearance. The length of time for use of the Seattle foot ranges from one month to two years with an average of 8.5 months (Fig. 3). <a href="/files/original/8487fa7a9496454abdd425b5a0d7785f.jpg" target="_blank" rel="noopener">Figure 3.</a> The length of time for use of the Seattle foot ranges from one month to two years, with an average of 8.5 months. The Seattle foot was fit on 29 below-knee amputees and two above-knee amputees. The heel stiffness in the Seattle foot was rated as acceptable in 80% of cases. Twelve percent (12%) felt it was too stiff. Eighty-one percent (81%) of respondents felt that they had good ankle motion with the Seattle foot, and 19% felt they did not. Seventy-four percent (74%) of respondents felt that the ankle motion was greater than with the previous foot, 16% felt it was the same, and 10% felt less ankle motion. When questioned about the shock stress at the hip or knee, 55% felt there was decreased shock stress and 39% felt that there was no change. When questioned about the effect of the Seattle foot on changing gait, 87% felt it was better and 13% felt it was the same. Eighty-seven percent (87%) were aware of toe-off action in the Seattle foot and 13% were unaware of it. The toe-off action was most noticeable when accelerating quickly, climbing up or down, playing ball sports, and running or walking on uneven ground. Forty-eight percent (48%) of the respondents would have preferred greater toe-off action, whereas 52% were satisfied with the toe-off. Half the respondents felt the Seattle foot had made a general difference to their recreational pursuits. When specific activities were rated, at least 50% of respondents felt that walking, going up and down stairs, hiking, dancing, and jogging were consistently easier than with the previous foot. Balance and endurance on the prosthesis was felt to be easier by about 61% of the respondents and smoothness was better in 87%. Uneven terrain was considered easier by 74%, but 3% said it was more difficult. In fact, the Seattle foot does not provide as much forefoot flexibility in the medial-lateral plane as with an articulated ankle joint. Walking and running was easier for 67% of the respondents (48% of the patients jogged). Of the 61% who dance, 74% found it easier. Of those people responding negatively to the Seattle foot, the pattern was either negative responses throughout the questionnaire (by four respondents) or negative responses for certain functions, such as the half who felt there was no difference in the recreational pursuits. Of these negative responses, there was no pattern either in terms of age, weight, or amputation site. The greatest advantages with the Seattle foot were reported to be a more natural and smooth action, resulting in an improved gait (Fig. 4), better ability to handle stairs and uneven ground, and improved abilities in sports. <a href="https://staging.drfop.org/files/original/6d91bb58231e3290cbcf8e2dd6de2830.jpg" target="_blank" rel="noopener">Figure 4.</a> The greatest advantages with the Seattle foot were a more natural and smooth action. The cosmetic design and the anatomical detail were appreciated by 97% of the respondents. Residual limb pain was felt to be decreased in 39% of respondents and unchanged in 45%. Sixteen percent (16%) did not respond to this question. The foot design had not been expected to have any effect on this problem. Skin problems were felt to be decreased in 55% of the respondents. Thirty-five percent (35%) said there was no change. The foot design was not expected to improve this clinical problem either. The Department of Veterans Affairs in Seattle has reported an evaluation of the Seattle foot.<a></a> Although a comparison of amputee groups was not possible, the results of this clinical survey compare favorably with the original study. Fig. 5, <a href="/files/original/07792a7c6f21b09b088faf9389ca2610.jpg" target="_blank" rel="noopener">Fig. 6</a>, and <a href="/files/original/11eb68ee39aa5ebeb200cda4a27eeebc.jpg" target="_blank" rel="noopener">Fig. 7</a> graphically demonstrate the comparison. <a href="https://staging.drfop.org/files/original/1b17acd6b2b5de624697430d6894d59e.jpg" target="_blank" rel="noopener">Figure 5</a>. A comparison of two clinical surveys of the Seattle foot for running and walking. <h3>Laboratory Investigation</h3> Electrogoniometric Evaluation A gait study using a single amputee with many years experience with a S.A.C.H. foot and several years experience with the Seattle foot was undertaken at the G.F. Strong Gait Laboratory. Motion in the lower extremity was analyzed using a computerized electrogoniometric system. This system accurately measures movement in three planes at the hip, knee, and ankle and stores data for subsequent analysis.<a></a> The S.A.C.H. foot, Seattle foot, and non-prosthetic side were compared. Patterns of movement measured at the hip were similar for the S.A.C.H. and Seattle feet and resembled those seen on the non-prosthetic side. At the knee, the Seattle foot produced a more repeatable pattern of internal-external rotation and varus-valgus than did the S.A.C.H. foot (<a href="/files/original/197c2d8a6200d52ac28aef88fcc77fdd.jpg" target="_blank" rel="noopener">Fig. 8 </a>and <a href="/files/original/afdc0eb1a348faf2d0c27285bcbb337e.jpg" target="_blank" rel="noopener">Fig. 9</a>). The greatest differences between the S.A.C.H. and Seattle feet were seen at the ankle. The patterns of forefoot abduction-adduction, plantar flexion-dorsiflexion, and in-version-eversion were all more repeatable for the Seattle foot. Also, the pattern of plantar flexion-dorsiflexion for the Seattle foot more closely resembled that of the non-prosthetic side (<a href="https://staging.drfop.org/files/original/2250f8e6296a64f9cab5e169d1c2b241.jpg" target="_blank" rel="noopener">Fig. 10</a> and <a href="/files/original/6a4612dbdc98238350b49fd1d433b615.jpg" target="_blank" rel="noopener">Fig. 11</a>). In summary, the Seattle foot generally produced a more repeatable pattern of motion at the knee and ankle than the S.A.C.H. foot, and the pattern of plantar flexion-dorsiflexion for the Seattle foot appeared more normal. Force Plate Evaluation Through the facilities of Simon Fraser University Kinesiology Department, a force plate study was done on the same single subject. The vertical compression forces generated by the S.A.C.H. and Seattle feet during stance were measured. Fig. 12 demonstrates typical forces measured during stance in a below-knee amputee on the non-prosthetic side. A maximum peak is seen immediately after heel strike. This is followed by a trough in mid-stance and a second, lesser peak at push-off. <a href="/files/original/013bbfd894737f6f6987e68067760431.jpg" target="_blank" rel="noopener">Figure 12</a>. Typical forces measured during stance in a below-knee amputee on the non-prosthetic side. Fig. 13 illustrates the forces generated in the same individual during stance on his prosthetic side while using a Seattle foot. Fig. 14 shows stance forces generated in the same individual on his prosthetic side using a S.A.C.H. foot. <a href="/files/original/6b60e9da47923de26b69a07869eb13ed.jpg" target="_blank" rel="noopener">Figure 13</a>. The forces generated in the same individual during stance on his prosthetic side while using a Seattle foot. <a href="/files/original/b6a47343d2d4db601a1452d432a910bb.jpg" target="_blank" rel="noopener">Figure 14</a>. Stance forces generated in the same individual on his prosthetic side using a S.A.C.H. foot. The initial peak is greater for the S.A.C.H. than the Seattle foot. This suggests more effective shock absorption at heel strike for the Seattle foot than the S.A.C.H. foot. The second peak is less than that seen on the non-prosthetic side with both feet, but is greater for the Seattle foot than the S.A.C.H. foot. Thus, the Seattle foot more closely approximates normal push-off force than the S.A.C.H. foot. The trough at mid-stance is shorter with the S.A.C.H. foot than on the non-prosthetic side. The mid-stance trough for the Seattle foot more closely approaches that of the non-prosthetic side, suggesting a more normal pattern of foot-ankle motion than with the S.A.C.H. foot. In summary, the Seattle foot generally appears to produce a more normal pattern of vertical forces than the S.A.C.H. foot and produces a greater force at push-off. <h3>Conclusion</h3> The overall patient response to the questionnaire regarding the effectiveness of the Seattle foot was positive. Comparison with the Seattle Study revealed similar results. Gait studies undertaken tended to support the clinical impression with regard to both kinetics and kinematics. Overall, this dynamic foot design offers definite advantages to the prosthetic user. At best, prosthetic users seem to get an increased gait smoothness, with the dynamic toe action positively influencing their abilities on rough ground and inclines. At worst, their gait pattern is not negatively influenced by this spring action. <h3>Acknowledgments</h3> The authors wish to thank the G.F. Strong Gait Lab and Dr. Cecil Herschler, as well as the Simon Fraser Kinesiology Department and Dr. Arthur Chapman for their technical assistance in the preparation of this study. References: <ol> <li>Orthopaedic Appliances Atlas. Vol. 2, Artificial Limbs, Editor J.W. Edwards, Ann Arbor, Michigan, 1960, pp. 149-151.</li> <li>Reswick, J.B., "Evaluation of the Seattle Foot," J. Rehab Research and Development, Vol. 23, No. 3, pp. 77-94.</li> <li>Burgess, E.M. et al., "Development and Preliminary Evaluation of the V. A. Seattle Foot," Journal of Rehabilitation Research and Development, Vol. 22, No. 3, B.P.R. 10-42, pp. 75-84.</li> <li>Chao, Edmund, "Justification of Triaxial Goniometer for the Measurement of Joint Rotation," J. Biomechanics, Vol. 13, 1980, pp. 989-1006.</li> </ol> *N. Russell, C.P.(C) Department of Medicine, Shaughnessy Hospital, Vancouver, British Columbia V6H 3M1. Dr. Murray is Professor and Head of the Department of Medicine at Shaughnessy Hospital. *E. Hommonay, C.P.O.(C) Department of Medicine, Shaughnessy Hospital, Vancouver, British Columbia V6H 3M1. Dr. Murray is Professor and Head of the Department of Medicine at Shaughnessy Hospital. *H. Anton Department of Medicine, Shaughnessy Hospital, Vancouver, British Columbia V6H 3M1. Dr. Murray is Professor and Head of the Department of Medicine at Shaughnessy Hospital. *W.J. Hartvikson Department of Medicine, Shaughnessy Hospital, Vancouver, British Columbia V6H 3M1. Dr. Murray is Professor and Head of the Department of Medicine at Shaughnessy Hospital. *D.D. Murray, M.D. Department of Medicine, Shaughnessy Hospital, Vancouver, British Columbia V6H 3M1. Dr. Murray is Professor and Head of the Department of Medicine at Shaughnessy Hospital. Page Number(s) 128 - 135 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-05.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/1988_03_128/1988_03_128-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1988_03_128/1988_03_128-14.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 With a Spring in One's Step Creator An entity primarily responsible for making the resource D.D. Murray, M.D. * W.J. Hartvikson * H. Anton * E. Hommonay, C.P.O.(C) * N. Russell, C.P.(C) * https://staging.drfop.org/files/original/666cfa2a8d900d4b2efb1a009252fa73.pdf f59717a74400ff0ab5095ddffea74b4f https://staging.drfop.org/files/original/17e8a00f37ae987d6c843c8412d4b0e2.jpg b63ddbe760c50ee253d76f42eca4d956 https://staging.drfop.org/files/original/46d862f73b2e9fc9ec844c2b951ca24e.jpg 748745d3b330d67f707679ee011a6836 https://staging.drfop.org/files/original/4242f12d317f1a7ab6d8045a8876497b.jpg 5402ccb72158719c003f664b4fd179c5 https://staging.drfop.org/files/original/8ee7cd25050f94773cb45ef98356241f.jpg 126d19241c60416ec37fa343f5b67a70 https://staging.drfop.org/files/original/bd0b9a100a09d924db2ddcfafb0bce26.jpg d56eb7f7a83a1e97e40b5c0d1717d804 https://staging.drfop.org/files/original/380a58ec4d8724fa7bfcaedf4a69050a.jpg 2c05e9d4f88546fe77cdbf7e84fd5833 https://staging.drfop.org/files/original/65a023e3490a43a115438d29c1640630.jpg 3b5b83d904e8f0092b48ac81539603f6 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/1988_03_123.pdf Text Any textual data included in the document <h2>Technical Note: Cosmesis and the Knee Disarticulation Prosthesis</h2> <h5>Robert Gilley, CP. <a style="text-decoration: none;">*</a></h5> One central problem confronts the prosthetist when fabricating a knee disarticulation prosthesis with side joints, regardless of the socket style (laminated, molded, leather, or flexible frame) used. As the knee flexes, the space anterioraly between the thigh section and the inner edge of the shin increases in width (Fig. 1). The result is cosmetically unacceptable. The gap develops because the radial distance from the knee joint center to the periphery of the socket gradually decreases from anterior to posterior (Fig. 2). Resolution of the problem may be achieved by building up the distal end of the socket so as to maintain a constant spherical shape through the full range of motion (Fig. 3). Observation over the years has led me to conclude that many younger prosthetists are not as familiar with the process as perhaps they should be. Therefore, these few notes are offered in hopes of redressing the situation. <a href="/files/original/17e8a00f37ae987d6c843c8412d4b0e2.jpg" target="_blank" rel="noopener">Figure 1.</a> As the knee flexes, the gap anterioraly increases. <a href="/files/original/46d862f73b2e9fc9ec844c2b951ca24e.jpg" target="_blank" rel="noopener">Figure 2.</a> This problem results from the fact that the radial distance from the knee joint center to the periphery of the thigh decreases from anterior to posterior. <a href="/files/original/4242f12d317f1a7ab6d8045a8876497b.jpg" target="_blank" rel="noopener">Figure 3</a>. The distal end of the thigh has been built up so that the space between the thigh and shin is constant throughout the range of motion. Fabrication of the prosthesis begins by mounting the proximal portion of both joints to the thigh, and similarly, mounting the distal portions in a suitably sized block of wood. Obviously, every effort should be made to maintain the narrowest possible medial-lateral diameter at the knee joint center and to keep the joints square. Wood is removed from between the distal joint sections to permit proper mating of the shin block to the thigh and full range of motion. The interior inner edge of the shin block should fit closely to the thigh in the fully extended position while allowing sufficient space distal to the edge for the material to be added to the thigh during finishing. The distal end of the thigh is then built-up with rigid urethane foam. The convex shape of the anterior socket from medial to lateral, and at the level of the proximal anterior edge of the shin block, is repeated radially about the knee joint axis from anterior to posterior. This can be accomplished, rather laboriously, by first removing enough extra material from the thigh to permit it to be assembled with the shin block in the fully extended position. Then, as the knee is gradually flexed through the full range of motion, the anterior edge of the shin is used as a guide to judge how much material to remove at each successive position of flexion. Sufficient material is removed to permit full range of flexion. Care must be taken to maintain a smooth, even surface from medial to lateral and to not remove too much material. Nonetheless, it will doubtlessly be necessary to add material. The posterior surface of the distal thigh is finished off flat from medial to lateral, so as to fill most of the posterior knee opening. It should not rise above the anterior rim of the shin in the fully flexed position, and at the same time, should not protrude too far posteriorly when in the fully extended position. The process can be greatly expedited if the following simple apparatus is used. Two aluminum plates are modified so that a piece of stiff paper or cardboard can be clamped between them (Fig. 4 and Fig. 5). The plates are cut away on one edge so as to span the largest socket. At the leading edge of the cut away side, two threaded rods with tapered points are mounted on a common axis (Fig. 6). These two rods permit the device to be mounted on the proximal knee joints and swung around the distal end of the thigh section (Fig. 7). The stiff paper clamped between the two plates of the device is cut to match the shape of the anterior surface of the thigh at the requisite level. The resulting template is then used to duplicate the shape through the full range of motion. (Some prosthetists will of course identify the device as a simple adaptation of the templates that were formerly used when shaping the ball of the knee of a handmade knee-shin set-up for an above-knee prosthesis.) The device described has been in use by us now for over a year. It greatly speeds up the process of finishing a knee disarticulation prosthesis. <a href="/files/original/8ee7cd25050f94773cb45ef98356241f.jpg" target="_blank" rel="noopener">Figure 4</a>. Knee spanning template holder. Six inch rule included in photograph to give a sense of scale. <a href="/files/original/bd0b9a100a09d924db2ddcfafb0bce26.jpg" target="_blank" rel="noopener">Figure 5</a>. Template holder with stiff cardboard template clamped between the two plates of the holder. <a href="/files/original/380a58ec4d8724fa7bfcaedf4a69050a.jpg" target="_blank" rel="noopener">Figure 6.</a> Exploded parts view of template holder and template. <a href="/files/original/65a023e3490a43a115438d29c1640630.jpg" target="_blank" rel="noopener">Figure 7</a>. Template holder in place mounted on the knee bolt of a conventional above-knee prosthesis (for illustrative purposes only, a knee disarticulation prosthesis was not available at the time this article was prepared). In conclusion, it is hoped that these comments on the matter will aid a prosthetist confronted for the first time with the task of finishing a knee disarticulation prosthesis-a task that is rather infrequently confronted in the United States and not always addressed by the schools. *Robert Gilley, CP. Robert Gilley, CP., is with Durr-Fillauer Medical, Inc., 2710 Amnicola Highway, Chattanooga, Tennessee 37406. Page Number(s) 123 - 127 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-5.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/1988_03_123/1988_03_123-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-7.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 Technical Note: Cosmesis and the Knee Disarticulation Prosthesis Creator An entity primarily responsible for making the resource Robert Gilley, CP. * https://staging.drfop.org/files/original/0f0eaf91a93d152fbbcaca14c3b43ebf.pdf 55a8a6c2698543a33379820f8c99af27 https://staging.drfop.org/files/original/9176ea93fc7422b272a48674e92598f3.jpg 64903f5b4a3cce6fe54c1ab66a83c375 https://staging.drfop.org/files/original/51e118cc092de53ecec3404a4302acab.jpg 9678319e36fff07a4dd43313518ea0b2 https://staging.drfop.org/files/original/b3a726660b994c9bbde0c48f30f4337c.jpg fb3cc03c33fbe565141cc63e008bcd97 https://staging.drfop.org/files/original/c0c5f86b34e55516bbefc6ca2d8b9f3c.jpg 0187a66c7a3b525a915dd5b9ad929a30 https://staging.drfop.org/files/original/3bb0b814dfe7768034c9b39057177e31.jpg 3520f17845a67a7b7af87cc94edfc339 https://staging.drfop.org/files/original/48af58273ca7d023d458415c3ede334c.jpg 73e1144efc791b010d100d5826ea86b0 https://staging.drfop.org/files/original/3e10a6a4eb37fe679d8d7dc788e153c7.jpg 2ac620871d4d7649e10c2cd6805c9efa https://staging.drfop.org/files/original/e190fcba30937120ad5a9a8f6b348187.jpg 7fb7b789229f3de781290a709a8c9c1c 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/1988_03_119.pdf Text Any textual data included in the document <h2>The CAT-CAM-H.D.(tm) A New Design for Hip Disarticulation Patients</h2> <h5>John Sabolich, B.S., C.P.O. <a style="text-decoration: none;">*</a> Thomas Guth, B.A., C.P.O. <a style="text-decoration: none;">*</a></h5> The innovative features of the CAT-CAM™ above-knee socket design were outlined in the Fall, 1985 issue of Clinical Prosthetics and Orthotics, Volume 9, Number 4. Shortly afterwards, RGP of San Diego and the Sabolich Prosthetic Research Center in Oklahoma City combined efforts to develop a CAT-CAM™ type hip disarticulation prosthetic socket design. It was intended that this new socket would hold the ischial tuberosity and descending ramus in a special compartment of the socket. RGP worked primarily on the suspension system, and Sabolich worked on the ischial ramus containment. The conventional hip disarticulation socket differs from the CAT-CAM™ type in that the old design has a flat inferior floor upon which the ischial tuberosity sits. Even worse, many times the tuberosity sits on the very edge of this table. As described in the original 1985 CAT-CAM™ article and in terms of the above-knee socket, this is not a desirable biomechanical situation because, first, the bone is touching a flat tangential surface rather than a contoured surface that conforms to the complex bony shape and thus distributes the load over a wider area and, second, because it does not provide medial-lateral stability. The new socket affords much more bony contact not only to the ischial tuberosity, but to the descending pubic ramus as well (Fig. 1and Fig. 2). Experience has shown that the ramus turns out to be of more importance than the ischial tuberosity when it comes to enhancing medial-lateral and rotational stability. Only the inferior pubis-ramus is allowed to exit the socket at the medial inferior dip of the medial wall (Fig. 3). <a href="/files/original/9176ea93fc7422b272a48674e92598f3.jpg">Figure 1.</a> Demonstrates depth of ischial seat area relative to medial brim. Also shows how the ischium and ramus are in the socket. <a href="/files/original/51e118cc092de53ecec3404a4302acab.jpg" target="_blank" rel="noopener">Figure 2.</a> Postero-medial view of transparent diagnostic test socket on the patient with a patch of white paper delineating the ischial-ramus compartment. <a href="https://staging.drfop.org/files/original/b3a726660b994c9bbde0c48f30f4337c.jpg" target="_blank" rel="noopener">Figure 3.</a> Medial view with rulers at the inferior-most point in the dip of the medial brim. In order to better understand the new hip disarticulation design, it must first be understood that the CAT-CAM™ above-knee design is not a narrow ML socket at the proximal portion. On the contrary, the proximal ML diameter of the CAT-CAM™ above-knee socket, which contains the pelvic bones, is wider than the mid and distal portions of the socket, which then narrows to conform to the medial-lateral thigh dimension in order to supply soft tissue compression. The new hip disarticulation socket follows this SCAT-CAM™ principle. Thus, it provides a better bony locking effect. Also, these bony pelvic structures are more fully encapsulated as a result of a V-shaped medial contouring of the socket and provide the hip disarticulation patient with a feeling akin to the above-knee socket, rather than that which results simply from sitting on a flat hard seat. Some of the principles of the CAT-CAM™ total flexible brim are also utilized in this type of hip socket. The entire socket is flexible except in the area where the hip joint is attached. This can be accomplished in two ways: first, with a rigid frame and a flexible inner socket much like with the CAT-CAM™ and SCAT-CAM™ above-knee design; second, by a heterogeneous monolithic polyester socket that is rigid in the joint area and then gradually becomes flexible throughout the remainder of the socket (Fig. 4 and Fig. 5). <a href="/files/original/c0c5f86b34e55516bbefc6ca2d8b9f3c.jpg" target="_blank" rel="noopener">Figure 4.</a> Laminated socket demonstrating flexibility of the contralateral portion of the socket. Superior portion of amputated side is flexible as well. <a href="https://staging.drfop.org/files/original/3bb0b814dfe7768034c9b39057177e31.jpg">Figure 5.</a> View similar to Figure 4 showing flexibility of socket. Also shows "V"-shaped contour of medial brim in sagittal plane. Like the SCAT-CAM™ design, the hip socket is more bone and muscle contoured than the traditional bucket shaped hip disarticulation design (Fig. 6). The new socket has a concave contour in the area of the ilium on the amputated side. On the contralateral side, there is a concave contour between the ilium and trochanter. This increases medial-lateral stability and results in improved gait when combined with the containment of the ilium, ischium, and ramus bones within the socket. This is contrasted to most conventional designs which bulge out and follow the flow of the soft tissue on both lateral sides of the socket rather than conforming to the body contours. <a href="/files/original/48af58273ca7d023d458415c3ede334c.jpg" target="_blank" rel="noopener">Figure 6.</a> Schematic cross-section through the frontal plane. Vectors 1 and 2 demonstrate the suspension principle and also refer to the dark lines which represent the socket walls. Notice how the superior edges of the socket do not come above the ilium crests and the concave contouring inferior to the illiae. Vector 3 refers to the bony lock. The "Inter Ilio Trochanteric Effect"<a style="text-decoration: none;">*</a> is one of the reasons it has been possible to suspend the socket in most cases without extending it above the iliac crests of the pelvis. Instead, the suspension is gained by conforming the socket into the notch between the ilium and trochanter and creating a counter pressure with the opposite concave shaped side of the socket. Of course, it is more difficult to suspend the socket in this manner when fitting heavy people with excessive adipose tissue. Normally with a conventional hip disarticulation, it is easy for a prosthetist to pull the prosthesis off the patient by sliding it into abduction, away from contact with the residual limb and the ischial tuberosity, when the prosthetic pylon is abducted off the floor. However, with the CAT-CAM-H.D.™ design, this maneuver is more difficult, and the socket resists this abduction tendency due to the bony lock about the ramus (Fig. 7). <a href="/files/original/3e10a6a4eb37fe679d8d7dc788e153c7.jpg">Figure 7.</a> Medial view of the transparent diagnostic test socket showing height of medial brim relative to inferior most portion of the socket. In the last four years, a combined number of 67 CAT-CAM hip disarticulation sockets have been fit in Oklahoma City and San Diego. These patients report that they do not feel like they are "sloshing around in a bucket" and have a "greater feeling of security and stability" (Fig. 8). Three of these patients can run with their new prosthesis in a hop, skip fashion which has been recorded during video gait analysis. Two patients have been able to manage limited step over step running. <a href="https://staging.drfop.org/files/original/e190fcba30937120ad5a9a8f6b348187.jpg" target="_blank" rel="noopener">Figure 8.</a> Posterior view of completed socket. <h3>Acknowledgments</h3> It should be noted that Mike Wilson, C.P.O., was the first person who suggested to me the principles of lateral pressure between the ilium and the trochanter on the contralateral side. He called it an "Inter Ilio Trochanter Effect." Appreciation is given to Don Landis, B.S., R.P.T., for his editorial help in preparing this manuscript. Appreciation is also given to Glenn Hutnick, C.P.O., and Alan Finnieston, CP., who will be contributing to the next phase of research in hip disarticulation designs. Footnote See acknowledgments. *Thomas Guth, B.A., C.P.O. Thomas Guth, M.D., C.P.O., is with RGP Orthopedic Appliance Co., 6147 University Avenue, San Diego, California 92115. *John Sabolich, B.S., C.P.O. John Sabolich, B.S., C.P.O., is President of Sabolich Prosthetic and Research Center, 1017 N.W. 10th Street, Oklahoma City, Oklahoma, 73106. <div style="width: 400px;"></div> <div style="width: 400px;"></div> Page Number(s) 119 - 122 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-5.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/1988_03_119/1988_03_119-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-7.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-8.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 The CAT-CAM-H.D.(tm) A New Design for Hip Disarticulation Patients Creator An entity primarily responsible for making the resource John Sabolich, B.S., C.P.O. * Thomas Guth, B.A., C.P.O. * https://staging.drfop.org/files/original/f27b5d0368f4e859eccd1d6f3bbc38f3.pdf 2f3ebf3eaaf369545618afd8223fa39a https://staging.drfop.org/files/original/f035dc301e4fd1b9f7d498b18103cf33.jpg bc8736187d5b1cf372db15bae5fecbd1 https://staging.drfop.org/files/original/2f7fa7cb9146f525c58ba9d5bcdceee4.jpg d214434a7961b9d5b14e264027271d7a https://staging.drfop.org/files/original/3a3c0bf2056231987373ba4f3814cbdf.jpg 23890f5cc143cafe9297a430b85fd568 https://staging.drfop.org/files/original/1a23101ee14ed4cb9aada341d3d3c26e.jpg 93936696164a3d915c3460beb861e616 https://staging.drfop.org/files/original/448a0c6b9b0421ba2d64bccc76c9c0ea.jpg d170fb3ae9f4307cbf7564df55fca257 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/1988_03_114.pdf Text Any textual data included in the document <h2>The UCLA Anatomical Hip Disarticulation Prosthesis</h2> <h5>David H. Littig, B.A., CP. <a style="text-decoration: none;">*</a> Judd E. Lundt, B.S., A.E. <a style="text-decoration: none;">*</a></h5> This article discusses a new approach to hip disarticulation and hemipelvectomy fittings developed at the UCLA Prosthetics Education Program. It employs fundamental principles and methods in a new and different combination to produce a more complex and more natural biomechanical system. The results include: <ul> <li> a smoother, and apparently less energy consuming gait </li> <li> improved stability </li> <li> improved suspension </li> <li> improved wearer comfort </li> </ul> <h3>Introduction</h3> For several years now, the UCLA Prosthetics Education Program has been involved in an effort to understand, develop, and refine a teaching method for the CAT-CAM Socket,<a></a> the anatomically shaped above-knee socket. The very essence of this effort is a broader and more detailed understanding of the pelvic anatomy and its optimal containment within the socket. With the dramatic above-knee results that have been achieved through this understanding has come a compelling and obvious need to examine the application of the same principles to hip disarticulation fittings. It was felt that a hip disarticulation socket design, which would encapsulate the ischium and ischial ramus in a more anatomical contour than previous socket designs, might produce an improved prosthetic fitting.<a></a> Since much of the CAT-CAM experience alluded to employed a frame supported flexible polyethylene socket, the flexibility of such a design applied to a hip socket seemed a reasonable way to provide more comfort. These factors formed the basis for this work. To date, three hip disarticulation patients and one complete hemipelvectomy patient have been successfully fit with the design described. The hemipelvectomy application followed the hip patient fittings by a number of months and was tried only as a whimsical experiment. Based upon the initial understanding of the biomechanics, this fitting was not expected to succeed. However, the results were quite surprising and motivated another look at the biomechanical analysis. Two of the hip cases and the hemipelvectomy case will be described in this article along with the biomechanics. <h3>Patient Experience</h3> The first hip disarticulation patient is a 23 year old male who had an amputation on the right side at age five for tumor, and who has rejected a prosthesis since age ten because it was too limiting and cumbersome. Owing to immature muscular and skeletal development at the time of amputation, he is significantly atrophied on the amputated side. This individual is extremely active, participates and excels in athletics as an equal with the able-bodied, and is impressively agile on crutches. Consequently, his remaining limb is hyperdeveloped to the extent that the thigh musculature extends well past the midline of the body. The second hip case, a right amputee as well, could be described as a more typical patient. He is a 40 year old professional, amputated at age 28, also due to a tumor. He has worn a prosthesis continuously since his amputation, the most recent being an Otto Bock en-doskeletal design. When this project was begun, he had recently taken delivery of a new one-piece flexible socket prosthesis which combined a Flex-Foot™ with Otto Bock endo-skeletal knee and hip components. The hemipelvectomy case was a 26 year old male who had undergone complete amputation on the left side for a massive tumor in the hip joint. At the time of the work described here, which was six months post-surgery, he had not yet been fit for a definitive prosthesis, but was wearing a socket only for sitting comfort. This patient was first seen as a demonstration subject for prosthetic certificate students at UCLA. For that program, he was fit with a fairly conventional design. However, since his level of amputation is somewhat uncommon, and because the patient was willing to experiment, the design was altered to include the suspension system that had been found to be so successful with the hip disarticulation patients. <h3>Fabrication</h3> The hip patients were cast using a similar technique with splints, circular wrap, iliac crest definition, anterior and posterior compression, and ischial weight-bearing while the plaster hardened. Since this was an attempt at a more anatomical socket, contours detailing the ischial ramus angle and the medial inclination of the ischium were included in the cast. Unlike the above-knee socket which flexes and extends with the femur through each stride, the hip socket is expected to remain relatively fixed, relative to the pelvic anatomy. Thus, the medial brim need not extend as high or contain as much of the ischial ramus. If properly executed, a cast which includes the bony contours of the pelvis will take much of the guesswork out of cast modification and fitting and should reduce the number of check sockets needed to attain an optimum result. The initial concept for a hip disarticulation socket was a one-piece polyethylene design with a laminated frame to which the hip joint would be attached. Accordingly, such a system was fabricated for the first fitting. The results were reasonably successful. However, sound side comfort and piston action of the resulting prosthesis were not wholly satisfying. Since this was an experiment, it was decided to push further. Through several reiterations of socket size, volume and shape, and through several experiments with suspension, the design described in this article was arrived at: a two-piece system composed of a laminated anatomically shaped socket, encompassing only the amputated side and connected to a polyethylene suspension segment for the sound side waist with Dacron® webbing (Fig. 1). <a href="/files/original/f035dc301e4fd1b9f7d498b18103cf33.jpg">Figure 1</a>. Posterior view of suspension system showing "X" pattern strapping. Fabrication of the socket for the hip patients was relatively simple because of the two-piece design. The original model was split and only the amputated side laminated. For the contralateral side, a shell of Aliplast®-lined polyethylene was vacuum formed over that half to serve as the suspension system. Since the initial fitting of the hemipelvectomy patient was meant to instruct the certificate students in basic prosthetics for this level of amputation, the approach was very straightforward. He was cast in a suspended attitude with a simple circular wrap. Modification involved little more than smoothing of the model. A total flexible polyethylene socket was vacuum formed over the entire model. Following this, a frame for mounting the hip joint was laminated over the amputated side only of the polyethylene socket. As this was a demonstration fitting with no intent to finish, the hip joint was only temporarily attached. Prostheses for all patients were assembled with Otto Bock endoskeletal 7E7 hip joints and 3R20/3R36 knee units. Several feet were experimented with on the first patient until an Otto Bock single axis foot proved optimum. The Flex-Foot™ that had been included with the second patient's recently delivered prosthesis was incorporated into his set-up. The hemipelvectomy patient was also fit with an Otto Bock single axis foot. The socket and sound side suspension segment for the hip disarticulations were joined posteriorally with Dacron® webbing. Using temporarily attached four-bar buckles and the webbing, the proximal and distal aspects of the socket and the polyethylene segment were connected with the webbing to form an "X" pattern across the posterior gap (Fig. 1). At their cross point, the straps are not connected but are allowed to freely move with respect to each other. The buckles were found to be necessary for "fine tuning" adjustments of the suspension during fitting and alignment. Anteriorly, a single strap attached at the distal aspect of the laminated socket was passed through a loop on the polyethylene portion and back to a roller buckle on the anterior proximal socket (Fig. 2). <a href="/files/original/2f7fa7cb9146f525c58ba9d5bcdceee4.jpg">Figure 2</a>. Anterior view of suspension system. <h3>Functional Results</h3> Results achieved with this combination of socket and suspension were dramatic. After some adjustments, the hip patients felt no discomfort from the socket, despite the obvious upward curve of the medial brim in the perineum. This edge, along with the distal portion of the socket, particularly under the ischium, were lightly padded with 1/8" Pe-Lite™, as is customary in most hip sockets. Neither patient perceived any piston action or discomfort from the proximal brim of the socket or the polyethylene waist segment. The most obvious benefit was a significant reduction in lateral trunk bending that is so common with hip disarticulation amputees. In fact, this gait anomaly was reduced beyond that usually seen with many above-knee amputees. Both patients were impressed with the comfort and secure feeling that the design afforded. With the adjustable diagonal posterior straps, which in the finished prosthesis are replaced with buckleless double Dacron® webbing, the socket can be optimally positioned under the pelvis to more effectively encapsulate the bony pelvic anatomy. This is somewhat akin to adducting an above-knee socket of similar medial brim design (CAT-CAM). By a careful balance in the strap length adjustments, comfort and suspension in the entire system can be achieved. Because of the success that had been achieved with the hip disarticulation patients with this suspension technique, it was decided to try it on the hemipelvectomy patient. His reasonably comfortable and functional single piece socket was modified by removing the center portion of polyethylene in the posterior and rejoining the two separate segments with Dacron® webbing in the same cross strap pattern. An anterior closure as previously described was also employed (Fig. 3). The result was about 1/8" of piston action and improved comfort over the one-piece design, probably because the prosthetic socket could more accurately follow the body contours. <a href="/files/original/3a3c0bf2056231987373ba4f3814cbdf.jpg">Figure 3.</a> Posterior view of hemipelvectomy setup showing adjustable cross strapping. <h3>Biomechanics</h3> In all cases, it appears that during the gait cycle the polyethylene segment that encompasses the contralateral hip will tilt from the vertical as it follows the changing sound side body contour. The forces thus imposed on each of the posterior straps will vary alternately, and their crosspoint will shift slightly with each stride. For example, as the amputee reaches heel strike on the prosthesis, tension in the strap originating at the posterior proximal socket (the lateral support strap) will build as the body moves forward, and the center of gravity begins to shift laterally. As the patient progresses, this force reaches its maximum at mid-stance (Fig. 4) and then begins to fall off. Tension in the other (suspension strap) is at its lowest at mid-stance on the prosthetic side and then begins to build toward its peak when the amputee reaches mid swing-through (Fig. 5). The cycle then repeats itself with each successive stride. This alternating action in the straps, coupled with an accurately contoured socket, provides a continuously snug and secure suspension without the need for excessive tightness. <a href="/files/original/1a23101ee14ed4cb9aada341d3d3c26e.jpg">Figure 4</a>. Suspension system forces at mid-stance. <a href="/files/original/448a0c6b9b0421ba2d64bccc76c9c0ea.jpg">Figure 5</a>. Suspension system forces during swing. At the outset of these efforts, it was believed that much of the success of the suspension system depended upon a well-contoured medial brim, which accurately encapsulated the ischium and ischial ramus. The hemipelvectomy fitting quickly dispelled this consideration as a major factor. However, all hip disarticulation patients fit to date have perceived far greater comfort and control when in a socket so described. The idea behind ischial containment is to provide greater mediolateral stability in the prosthesis. It appears that the cross strap suspension is contributing the better part of this stability. Results to date suggest that the two-part socket and posterior cross strapping provide a mechanism which more closely conforms to changing soft tissue and muscle contours through the gait cycle. With a one-piece socket, regardless of flexibility, slight and subtle motions about all three body axes are not fully accommodated by "give" in the socket, as well as they seem to be in the one described here. Thus, the body must either move inside the socket or limit its movements due to the restrictions imposed by the rigidity of the socket. In either case, the result is a less natural gait and a greater apparent expenditure of energy. With this new approach, these shortcomings of the hip and hemipelvectomy fittings seem to be significantly reduced. References: <ol> <li>Sabolich, John, "Contoured Adducted Trocanteric Controlled Alignment Method (CAT-CAM): Introduction and Basic Principles," Clinical Prosthetics and Orthotics, Vol. 9, No. 4, Fall, 1985, pp. 15-26.</li> <li>Sabolich, John and Tom Guth, "CAT-CAM Innovations," Ability, Vol. 6, No. 3, Winter, 1986, p. 48.</li> </ol> *Judd E. Lundt, B.S., A.E. UCLA Prosthetics Education Program, Rehabilitation Center, 1000 Veteran Avenue, Room 22-41, Los Angeles, California 90024. *David H. Littig, B.A., CP. UCLA Prosthetics Education Program, Rehabilitation Center, 1000 Veteran Avenue, Room 22-41, Los Angeles, California 90024. Page Number(s) 114 - 118 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-5.jpg 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 UCLA Anatomical Hip Disarticulation Prosthesis Creator An entity primarily responsible for making the resource David H. Littig, B.A., CP. * Judd E. Lundt, B.S., A.E. * https://staging.drfop.org/files/original/730cd988b459c0470f09d2a2b1c901c0.pdf c64b39002b638752f02a6481b5256f6c https://staging.drfop.org/files/original/f5b53660057bef0aa5062375e0944618.jpg 71c691b1acd762609be7aef78e31a615 https://staging.drfop.org/files/original/507f8e598d697564a8825ef436c9831f.jpg 8c2dab42f1da4a77dd5b8083f04dce69 https://staging.drfop.org/files/original/541b427a8b6b0e194b041e8cc2c59da1.jpg 6919d95465a51c86db5c65678cb30502 https://staging.drfop.org/files/original/3d90295042f79f041d671c5d41f0392d.jpg 7d59e48c5e8c4047578f190b6e516375 https://staging.drfop.org/files/original/71925d0bb446f6b649060c3ce4462e59.jpg 9b323c95c211ec10d01e7feee755cd18 https://staging.drfop.org/files/original/3396fe9730b14b2e8657689fe74865b5.jpg 643294f08d5a592e58d3ea194294785d https://staging.drfop.org/files/original/b9a09fc152979d703b46c792aed66798.jpg a101cb269531ad4c2ddca3abe3c64fb3 https://staging.drfop.org/files/original/a310a604046c1382bc0c3548b947c299.jpg 0c5f822f77e1f2a66fd8f148fb0fb1b0 https://staging.drfop.org/files/original/2a80303457c8a42d0517fa0e01a299e9.jpg 44668a6d1b6a2b3675ba14074520a508 https://staging.drfop.org/files/original/3df94aa6ab1f93ff4d20a470503069ef.jpg f0c64be6e5bbae5c7b28834975248ee8 https://staging.drfop.org/files/original/3afb84d3903ae00d345a76156822ebc2.jpg c8495b91e25a321f39294efe21e110ad 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/1988_03_109.pdf Text Any textual data included in the document <h2>The Hip Disarticulation Prosthesis as Developed by the O.I.M. Noord Nederland</h2> <h5>Peter Tuil <a style="text-decoration: none;">*</a></h5> What characterizes the hip disarticulation prosthesis of the O.I.M. Noord Nederland is the use of a four-bar Otto Bock knee joint as a hip joint. O.I.M. Noord Nederland has used this variation with much success over the last five years. At first, it was questionable whether the joint would be strong enough, but this has proven not to be an issue. There have been some problems with the 3R21, but only when it is used as a knee joint. These complications have been due to extreme flexion, lamination sections that were too thick and caused the joint to tear apart during flexion, or too much external rotation. There are two advantages in the use of the four-bar hip joint. First, the patient walks with a lower energy expenditure because the prosthesis shortens the swing phase. In contrast to patients who have worn older style hip disarticulation prostheses (for years patients used to be fitted with a tilting-table prosthesis or later with a wooden "Canadian hip" prosthesis), the patients with the new style prosthesis walk more and have indicated that they use less energy. Second, there is hardly any strain on the cosmetic cover, so much less damage is done. An additional advantage of the four-bar joint is that the construction can be less critical. Besides, the whole prosthesis can be readily adjusted. <h3>Description of the Fabrication Method</h3> To make the plaster impression, two wooden blocks are mounted on a table or casting stand. (Editorial note: Presumably this stand is adjustable in height.) These wooden blocks have sloped planes so that a wedge-formed gap is created between them (Fig. 1). In the back, the sloped side forms a 60° angle. In the front, the sloped side is divided into two different angles (Fig. 2). Both blocks can rotate around their vertical axles with regard to the table to which they are attached. They can also be shifted with regard to each other in the sagittal plane by means of a spindle (worm gear mechanism). The blocks are primarily meant to provide a good fitting of the residual limb and pressure relief in the places where that is necessary. <a href="/files/original/f5b53660057bef0aa5062375e0944618.jpg">Figure 1</a>. Apparatus used for casting. <a href="/files/original/507f8e598d697564a8825ef436c9831f.jpg">Figure 2</a>. Side view of the wooden blocks. The four-bar joint is attached to the socket by means of a specially manufactured adaptor (Fig. 3 and Fig. 4). The adaptor, which will later be incorporated into the socket, mimics the wedged shape of the wooden blocks (Fig. 5). <a href="/files/original/541b427a8b6b0e194b041e8cc2c59da1.jpg">Figure 3.</a> The adaptor. <a href="/files/original/3d90295042f79f041d671c5d41f0392d.jpg">Figure 4</a>. Shows how the adaptor, which will later be laminated into the socket, relates to the wedged form of the wooden blocks. <a href="/files/original/71925d0bb446f6b649060c3ce4462e59.jpg">Figure 5.</a> The apparatus forms a good plane of reference. Finally, the impression of the wooden table provides a good plane of reference for the plaster model (Fig. 6). <a href="/files/original/3396fe9730b14b2e8657689fe74865b5.jpg">Figure 6</a>. Position of the adaptor as related to the pelvic socket. This impression of the horizontal plane must remain horizontal during the construction process. During plaster modification, one should maintain unchanged the medial of the plaster model in the transverse plane, so that the impression of this edge will always indicate the line of progression of the plaster model. The socket is laminated in three layers. First though, a layer of Pe-Lite™ is put on the plaster model, followed by a layer of stockinette, and finally a layer of P.V.A. foil. The layer of stockinette is always applied under the first layer of foil. This will provide better suction, absorb some moisture, and the plaster model need not be as smooth. The first layer is laminated from flexible resin with two layers of Perlon stockinette, which is elastic in two directions. Subsequently the adaptor is located as shown in Fig. 7. <a href="/files/original/b9a09fc152979d703b46c792aed66798.jpg">Figure 7</a>. Reinforcement of the socket. The space between the adaptor and the plaster model is filled with "leichtspatel" (filler). The base of the plaster model must stand horizontally. The adaptor is placed approximately 4 to 5cm lateral of the groin. The maxim is to get the adaptor directly underneath the ischial tuberosity. However, this is influenced by the needs of the cosmetic cover. The adaptor is then covered with two layers of stockinette and a reinforcing layer of carbon fiber matting to prevent the adaptor breaking loose from the forces generated at heel strike. A strip of carbon fiber is put in the front to prevent the pelvis socket from curling inward. A reinforcing band of glass fiber is placed diagonally as shown in Fig. 8. Over this, two layers of stockinette are placed. First, rigid lamination resin is applied on those areas where the socket must be rigid. The rest is laminated with flexible resin. An adjustable "jig" is necessary in order to be able to turn the model around in the bench-vice quickly. The final layer is done with flexible resin and two layers of stockinette. <a href="/files/original/a310a604046c1382bc0c3548b947c299.jpg">Figure 8</a>. Alignment is first considered with the patient seated. A layer of stockinette and P. V. A. foil are put on the socket. Then, the little cap needed to finish the cosmetic cover is laminated with three or four layers of stockinette and one layer of carbon fiber. The extra time needed to form this cap will later save a lot of time during the finishing of the cosmetic cover. The prosthesis is completed with a four-bar knee joint (3R21), a single axis ankle joint foot, and a rotation adaptor. The alignment of the prosthesis is first considered in the sitting position. One must take into account the symmetry in comparison to the healthy limb (Fig. 9 and Fig. 10). The definitive alignment is settled upon during stance and walking exercises (Fig. 10). The adjustment of the 3R21 knee joint is very important. Mistakes in alignment can cause malfunctions of the knee joint. Many adjustments are possible with regard to rotation in the hip joint itself. The lack of facility to adjust abduction has never been a problem. <a href="/files/original/2a80303457c8a42d0517fa0e01a299e9.jpg">Figure 9</a>. Side view of the patient sitting and wearing the prosthesis. <a href="/files/original/3df94aa6ab1f93ff4d20a470503069ef.jpg">Figure 10</a>. The realization of definitive alignment. The freedom of movement when seated is considerable (Figs. 11 and 12). <a href="/files/original/3afb84d3903ae00d345a76156822ebc2.jpg">Figure 11 and 12.</a> Freedom of movement when seated. The cosmetic cover is shaped in the hip area, as well as in the knee area, so that less tension will be induced in the cover during flexion and when seated. Finally, a long elastic strip is glued to the inner anterior wall of the cover. This is done to protect the foam-cover. The construction process for a prosthesis for a hemipelvectomy is similar. *Peter Tuil Peter Tuil can be contacted at Stitchting Orthopedische Instrumentmakerij, Noord-Nederland Dilgtweg 5, 9751 ND Haren (Gn), The Netherlands. Page Number(s) 109 - 113 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-05.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/1988_03_109/1988_03_109-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-10.jpg Figure 11 FIGURE 11 & 12 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-11.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 The Hip Disarticulation Prosthesis as Developed by the O.I.M. Noord Nederland Creator An entity primarily responsible for making the resource Peter Tuil * https://staging.drfop.org/files/original/f97cfd5235b0aee89a8a246f3bb36a96.pdf 0611831203afbaea806f867bafac8a09 https://staging.drfop.org/files/original/c4503bd0ade204d8bd8febe76bbb6f56.jpg 19fcf5623ec96a54d6f85f8b60b2d008 https://staging.drfop.org/files/original/fb7cc1d43658e6003753aaa44c247f01.jpg 4ff3ceb12158adbee0cf9b90e7a640f2 https://staging.drfop.org/files/original/3fa04d3962c39877277abfdfa7e54654.jpg c5e9b43e7d407777ca340bd7247b7a56 https://staging.drfop.org/files/original/48dff4cea5f12c24f5a7ec7718c459fe.jpg 78b79fa22696174683179cfcb09a400f https://staging.drfop.org/files/original/01326057960c319c4b1259bcd805ddd3.jpg d07268216e98fea759014f362be88ab8 https://staging.drfop.org/files/original/d9b33408099151592c9792c42710a205.jpg 18fbe3ca5c7150b3dfecd879beced63b https://staging.drfop.org/files/original/62b4779e67198aad3af7f94c6224cfa5.jpg 97a440c22672ac2d9f3359115cf894d0 https://staging.drfop.org/files/original/14d93f4c4979723e691b143fa14c65ef.jpg 910dfa8cf554c1cb90120318e8acf61b 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/1988_03_099.pdf Text Any textual data included in the document <h2>Component Selection Criteria: Lower Limb Disarticulations</h2> <h5>John Michael, M.Ed., C.P.O. <a style="text-decoration: none;">*</a></h5> Because disarticulations comprise only a small percentage of the lower limb amputations performed each year,<a></a> questions sometimes arise regarding the most appropriate components to select. This paper will present a brief overview in an effort to clarify the criteria involved. <h3>Hip Disarticulation/Hemipelvectomy Components</h3> For the hip disarticulation or hemipelvectomy case, component selection is generally analogous to the more familiar above-knee patient. Endoskeletal components are preferred for the high level amputee because they offer light-weight and enhanced cosmetic appearance. A clear trend away from steel components to the much lighter titanium or carbon fiber versions is apparent. Most systems (particularly the Otto Bock "Modular") also permit subtle realignment, even in the definitive prosthesis. This can be an advantage due to the complex interplay between the mechanical hip, knee, and foot mechanisms. <h3>Hip Joint Mechanisms</h3> In general, a free motion hip joint is preferred, as originally proposed by McLaurin in 1954.<a></a> Careful attention to alignment details results in a very stable configuration by virtue of the weight line and reaction line forces. This permits very safe weight-bearing, yet allows easy hip flexion during swing phase. Stride length is generally controlled by a spring or elastic flexion limiting apparatus, sometimes called an "extension bias." In modern practice, the joint is placed near the anterodistal quadrant of the socket, which sometimes requires a slightly shorter thigh segment for the best appearance when sitting. Manual locking hip joints are also available but should be reserved as the component of last resort, even for bilateral amputees. In addition to disrupting swing phase, locked joints require the use of one hand on the unlocking mechanism during sitting. This often makes a difficult task more complicated, particularly for the double amputee. More importantly, a locked hip joint may place the patient in a more dangerous position during a fall backwards. If the joint prevents flexion at the hips, the head rather than the buttocks may strike the ground first. In our last 50 consecutive fittings at Duke, both unilateral and bilateral hip/hemi patients have never required a locked joint to ambulate securely. Two variations in hip joint design warrant mention. Peter Tuil of the Netherlands advocates the use of a reversed polycentric knee disarticulation joint (Otto Bock 3R21) as a hip joint.<a></a> Benefits claimed are parallel to those expected from a polycentric knee unit: increased ground clearance during swing phase due to the inherent "shortening" of the linkage in flexion and enhanced stability at heel strike (Fig. 1). <a href="/files/original/c4503bd0ade204d8bd8febe76bbb6f56.jpg">Figure 1</a>. Prosthesis utilizing reversed polycentric knee disarticulation mechanism at the hip, as proposed by Peter Tuil of the Netherlands. (Courtesy of Orthotics & Prosthetics, 38/1, p. 33.) This view has been corroborated in a number of fittings over the past few years at the Royal Ottawa Regional Rehabilitation Centre in Canada.<a></a> Such a technique has also worked well in our hands at Duke, although we are not certain the benefits fully justify the special effort involved. An even more intriguing concept is the "Hip Flexion Bias" modification promulgated by Haslem, et al. of Houston, Texas.<a></a> In this system, hip extension from heel strike to mid-stance compresses a specially selected spring, which encircles the endoskeletal pylon. At toe-off, this kinetic energy is released and the thigh segment is propelled briskly forward (Fig. 2). <a href="/files/original/fb7cc1d43658e6003753aaa44c247f01.jpg">Figure 2</a>. Hip Flexion Bias system designed by Haslam et al. of Houston, Texas. Note compression spring encircling thigh tube, which propels the limb forward during swing phase. (Redrawn from reference 5) Not only does this result in a much more cosmetically "normal" gait, it also significantly improves ground clearance in swing phase. One of the inherent limitations of the Canadian hip disarticulation alignment system is the prosthesis must be significantly short (1cm+) to avoid forcing the amputee to vault for toe clearance. Fig. 3 and Fig. 4 illustrate the biomechanics of the Canadian design. At toe-off, the heel rises up during knee flexion and pulls the hip joint firmly against its posterior (extension) stop. The thigh segment remains vertical until the knee has reversed its direction of motion and contacted the knee stop. Only then does the thigh segment rotate anteriorly, causing the hip joint to flex. In essence, the prosthesis is at its full length during midswing. Since the patient has no voluntary control over any of the passive mechanical joints, the prosthetist is forced to shorten the limb for ground clearance. <a href="/files/original/3fa04d3962c39877277abfdfa7e54654.jpg">Figure 3</a>. Canadian prosthesis in early swing phase. Hip joint remains neutral as shank swings forward. (Redrawn from reference 13) <a href="/files/original/48dff4cea5f12c24f5a7ec7718c459fe.jpg">Figure 4</a>. Canadian prosthesis just after mid-swing. Hip joint does not flex until shank motion is arrested by terminal extension stop. Prosthesis is fully extended at the instant of mid-swing. (Redrawn from reference 13) The hip flexion bias system neatly avoids this dilemma. As a result, the prosthesis can be lengthened to a nearly level configuration in most cases. However, two potential problems have been noted with this approach. One is the development of annoying squeaks in the spring mechanism after a few months of use, which sometimes tend to recur inexorably. A more significant concern is that as the spring compresses between heel strike and midstance, it creates a strong knee flexion moment. Unless this is resisted by a stance control knee with friction brake or a polycentric knee with inherent stability, the patient may fall. Since the friction brake mechanisms lose their effectiveness as the surface wears, the polycentric knee is the preferred component with this hip mechanism.<a></a> <h3>Knee Joint Mechanisms</h3> Other than the exception discussed above, knee mechanisms are selected by the same criteria as for above-knee amputees. The single axis/constant friction design remains the most widely utilized due to its light weight, low cost, and excellent durability. The friction resistance is often removed to ensure the knee reaches full extension as quickly as possible. A strong knee extension bias enhances this goal, offering the patient the most stable biomechanics possible with this mechanism. Although this was proposed as the knee of choice for the Canadian hip disarticulation design, more sophisticated mechanisms have proven their value and are gradually becoming more common. The friction brake stance control knee (Otto Bock 3R15 or equivalent) is probably the second most frequently utilized component. Because there is very little increase in cost or weight and reliability has been good, many clinicians feel the enhanced knee stability justifies this approach—particularly for the novice amputee. Mis-steps causing up to 15° knee flexion will not result in knee buckle, making gait training less difficult for the patient or therapist. The major drawback to this knee is that the limb must be non-weight-bearing for knee flexion to occur. Although this generally presents no problem during swing phase, some patients have difficulty mastering the weight shift necessary for sitting. It should be noted that use of such knee mechanisms bilaterally must be avoided. Since it is impossible for the amputee to simultaneously unload both artificial limbs, sitting with two stance control knees also becomes nearly impossible. A third class of knee mechanisms which has proven advantageous for this level of amputation is the polycentric group (Otto Bock 3R20 or equivalent). Although slightly heavier than the previous two types, this component offers maximum stance phase stability. Because the stability is inherent in the multi-linkage design, it does not erode as the knee mechanism wears during use. In addition, all polycentric mechanisms tend to "shorten" during swing phase, adding slightly to the toe clearance at that time. Many of the endoskeletal designs feature a readily adjustable knee extension stop. This permits significant changes to the biomechanical stability of the prosthesis, even in the definitive limb. Because of the powerful stability, good durability, and realignment capabilities of the endoskeletal polycentric mechanisms, they are particularly well suited for the bilateral amputee.<a></a> All levels of amputation, up to and including bilateral hemipelvectomy (hemicorporectomy), have successfully ambulated with these components. At first glance, a manual locking knee seems a logical choice. However, experience has shown this is rarely required, and should be reserved as a prescription of last resort. Only multiple medical disabilities (e.g. concomitant blindness) will require this mechanism. The complications in unlocking a joint for sitting by the unilateral have been discussed previously; expecting a bilateral amputee to cope with dual locking knees and dual locking hips can be an overwhelming task. For many years, the use of fluid controlled knee mechanisms for high level amputees was considered unwarranted, since these individuals obviously walked at only one (slow) cadence. The development of the hip flexion bias mechanism and more propulsive foot designs have challenged this assumption. Furthermore, a more sophisticated understanding of the details of prosthetic locomotion has revealed an additional advantage for the hip/hemi amputee. It is well accepted that any fluid control mechanism (hydraulic or pneumatic) results in a smoother gait.<a></a> Motion studies conducted at Northwestern University revealed that a more normal gait for the hip/hemi patient is also a by-product.<a></a> The preferred mechanism has separate knee flexion and extension resistance adjustments. A relatively powerful flexion resistance limits heel rise and initiates forward motion of the shank more quickly. In essence, the limb steps forward more rapidly. As the shank moves into extension, the fluid resistance at the knee transmits the momentum up the thigh segment, pushing the hip joint forward into flexion. In essence, the fluid controlled knee results in a hip flexion bias effect (Fig. 5). <a href="/files/original/01326057960c319c4b1259bcd805ddd3.jpg">Figure 5</a>. Canadian prosthesis with fluid controlled knee mechanism at mid-swing. Hydraulic extension resistance allows shank momentum to flex hip joint. Increased ground clearance may result. (Adapted from reference 13) Sophisticated gait analyses have demonstrated that this results in significantly more normal range of motion at the hip joint during the walking cycle.<a></a> Clinical observations suggest that a more varied cadence is possible, and the prosthesis can usually be fabricated to nearly full length without swing phase difficulties. Richard Lehneis, et al. have reported on a coordinated hip-knee hydraulic linkage using a modified hydrapneumatic unit.<a></a> This was designed to create a hip extension bias, and resulted in a smooth gait. We have no experience with this particular component at Duke. Finally, a number of new components have been developed recently which combine the characteristics of some of the above classes of knee mechanisms. For example, Teh Lin manufactures a "Graphlite" knee consisting of a polycentric set-up with pneumatic swing phase control in a carbon fiber receptacle. <h3>Foot Mechanisms</h3> Traditionally, the Solid Ankle Cushion Heel (SACH) has been considered the foot of choice for the Canadian hip disarticulation design due to its light weight, low cost, and excellent durability.<a></a> Provided the heel durometer is very soft, knee stability with this foot has generally been quite acceptable. In those cases where slightly more knee stability was desired, a single axis foot with a very soft plantar flexion bumper was preferred.<a></a> Added weight, maintenance, and cost, plus reduced cosmesis are the liabilities of this component. Multi-axis designs (such as the Greissinger) have similar liabilities to the single axis versions, but add extra degrees of freedom via hindfoot inversion/eversion and transverse rotation. In addition to accommodating uneven ground, absorbing some of the torque of walking, and protecting the patient's skin from shear stresses, multi-motion feet seem to decrease the wear and tear on the prosthetic mechanisms as well.<a></a> In the last five years, more sophisticated foot mechanisms have reached the market, and all have been demonstrated to function successfully for the high level amputee. The Solid Ankle Flexible Endoskeleton (SAFE) foot inaugurated a class that could be termed "Flexible Keel" designs.<a></a> Other members of this class include the STEN foot and the Otto Bock 1D10 Dynamic foot. All are characterized by a softer, more flexible forefoot, resulting in a smoother rollover for the patient. The SAFE version offers some transverse rotation as well.<a></a> In general, a softer forefoot requires special care during dynamic alignment to ensure that knee buckle does not occur inadvertently. However, when used in concert with a polycentric knee, the reverse occurs: the prosthesis actually becomes safer during late stance phase. The polycentric knee mechanism strongly resists a bending moment, which leads to its powerful stability at heel strike. It flexes during swing phase only if the forefoot remains firmly planted on the floor as the body "rides" the prosthesis over it.<a></a> This creates a shearing force which disrupts the linkage and permits easy flexion of the knee. Because the softer flexible keel delays this shearing moment, the polycentric knee is actually more stable in late stance than with a more rigid foot. Dynamic Response feet, which provide a subjective sense of active push-off, can also be used to advantage for the hip/hemi amputee.<a></a> Carbon Copy II, Seattle foot, and Flex-Foot(tm) have all been successfully utilized for this type of patient. They seem to provide a more rapid cadence, as evidenced by one long-term hip disarticulation wearer, who stated after receiving a Seattle foot, "For the first time in my life, I can pass someone in a crowd."<a></a> Once again, the interaction between the foot and knee must be carefully monitored. In general, the more responsive the foot mechanism, the more important the knee unit resistances become. Many practitioners prefer a fluid controlled knee, or at least one with powerful friction cells.<a></a> Otherwise, much of the forward momentum of the shank can be wasted as abrupt terminal impact of the knee. Presumed reductions in energy consumption have not yet been documented by scientific studies. In addition to the foot mechanisms, several ankle components have recently reached the American market. These can be paired with most of the feet mentioned above, adding additional degrees of motion as desired. Examples include the SwePro ankle from Sweden, the Blatchford (Endolite) Multifiex ankle from England, and the recently announced Seattle ankle. Torque absorbing units are often added to hip/hemi prostheses to reduce the shear forces transmitted to the patient and components.<a></a> Ideally, they are located just beneath the knee mechanism. This increases durability by placing the mechanism away from the sagittal stresses of the ankle, yet avoids the risk of introducing iatrogenic swing phase whips. The major justification for such a component is that the high level amputee has lost three biological joints and, hence, has no way to compensate for the normal rotation of ambulation. Torque absorbers can be combined with virtually any foot available, if desired. Finally, transverse rotation units originally developed for the Oriental world have become available. Installed above the knee mechanism, these devices permit the amputee to press a button and passively rotate the shank 90° or more for sitting comfort. They not only facilitate sitting cross-legged upon the floor, but also permit much easier entry into automobiles and other confined areas. <h3>Knee Disarticulation Components</h3> Although it is generally agreed that knee disarticulation offers the possibility of increased function over an above-knee amputation,<a></a> it clearly restricts patients' options in knee mechanisms and results in cosmetic compromises as well. For these reasons, its advisability remains hotly contested among knowledgeable surgeons and prosthetists. <h3>Knee Mechanisms</h3> The traditional knee mechanism for disarticulation has been the single pivot external hinges. Inherent disadvantages have been the lack of swing phase control (no friction adjustments) and rapid wear due to the small bearing surface compared to the typical 4" long axle of the above-knee set-up. Even with the addition of a posterior "back check" to limit extension, rapid wear of the extension stops is common. The major virtues of this design are its simplicity and low cost. It probably functions best for small children. Although the knee ball does not protrude when sitting, external hinges result in a slightly wider mediolateral configuration which some patients find objectionable. Heavy duty wearers can quickly destroy these relatively slender joints. One manufacturer provides a yoke attachment permitting the use of a fluid-controlled cylinder with these hinges (Fig. 6). This improves swing phase significantly, but long-term durability remains problematic. <a href="/files/original/d9b33408099151592c9792c42710a205.jpg">Figure 6</a>. Cut-away drawing of special hydraulic mechanism with yoke, permitting swing phase control for knee disarticulations with single pivot external hinges. (Redrawn with permission of Hosmer-Dorrance Corporation) The only other type of knee possible is a special polycentric design. By using longer linkage arms, the shank appears to fold back under the thigh when sitting, thus minimizing the apparent protrusion of the knee (Fig. 7). Since no mechanism is alongside the knee, the me-diolateral silhouette is more acceptable as well. <a href="/files/original/62b4779e67198aad3af7f94c6224cfa5.jpg">Figure 7</a>. Polycentric knee disarticulation mechanism flexed to 90°. Note how linkage "folds up" beneath the thigh segment, effectively shortening the shank and minimizing anterior protrusion when sitting. Several manufacturers offer the option of fluid controlled units along with the polycentric mechanism, and almost all have friction control options as well. For this reason, swing phase functioning is much better than the simple external hinge design (Fig. 8). <a href="/files/original/14d93f4c4979723e691b143fa14c65ef.jpg">Figure 8</a>. Example of polycentric mechanism permitting interchange of mechanical and fluid control swing phase units. (Designed by Orthopedic Hospital of Copenhagen; redrawn with permission of United States Manufacturing Company) All polycentrics offer powerful inherent stance phase control, and this group is no exception. However, because distal weight-bearing dramatically simplifies the biomechanics of knee control, this feature is seldom of great value to the patient. One manufacturer offers a manual locking module as well, but this should be used only as a last resort. One subtle problem with knee disarticulation polycentrics is that the relative "shortening" of the shank in sitting may lift the foot completely off the floor, particularly for husky individuals who are less than 5' 6" tall. The resulting sense of insecurity can be very disconcerting to the amputee and may result in rejection of the prosthesis. Durability can sometimes be a problem, although it is generally better than for external hinges. Most knee disarticulation polycentrics work quite well for geriatric patients but can become increasingly problematic for extremely vigorous individuals. In some cases, the only effective solution to chronic breakage problems is to switch to a conventional above-knee set-up. This results in protrusion of the knee ball by at least 2", making sitting in tight spaces (such as bus seats) nearly impossible. Although the function and durability are excellent, the cosmetic liability of such malalignment is obvious to the casual observer as well. <h3>Foot Mechanisms</h3> Knee disarticulates can utilize all the feet and ankle options of the higher level amputee, as previously discussed. Knee stability is rarely a concern, but reducing stress on the relatively fragile knee mechanism is a concern. For that reason, the author favors flexible keel designs, with or without a torque absorbing unit, since these components reduce the forces transmitted to the limb. <h3>Ankle Disarticulation (Symes)</h3> Like his knee disarticulate brethren, the Symes amputee has a very limited range of choices in prosthetic componentry. In addition, a significantly poorer cosmetic result is inevitable. These disadvantages must be weighed against the functional advantages of distal weightbearing and the documented reduction in energy consumption over the below-knee amputee.<a></a> <h3>Foot Mechanisms</h3> The Symes amputation generally precludes the use of any articulated ankle mechanism, due to space limitations. The heavy metal frame of yesteryear is virtually extinct. Most of today's Symes amputees are fitted with a SACH foot. The specially designed Symes version suffers from reduced durability due to the greater stresses the end-bearing residual limb can exert on the prosthesis. However, it can often be replaced economically if broken. The external keel SACH design limits inversion and eversion almost completely but can be more durable and more cosmetically pleasing than the standard SACH. Since its use precludes any alteration of alignment after transfer and finishing, great care must be exercised during the fitting. The Stationary Ankle Flexible Endoskeleton (SAFE) foot, discussed earlier, has a Symes version. This offers a flexible keel and much smoother roll-over. This reduces the forces transmitted to the prosthetic socket, increasing both patient comfort and socket durability. Reliability is adequate, and replacement is possible. The author prefers this design for Symes amputees for the reasons cited. The Carbon Copy II has recently developed a dynamic response design suitable for many adult male Symes. Patient response has been favorable, as they sense the dynamic push-off it offers. External appearance is excellent, as is the weight reduction. Our experience at Duke is too short to comment at this time on durability of this component or its effect on socket stresses. <h3>Summary</h3> Although disarticulations represent less than five percent of the lower limb amputees fitted annually,<a></a> appropriate components can be selected based on logical criteria. Both Symes and knee disarticulates, however, have limited component options, often with decreased reliability plus cosmetic limitations compared to more conventional amputation levels. Hip disarticulates and hemipelvectomies have as broad an array of choices as the above-knee, prescribed for generally analogous reasons. As our understanding of biomechanics has improved, more sophisticated mechanisms have been successfully provided to this group of patients. Current state-of-the-art requires careful consideration of the subtle interactions between the foot, ankle, hip, and ancillary mechanisms to ensure the optimum result for each patient. References: <ol> <li><a href="al/1963_01_005.asp">Glattly, Harold W., "A Preliminary Report on the Amputee Census," Artificial Limbs, 7(1), 1963, pp. 5-10.</a></li> <li>McLaurin, C.A., "Hip Disarticulation Prosthesis," Report No. 15, Prosthetic Services Centre, Department of Veterans Affairs, Toronto, Canada, 1954.</li> <li>Webster, B. and P. Tuil, "Heupexarticulates Onder De Loep," Infortho, August, 1982.</li> <li>Van der Waarde, Tony, "Ottawa Experience with Hip Disarticulation Prostheses," Orthotics and Prosthetics, 38(1), 1984, pp. 29-33.</li> <li>Haslam, T. and M. Wilson, "Hip Flexion Bias," Concept 80, Medical Center Prosthetics, Houston, Texas, 1980.</li> <li>Ibid.</li> <li>McLaurin, op. cit.</li> <li>Greene, Michael, "Four Bar Knee Linkage Analysis," Orthotics and Prosthetics, 37(1), 1983, pp. 15-24.</li> <li>Mooney, Vert, in Atlas of Limb Prosthetics, C.V. Mosby Company, St. Louis, 1981, pp. 391-395.</li> <li>Van Vorhis, Robert, "Clinical Analysis of Hip Disarticulation Prostheses," 31st Scientific Meeting, Midwest Chapter, AAOP, Lincolnshire, Illinois, 1981.</li> <li>Ibid.</li> <li>Lehneis, H.R. et al., Prosthetics Management for High Level Lower Limb Amputees, Institute of Rehabilitation Medicine, New York, New York, 1980.</li> <li>Hampton, F., A Hemipelvectomy Prosthesis, Northwestern University Prosthetic Research Center, Chicago, Illinois, 1964, p. 32.</li> <li>Gehl, Gunter, "Proper Selection of Prosthetic Components," Northwestern University Prosthetic Orthotic Center, Certificate course, Chicago, Illinois, 1976.</li> <li>Ibid.</li> <li>Michael, John, "Analysis of Energy Storing Feet," AAOP Annual Meeting and Scientific Symposium, Newport Beach, California, 1988.</li> <li>Campbell, J. and C. Childs, "The S.A.F.E. Foot," Orthotics and Prosthetics, 34(3), 1980, pp. 3-17.</li> <li>Nader, Max et al., "Polycentric, Four Bar Linkage Knee Joint," Technical Information Bulletin No. 45, Otto Bock Industries, Duderstadt, West Germany, 1988, p. 3.</li> <li>Michael, op. cit.</li> <li>Michael, J., "Energy Storing Feet: A Clinical Comparison," Clinical Prosthetics and Orthotics, 11(3), 1987, pp. 154-168.</li> <li>Leal, J., personal communication, 1987.</li> <li>Nader, Max et al., "Torsion Adapter With Tube," Technical Information Bulletin No. 2.6.1, Otto Bock Industries, Duderstadt, West Germany, 1986, p. 3.</li> <li><a href="poi/1983_02_119.asp">Jensen, J.S. and T. Mandrup-Poulsen, "Success Rate of Prosthetic Fitting After Major Amputations of The Lower Limb," Prosthetics and Orthotics International, 7(2), 1983, pp. 119-122.</a></li> <li>Waters, R.L. et al., "Energy Costs of Walking of Amputees: The Influence of Level of Amputation," Journal of Bone and Joint Surgery, 58A, 1976, p. 46.</li> <li>Glattly, op. cit.</li> </ol> *John Michael, M.Ed., C.P.O. John W. Michael, M.Ed., C.P.O., is Director and Assistant Clinical Professor at Duke University Department of Prosthetics and Orthotics, Duke University Medical Center, P.O. Box 3885, M04 Davison, Durham, North Carolina 27710; (919) 684-2474. Page Number(s) 99 - 108 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-5.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/1988_03_099/1988_03_099-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-7.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-8.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 Component Selection Criteria: Lower Limb Disarticulations Creator An entity primarily responsible for making the resource John Michael, M.Ed., C.P.O. * https://staging.drfop.org/files/original/f19a203dc83608d15f834f83cded733e.pdf 6d2e37d1ab4e9eb40057c0b1eda9787a https://staging.drfop.org/files/original/626bec40f3c1712a163754c6407d8b7f.jpg 0889da54c981b532c0f7f9fca7ab7393 https://staging.drfop.org/files/original/4d23e4efd15dbd56d0d3c0d64d42a12c.jpg 235bf482c5bbd2d6df9a57a8e062d9f8 https://staging.drfop.org/files/original/84c1981f28fb0bd2b78a57f08cd3370e.jpg 29185ddb7cfae11354a16dd183354883 https://staging.drfop.org/files/original/be68f5014bf3e41306651775bb6aaa72.jpg 8728c5cf6a697fb1e11581b23e406435 https://staging.drfop.org/files/original/d47a2e29fc5ef0a8ed843d1a7dda7878.jpg db1eff3b83d2b60637bad4ef7307fada https://staging.drfop.org/files/original/5acc660a9991a044a33f6cdb80803607.jpg 3728771041c94d3d1d9b937fd099d600 https://staging.drfop.org/files/original/1f702da7b89a464c498010a1abcc516c.jpg 3dfc6a240ebdc1b4f044c9d2a70f29fc https://staging.drfop.org/files/original/350e92414c3f250e585c0c410483f05f.jpg e5cc9412d004ff923fa9cfe0116c8d67 https://staging.drfop.org/files/original/e0c8a2a383af1b8f73d88ad5a6e19878.jpg d135ed31bad70f44ed05da85fa80e938 https://staging.drfop.org/files/original/3d5ad29d6d20a80babbcb352572dc9c3.jpg 3dd7c369b1d5402e8bec9a1a13200601 https://staging.drfop.org/files/original/23e38cbe718dfe3bb7d85f6ed388efd9.jpg cfcb75970fefc5d722cd18ebb13f14af https://staging.drfop.org/files/original/83d73db1e1c4c310e0f458551ea5dbe8.jpg 41dc790f623b91b39085ce3145a0c1c4 https://staging.drfop.org/files/original/cbdfe4b7b4f81d816508d5add65aa3ed.jpg 6bd1b183c2bb185fdd17b2df9045e440 https://staging.drfop.org/files/original/0f06eae8e85a93d7810db6e5d53ec00d.jpg c2853522e2b04d169b43a87fb15b85e2 https://staging.drfop.org/files/original/a974bfac3181ff32c7452e179378f236.jpg 75455b1a6dc267f36a971693a75beeba 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/1988_02_081.pdf Text Any textual data included in the document <h2>Report From: International Workshop on Above-Knee Fitting and Alignment Techniques</h2> <h5>C. Michael Schuch, C.P.O. <a style="text-decoration: none;">*</a></h5> An "International Workshop on Above-Knee Fitting and Alignment Techniques" was held in Miami, Florida, May 15-19, 1987. Conceived and organized by A. Bennett Wilson, Jr. and Melvin L. Stills, CO., the workshop was supported and sponsored jointly by the International Society for Prosthetics and Orthotics and the Rehabilitation Research and Development Service of the Veteran's Administration. Hosting the workshop was the Prosthetics and Orthotics Education Program of the School of Health Sciences, Florida International University, and more specifically, Dr. Reba Anderson, Dean of Health Sciences and Ron Spiers, Director of Prosthetic Orthotic Education. Approximately 50 invited professionals attended the workshop, representing the United States, England, Scotland, Denmark, Sweden, Israel, the Netherlands, and Germany. Invited professionals included physicians, engineers, educators, and researchers, as well as prosthetic practitioners, all known to be active in the field of prosthetics. The intent of the workshop was an organized sharing and discussion of information and experiences relative to the management of above-knee amputees. Above-knee socket design variables, specifically the accepted and established quadrilateral design and the newer ischial-con-tainment designs known by various acronyms (CAT-CAM, NSNA, Narrow M-L), were discussed in great detail. Goals were to determine differences/similarities, advantages/disadvan-tages, indications/contraindications, as well as to develop recommendations for future action with respect to the various socket designs. While many prosthetists and/or clinics may have considerable experience with the newer above-knee socket designs within the United States, it is true that there are still many questions and concerns on the part of consumers, prescribing physicians, third party paying agencies, and educators in the U.S., as well as a great curiosity on the part of our international colleagues abroad. After introductory remarks from Dr. Anderson, Dean of Health Sciences at Florida International University, Mr. John Hughes, President of ISPO, and Dr. Margaret Gianninni, Director of the Rehabilitation Research and Development Service of the Veteran's Administration, the program began with a presentation by A. Bennett Wilson entitled, "Recent Brief History of AK Fitting and Alignment Techniques." This paper began with the advent of the suction socket in the U.S. shortly after World War II and proceeded with the development of the total contact quadrilateral socket in the early 1960's. The audience was reminded that the total-contact quadrilateral socket, with or without suction suspension, was the socket design of choice from 1964 until very recently, when ischial-containment socket designs emerged. It was noted that, at present, the three senior prosthetic education programs in the U.S. (UCLA, Northwestern University, and New York University), in addition to teaching the application of the standard total contact quadrilateral socket, are offering special courses in what at first glance appear to be radical departures from the quadrilateral design. The technique at UCLA is known as CAT-CAM (Contoured Adducted Trochanteric-Con-trolled Alignment Method), based on work by John Sabolich, C.P.O., and inspired by Ivan A. Long, CP. The technique being presented at Northwestern University is said to be based more directly on the Ivan Long technique and is known as NSNA (Normal Shape-Normal Alignment). The technique taught at New York University is usually referred to as the narrow ML socket design based on a special tool designed by Daniel Shamp to facilitate casting. Mr. Wilson concluded his remarks by saying "unfortunately, none of these techniques has been subjected to an evaluation program independent of the development group, and a great deal of confusion exists among clinicians responsible for amputee care. I hope that this workshop can be helpful in clearing away some of the confusion, and point the way for action that will bring order to the present day practice of above-knee prosthetics." The next speaker on the agenda was Charles Radcliffe, Professor of Mechanical Engineering at the University of California, Berkeley. Professor Radcliff's presentation was entitled, "Review of UCB Quadrilateral Socket and Alignment Theory." Having been a member of the Prosthetic Devices Research Project of UC Berkeley in the 50's and 60's, Professor Rad-cliff is still a strong proponent of the quadrilateral socket. He presented a detailed review of the history and development of the quadrilateral socket and summarized this section of his presentation with the following comments. "The net result of all of this work in the 1950-1963 period was a better understanding of the complex interrelationships between the functional capability of the amputee, the rehabilitation goals, the prosthetic components required in the prescription, the gait of the amputee, the biomechanical forces generated, the socket shape, and the alignment. The socket was no longer described as a cross-section shape at the ischial level, but rather a three-dimensional receptacle for the stump with contours at every level which could be justified on a sound biomechanical basis. ... It should be emphasized again that the quadrilateral type of fitting is not just a socket, it is a complete system which includes the amputee as a most important component. The socket is the interface between stump and prosthesis, and its primary functions are to provide for weight-bearing in the stance phase, allow the use of the stump and hip musculature to control motion and posture of the upper body in the stance phase (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-01.jpg">Fig. 1</a>), and to provide for control of the prosthesis in the swing phase of walking." <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-01.jpg">Figure 1. Biomechanical forces diagram, Above-knee amputee weight-bearing in the stance phase.</a> The next section of Professor Radcliffe's presentation focused on biomechanical and alignment principles of a prosthesis with a quadrilateral socket. Here he related his feelings that many of the biomechanically related claims made by proponents of the newer non-quadrilateral socket designs are equally attainable in the quadrilateral socket if the original biomechanical principles are followed. "Regardless of the fitting method employed, the socket for any patient must provide the same overall functional characteristics, including comfortable weight-bearing, a narrow base gait, and as normal a swing phase as possible consistent with the residual function available to the amputee after amputation. It is possible to provide this with a quadrilateral socket and it is being done routinely in many facilities." Professor Radcliffe went on to say, "In most of the recent articles that I have read, statements have been made which indicate clearly that the author is comparing very poorly fitted quadrilateral sockets to the results obtained using the new technique. They show diagrams of typical fittings and gait deviations which can only be described as a complete list of horror stories describing what not to do in fitting a quadrilateral socket. Any prosthesis with the problems listed in these articles should never have been delivered. If the average pros-thetist in the United States is having the problems described by Long, Shamp, and Sabolich, then I must suggest that something is wrong with the methods being taught and used in daily practice. I am aware that the schools have made significant changes in the way that the principles are taught, with each school emphasizing different aspects of the problem. I suspect that there may have been a shift away from the fundamentals of teaching of overall objectives, including the interrelationships of amputee evaluation, components prescribed, biomechanics, and why sockets are fitted with particular contours." Following Professor Radcliffe was Tim Staats, Director of the UCLA Prosthetics Education Program. Mr. Staats' presentation was on the "UCLA CAT-CAM." UCLA began teaching CAT-CAM above-knee prosthetics with a pilot course in March 1985, which included both John Sabolich and Tom Guth as course instructors. Mr. Staats made it clear that the UCLA CAT-CAM philosophy of 1987 has departed from that of Sabolich, Guth, et al. and that the UCLA philosophy has now evolved to the point where a third edition of a teaching manual was published in March, 1987. To quote Mr. Staats as he spoke about this new manual, "the third edition of the UCLA CAT-CAM Above-Knee Prosthesis teaching manual integrates much additional material, covering the anatomy/socket relationship and how this is best achieved—material not yet fully understood and synthesized at the time of preparation of the previous edition. The UCLA CAT-CAM above-knee socket is a variation of the CAT-CAM design developed by John Sabolich, C.P.O., and Tom Guth, CP., and the NSNA AK prosthesis of Ivan Long, CP. Through countless hours of literature search, discussion, and intensive training given in this and nine foreign countries, and through the results of over 200 students who have fabricated and fit over 1,000 sockets under the guidance of our staff, a new insight has been developed. Our staff has refined the techniques of measurement, casting, and model modification to the point where it is a clearly teachable and viable above-knee fitting method. It is with great respect that we continue to recognize the published contributions of John Sabolich, C.P.O., Tom Guth, CP., and Ivan Long, CP., to the development and evolution of the UCLA technique. We would hope that this manual captures, blends, and enhances their philosophies. We recognize that our technique and CAT-CAM evolved from NSNA and we hope that these professionals can appreciate our efforts to refine and further evolve their clinical approach into a methodical step-by-step teaching manual." At this point I will briefly review the highlights of the UCLA CAT-CAM sequence, beginning with patient evaluation and measurement and proceeding through model modification and bench alignment. For the details, I suggest referencing the third edition of the UCLA manual. The recommended evaluation/measurement protocol is very complete and detailed, covering many of the procedures with which we should all be familiar. Adduction and flexion analysis of the residual limb are emphasized. Some new measurements and/or evaluations are introduced and illustrated: <ul> <li> Skeletal ML dimension, actually measured on patient (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-02.jpg">Fig. 2</a>) <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-02.jpg">Figure 2. UCLA CAT-CAM medial-lateral diameter measurements.</a></li> <li> Soft tissue ML dimension, taken from Ivan Long's chart of circumferences and related ML values (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-02.jpg">Fig. 2</a>) </li> <li> Ilio-femoral angle, actually measured on the patient (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-03.jpg">Fig. 3</a>) <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-03.jpg">Figure 3. Ilio-femoral angle, as measured for UCLA CAT-CAM.</a></li> <li> Public arch angle, evaluated by palpation and captured in the wrap cast (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-04.jpg">Fig. 4</a>) <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-04.jpg">Figure 4. The pubic arch angle, as evaluated for UCLA CAT-CAM.</a></li> <li> Ischial inclination, evaluated by palpation and captured in the wrap cast (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-05.jpg">Fig. 5</a>) <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-05.jpg">Figure 5. The ischial inclination angle, as evaluated for UCLA CAT-CAM.</a></li> </ul> The wrap cast is taken with the patient in a standing position, and all shaping of the cast is accomplished by hand molding. The goal is good definition and containment of the medial and posterior aspects of the ischial tuberosity and ischial ramus within the wrap cast and subsequent socket, as well as allowance for the pubic ramus to exit the socket near the midline of the medial wall (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-06.jpg">Fig. 6</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-06.jpg">Figure 6. Medial view of pelvis-socket relationship, UCLA CAT-CAM.</a> The initial trimlines for the resultant socket are as follows: <ol> <li> Anteriorly, just proximal to the inguinal crease. The anterolateral brim must clear the superior iliac spine when the patient is sitting. </li> <li> Laterally, the brim extends approximately 3" above the trochanter. The final height of this wall will be determined during fitting. </li> <li> Posteriorly, the trim line should begin at least 1" above the level of the inferior border of the ischial tuberosity. The curve that defines the posterior to lateral trim line normally begins at a point between the lateral third and the midline of the socket ML dimension at ischial level. </li> <li> The medial proximal brim will be "V" shaped, with the vortex of the "V" located at the point where the pubic ramus crosses the medial wall. This trim line projects upward from the vortex, posteriorly to encapsulate the medial aspect of the ischial ramus and tuberosity. (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-06.jpg">Fig. 6</a>) A circumference reduction chart is used to attain suction suspension. The values used in this chart are slightly less than those normally used in quadrilateral suction sockets. </li> </ol> For bench alignment, the following references are used: <ol> <li> Posteriorly, bisect the socket at the level of the soft tissue ML, this reference line should fall as a plumb line to the center of the heel. </li> <li> Laterally, bisect the socket AP dimension at ischial level, this reference line should fall as a plumb line between 0" and 1" anterior to the foot bolt. </li> <li> Socket is set in measured adduction, and measured flexion plus 5°. </li> <li> The distal aspect of the medial wall should be on the line of progression. </li> <li> The knee bolt is externally rotated 5°. </li> <li> The top of the foot, as well as the prosthetic shank should lean medially 4°, or alternatively, the socket is hyper-ad-ducted 4° beyond measured adduction with the foot parallel to the floor and the shank perpendicular to the floor. </li> </ol> The UCLA CAT-CAM can be fabricated using rigid socket or flexible socket techniques. If a flexible socket or brim system is desired, the proximal medial trimline in the ischial area must be more aggressive during casting to allow for the linear shrinkage factor known in most thermoplastics. A final comment: the manual reflects the accumulated experience of the UCLA staff and includes a section on problem solving the difficulties that might be experienced in the CAT-CAM socket. Next to speak was Gunther Gehl, CP., Director of Prosthetic Education at Northwestern University in Chicago. Northwestern has been teaching the NSNA AK techniques of Ivan Long for several years now, and it was Mr. Gehl's task to report to the workshop on NSNA and Long's Line. He said that he and his staff taught NSNA as presented by Ivan Long with no changes. Ivan has been fitting Long's Line, now known as NSNA, for more than 12 years, and his approach has been consistent, with few changes. Perhaps changing the name from Long's Line to NSNA in July, 1985 is the most significant change. Mr. Long has published three technical papers describing his technique: "Allowing Normal Adduction of the Femur in Above Knee Amputees," (Orthotics and Prosthetics, December, 1975); "Fabricating the Long's Line Above Knee Prosthesis," (1981); and as a reprint of the Long's Line article with new title, "Normal Shape-Normal Alignment (NSNA) Above Knee Prosthesis," (Clinical Prosthetics and Orthotics, Fall, 1985). These articles were the basis for Gunther Gehl's presentation to the International Workshop. I will attempt to review and highlight the NSNA philosophy as I did the UCLA CAT-CAM. Again, within the limitations of this report, this will only be an overview. With the widespread availability of Ivan's publications, it does not seem necessary to go into details. NSNA is less detailed regarding evaluation and measurements, placing great emphasis on the wrap cast, subsequent model modification, and alignment, all based on Long's Line, which is defined as a straight line, starting approximately at the center of a narrow socket, passing through the distal femur, and on down to the center of the heel (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-07.jpg">Fig. 7</a>). Long's Line is not always vertical because it shifts constantly when the amputee goes from a standing position to a walking position. <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-07.jpg">Figure 7. Long's Line.</a> The wrap cast is taken with the patient in a standing position. The important points about the wrap cast procedure are identification of the ischium and proper alignment. The hand will be held to indicate the medial and posterior surface of the ischium, but not forward of the ischium. The amputee then adducts as tightly as possible and extends his thigh to tighten the hamstrings. At this point a lateral reference line is established. The resultant cast model is oversized and will require considerable modification. Practically all modification will take place on the lateral wall. Following is a brief description of modification goals and resultant trimlines, taken from Mr. Gehl's presentation and from Mr. Long's publications. <ol> <li> The lateral wall is to be shaped to give support over a wide area, and particularly the lateral-posterior aspect of the socket. </li> <li> The medial wall will be lower than seat level, and the wrap cast will be the guideline as to how low. </li> <li> Depth of the socket will be the same as the measured length of the thigh. </li> <li> The seat will be at a right angle to Long's Line. </li> <li> Long's Line is drawn from the center of the seat level ML to the center of the distal femur. The distal femur will be very close to the lateral surface, probably only covered by skin. </li> <li> The top 1" of the medial wall will flare outward at 45°. </li> <li> The lateral wall extends above the trochanter. </li> <li> The ischium will bear on the flare of the socket, both medially and posteriorly. </li> <li> The cast is taken down in the ML as though the trochanter does not exist. In order to achieve the desired ML, many casts will be reduced 2" or more. The desired ML dimension is taken from Ivan's chart of ML values related to the thigh circumference just below the ischium (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-08.jpg">Fig. 8</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-08.jpg">Figure 8. Table of M-L values determined from circumference just below ischium, used in NSNA.</a></li> </ol> Circumference reductions for suction suspension begin at 1" of tension proximally, reducing to 3/4", then 1/2", with the remaining tensions at 1/4". Mr. Long does not advocate use of an alignment device. Bench alignment is critical and is based on Long's Line. The center of the lateral wall is marked at seat level for TKA and the vertical reference line established during casting should parallel the TKA line. Long's Line is marked on the posterior of the socket. For the male, the socket is mounted with the inner aspect of the medial wall (which follows the pubic ramus angle) in 30° internal rotation to the line of progression (the outer edge of the medial trimline is on the line of progression), and with the knee bolt axis 4° higher on the lateral side. This is the same as adding 4° additional adduction to Long's Line. For the female, the socket is mounted with the inner aspect of the medial wall in 40-45° internal rotation to the line of progression (again, the outer edge of the medial trimline is on the line of progression), and with the knee bolt axis 7° higher on the lateral side (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-09.jpg">Fig. 9</a>). Mr. Long emphasizes that it is not necessary to change the alignment. When the amputee is allowed time to adjust to the new prosthesis, then alignment changes will not be necessary. <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-09.jpg">Figure 9. NSNA socket shape and alignment diagram, male and female.</a> Following Gunther Gehl was Daniel Shamp, C.P.O., presenting, "The Shamp Brim, For the Narrow ML Above-Knee Prosthetic Socket." Mr. Shamp's system of brim casting and evaluation is currently the content of a special short course offered by New York University's Prosthetic and Orthotic Education Program. Long and Sabolich, as well as UCLA, advocate that the hand casting technique is the most successful in their experience with the narrow ML, wide AP, or ischial-containment socket for above-knee amputees. In response, Mr. Shamp stated, "Experience with the Shamp Brim system has proven to make the procedure more uniformly successful and more easily learned and applied by the practitioner who has spent years working with the brim method for quadrilateral socket casting and modification." Mr. Shamp went on to present detailed biomechanical rationale for the narrow ML socket. Biomechanical descriptions such as bony lock on the ischium, ischial containment within the socket, retention of normal adduction, etc., are consistently relevant to Mr. Shamp's socket system, as well as all of the latest ischial-containment socket designs. Two noticeably different aspects of Mr. Shamp's technique are (1) the brim forming system itself, which allows for evaluation of brim design under weight bearing conditions before proceeding with the wrap cast, and (2) what Mr. Shamp refers to as centralization of the femur. To accomplish centralization of the femur, during the casting procedure, the prosthetist pulls the distal medial tissue in a lateral direction while stabilizing the femur with the other hand by means of a 45° force against the lateral shaft of the femur (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-10.jpg">Fig. 10</a>). Mr. Shamp stated that this centralization procedure is essential to prevent a large medial-distal bulge with resultant cosmetic problems when the femur is maintained in a position of maximum adduction in the AK prosthesis. <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-10.jpg">Figure 10. Centralization of the femur, as proposed by Dan Shamp for Narrow ML Socket.</a> Again, I will present an overview of the Shamp Narrow ML technique, summarizing from Mr. Shamp's presentation and from the "Manual for use of The Shamp Brim," which was provided for the workshop attendees. This manual was produced by Prosthetic Consultants, Incorporated of Akron, Ohio in cooperation with the Department of Prosthetics and Orthotics, New York University Post-Graduate Medical School, and is published by the Ohio Willow Wood Company. The measurement and evaluation procedure includes a careful observation and recording of the characteristics, lengths, and circumferences requested on the Narrow ML AK Information Chart. Review of this information chart will show the practitioner who is familiar with the technique for the quadrilateral socket that only a small number of measurements are different for the Narrow ML socket. It is important to note that three ML measurements must be taken precisely as follows: <ol> <li> Distal Ischial Tuberosity (DIT): firm ML measurement of the anatomy taken 1" to 2" distal to the ischial tuberosity (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-11.jpg">Fig. 11</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-11.jpg">Figure 11. Distal Ischial Tuberosity (DIT), medial-lateral diameter measurement for Narrow ML Socket</a>.</li> <li> Oblique ML (OB): firm ML measurement taken from the medial side of the ramus of the tuberosity to a point just superior to the greater trochanter of the femur (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-12.jpg">Fig. 12</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-12.jpg">Figure 12. Oblique ML (OB), medial-lateral diameter measurement for Narrow ML Socket.</a></li> <li> Ischial Tuberosity ML (IT): firm ML measurement taken from the medial border of the ramus of the ischial tuberosity to the subtrochanteric area of the femur (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-13.jpg">Fig. 13</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-13.jpg">Figure 13. Ischial Tuberosity ML (IT), medial-lateral diameter measurement for Narrow ML Socket.</a></li> </ol> The Shamp Brim, which is compatible with the Berkley brim stand, is now set up and adjusted to the patient's measurements. As stated earlier, the brim allows for weight-bearing evaluation of the patient with regard to socket design before the actual wrap cast is taken. As with all of the ischial-containment socket designs discussed at the Workshop, the location of the ischial tuberosity in the socket is essential to both a comfortable fit and a stable femur in maximum adduction. For the Shamp technique, the ideal location is 1/2" inside the medial-proximal wall of the prosthesis and indicates the area referred to as the IT ML measurement. The medial wall has a 45° angle that assists the wedge effect in stabilizing the femur and so the location of the tuberosity on this slope is important. The trimlines are similar to both NSNA and the UCLA CAT-CAM, including the low anterior wall with clearance for the ASIS, the relatively horizontal posterior wall, and the high lateral wall, which extends generously above the trochanter. Although, not as exaggerated as the UCLA CAT-CAM, the medial wall is lowered as it approaches the anterior wall, allowing for the pubic ramus to pass from within the socket. Alignment follows generally accepted quadrilateral alignment principles for TKA and knee bolt external rotation. For alignment in the frontal plane (posterior view, ML plane), Mr. Shamp advocates the principles of Long's Line. Dr. Hans Lehneis, C.P.O., of the Rusk Institute of Rehabilitation Medicine was the next speaker and his presentation covered work done at the Rusk Institute and the New York Veterans Administration. Dr. Lehneis and associates are investigating anatomical, physiological, and biomechanical characteristics of geriatric above-knee amputees in an attempt to develop a set of design criteria for geriatric above-knee sockets. As this project is still in the developmental stages, I will not elaborate on this subject. Following Dr. Lehneis was OssÃ¼r Kris-tinsson of Iceland. As the developer of the flexible socket-rigid frame system, he was the first to speak on flexible sockets. Mr. Kris-tinsson reported that he was continuing development of flexible sockets, including walls and brims. He is conducting an extensive materials search in hopes of finding the materials that will make possible the ultimate flexible socket design. Mr. Kristinsson went on to say that we need some simple definition of flexible socket characteristics. "To label a socket as flexible, I would say that you should be able to deform it by your hands, and the material should not be elastic enough to stretch under the loads it will be subjected to." Concerning flexible socket design, Mr. Kristinsson stated, "When designing a flexible socket system, the most critical aspect for the comfort of the wearer is how the frame is designed. It has to be capable of supporting the flexible socket, preventing permanent deformation, and the socket-frame combination has to be structurally strong and stable enough to counteract the reaction forces." Mr. Kristinsson made a final, important point: "There may be doubt among professionals and users about the value of the flexible wall. I am, however, totally convinced that the flexible socket is here to stay. If anything, I think it will get more flexible as we gain access to more suitable materials than we are using today, and some obstacles on the way to proper understanding of the socket-stump interaction are overcome." Continuing the flexible socket presentations was Norman Berger of New York University's Prosthetic Orthotic Program. Mr. Berger's presentation was the ISNY (Icelandic-Swedish-New York) flexible socket design as taught by NYU. Mr. Berger described the socket and frame fabrication technique used in the ISNY. Three interesting points are worthy of mention: <ol> <li> The flexible socket is fabricated with polyethylene, which has a known shrinkage factor. </li> <li> The desired wall thickness of the flexible socket is 60/1000". </li> <li> Lateral distal support for the femur is not provided for by the frame. </li> </ol> The final presentor on the topic of flexible sockets was Charles Pritham, C.P.O. of Durr Fillauer Medical Company. A co-author and co-developer of Durr-Fillauer's flexible socket technique, Mr. Pritham described the biomechanical function of the flexible walled ischial-gluteal bearing quadrilateral socket as follows: <ol> <li> Ischial/gluteal weight bearing; </li> <li> Stabilization of the distal femur laterally; </li> <li> Total contact; and </li> <li> Flexible walls. </li> </ol> Note the mention of stabilization of the distal femur laterally; this is provided for by the frame design of the Scandinavian Flexible Socket. Mr. Pritham went on to say, "It will be appreciated that the design is actually not fundamentally different, flexible walls aside, from a similarly designed socket in the rigid walls. Indeed one of the factors that undoubtedly hastened its acceptance was the fact that previously learned methods of casting and fitting quadrilateral sockets were fully acceptable when fitting a flexible walled socket. While the advantages cited are formulated with the quadrilateral socket in mind, there is no reason to suspect that they are significantly different from non-quadrilateral above-knee sockets. Indeed, flexibility is often considered by the designers of one another of the various designs as an integral factor in their success." Mr. Pritham listed advantages of flexible walled sockets as: <ol> <li> Flexible walls; </li> <li> Improved proprioception; </li> <li> Conventional fitting techniques; </li> <li> Minor volume changes readily accommodated; </li> <li> Temperature reduction; and </li> <li> Enhanced suspension. </li> </ol> Indications for use of the flexible wall socket are: <ol> <li> Mature stumps (where frequent socket changes are not anticipated); </li> <li> Medium to long stump (where a significant portion of the wall will be left exposed and flexible); and </li> <li> Suspension is not a factor. </li> </ol> While the use of flexible wall sockets has been well accepted, Mr. Pritham pointed out that questions have arisen in at least three areas. Material Both Surlyn® and low density polyethylene (in a variety of types and name brands) have been used successfully and each has its advocates. Mr. Pritham and colleagues at Durr Fillauer prefer Surlyn® for three reasons: clarity, no shrinkage, and ease of rolling the edge. Thickness Originally socket walls of 30/1000" thickness were specified, however, this proved to lack durability. Subsequently, thickness in the neighborhood of 80-90/1000" were specified and are preferred. (Note: NYU prefers 60/1000".) Frame configuration At least three different configurations have been described for quadrilateral sockets. The differences center on the lateral wall and the amount of support considered necessary for the femur. A variety of designs have been put forth in order to achieve specific features in non-quadrilateral sockets, including the well known total flexible brim. Mr. Pritham concluded his presentation by saying, "the crucial point would seem to be that flexibility is independent of socket shape and can be modified to provide specific design features in a socket-frame system. The specific configuration depends upon the prosthetist's experience and fitting philosophy and the needs of the individual patient." Rounding out the first day of presentations was Dr. Robin Redhead, Senior Medical Officer at the Roehampton Limb Fitting Centre in London. Dr. Redhead's paper was entitled "Experience With Total Surface Bearing Sockets." This presentation centered more on weight-bearing distribution and biomechanics than on socket design or shapes. Dr. Redhead and associates maintain that regardless of socket shape or design, well distributed weight-bearing can eliminate the need for single point, bony weight bearing (such as ischial weight-bearing). This system of well distributed weight-bearing was referred to as a total-surface-bearing socket. It infers a hydrostatic type of socket fit utilizing the incom-pressibility of the fluids in an above-knee residual limb. This presentation brought a reaction from of Professor Radcliffe, who doesn't agree with the hydrostatic concept of weight-bearing in prosthetics. He stated that "you need a closed system for hydrostatics and the AK residual limb is not a closed fluid system. With an open fluid system, the fluids are pushed out." There was considerable discussion on this topic, both pro and con, and it was never resolved. Beginning the morning of the second day, John Sabolich, C.P.O., from Oklahoma City, and Glenn Hutnick, CP., from New York, presented another view of CAT-CAM. As stated earlier, Tim Staats, C.P.O. reported that the UCLA CAT-CAM is evolving independently of the CAT-CAM technique of the original developers. Sabolich and Hutnick report that the original CAT-CAM is continuing to evolve and develop. Sabolich stated that, "it took five to six years to develop the current medial wall design, which has become increasingly more aggressive in enclosing and capturing the ischial ramus." They advocate use of the total flexible brim. "The key is the flexible brim system—it is totally flexible in the proximal area, where most patients complain." Aside from 100% use of the total flexible brim, the Sabolich/Guth CAT-CAM differs from NSNA and the UCLA CAT-CAM by not advocating the 4° to 7° medial lean of the foot, pylon, and knee bolt in bench alignment as proposed by Long and UCLA. John Sabolich went on to say "this additional adduction or tilting of the knee bolt is a cover-up for lost stability due to inadequate ischial containment." Mr. Long's response was that this was incorrect. Probably the most noticeable aspect of design that separates the Sabolich/Guth CAT-CAM apart from the other recent ischial-containment designs is the earlier mentioned aggressive capture of the ischial tuberosity and ramus. Sabolich claimed that they are enclosing more and more of the ischial ramus, as much as possible and still allow pubic ramus comfort. This ramus enclosure provides two biomechanical functions: (1) a medial bony stop for ML stability, and (2) rotational control, especially on soft fleshy residual limbs. Other than these departures, the Sabolich/Guth CAT-CAM differs very little from the UCLA CAT-CAM, especially in terms of brim shape, trimlines, and biomechanics. Sabolich, unlike Long, does advocate the use of dynamic alignment devices. At this point in the Workshop, Professor Radcliffe returned to the podium in an attempt to present and clarify the comparative biomechanical principles of both quadrilateral and ischial-containment sockets. The following biomechanical analyses are taken from Professor Radcliffe's discussion and from the paper he later submitted reviewing his presentations. "It has been demonstrated that pressure against the medial aspect of the pubic ramus can be used to supplement the weight-bearing on the tuberosity of the ischium and contribute to medial stabilization in the upper one-third of the above-knee socket. In taking advantage of the weight-bearing potential on the medial aspect of the ramus, the prosthetist is creating a situation much like weight-bearing on the seat of a racing bicycle. To prevent the ramus from sliding laterally and downward into the socket, the prosthetist must exaggerate the counterpres-sure from the lateral side. This has been done by a reduction in the M-L dimension particularly in the area just distal to the head of the trochanter. The soft tissue must be accommodated. Therefore, the A-P dimension is correspondingly increased as compared to the quadrilateral socket. As compared to the quadrilateral fitting, the height of the anterior brim is typically lowered and flared and the gluteal area is filled in and fitted higher as a result of the ischium being encased deeper into the socket." "The medial brim of the socket must slope forward and downward to the point where the pubic ramus crosses the medial brim and emerges from the socket. The ischial ramus clearly is capable of providing medial counter-pressure which supplements the medial pressure on the adductor musculature. Since the socket slopes downward and inward along the entire medial brim, this contour is flared into the medial wall of the socket, which gives the impression of exaggeration of the medial coun-terpressure in the upper one-third of the socket." "The adduction of the socket and the use of lateral stabilization should not differ from that achieved by a properly fitted quadrilateral socket. There is an apparent exaggeration of the modification of the lateral wall, but this is primarily limited to the area just below the trochanter where the M-L dimension has been reduced to insure that the encased pubic ramus and ischium are maintained in the desired position on the medial brim. The exaggeration of the medial flare and reduction of the M-L dimension in the upper third of the socket leads to the impression of a greater angle of femur adduction, but the actual angle of the femur should be similar in both types of fittings if the quadrilateral socket is properly fitted and aligned." "Long's Line as proposed by Ivan Long is the anatomical axis of the lower extremity as described in anatomy textbooks. Placing the fe-mural stump in an advantageous position for normal use of the hip musculature by adduction and flexion of the socket has been a part of good prosthetic practice for at least 40 years in the United States and perhaps longer in certain European centers. Mr. Long's Line appears to be most useful in the cast taking procedure and subsequent modifications of the model rather than have any fundamental bearing on the alignment of the prosthesis. It appears to offer no new concepts useful in the bench or dynamic alignment of the prosthesis." Professor Radcliffe told the Workshop attendees that the use of "catchy names" should be avoided, and he therefore proposed the terminology of Ischial-Ramal weight-bearing socket, as well as Ischial-Gluteal weight-bearing socket. Professor Radcliffe continued his biomechanical analysis by saying "The biomechanics of the ischial-ramal weight-bearing socket are similar to the ischial-gluteal weight-bearing quadrilateral socket. The major differences are in the manner in which the ischium is maintained in position within or on the brim of the socket. In each case, there must be vertical support with a combination of lateral and anterior counterpressure to maintain the ischium in position" . . . "Some of the socket shape diagrams I have seen published are so crude and inaccurate as to be almost meaningless. The level of the cross section shown is often not indicated and a section at ischial level is sometimes compared to a section which is obviously higher or lower." Professor Radcliffe then sketched on the blackboard what he believed to be a more accurate comparison with emphasis on the three-dimensional shape both above and below the level of the tuberosity of the ischium. In each case, he showed a cross section of the socket at, (1) ischial level with the medial wall projected upward to this level; and (2) the outline of the highest points on the brim (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-14.jpg">Fig. 14</a> and <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-15.jpg">Fig. 15</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-14.jpg">Figure 14. Socket contours for an Ischial-Gluteal weight-bearing socket using the UC Berkeley Brims.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-15.jpg">Figure 15. Socket contours for an Ischial-Ramal weight-bearing socket of the NSNA type provided by Ivan Long.</a> This concluded all presentations of current fitting techniques. The remaining presentations were concerned with evaluation techniques. Bo Klasson of Een-Holmgren Company in Sweden presented on "Socket Fit With Reference to Soft Tissue Force Transmission." Briefly, Mr. Klasson's theory is that we should attempt to design sockets with physical characteristics that match the physical characteristics of the residual limb. In other words, where the tissues of the residual limb are firm, so should the matching area of the socket material be; where the tissues are soft and flexible, so should the socket be. Mr. Klasson refers to this as "surface matching." The next speaker was Professor George Murdoch of Dundee, Scotland, presenting "A Method for the Description of the Amputation Stump." Professor Murdoch's paper was based on his premise that there is a need for an international classification system for residual limbs to be developed in order to compare one publication with another, one patient with another, one fitting technique with another. The final presentation was made by A. Bennett Wilson on "Physiological Monitoring Equipment in Evaluation of Lower Limb Prosthetic Components and Techniques." He reported on a system of physiological monitoring originally developed by MacGregor of the University of Strathclyde in the 1970's. Recently modified for use by the University of Virginia Division of Prosthetics and Orthotics, this system consists of a compact tape recording component worn on a waist belt that records electronically, step count, walking velocity, standing versus sitting, and heart rate, plotted against time up to 24 hours. The tapes are then analyzed by a special micro-computer program, which subsequently prints the information in digital and graphic format. Under some circumstances the heart rate data can be useful in providing an energy index, but probably more importantly, the step count, standing versus sitting, and velocity data provide specific information about the activity of the subject. Mr. Wilson and colleagues have recently developed a solid state device which is less costly and more reliable. The new system has 17 information gathering channels. Mr. Wilson concluded by saying, "At this point, we do not have sufficient experience to know how many subjects have to be monitored and how much data is needed to show significant differences, but it certainly appears that at last we have a breakthrough in instrumentation for evaluation of prosthetic devices and other treatments involving the function of the musculoskeletal system. With all presentations complete, the plenary group was divided into six panels of six to nine members with the following charges: <ol> <li> Determine similarities </li> <li> Determine differences </li> <li> What is the role of flexible walls? </li> <li> Indications and contraindications </li> <li> Recommendations for future action <ol> <li> Evaluation </li> <li> Education </li> <li> Application </li> </ol> </li> </ol> This first group of panels reported back on Sunday morning. The reports were quite consistent among the different panels. A synopsis of these reports will be presented in concluding this report. On Monday, new panels were formed to re-study the rationale for and possibly develop protocol for evaluation. The reports from this second group of panels was heard in plenary session on Tuesday morning. The meeting was adjourned Tuesday, May 19, 1987 at noon. What follows here is a synopsis of the conclusions and recommendations of the panel reports. <ol> <li> Similarities & Differences <ol> <li> Biomechanics <ol> <li> Ischial Containment: <ol> <li> similarities: <ul> <li> all ischial containment sockets advocate and utilize varying degrees of ischial containment </li> </ul> </li> <li> differences: <ul> <li> quads do not utilize ischial containment </li> <li> ischial containment sockets, amount of ischial containment </li> </ul> </li> </ol> </li> <li> Weight Bearing Distribution: <ol> <li> similarities: <ul> <li> ischial containment sockets, combination of ischial tuberosity and ramus, and peripheral (soft tissue) </li> </ul> </li> <li> differences: <ul> <li> quads, ischial-gluteal weight bearing </li> </ul> </li> </ol> </li> <li> ML Stability—maintenance of adduction <ol> <li> similarities: <ul> <li> goal of all AK socket systems </li> <li> greater success and maintenance in ischial containment sockets due to ischium acting as bony stop or lock </li> </ul> </li> <li> differences: <ul> <li> quad, soft tissue lock only, no bony lock </li> <li> less successful maintenance of adduction, thus less ML stability </li> </ul> </li> </ol> </li> <li> Socket Shape—ischial level cross section <ol> <li> similarities: <ul> <li> ischial containment sockets, narrow ML, wider AP, concave post-trochanteric shape </li> </ul> </li> <li> differences <ul> <li> quad, wider ML, narrower AP </li> </ul> </li> </ol> </li> <li> Trimlines: <ol> <li> similarities: <ul> <li> ischial containment sockets, generally; especially anterior, posterior, and lateral wall trimlines </li> </ul> </li> <li> differences: <ul> <li> quads, especially higher anterior, lower posterior and lateral wall trimlines </li> <li> medial wall of CAT-CAM </li> </ul> </li> </ol> </li> <li> Suspension: <ol> <li> similarities: <ul> <li> all compatible with suction </li> </ul> </li> <li> differences: <ul> <li> ischial containment sockets, unclear about auxiliary suspension </li> </ul> </li> </ol> </li> <li> Alignment: <ol> <li> similarities: <ul> <li> all but NSNA utilize alignment devices </li> <li> ischial containment sockets, medial wall not on line of progression </li> <li> NSNA & UCLA CAT-CAM, tilting of knee bolt in bench alignment </li> <li> Shamp Narrow ML & NSNA, use of Long's Line </li> <li> ischial containment sockets,TKA bench alignment, socket midline </li> </ul> </li> <li> differences: <ul> <li> NSNA does not use dynamic alignment device </li> <li> quad medial wall on LOP </li> <li> not all tilt knee bolt </li> <li> NSNA, varying degrees of knee bolt tilt, 7°, female, 4°, male </li> <li> quad, bench alignment, more stable TKA, T reference point is located at posterior l? of socket </li> </ul> </li> </ol> </li> <li> Rotational Control: <ol> <li> similarities: <ul> <li> ischial containment sockets, bony lock of Ischium and post-trochanteric concavity </li> </ul> </li> <li> differences: <ul> <li> quad, muscular-soft tissue cross-section </li> </ul> </li> </ol> </li> </ol> </li> <li> Method of Obtaining Cast <ol> <li> similarities: <ul> <li> quad and Shamp Narrow ML utilize a casting brim </li> <li> UCLA CAT-CAM & Sabolich/Guth CAT-CAM, hand molding technique </li> <li> NSNA & UCLA CAT-CAM, standing </li> </ul> </li> <li> differences: <ul> <li> CAT-CAM & NSNA, hand molding technique </li> <li> Sabolich/Guth CAT-CAM, sometimes cast lying down </li> </ul> </li> </ol> </li> <li> Anatomical Considerations <ol> <li> UCLA CAT-CAM detail about pelvic differences: <ul> <li> ischial inclination </li> <li> pubic arch angle </li> <li> ilio-femoral angle </li> </ul> </li> <li> NSNA male, female alignment differences: <ul> <li> bolt tilt </li> </ul> </li> </ol> </li> </ol> </li> <li> Role of Flexible Walls <ul> <li> not linked to any one philosophy of designing an AK socket </li> <li> vital to the success of the Sabolich/Guth CAT-CAM </li> <li> improved sitting comfort </li> <li> improved proprioception </li> <li> better heat dissipation </li> <li> improved muscle activity </li> <li> reduced weight </li> <li> ease of socket change within frame, no loss of alignment </li> <li> enhanced suspension, if suction suspension </li> </ul> All participants agreed there is great need for improved flexible materials. </li> <li> Indications and Contraindications <ul> <li> there were no specific contraindications noted for any socket design </li> <li> some advocated not changing successful quad wearers </li> <li> quads are most successful on long, firm residual limbs with firm adductor musculature </li> <li> ischial containment sockets are more successful than quads on short, fleshy residual limbs </li> <li> ischial containment sockets are the better recommendation for high activity/sports participation/running </li> <li> lack of agreement on best recommendation for bilateral above-knee </li> </ul> </li> <li> Recommendations The panels' conclusions and recommendations were remarkably consistent. Most consistent was the recommendation for improved terminology, lumping what I have referred to as ischial containment into a single, workable term. Suggestions ranged from "Narrow ML" to Ischial/ Ramus Containment (IRC) and Non-Ischial Containment (Non-IRC). Due to time constraints, arguments about this recommendation were never resolved. It is hoped that all recommendations can be addressed in a future workshop or through some other form of action. <ol> <li> Evaluation There was unanimous agreement for formal evaluation of the newer above-knee techniques (NSNA, CAT-CAM, Shamp Narrow ML) as well as evaluation of implications of the inferiority of the quadrilateral technique. <ol> <li> A program for scientific/laboratory evaluation should be set up at a center or multiple centers, depending upon resources. This study might include: cinematography, force plate, motion analysis, gait mat and other "gait lab" studies as well as radiographical data on alignment and containment, physiological data, residual limb/socket force analysis, and/or any other relevant laboratory studies. </li> <li> A program of clinical evaluation, based on previous fittings and continuing fittings in clinics already utilizing new fitting techniques. This would be a more subjective study, and would require a greater effort for coordination and pooling of data. </li> <li> Complete manuals should be developed for each individual technique, unless the developers can find it mutually agreeable to work together and blend the new techniques. The panels found the latter option to be most desirable. </li> <li> Evaluation should be independent of the developers. </li> <li> Any evaluation needs to be coordinated by an authoritative group. ISPO and/or the U.S. Veterans Administration were recommended. The American Academy of Ortho-tists and Prosthetists should also be involved. </li> <li> Possible funding sources within the states include the Veterans Administration and the National Institute on Disability and Rehabilitation Research (NIDRR). </li> </ol> </li> <li> Education The post-graduate, specialized courses for experienced practitioners appear to be most appropriate for teaching these newer techniques at this time. Incorporation into entry level education programs should follow as well written, experience based manuals are developed. Any teaching course should include "hands-on", patient contact, fitting, and management as part of the curriculum. </li> <li> Application The application of these new techniques, while certainly not as widespread and accepted as the quadrilateral technique, or even the flexible socket technique, is occurring at this time. Growing acceptance and application will most certainly follow. It is hoped that this workshop, as well as future workshops, will aid in safe and proper application of these and future advances and developments in prosthetics. </li> </ol> </li> </ol> References: <ol> <li>UCLA AK Teaching Manual, 1977-1978.</li> <li>UCLA CAT-CAM Above Knee Prosthesis, Teaching Manual, Third Edition, March 1987.</li> <li>Fabricating The Long's Line Above-Knee Prosthesis, by Ivan long, 1981.</li> <li>Ivan Long's business card.</li> <li>Manual for use of THE SHAMP BRIM for the Narrow ML Above-Knee Prosthetic Socket, The Ohio Willowwood Co., 1987.</li> <li>By Charles Radcliffe. Re-drawn by A. Bennett Wilson, Jr.</li> </ol> *C. Michael Schuch, C.P.O. C. Michael Schuch, C.P.O., is Assistant Professor of Orthopaedics and Rehabilitation and Associate Director of the Department of Prosthetics and Orthotics at the University of Virginia Medical Center, Box 467, Charlottesville, Virginia 22908. Page Number(s) 81 - 98 Year 1988 Volume 12 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Report From: International Workshop on Above-Knee Fitting and Alignment Techniques Creator An entity primarily responsible for making the resource C. Michael Schuch, C.P.O. * https://staging.drfop.org/files/original/c9f248aba5f777b90137fc5f653684ca.pdf f8b086eeef728c09345c4e2f59e8dd7e https://staging.drfop.org/files/original/c065f49a310f10a589f0a327d3e553c5.jpg 186d2ba85e30b71c039fa0154657cdce https://staging.drfop.org/files/original/bff051b61f6196998c950cf38167980c.jpg f771a9bfcf3050739cc85923b4f49d6f https://staging.drfop.org/files/original/d9d6a4e0ab4404f5bbe8bc6f1cc09fd1.jpg 1f970c7584285f498d6bf17c65c6f630 https://staging.drfop.org/files/original/febaffd06b576a9e62a93e9a0b40cd51.jpg 6acd7a71a2979ec382b0556569e30af1 https://staging.drfop.org/files/original/2bfcdb6e9deb8c4cf2472673f5174ef5.jpg 89553677fd4b9ef73da3014c83f7f72e https://staging.drfop.org/files/original/3e612a67d3f33d4c3dda57bb05207afc.jpg 23c4714870273c39c3ba99be300cd7c5 https://staging.drfop.org/files/original/8e70952489609f15226daf7eab16de3f.jpg 14e82719d1cbe0351948564744c75375 https://staging.drfop.org/files/original/1376f07c00973223d41d772b54427ee4.jpg 01ff296c026fd5f2d7c9b038490105b2 https://staging.drfop.org/files/original/0613d64bd48e27b9c797a6d197e3e2fc.jpg 106950e908dfdc134018cf1c8ecc0bf6 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/1988_02_074.pdf Text Any textual data included in the document <h2>Orthopedic Walkers: Effect on Plantar Pressures</h2> <h5>James A. Birke, P.T., M.S. <a style="text-decoration: none;">*</a> Deborah A. Nawoczenski, P.T., M.Ed. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> Short leg (SLW) and patellar tendon bearing walkers (PTBW) are orthotic appliances<a style="text-decoration: none;">*</a> which have been recently designed as alternative devices to traditional plaster cast immobilization. The indications for use of lower leg walkers include severe ankle sprains, and ankle and foot fractures. Orthopedic walkers are convenient to use, lightweight, and removable to perform joint range of motion or inspect the extremity. Short leg walkers have been shown to be as effective as walking casts in healing stable ankle fractures, and patients treated with short leg walkers have shown significantly less edema, tenderness, and joint stiffness after six weeks of immobilization.<a></a> The authors feel that orthopedic walkers may also prove to be a beneficial alternative to traditional management of neuropathic fractures and plantar ulcerations, which are commonly seen in diabetes mellitus and Hansen's disease. Neuropathic foot lesions are the result of abnormal or repetitive stress.<a></a> Treatment techniques for neuropathic foot conditions should be effective in reducing pressure and shear stress. Traditional methods of treating neuropathic foot lesions include walking casts, fixed ankle braces, and PTB braces.<a></a> Plaster walking casts and PTB braces have been shown to significantly reduce pressure on the plantar surface of the foot during walking.<a></a> The total contact walking cast is considered effective in reducing pressure on the foot by redistributing forces on the plantar surface of the foot and lower leg. Several features of PTB orthoses shown to be important in achieving maximal weight bearing reduction on the foot include a rigid closure PTB shell, a heel-shoe clearance of 3/8" to 1", a fixed ankle joint, and a rocker sole.<a></a> Orthopedic walkers incorporate these same design features to varying degrees which has generated our interest in studying their effectiveness in reducing pressure on the foot. The SLW has a fixed ankle joint, rocker sole, and a polyurethane liner which is snugly secured to the leg with Velcro® closures (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-1.jpg">Fig. 1</a>). The PTBW incorporates all the features of the SLW, as well as a non-custom molded, semi-rigid polyethylene PTB shell (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-2.jpg">Fig. 2</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-1.jpg">Figure 1. Short Leg Walker.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-2.jpg">Figure 2. Patellar Tendon Bearing Walker.</a> The effectiveness of the SLW or PTBW in reducing pressure or shear stress on the foot has not previously been studied. The potential value of these devices in managing the neuropathic foot may be evaluated by their effectiveness in reducing pressure and shear stress. Currently, there are unreliable methods for measuring shear stress. However, shear is directly related to the perpendicular forces acting on the foot. Pressure equals the perpendicular forces per unit area. Pressure transducers provide a repeatable measurement of relative pressure inside footwear when the material interfacing with the transducers is controlled.<a></a> <h3>Purpose</h3> The purpose of this study was to determine the effectiveness of SLW and PTBW in reducing the pressure distribution on the normal foot during walking. <h3>Method</h3> Ten subjects (6 male and 4 female) without a history of foot pathology participated in this study. Capacitive pressure transducers<a style="text-decoration: none;">*</a> 2mm thick and 1.5cm in diameter were taped to the first metatarsal head (MTH), third MTH, fifth MTH, and plantar heel of the right foot of each subject (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-3.jpg">Fig. 3</a>). The foot was covered with a thin cotton stockinette which remained undisturbed during the study. Transducers were calibrated according to the manufacturer's instructions prior to testing each subject. Pressure recordings were made using a four-channel capacitive impedance bridge amplifier<a style="text-decoration: none;">*</a> and oscillographic recorder<a style="text-decoration: none;">*</a> while subjects walked in a cast shoe (CS-1) (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-4.jpg">Fig. 4</a>), short leg walker (SLW), patella tendon bearing walker (PTBW), and again in a cast shoe (CS-2). All the walking devices were fabricated by the same manufacturer.<a style="text-decoration: none;">*</a> The cast shoe was identical to the foot component of both the SLW and PTBW, utilizing identical rocker out-ersoles and 2.4mm polyurethane material insoles. SLW and PTBW were applied to the leg with a 3/8" heel-shoe clearance. Subjects walked a distance of 100 meters for each treatment condition. The testing order of treatments SLW, PTBW, and CS-2 was randomly assigned to eliminate systematic error. <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-3.jpg">Figure 3. Pressure transducer placement on selected areas of the foot.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-4.jpg">Figure 4. Cast Shoe.</a> Relative pressure was measured in millimeters of peak to peak chart deflection for 24 steps for each treatment condition. The middle distance of each run was used for analysis in order to eliminate pressure variations due to the acceleration and deceleration phases of each trial. Percent pressure change relative to CS-1 was calculated for treatments SLW, PTBW, and CS-2. Means and standard deviations were computed for treatments at each transducer site. An analysis of variance for repeated measures was used to determine whether treatment differences were significant within each site. Duncan's test was used for post-hoc analysis of means. A significance level of 0.05 was used for comparisons. <h3>Results and Discussion</h3> An analysis of variance (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-5.jpg">Table I</a>) for mean percent reduction in pressure was highly significant at all sites tested (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-6.jpg">Fig. 5</a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-7.jpg">Fig. 6</a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-8.jpg">Fig. 7</a>, and <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-9.jpg">Fig. 8</a>). Duncan's test was performed to establish which treatments differed. Significant differences were found between the percent reduction in pressure walking in SLW and PTBW as compared to the CS-2 at all sites. No difference was found between SLW and PTBW at any site. The percent pressure reduction using the walker devices was comparable at all the sites tested. <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-5.jpg">Table I. Analysis of Variance of Percent Pressure Reduction.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-6.jpg">Figure 5. Percent pressure reduction at the first metatarsal head (1 MTH) walking in cast shoe-2 (CS-2), short leg walker (SLW) and patellar tendon bearing walker (PTBW) compared to walking in cast shoe-1.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-7.jpg">Figure 6. Percent pressure reduction at the third metatarsal head (3 MTH) walking in cast shoe-2 (CS-2), short leg walker (SLW) and patellar tendon bearing walker (PTBW) compared to walking to in cast shoe-1.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-8.jpg">Figure 7. Percent pressure reduction at the fifth metatarsal head (5 MTH) walking in cast shoe-2 (CS-2), short leg walker (SLW) and patellar tendon bearing walker (PTBW) compared to walking in cast shoe-1.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-9.jpg">Figure 8. Percent pressure reduction at the heel walking in cast shoe-2 (CS-2), short leg walker (SLW) and patellar tendon bearing walker (PTBW) compared to walking in cast shoe-1.</a> This study demonstrated the effectiveness of the short leg and patellar tendon bearing walkers as compared to the cast shoe in reducing plantar pressure on the foot. Since all the devices in this study had the same sole design and insole materials, treatment differences must be attributable to proximal orthotic components including the polyurethane liner, fixed ankle uprights, and Velcro® closures. The SLW and PTBW differed only by the polyethylene, non-custom molded patellar tendon cuff. Since no treatment difference was seen between these devices, the PTBW cuff design must not have been effective. However, in follow-up, single subject trials, we were not able to change walking pressures by redesigning the PTBW cuff using polyethylene or plaster custom molded PTB cuffs. An alternative conclusion is that the SLW design alone optimally reduced plantar pressure by the fixed ankle joint and uprights snugly supporting the lower leg and calf. In this study, orthopedic walkers were equally effective in reducing pressure at all sites tested on the foot. In previous studies, casts were shown to reduce pressure more effectively in the forefoot than the heel, and PTB orthotics reduced pressure more effectively in the heel than the forefoot.<a></a> Based on the results of this study, othopedic walkers may be effective devices in the reduction of plantar foot pressure in patients with neuropathic conditions of the foot. There is no evidence to show that the PTBW will be more effective than the SLW. Further study utilizing a patient population is recommended. <h3>Conclusions</h3> Within the scope of this study, it is possible to conclude the following: (1) SLW and PTBW orthopaedic walkers are effective in reducing pressure at the first MTH, third MTH, fifth MTH and heel in normal subjects during walking, and (2) there is no difference in pressure distribution between the SLW and PTBW during walking. References: <ol> <li>Anderson, J.G., "Treatment and Prevention of Plantar Ulcers," Leprosy Review, 35, 1964, pp. 251-258.</li> <li>Birke, J.A. and D.S. Sims, "Walking Casts: Effect on Plantar Foot Pressures," Journal of Rehabilitation Research and Developement, 22:3, July, 1985, pp. 18-22.</li> <li>Brand, P.W., "The Insensitive Foot," Editor M.H. Jahss, Disorders of the Foot, Vol. II, W.B. Saunders, 1982, p. 1266.</li> <li>Cterctecko, G.C., M. Dhanendran, W.S. Hutton, and L.P. LeQuesne, "Vertical Forces Acting on the Foot of Diabetic Patients with Neuropathic Ulceration," British Journal of Surgery, 68, 1981, pp. 609-614.</li> <li>Coleman, W.S., P.W. Brand, and J.A. Birke, "The Total Contact Cast: A Therapy for Plantar Ulceration of the Insensitive Foot," Journal of the American Pediatric Medical Association, 74:11, November, 1984, pp. 548-552.</li> <li>Enna, CD., P.W. Brand, J.K. Reed, and D. Welch, "The Orthotic Care of the Denervated Foot in Hansen's Disease," Orthotics and Prosthetics, 30:1, March, 1976, pp. 33-39.</li> <li>Gristina, A.G., A.L.W. Thompson, N. Kester, W. Walsh, and J.A. Gristina, "Treatment of Neuropathic Conditions of the Foot and Ankle with a Patellar-Tendon-Bearing Brace," Archives of Physical Medicine and Rehabilitation, 54, December, 1973, pp. 562-564.</li> <li>Hall, O.C. and P.W. Brand, "The Etiology of the Neuropathic Plantar Ulcer," Journal of the American Pediatric Medical Association, 69:3, March, 1979, pp. 173-177.</li> <li>Helm, P.A., S.C. Walker, and G. Pullium, "Total Contact Casting in Diabetic Patients with Neuropathic Foot Ulcerations," Archives of Physical Medicine and Rehabilitation, 65, 1984, pp. 691-693.</li> <li>Lang-Stevenson, A.I., W. Sharrard, R.P. Betts, and T. Duckworth, "Neuropathic Ulcers of the Foot," Journal of Bone and Joint Surgery, (British) 67B, 1985, pp. 438-442.</li> <li>Lehmann, J.F., CG. Warren, D.R. Pemberton, B.C. Simons, and B.J. DeLateur, "Load-bearing Function of Patellar Tendon Bearing Braces of Various Designs," Archives of Physical and Medical Rehabilitation, 52, August, 1971, pp. 366-370.</li> <li>Patterson, R.P., and S.V. Fisher, "The Accuracy of Electrical Transducers for the Measurement of Pressure Applied to the Skin," IEEE Transactions on Biomedical Engineering, 26:8, August, 1979, pp. 450-456.</li> <li>Polakoff, D.R., S.M. Pearce, D.P. Grogan, and W.Z. Burkhead, "The Orthotic Treatment of Stable Ankle Fractures," Orthopedics, 7, 1984, pp. 1712-1715.</li> <li>Pollard, J.P., and L.P. LeQuesne, "Method of Healing Diabetic Forefoot Ulcers," British Medical Journal, 286, February, 1983, pp. 436-437.</li> <li>Pollard, J.P., L.P. LeQuesne, and J.W. Tappin, "Forces Under the Foot," Journal of Biomedical Engineering, 5, 1983, pp. 37-40.</li> <li>Sabato, S., Z. Yosipovitch, A. Simkin, and J. Sheskin, "Plantar Trophic Ulcers in Patients with Leprosy," International Orthopedics, 6, 1982, pp. 203-208.</li> <li>Soderberg, G., "Follow-up of Application of Plaster-of-Paris Casts for Noninfected Plantar Ulcers in Field Conditions," Leprosy Review, 41, 1970, pp. 184-190.</li> </ol> Footnote 3D Orthopedics, Inc., 10520 Olympic Drive, Dallas, Texas 75220. Footnote Gulton TR-400a, Gulton Industries, Inc., East Greenwich, Rhode Island. Footnote Hercules Orthoflex Data System, Allegany Ballistics Lab, Cumberland, Maryland. Footnote Hercules Orthoflex Data System, Allegany Ballistics Lab, Cumberland, Maryland. *Deborah A. Nawoczenski, P.T., M.Ed. Deborah A. Nawoczenski, P.T., M.Ed., is Assistant Professor at the Department of Physical Therapy for the College of Allied Health Professions at Temple University, Philadelphia, Pennsylvania 19140. *James A. Birke, P.T., M.S. James A. Birke, P.T., M.S., is Chief of the Physical Therapy Department at G.W. Long Hansen's Disease Center, Carville, Louisiana 70721. Page Number(s) 74 - 80 Year 1988 Volume 12 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-4.jpg Figure 5 TABLE I http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 FIGURE 5 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-6.jpg Figure 7 FIGURE 6 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-7.jpg Figure 8 FIGURE 7 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-8.jpg Figure 9 FIGURE 8 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-9.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 Orthopedic Walkers: Effect on Plantar Pressures Creator An entity primarily responsible for making the resource James A. Birke, P.T., M.S. * Deborah A. Nawoczenski, P.T., M.Ed. * https://staging.drfop.org/files/original/0833619f5e725925cd800c92714e217a.pdf f8cc7a22aa74728474f8dd18a422e13a https://staging.drfop.org/files/original/93b6e8e78d28f3a4b19219d5d0780629.jpg 04cc15ee28e53828d5d326dd88090b20 https://staging.drfop.org/files/original/345e28e78e61de9956f328db53407a53.jpg cc7d3094bd8e533f530e57c763d89156 https://staging.drfop.org/files/original/912b1afa69cacdf58a67897a83dcb315.jpg 7d3276d165a85f49bcaa170b6d63d8c2 https://staging.drfop.org/files/original/a336421d18e76b67aa3f15362a01a722.jpg 5424cf6316a027878c7cc16d28562dcd https://staging.drfop.org/files/original/ed019ac44a487f5a4d063bc3257f6613.jpg e0c695cdd2bdf121fba9bca5e8ec4b72 https://staging.drfop.org/files/original/6f79e7026b83de4890fedbf81936bf61.jpg 8829aadb1e7bf6c1a2f5b7ef81380d25 https://staging.drfop.org/files/original/f12ba0f6a5db975123a05a0ecc61bf8c.jpg d49c7e19a6ae87c07570043983a8154b https://staging.drfop.org/files/original/8111a6f2f5c9866102adc00d9369ba3a.jpg b550bebd56a8d3d8b5c4622eb2bfb636 https://staging.drfop.org/files/original/6f66c873f335c178a868bb081b408a99.jpg fee6486ffc1b68ab2e75eb9e394bfca2 https://staging.drfop.org/files/original/1e33291187b5f81e97bd34ef54e5ea18.jpg 0b0317c0877ceedfc4841a2f6b45464d https://staging.drfop.org/files/original/6d31a1a5146ef36443a7083f8fe0dce2.jpg 0e19dfad8f02ba4aba2378536fcc1854 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/1988_02_067.pdf Text Any textual data included in the document <h2>Soft Molded Sandals for Insensitive Foot Care</h2> <h5>William C. Coleman, D.P.M. <a style="text-decoration: none;">*</a> Arthur Plaia, M.A. <a style="text-decoration: none;">*</a></h5> In the United States, the most common cause of sensory loss on the foot is diabetes. Fifty to seventy percent of all non-traumatic amputations in this country are performed on diabetics.<a></a> In Atlanta, Georgia, the amputation rate was lower by half after a program of foot inspection, footcare, and shoe-fitting was instituted. A person with loss of sense of touch and pain in the feet should never walk barefoot. A single step on a sharp object or hot surface with bare feet often results in permanent loss of foot function or eventual amputation of the foot. A comprehensive program of medically-prescribed, therapeutic footware should address the patient's need for appropriate shoes at all times. Once the need for prescribed footwear has been identified, there is a period between the time the prescription is written and time when the definitive shoes are dispensed to the patient. During that period, the feet still need protection. A form of protective, temporary footwear, needs to be worn by the patient until those shoes are ready. There are a wide variety of devices used for this purpose around the country. The form of these devices is largely dependent on the available facilities and footwear expertise. A person with a plantar ulcer on an insensitive foot should never walk in shoes or sandals. The most important therapeutic consideration for a person with no sense of pain is to control the mechanical stresses during the healing of these wounds.<a></a> Shoes and sandals do not provide enough control over these forces. After a wound has been covered completely by skin, the healing and repair of the injury is not complete. A person with sensory loss needs very careful monitoring during this period immediately after closure, because they are at very high risk of reulcerating the area.<a></a> Temporary footwear, which provides a high level of protection, should be worn during this time. Usually, unmodified Plastazote®<a style="text-decoration: none;">*</a> shoes or postoperative wooden soled shoes are used as the temporary protection. Once they have served this temporary function, the shoes are discarded and only the definitive shoes are worn from then on. There are many other times, however, when protection of the insensitive foot is needed and custom molded footwear would be the best form of protection. Other times when protective footwear is needed are listed here. <ol> <li> Many people do not want to wear their street shoes around the house until bedtime. Since a person with insensitive feet should never walk barefoot, protective footwear, for use in the house, should be worn. Most commercial house slippers have thin soles which are not intended for walking on rough surfaces and do not provide any significant protection from sharp objects on the floor. </li> <li> Plantar foot deformity is often present when prescribed footwear is a necessity. With bony prominences or loss of plantar fat-pads, a person should never walk or stand barefoot on hard surfaces. This is a problem, particularly when this person showers and they stand on porcelain, concrete, or tile. </li> <li> A person who needs prescribed footwear should always have at least two pairs. Most people, who need them, do not. This is important during periods of time when these shoes are being repaired or the prescription is changed. </li> </ol> Plastazote® was first used for orthopedic purposes by William Tuck, in England, in 1967.<a></a> He notified Dr. Paul Brand in Carville, Louisiana and the first Plastazote® sandals were constructed soon after. Plastazote® provided a material which was easily molded directly on the foot so protective, interim footware could be quickly constructed. Prior to the introduction of Plastazote®, sandals at Carville were constructed of 5/8" thick microcellular rubber. Microcellular rubber is not a moldable material and foot conformity had to be accommodated by constructing microcellular pads and wedges.<a></a> This was imprecise and time consuming. Over the years, several people have contributed modifications to the design and construction techniques of the "Carville" sandal.<a></a> It has become an integral part of the total foot program. <h3>Materials and Equipment Used to Construct the Sandal</h3> The following is a list of the materials used to build the sandal. Materials for the Plastazote® Foot Bed <ul> <li> 2 pieces of 1/2" x 6" X 12" Plastazote® #1 (medium)<a style="text-decoration: none;">*</a> </li> <li> 2 pieces of 1/2" x 6" x 12" Plastazote® #2 (firm)<a style="text-decoration: none;">*</a> </li> <li> 2 pieces of 1/4" x 5" x 12" Plastazote® #3 (rigid)<a style="text-decoration: none;">*</a> </li> <li> 2 pieces of Plastazote® #2, 5" x 10" X 1/2" thick to provide heel lift </li> <li> 2 pieces of 1/4" x 3" x 33" Plastazote® #3 for wrapping the sides of the sandals </li> </ul> Additional Materials <ul> <li> Neoprene crepe soling (12 iron = 1/4") (24 iron = 1/2") (1" x 9") Spring steel cut to the full length of the sandal's length. </li> </ul> Webbing for Straps <ul> <li> 2 pieces of cotton webbing 1" x 9" </li> <li> 2 pieces of cotton webbing 1" X 8 1/2" </li> <li> 2 pieces of cotton webbing 1 1/2" x 9" </li> <li> 2 pieces of cotton webbing 1 1/2" x 8 1/2" </li> <li> 2 pieces of cotton webbing 1" x 12" </li> </ul> Velcro® to be sewn to webbing <ul> <li> 2 pieces of 1" x 2 1/2" Velcro® hook </li> <li> 2 pieces of 1 1/2" x 2 1/2" Velcro® hook </li> <li> 2 pieces of 1" x 2 1/2" Velcro® pile </li> <li> 2 pieces of 1 1/2" x 2 1/2" Velcro® pile </li> </ul> Glue <ul> <li> Contact Cement or other adhesive </li> </ul> <h3>Tools</h3> <ul> <li> Skiving knife </li> <li> Ruler </li> <li> Scissors </li> <li> Polyfoam block (size 8" high x 12" wide x 18" long) cut at approximately 45° from the top to the base at the front of the block. </li> </ul> <h3>Equipment</h3> <ul> <li> Sewing machine or Patcher machine </li> <li> Finishing sander or grinding wheel </li> <li> Oven </li> </ul> <h3>Pieces of the Sandal Prepared in Advance</h3> Most of the materials used in the construction of a sandal are pre-cut and pre-sewn in the shop to speed the construction process. All pieces of Plastazote® are cut from large sheets into the rectangular sizes listed above. The cotton webbing and Velcro® are purchased on large rolls and cut to the sizes above in advance. A 1 1/2" x 2 1/2" patch of hook Velcro® is sewn to one end of a 1 1/2" x 9" piece of webbing. Approximately 1/2" of cotton webbing is left exposed on the very end so the end can be grasped by the patient to release the strap. A 1 1/2" x 2 1/2" piece of pile Velcro® is sewn to the end of a 1 1/2" x 8 1/2" piece of webbing. This procedure is repeated on the 1" x 8 1/2" and 1" x 9" pieces of cotton webbing. The oven should be preheated to a temperature of 140° Celsius (285° Fahrenheit). This is the temperature at which all polyethylene materials should be heated. Plastazote® is a closed-cell polyethylene foam material. If polyethylene foam materials are overheated, the cell structure is weakened and the material shrinks in all directions. To determine the amount of time a polyethylene foam should be heated, measure the thickness of the material in millimeters and multiply the thickness by twelve (10 mm x 12 = 120 seconds). The answer will be the time of heating in seconds. To mold the Plastazote® directly on the foot, the heated Plastazote® is placed between the foot and a thick foam rubber block. The foot is pressed into the foam and Plastazote®. The foam presses the polyethylene foam up around the sides of the foot and into every plantar hollow and the material cools and remains in this shape. The top/front of the foam a block is cut at a 45° angle to prevent obtaining a deep mold of the toes (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-01.jpg">Fig. 1)</a>. A deep mold would create a ridge distal to the ends of the toes. During gait, the medial foot enlongates with pronation. This elongation could result in distal toe damage on an insensitive foot if this ridge were present. <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-01.jpg">Figure 1. The open-celled foam block used to mold the Plastazote® footbed is cut on the top/ front to prevent deep-molding the toes into the Plastazote®.</a> <h3>Construction of the Sandal</h3> Patients are seated in an adjustable chair to insure the knee and ankle can be maintained at right angles as the Plastazote® is molded to their foot. Patients with insensitive feet are asked to wear socks for heat insulation from the warm polyethylene foam. To begin the sandal, a piece of 6" x 12" x 1/2" thick, medium, Plastazote® #1 is heated according to the above formula. After the Plastazote® has been heated, it is placed on the foam block with the toe region hanging over the 45° cut of the foam block. The foot is aligned over the Plastazote® with the metatarsal heads positioned over the top edge of the cutoff section of the foam block. The patient's foot is then pressed into the Plastazote®. After the Plastazote® foot bed has cooled, but before the patient is asked to lift their foot, an outline is drawn to mark a reference for what will become the outer sides of the sandal (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-02.jpg">Fig. 2</a>). Hold the pen marking this line in a vertical position. Purposely draw the toe area distal to the foot further distal to the toes than needed. Mark the toe of the sandal about 1" distal than the toes of the foot. Material used to wrap the sides of the sandal will pull the distal end of the sandal back. <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-02.jpg">Figure 2. As the first Plastazote® layer is cooling, a line is drawn to mark the outer edge of the sandal.</a> Cut the molded piece of Plastazote® around the outside of the molded portion to remove excess material. Make this cut approximately 1/2" outside the drawn line. This will allow for better control of shaping the sandal during a later grinding process. Apply adhesive to the bottom (convex side) of the molded material and to one side of a 6" x 12" x 1/2" firm, #2 Plastazote® piece. Then heat the #2 Plastazote®. Set the heated #2 piece on the foam block and the molded #1 Plastazote® piece on top of it (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-03.jpg">Fig. 3</a>). Place the foot back into the molded #1 piece and then press down to mold the #2 Plastazote® piece to the bottom of the #1 piece. Plastazote® #1 and #2 are autoadhesive, but this characteristic of the material has not proven to form a dependable bond in these sandals. <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-03.jpg">Figure 3. The molded #1 Plastazote® is set on the glued surface of the heated #2 prior to molding the two together.</a> Then cut the #2 piece to the edge of the # 1 piece and ground both pieces vertically to meet the line drawn earlier. At this time, ground flat some of the roundness on the plantar surface of the molded #2 piece and flatten by grinding the area under the metatarsal heads and toes. Use the 1 1/2" wide webbing to build the strap which will cross over the midfoot region just in front of the ankle. Use the 1" webbing for the strap which will cross over the top of the metatarsals just proximal to the metatarsal heads. Also use 1" strapping behind the heel. Place the patient's foot in the foot bed and "velcro" the straps together and hold them in place over the foot. Align the straps over the foot and mark the Plastazote® and straps (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-04.jpg">Fig. 4</a>). Glue together the Plastazote® footbed and straps, using the marks as a reference. Cut the straps under the sandal so they don't overlap (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-05.jpg">Fig. 5</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-04.jpg">Figure 4. The cotton-webbing straps are held in place while the sandal and straps are marked for later gluing.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-05.jpg">Figure 5. The straps are cut so they do not overlap under the footbed.</a> Coat with glue the 5" x 10" x 1/2" scrap piece of #2 Plastazote® and the bottom of the molded footbed and heat the #2 piece. Glue the #2 piece under the heel arch and metatarsal heads. Ground down the bottom to form a 1/2" high wedge heel which tapers down to the metatarsal heads (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-06.jpg">Fig. 6</a>). This heel lift also serves to fill any remaining arch and curvature under the sides of the molded footbed. <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-06.jpg">Figure 6. The bottom of the sandal is ground flat under heel, arch, and metatarsal heads after the heel wedge is glued on. The area under the toe is ground up to form the rocker.</a> The sole of these sandals should be absolutely rigid. On smaller patients the rigid Plastazote®, which will be added later, will be sufficient to accomplish this. But in larger, heavier patients, it may be necessary to include a rigid steel shank from the heel to the toe. For those patients, glue a piece of leather to the bottom of the footbed to prevent penetration of the steel through the footbed. Bend up the steel from the metatarsal heads to the end of the toe of the sandal in the form of a rocker. Glue the steel shank to the bottom of the leather, and shape and grind flat a filler material around the shank so bumps will not form in the outer sole of the sandal. If the steel shank is not used, coat with glue a piece of 5" x 12" x 1/4" rigid #3 Plastazote® and the bottom of the footbed. Heat the #3 piece and then attach it to the bottom of the footbed. This is done by adhering the heel of the sandal to the #3 piece first and then, in a rolling motion, elevate the heel of the sandal as the toe is pressed down onto the material piece<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-07.jpg"> (Fig. 7</a>). This creates a rocker sole with increased toe spring under the toes. <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-07.jpg">Figure 7. The heel of the sandal is lifted before the front of the heated #3 Plastazote® is glued to the footbed to help form the rocker sole.</a> Skive back one end of a piece of rigid Plastazote® 3" wide by 33" long and 1/4" thick to a distance of 2" and at a shallow angle. Then apply glue over the 2" skived portion and the entire other side of the rigid Plastazote® piece. Coat the sides of the footbed with glue. Heat the rigid Plastazote® and glue it vertically around the perimeter of the sandal (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-08.jpg">Fig. 8</a>). Glue the skived end to the medial arch area of the footbed first. This leaves the glue coated skived area facing out from the sandal. Completely wrap the #3 strip around it, overlapping onto the skived area, and cut off the excess. Trim the bottom flat and round the upper edge level with the top of the footbed by grinding. Then glue neoprene crepe soling to the bottom. <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-08.jpg">Figure 8. The sandal is made more rigid by gluing 1/4" #3 Plastazote® vertically around the footbed.</a> Place the patient's foot into the sandal to fit a heel strap. The strap is 1" cotton webbing. Mark the location of the strap. Remove the sandal and sew the strap into place (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-09.jpg">Fig. 9</a>). Rivets can also be used to attach the strap. <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-09.jpg">Figure 9. The completed sandal with neoprene crepe soling and heel strap attached.</a> For shortened feet, use only a single vertical, instep strap of 1 1/2" to 2" width and attach the heel strap to this single strap (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-10.jpg">Fig. 10</a>). For more long-term use, construct the straps and sides of leather (Fig. 11). If the patient's skin is thin and atrophied, softer materials such as beta-pile can be used as straps. <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-10.jpg">Figure 10. For shortened feet a single, broad strap can be used across the instep.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-11.jpg">Figure 11. Leather can be used for sandals intended for long-term or outdoor wear.</a> <h3>Considerations for Insensitive Feet</h3> In a series of 41 diabetic patients with sensory neuropathy in their feet, when measured with pedobarograph, 51% had abnormally high pressure under their metatarsal heads.<a></a> This is compared to only 7% of non-diabetic patients displaying higher pressures. The skin under the metatarsal heads has been shown in many studies to be the most frequently ulcerated part of the insensitive foot.<a></a> The forefoot region of insensitive feet needs a higher level of protection than the rest of the foot. This can be accomplished in the Plastazote® sandal by making the sole rigid and creating a rocker effect in the sole design.<a></a> A rigid sole minimizes shear between the sandal and skin. It also eliminates flexion and extension at the metatarsal-phalangeal joints.<a></a> If the toes of the foot are rigid, a flexible soled shoe will press up into the toes during gait. Rocker soles have been shown to greatly reduce foot pressure during gait. The point on the sole where rocking begins should always be posterior to the metatarsal heads, but ideally would be placed near the middle of the sandal. These rocker styles of sole are also helpful in the rehabilitation of patients with fused ankles.<a></a> <h3>Conclusion</h3> For 20 years at the Gillis W. Long Hansen's Disease Center in Carville, Louisiana, Plastazote® sandals have proven to be an effective form of interim footwear for insensitive patients. The technique is simple and highly adaptable to many types of foot therapy. References: <ol> <li>"A Report of the National Diabetes Advisory Board," NIH Publication No. 81-2284, Bethesda, Maryland, November, 1980. p. 25.</li> <li>Boulton, A.J.M., M.D., C.A. Hardisty, M.D., R.P. Betts, Ph.D., C.I. Franks, Ph.D., R.C. Worth, MD., J.D. Ward, M.D., and T. Duckworth, M.D., "Dynamic Foot Pressure and Other Studies as Diagnostic and Management Aids in Diabetic Neuropathy," Diabetes Care, 6, June, 1983, pp. 26-33.</li> <li>Duckworth, T., M.D., A.J. Boulton, M.D., R.P. Betts, Ph.D.. C.I. Franks, M.D. and J.E. Ward, M.D., "Plantar Pressure Measurements and the Prevention of Ucleration; in the Diabetic Foot," The Journal of Bone and Joint Surgery, 67, January, 1985, pp. 79-85.</li> <li>Karat, S., M.D., "The Role of Microcellular Rubber in the Preservation of Anaesthetic Feet in Leprosy," Leprosy Review, 40, July, 1969, pp. 165-170.</li> <li>Milgram, JE., M.D., "Office Measures for Relief of the Painful Foot," Journal of Bone and Joint Surgery, 46, July, 1964, pp. 1095-1116.</li> <li>Pati, L., M.D. and F. Behera, M.D., "Metatarsal Head Pressure (M.H.P.) Sores in Leprosy Patients," Leprosy in India. 53, October, 1981. pp. 588-593.</li> <li>Price, E.W., M.D., "Studies on Plantar Ulceration In Leprosy VI, The Management of Plantar Ulcers," Leprosy Review, 31:3, July, 1960, pp. 159-171.</li> <li>Reed, J.K., RPT, "Plastazote® Insoles, Sandals, and Shoes for Insensitive Feet," Surgical Rehabilitation in Leprosy, Editors F. McDowell and CD. Enna, Williams and Wilkins, 1974, pp. 323-329.</li> <li>Ross, W.F., M.D., "Footwear and the Prevention of Ulcers in Leprosy," Leprosy Review, 33, February, 1962, pp. 202-206.</li> <li>"Selected Statistics on Health and Medical Care of Diabetics," The National Diabetes Data Group, 1980, pp. A-3.</li> <li>Tuck, W.H., C.P.O., "The Use of Plastazote® to Accommodate Deformities in Hansen's Disease," Leprosy Review, 40, July, 1969, pp. 171-173.</li> </ol> *Footnote The numerical identifications of the different densities of Plastazote® correspond with the designations assigned for these densities by Alimed Inc., 297 High Street, Dedham, Massachusetts 02026. *Footnote Plastazote® is a trademark of BXL Plastics Limited, 675 Mitcham Road, Croydon CR9 3AL England. *Arthur Plaia, M.A. Arthur Plaia, M.S., is Chief of the Orthotic Department, Gillis W. Long Hansen's Disease Center. *William C. Coleman, D.P.M. William C. Coleman, D.P.M., is Chief of the Podiatry Department at the Gillis W. Long Hansen's Disease Center, Carville, Louisiana 70721. <div style="width: 400px;"></div> Page Number(s) 67 - 73 Year 1988 Volume 12 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-11.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 Soft Molded Sandals for Insensitive Foot Care Creator An entity primarily responsible for making the resource William C. Coleman, D.P.M. * Arthur Plaia, M.A. * https://staging.drfop.org/files/original/d926666429d9f2cdaf83ae21fe646c4f.pdf fc83de5564adb8c10840e56fc70c62ee https://staging.drfop.org/files/original/3b5e2b430dabd8baf145e6318ad9a8ac.jpg 01ae62dacd8de2696172979a524bc346 https://staging.drfop.org/files/original/c3618fa7bba7b72cca5c7f35c50ccebf.jpg 6ffb262220815834326298815ce4703a https://staging.drfop.org/files/original/6e60ab4bfaa6a84d3cd16563dd3a1b00.jpg b7d55619ad69dca45bb140cb75b7ff3d https://staging.drfop.org/files/original/6cef018bad60db66a6ccacad7eaa8947.jpg 5567ec543d1d62d47c68c307b1277865 https://staging.drfop.org/files/original/720bdb4a059cfeabf344aa1141a372ae.jpg 6858cb4c2244e6b253e500666c4e1865 https://staging.drfop.org/files/original/92e2ffc11c03bf7e45ccd8ceb1d94c1a.jpg 9c8423654d6cb14560a481688f433867 https://staging.drfop.org/files/original/7ccbc9292d966c3628e96d4de8252295.jpg 829221dd8b8b0904dfb59d0079def2c8 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/1988_02_061.pdf Text Any textual data included in the document <h2>The Susceptible Insensate Foot</h2> <h5>Mitchell E. Kalter, M.D. <a style="text-decoration: none;">*</a> Richard L. Jacobs, M.D. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> Patients with limbs which are both insensate and functionless often are best treated with amputation to improve hygiene, functional potential with prosthetics, and often cosmesis. There exists, however, a large population of patients whose lower extremities are insensate, but remain functional. Because of continued functional demands, and the loss of important protective mechanisms, breakdown of the delicate articulations occurs resulting in neuropathic arthropathy. While there are a multiplicity of disease states associated with neuropathic arthropathy, there are certain general principles and characteristics inherent in the final common pathway of the Charcot joint. In years past, neuro-syphillis was the major cause. Nowadays, diabetes mellitus is by far the most common cause. This article will explore some of the historical aspects, causes, pathophysiology, clinical manifestations, and principles of treatment as they relate to neuropathic arthropathy of the susceptible insensate foot. <h3>Historical Aspects</h3> Jean Martin Charcot, at La Salpetriere in 1868, first called attention to "ataxic" forms of arthropathy associated with neurological diseases, the most commonly recognized cause being tabes dorsalis.<a></a> Charcot attributed the acute and destructive arthropathy to the loss of certain "neurotrophic influences" ncessary to support the normal joints.<a></a> Charcot's contemporaries, Volkmann and Virchow, disagreed with this "trophic," or what was known as the "French" theory.<a></a> They argued that the arthropathy was due to continued mechanical stress and trauma on an insensitive biological structure.<a></a> These stresses continued in the absence of normal protective reflexes, which inevitably lead to a cycle of injury, inflammation, further injury, and finally instability and joint destruction. The end result, now the "Charcot joint." This basic process was gradually recognized in an ever broadening horizon of disease entities. Myelitis and syringomyelia were recognized as causes in 1875 and 1892 respectively.<a></a> It was not until 1936 that Jordan described neuropathic arthropathy in the diabetic,<a></a> now the most common cause of Charcot joints.<a></a> <h3>Etiologic Factors</h3> The myriad of conditions which can produce Charcot joints is well outlined elsewhere.<a></a> The three most common causes are diabetes mellitus, tabes dorsalis, and syringomyelia.<a></a> The prevalence of neuropathic arthropathy in diabetes is only 0.1% to 0.5%, as compared to tabes dorsalis and syringomyelia which are 5% to 10% and 25%, respectively.<a></a> The almost epidemic numbers of diabetics makes them the largest group seen clinically, however. Various theories have been espoused, such as Charcot's "neurotrophic" theory, Volk-mann's "mechanistic" theory, and "neurovascular" theories.<a></a> Each stresses some aspect of the observations made in the neuropathic ar- thropathy process. Certainly, "trophic" nerves have never been proven.<a></a> Mechanical trauma most certainly has a major role in the process, as is noted by many authors.<a></a> The basic concept of the mechanical theory is the blunting or eliminating of pain and proprioceptive information received from the involved body part. This dampens the afferent input for both conscious and nociflexive response patterns which have evolved to protect the extremity from intolerable mechanical stresses, and thus avoid injury.<a></a> The loss of proprioceptive and fine sensory input leads to ataxic gait patterns which further increase mechanical stresses. The spectrum of sensory deficit can be from an apparently normal sensory examination, to complete anesthesia.<a></a> Patients can experience pain, but it is invariably much less than expected for the degree of trauma and distortion of bone and soft tissues.<a></a> When pain does occur, it is usually secondary to severe posttraumatic inflammation of richly innervated synovial and pericapsular structures.<a></a> Joint proprioception, which normally inhibits hypermo-bility, is diminished, or absent, allowing instability to develop and progress.<a></a> Attempts to explain the rapidity of the process and bony reabsorption, seen especially in the diabetic patient,<a></a> have been made with the "neurovascular" theory.<a></a> This theory states that an abnormal "neurovascular reflex"<a></a> increases blood flow, resulting in bony washout, and hyperemic distensible soft tissue supports, all of which predispose the joint to a destructive process with normal stresses. The high incidence of objective autonomic dysfunction in diabetics lends some support to this theory.<a></a> As stated by Hurzwurm and Barja,<a></a> ". . . a more plausible explanation is that all of the above theories play a role . . . ," but to different degrees in each patient. Simply, relatively minor fractures in an otherwise normal foot or ankle can lead to rapid Charcot arthropathy if neuropathy is present.<a></a> One can think about the insensate foot like the insensate mouth after our friendly dentist mercifully relieves pain. If we insist on eating before the anesthetic wears off, despite his instructions, we can induce a "Charcot mouth." We will have pain for our indiscretion within several hours. The patient with neuropathy will continue to "chew away," oblivious of the damage he creates. <h3>Clinical Features</h3> The foot is the most commonly affected part of the appendicular skeleton.<a></a> However, it should be noted that different distributions of skeletal involvement can be seen, such as primarily upper extremity involvement with syringomyelia. The spine, knee, and hip may also be involved.<a></a> Why one joint in an insensate extremity is involved, while other joints remain normal, has remained unanswered.<a></a> Patients commonly present with the chief complaint of swelling, deformity, or mal perforant ulcers.<a></a> Pain may or may not be present, but is usually dependent upon presence of acute inflammation.<a></a> As described by Charcot and Volkmann,<a></a> the process of joint disruption begins with a period of swelling, erythema, local hyperemia, and effusion. This acute phase presentation is a manifestation of a normal acute inflammatory response to injury. If the injury is not perceived, the already edematous and hyperemic tissues receive continued trauma, recurrent inflammation, and poor, inadequate healing occurs. This eventually, if unchecked, leads to progressive soft tissue and bony deformity,<a></a> more characteristic of the chronic phase. An important distinction must be made between acute inflammation and infection, as both can present with the same local findings of swelling, erythema, and increased skin temperature. In the Charcot joint, however, laboratory studies, such as the white blood and differential counts and sedimentation rate, are normal; and importantly, there are no systemic manifestations such as fever or signs of sepsis.<a></a> Usual deformities include increasing flat foot to complete arch collapse, ankle and hindfoot valgus (or varus), and forefoot external rotation and eversion.<a></a> Mal perforans ulcers are formed intradermally, under heavy callous, caused by abnormal weight bearing.<a></a> A 50% association of diabetic mal perforans with neuroarthropathy has been described,<a></a> usually occurring at the metatarsophylangeal joint level. Patterns of joint involvement have been described in the diabetic. Primary ankle and subtalar joint patterns are frequent, with mid-tarsal joints most frequently involved.<a></a> Tarsometatarsal and metatarsophalangeal involvement have each been described in up to 30% of cases<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-1.jpg">Fig. 1A</a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-2.jpg">Fig. 1B</a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-3.jpg">Fig.1C</a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-4.jpg">Fig. 1D (1)</a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-5.jpg">Fig. 1D (2)</a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-6.jpg">Fig. 1E</a>, and <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-7.jpg">Fig. 2</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-1.jpg">Figure 1A. Initial evaluation of a 54 year old female diabetic. Normal AP, lateral, and oblique views of the left foot.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-2.jpg">Figure 1B. At age 59 years, the lateral view is still normal.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-3.jpg">Figure 1C. Only ten months later, lateral view of same foot shows advanced Charcot changes of the ankle, subtalar, and metatarsalphylangeal joints.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-4.jpg">Figure 1D. AP view.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-5.jpg">Figure 1D. Oblique view.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-6.jpg">Figure 1E. AP and mortise views of the ankle at the same time as 1C and ID.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-7.jpg">Figure 2. The right foot of same patient in Figure 1. Lateral, oblique, and AP views show mid-tarsal, tarsal-metatarsal, as well as interphylan-geal Charcot joint changes—a different pattern of joint involvement in the same patient. Elements of bone fragmentation, joint subluxation and dislocation and bone formation are represented.</a> Radiological characteristics of neuropathic arthropathy progress from debris at the articular margins and periarticular calcifications, to diffuse bony fragmentation which can coalesce to larger fragments and large osteophytes.<a></a> Later changes include bony marginal sclerosis in attempts to reform articulations<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-7.jpg">Fig. 2</a>). Pathologic examination reveals bone and cartilage fragments in the synovial tissues, and fibroblastic reaction with some round cell infiltrates in ligamentous and capsular soft tissues.<a></a> Circulatory status may be good in the Charcot foot,<a></a> but it is crucial to establish the diagnosis of vascular compromise on first evaluation as this can drastically affect treatment and outcome, especially in the diabetic.<a></a> Neuropathic arthropathy can be the presenting problem with previously undiagnosed diabetics.<a></a> Complicating factors in the clinical course are spontaneous fractures, which can hasten the degenerative process; deformity, which can be quite rapid in syringomyelia, tabes dorsalis, and with varus deformities; and soft tissue injury, predominantly neurotrophic plantar ulcers.<a></a> <h3>Treatment</h3> Treatment follows from the recognition that the extremity is injured; and is likely to have continued trauma because of the neuropathy. Early recognition should allow curtailment of the progression, but because of the 'nature of the beast', there is often significant arthropathy at presentation. Control of neuropathy, if this is possible, should be a primary consideration. This should be followed by attention to soft tissue injuries, or skin ulcerations which may require local debridement.<a></a> Evaluation of circulation is also part of the initial evaluation,<a></a> with necessary vascular intervention performed if this is a concomitant problem. Cast immobilization to decrease edema, allow bony and soft tissue healing, and avoid or correct deformity, has been advocated by many authors.<a></a> Prolonged immobilization is essential to allow healing and stabilization.<a></a> Casting should continue until the local temperature has returned to that of the uninvolved or inactive side. It can then be assumed that the acute repair process has abated, and progression to supportive and protective orthoses is possible.<a></a> Because of the potential for rapid progression, periodic x-rays must be obtained to assess progression which may alter therapy<a></a> (Compare <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-2.jpg">Fig. 1B</a> and <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-3.jpg">Fig.1C</a>). The indications for orthopaedic surgical intervention include unacceptable deformity, making shoeing difficult; bony prominences, causing ulceration; concomitant infection, requiring debridement and drainage; and deformities with a high likelihood of progression (i.e. varus).<a></a> "Bumpectomies," decompressive fusions of digits, Keller bunionectomies, and subtalar or ankle debridements and fusions are some of the more commonly indicated procedures.<a></a> Total joint arthroplasty has no place in the neuropathic patient as it will inevitably be disrupted by the same process that destroyed the natural joint.<a></a> <h3>Conclusions</h3> The major problem of the insensate foot is its susceptibility. Ataxia, secondary to neuropathy, imparts abnormal stresses and trauma to an extremity no longer able to detect injury. The neuropathy is usually irreversible, so defensive measures must be taken to control the process of joint destruction. Well fit ankle and foot orthoses to support unstable joints and redistribute weight bearing forces more evenly are the next line of defense once cast immobilization has controlled the injury reaction and allowed healing. Surgery is useful to correct unacceptable or unstable deformities and relieve skin pressures. By understanding the patient's perceptions, and the pathophysiology of the Charcot foot, we can provide treatment to prolong the functional life and avoid the complications of the insensate foot. References: <ol> <li>Curtiss, P.H., "Neurologic Diseases of the Foot," Foot Disorders: Medical and Surgical Management, Editor N.J. Giannestras, Lea & Febiger, Philadelphia, 1973, pp. 500-503.</li> <li>Delano, P.J., "The Pathogenesis of Charcot's Joint," American Journal of Radiology, 2:56, August, 1946, pp. 189-200.</li> <li>Donovan, J.C. and J.L. Rowbotham, "Foot Lesions in Diabetic Patients: Cause, Prevention, and Treatment," Joslins's Diabetes Mellitus, 12th Edition, Editors A. Marble, et al., Lea & Febiger, Philadelphia, 1985, pp. 732-736.</li> <li>Herzwurm, P.J. and R.H. Barja, "Charcot Joints of the Foot," Contemporary Orthopaedics, 3:14, March, 1987, pp. 17-22.</li> <li>Jacobs, R.L., "Neuropathic Foot in the Diabetic Patient," Foot Science, Editor M.E. Bateman, W.B. Saunders Co., 1976, pp. 235-253.</li> <li>Jacobs, R.L. and A.M. Karmody, "The Charcot Foot," The Foot, Editor M. Jahss, W.B. Saunders Co., 1982, pp. 1248-1265.</li> <li>Kristiansen, B., "Ankle and Foot Fractures in Diabetics Provoking Neuropathic Joint Changes," Acta Orthopaedics Scandanavia, 51, 1980, pp. 975-979.</li> <li>Locke, S. and D. Tarsy, "The Nervous System and Diabetes," Joslin's Diabetes Mellitus, 12th Edition, Editors A. Marble, et al., Lea & Febiger, Philadelphia, 1985, pp. 665-685.</li> <li>Mooney, V. and W. Wagoner, "Neurocirculatory Disorders of the Foot," Clinical Orthopaedics, 122, January-February, 1977, pp. 53-61.</li> <li>Podolsky, S. and A. Marble, "Diverse Abnormalities Associated with Diabetes," Joslin's Diabetes Mellitus, 12th Edition, Editors A. Marble, et al., Lea & Febiger, Philadelphia, 1985, pp. 843-866.</li> <li>Salter, R.B., "Degenerative Disorders of Joints and Related Structures," Textbook of Disorders and Injuries of the Musculoskeletal System, Williams & Wilkins Co., Baltimore, 1970, pp. 219-220.</li> </ol> *Richard L. Jacobs, M.D. Division of Orthopedic Surgery at Albany Medical College, Albany, New York *Mitchell E. Kalter, M.D. Division of Orthopedic Surgery at Albany Medical College, Albany, New York Page Number(s) 61 - 66 Year 1988 Volume 12 Issue 2 Figure 1 FIG 1A http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-1.jpg FIG1B http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-2.jpg FIG 1C http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-3.jpg FIG 1D-1 http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-4.jpg FIG 1D-2 http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-5.jpg FIG 1E http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-6.jpg Figure 2 FIG 2 http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-7.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review 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 Susceptible Insensate Foot Creator An entity primarily responsible for making the resource Mitchell E. Kalter, M.D. * Richard L. Jacobs, M.D. * https://staging.drfop.org/files/original/e2c61c59f3027ddb38ee4b0cad58918d.pdf 4858353a3eb0b95867caf9f1b1f0c2c5 https://staging.drfop.org/files/original/72d955fc50fde2bd2b5b4b1b61fa890d.jpg d1cb7af36eaa7f8d6fd1559e80442210 https://staging.drfop.org/files/original/2e7f596162524cefe76991581bbe8944.jpg c34932f2a3cf4306da2927cccbfd11f7 https://staging.drfop.org/files/original/6c08f5085c2f2e75abf1441c0fa75629.jpg 0da2cfe04fc70164f72489961e1c2d0e https://staging.drfop.org/files/original/6fc1780773a623d6bb12e14f72ae0de1.jpg 3f220ea36778d047dc8b3721a0987cc5 https://staging.drfop.org/files/original/5121ad2531312a946139f0f9fa81398c.jpg 20a8db15337befcfaebf9f8aa41d2bfc https://staging.drfop.org/files/original/7c209157d86272c7ca4678ada3e56a6d.jpg a2425d95830f7f8591ade9da25680e2a https://staging.drfop.org/files/original/37f4302ab2b2754b3775add6ca724672.jpg 77078b8c21f4ee471eeb1c731d3709c6 https://staging.drfop.org/files/original/49e03ca05a09b28f85c4d5ec8471ad81.jpg 8b088903d6682e433d8281cdb98047f7 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/1988_02_051.pdf Text Any textual data included in the document <h2>Orthotic Management of the Arthritic Foot</h2> <h5>C. Michael Schuch, C.P.O. <a style="text-decoration: none;">*</a></h5> With ever increasing public exposure, orthotists are being requested more frequently to confront new challenges caused by physical disability. In the spectrum of orthotic protocols, management of the arthritic foot and ankle is a relatively new challenge. During the past five years, the Department of Orthopaedics and Rehabilitation, the Division of Rheumatology, and the Division of Prosthetics and Orthotics, all of the University of Virginia Medical Center, have comprised an Arthritis Rehabilitation Research and Training Center, providing a regional referral center for arthritis patients. Orthotic services for these patients have concentrated on the foot and the ankle, and this population of patients has been substantial enough to permit the development of a consistently successful protocol of management. The intent of this paper is to review the skeletal anatomy of the ankle and foot, discuss the types of arthritis and their relative pathophysiology and clinical manifestations, and finally to present our protocol for management of the various problems presented by the arthritic foot and ankle. <h3>Review of Ankle-Foot Anatomy</h3> The skeleton of the foot consists of three groups of bones: tarsal bones, metatarsal bones, and phalanges. The tarsal bones are further divided into two groups, the first group consisting of the talus and the calcaneus, together forming the hindfoot. The talus, which is the only bone to articulate with the tibia and the fibula, acts as a rocker by which the foot as a unit can be dorsiflexed and plantarflexed at the hinge of the ankle joint. In stance, the talus receives the entire weight of the lower limb; half this weight is transmitted forward to the bones forming the arch of the foot, and half of the weight is transmitted downward to the heel or calcaneous. The calcaneus, or os calcis, is the bone of the heel. It supports the talus, withstands shock as the heel strikes the ground, and transfers forward the portion of body weight it receives from the talus. The second group of tarsals consists of the five bones anterior to the talus and the calcaneus. The navicular, cuboid, and three cuneiforms increase flexibility of the foot, particularly in its twisting movements. These bones form the longitudinal arch of the foot, and are referred to collectively as the midfoot. The five metatarsal bones lie anterior to and articulate with the second group of tarsal bones described above. Each metatarsal consists of a base, a shaft, and a head, in respective order from proximal to distal. The distal-most bones of the foot are the five phalanges, which extend from the five metatarsals and form the bones of the toes. The metatarsals and the phalanges form the forefoot. The foot has three arches: the medial, lateral, and transverse. The normal medial arch rises through the calcaneous to the head of the talus, and from this high point it descends forward through the navicular, cuneiforms, and first three metatarsal heads. The lateral arch, which is lower than the medial, extends from the calcaneus to its high point at the cuboid, and down through the fourth and fifth metatarsals. The transverse arch rises across the width of the foot between the medial and lateral borders, primarily under the metatarsal shafts. The junctions of these various groups of bones form the joints that allow the functional motions of the ankle and foot to occur. The talocrural (ankle) joint consists of the medial and lateral malleoli and the trochlear surface of the talus. This joint permits the motion of plantar-flexion and dorsiflexion. The subtalar (talocal-caneal) joint is formed by the articulation of the talus and the calcaneus, and permits the heel to share in inversion and eversion. The transverse tarsal (midtarsal) joint is not an anatomic entity, but an important functional grouping of two joints which occur anterior to the talus. These two joints, the talocalcaneonavicular and the calcaneocuboid, permit much of the inversions version of the foot. The other tarsal joints, tarsometatarsal joints, and distal joints aid in flexibility of the foot from heel strike through mid-stance, and help the foot form a rigid lever during toe-off, or the propulsion part of the gait cycle. Each of the joints of the ankle and foot, including the joints between the sesamoids and the first metatarsal are lined with synovium so that when inflammatory conditions that affect the synovium are present, the foot and ankle may show dramatic changes clinically, radio-graphically, and pathologically. <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-1.jpg">Figure 1. View of patient's feet afflicted with rheumatoid arthritis. Note, hallux valgus, claw toes, depressed longitudinal arch, and pronation or eversion at the subtalar joint.</a> <h3>Types and Pathophysiology of Arthritis</h3> While there are a half dozen or more differing types of arthritis,<a></a> we will limit our discussion to the types that have a tendency to involve the foot and ankle. The most commonly seen and most debilitating form of arthritis is rheumatoid arthritis. Rheumatoid Arthritis Rheumatoid arthritis is an inflammatory condition of unknown etiology that primarily affects the synovial lining of joints, tendons, and bursae. Secondarily, it may cause destruction to cartilage, bone, ligaments, and other soft tissue. Most people with rheumatoid arthritis have some degree of foot and/or ankle involvement.<a></a> The joints of the feet are initially involved more often than the joints of the hands.<a></a> Vaino showed that more than 88% of adults and 69% of children with rheumatoid arthritis have involvement of the feet during some phase of the disease.<a></a> Guerra states that the earliest sign of rheumatoid arthritis is congestion of the synovial membranes with edema.<a></a> As the synovial inflammatory tissue and fluid within the joint accumulate, there is swelling of the soft tissue, and decreased range of motion of the joint. The inflamed synovium adjacent to the marginal bare areas causes destruction of bone, resulting in bony erosion at the margins. Because the inflamed synovium, known as the pannus, also proliferates, expansion occurs over the cartilage and destroys the cartilage through enzymatic action, producing symmetrical joint space narrowing. The pannus may also penetrate the unprotected bare bone and cause destruction of the cartilage from the marrow side. The reactive hyperemia, part of the inflammatory process, is implicated in the periarticular osteoporosis and the discontinuity of the subchondral bony plate.<a></a> Joint destruction and deformities occur and become fixed as the weakened support structure of the ankle and foot gives way to the normal mechanical stresses placed upon it; changes in alignment of joints allow muscles, tendons, and ligaments that cross the joints to exert different forces, and stiffness and pain in the joints prevent mobility.<a></a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-2.jpg">Figure 2. Schematic view showing the effects of claw toes with subluxed MTP joints, resulting in metatarsal head prominences on the plantar surfaces of the foot.</a> Clinical manifestations can include all joints of the ankle-foot, collectively or individually. Ankle involvement in rheumatoid arthritis is not as common as involvement of other joints of the foot.<a></a> The clinical picture of ankle involvement is less dramatic than with the other joints, with swelling, stiffness, decreased range of motion, and pain being the indicators. Unlike the ankle, the hindfoot is often affected early in rheumatoid arthritis. The most common deformity of the hindfoot is pes plano-valgus, or more simply, valgus of the hindfoot and flattening of the longitudinal arches.<a></a> The midfoot-tarsal joints develop inflammatory changes that contribute to the pes planovalgus deformity of the hindfoot and midfoot.<a></a> In time, each of the tarsal bones seem to be equally involved, causing loss of pronation-supination and malleability of the foot in general. The forefoot shows marked abnormalities on clinical and radiologic examination. The altered forces created by hindfoot and midfoot deformities act with the inflammatory process, affecting the metatarsal-phalangeal (MTP) joints and proximal interphalangeal (PIP) joints to give the typical findings of hallux valgus, claw toes, subluxation and depression of the metatarsal-phalangeal joints, abduction of the forefoot, and splay foot. Involvement here as in other parts of the foot is symmetric and increases with disease duration.<a></a> Osteoarthritis The next most commonly seen type of arthritis to cause foot problems is osteoarthritis, or degenerative joint disease. This form of arthritis is not a systemic inflammatory disease; rather it is a disease that is secondary to the wear and tear phenomena on joints. Disruption of the cartilagenous matrix occurs as a result of enzymatic action. Large weight-bearing joints of the body are particularly prone to dysfunction. The ankle joint and the first MTP joint seem most susceptible, with weight bearing, trauma, and footwear having all been implicated as causative agents. Radiologic examination reveals asymmetric narrowing of the joint space, the areas of stress demonstrating less interosseous space.<a></a> Other Arthritis Types The arthritis patient population requiring foot orthotic management primarily falls into one of the above two categories of diagnosis. However, occasions will arise necessitating foot and or ankle management for patients with other arthritic diagnoses. The seronegative arthridities are ankylosing spondylitis, Reiter's syndrome and its variants, and psoriatic arthritis. Two additional types of arthritis that may affect the foot and/or ankle are gout and systemic lupus erythematosis. While differing in pathophysiology from rheumatoid arthritis and osteoarthritis enough to warrant separate diagnostic classification, the clinical manifestations of the ankle and foot are similar. <h3>Orthotic Designs and Indications</h3> As in all orthotic management, the scope of the problem dictates the complexity of the orthosis. We have been pleased with the simplicity of the decision making process that has been developed at the University of Virginia. Sophisticated evaluation processes are not necessary; patient communication concerning location of pain and routine physical examination of ankle-foot abnormalities are sufficient. Observation of gait irregularities usually reinforce communication/physical examination findings. Orthotic management conveniently falls into two levels of complexity: foot orthoses (FO's) and ankle-foot orthoses (AFO's). Foot Orthoses The objectives of foot orthoses for arthritic patients include, (1) maintainence and support of existing arches of the foot; (2) re-establishment of fallen arches when flexibility permits; (3) provision of inversion-eversion balance or stability; (4) distribution of weight bearing pressures; and (5) provision of soft tissue supplement. The clinical picture requiring this level of orthotic management can range from mild longitudinal arch depression with callous formation under the metatarsal heads to severe loss of the longitudinal arches, medial drift of the talocalcaneonavicular joint complex, subluxation of MTP joints with depressed and protruding metatarsal heads, hallux valgus, and claw deformities of the phalanges. Traditional foot orthoses for this type of clinical picture have been Plastizote® inserts, molded directly to the patient's foot. However, Plastizote® is not durable; it packs down quickly with wear. The more severe the deformity, the quicker the material loses its integrity and ability to meet the objectives of foot orthoses as described above. Occasionally, arthritic patients have presented or reported being fit with rigid foot orthoses, fabricated of Nyloplex (Rohadur), usually provided by podiatrists. While this material selection and orthotic design are ideal for many cases, we have found it to be highly unsuccessful with arthritic patients to the point that we consider rigid foot orthotics contraindicated for this patient population. Our experience has shown that this type of orthosis lacks the flexibility and soft tissue supplement necessary to promote acceptance by patients with arthritis. The choice of materials and design for arthritic foot orthoses at the University of Virginia has been PVC-Pelite™ foot orthoses, molded over positive models of the patient's foot or feet. <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-3.jpg">Figure 3. View showing left foot impression taken in foam foot impression block. Note "X" identifying metatarsal head prominence.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-4.jpg">Figure 4. Foot impression filled with molding plaster forming a positive model of the patient's foot.</a> Description of Technique Negative impressions of the patient's feet are obtained using any of the commercially available foam impression blocks. This impression is taken with the patient seated, to capture the shape of the existing arches at their maximum height, free of weight-bearing loads. Care should be taken to balance inversion-eversion as the foot is pressed into the foam. Positive models are obtained in the conventional manner by pouring molding plaster into the impression forms. Modification of the positive model is necessary to meet the objectives of foot orthoses for arthritic patients as discussed above. The longitudinal arch is increased mildly, especially posteriorly, as proposed by Carlson, et al., in their technique for modification of the UCB foot orthosis.<a></a> This modification meets the objectives of maintenance and support of existing arches, provision of eversion or valgus stability, and distribution of weight bearing forces. The metatarsal or transverse arch modification is perhaps most important, and the degree of this modification in terms of size and depth parallels the severity of MTP subluxation and metatarsal head depression. It is frequently greater than 1/2" in depth. The shape of this modification should simulate that of prefabricated rubber metatarsal pads, which are commercially available in varying sizes and depths. Proper placement of this modification is critical; when an existing transverse arch can be identified, it should be exaggerated. If there is no identifiable transverse arch, the modification for this arch in the positive model falls under the metatarsal shafts, with the dome or apex of the plaster removal just posterior to the metatarsal heads, and the proximal edges blending gradually into the longitudinal arches. This modification provides support to uplift the depressed metatarsal heads and reduce trauma at the push-off phase of the gait cycle. It also meets the objectives of maintenance and support of existing arches in some cases, re-establishment of fallen arches in other cases, and better distribution of weight-bearing loads. The final modification to the positive model includes adding plaster to the plantar aspect of the PIP joints of the phalanges, which aids in providing a smooth transition from the MTP to the phalangeal area of the foot orthosis. The positive model is now complete and ready for molding of the base material, PVC Pelite™, which is available in 4' square sheets, 1/8" thick. PVC Pelite™ is ideal for foot orthoses because: (1) the PVC laminate (vinyl covering) assists the Pelite™ in maintaining its desired shape after heat molding; (2) the PVC laminate provides strength and durability, decreasing and even eliminating incidences of the Pelite™ packing down, and (3) the PVC laminate consists of closed cells and is waterproof, which makes it easy to clean and discourages the growth of bacteria and fungus. The size of the PVC Pelite™ sheet to be molded over the positive model is determined by closely tracing the positive model onto the PVC Pelite™ and allowing extra material to cover the longitudinal arch and extra material beyond the phalanges. Care should be taken to closely trace the lateral and posterior aspects of the positive model, because excess material here makes molding or vacuum forming more difficult, frequently resulting in bunching or folding of the material and, thus, an unacceptable orthosis. Heating the PVC Pelite™ sheet can take place in an oven, an electric skillet, or with a heat gun. The vinyl covering of PVC Pelite™ should not be subjected to high heat or heated directly since it can delaminate under these conditions and develop bubbles or blisters. When sufficiently pliable and moldable from the heat, the PVC Pelite™ sheet is molded in place over the plantar surface of the positive model using any of the following techniques: <ol> <li> Wrapping the PVC Pelite™ in place around the positive model with an elastic bandage. </li> <li> Vacuum formed in place using a vacuum hose placed inside a small airtight plastic bag. </li> <li> Vacuum formed in place using a commercially available foot orthosis vacuum-forming machine. </li> </ol> <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-5.jpg">Figure 5. Positive models of patient's feet, plantar surface facing up. Note identification of transverse (metatarsal) arch and prominent metatarsal heads.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-6.jpg">Figure 6. Molded PVC-Pelite™ foot orthosis, with longitudinal and metatarsal arch support.</a> Once the PVC Pelite™ is molded in place and cooled sufficiently for the molded shape to be maintained, a sheet of 1/2" thick medium density Pelite™ is cut to fill the transverse and longitudinal arch areas as a single piece. (To save time we have these precut in large numbers to a single large size that can be trimmed to fit a given positive mold.) This piece of 1/2" medium density Pelite™ is heated to a moldable state using oven, skillet, or heat gun, and is then molded or vacuum formed in place as was the PVC Pelite™. When sufficiently cooled, it is glued in place using Polyadhesive and sanded to a feather edge so that it will blend with the PVC Pelite™. Additional modifications to this PVC Pelite™ foot orthosis design may include either of the following: <ol> <li> For increased soft tissue supplement and shock absorption, 1/8" PPT can be glued to the bottom surface of the PVC Pelite™ foot orthosis. </li> <li> For maximum soft tissue supplement in cases of severe metatarsal head protrusion, nylon lined 1/8" PPT may be glued on top of PVC Pelite™ foot orthosis. </li> </ol> Either modification will require greater depth within the patient's shoes. With or without the above modifications, final shaping and fitting are done to the patient and his shoes. An additional point worthy of mention: soft tissue supplement, weight bearing pressure distribution, metatarsal head pain relief, and other plantar surface objectives can be attained with this foot orthosis system regardless of shoe integrity. However, when the objective is control of the inversion-eversion (varus-valgus) balance in the foot, or maintenance, support, or re-establishment of the longitudinal arch, the shoes become an adjunct to the foot orthosis and thus must have a firm heel counter with good integrity along the medial aspect of the longitudinal arch. <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-7.jpg">Figure 7. Rheumatoid arthritis patient wearing right molded, rigid copolymer AFO and left molded, weight-bearing, bivalve, rigid AFO.</a> Ankle Foot Orthoses Although somewhat rare compared to the numbers of patients we have encountered requiring foot orthotic management, there are those arthritics with severe enough involvement to warrant a higher level orthosis. The typical picture requiring AFO management is pain, swelling, and decreased range of motion located in the ankle (talocrural) joint, with frequent moderate to severe pes planus and subtalar (talocalcaneal) erosion. Although rheumatoid arthritis patients dominate this type of patient population, it is not unusual for patients with osteoarthritis to present at this level. Again, severity of involvement dictates the complexity of the orthosis. We have used two types or designs of AFO's in our management of these kinds of problems: rigid, molded plastic AFO's and bivalved, weight bearing, rigid, molded plastic AFO's (also known as PTB AFO's or axial load resist AFO's.) The distinction between the two is quite simple. When pain in the ankle or subtalar joint is due to the forces of walking or movement, i.e. if the normal movements of the ankle-subtalar complex in the course of walking causes or increases pain, yet standing stationary is comfortable and pain-free, the only need is elimination of motion which can be provided by a rigid, molded AFO. When pain is experienced in both standing and ambulation, the goals are to redistribute weight-bearing loads by reducing the amount of weight to be borne through the diseased ankle-foot complex and to eliminate range of motion. These objectives can be met with a bivalved, weight-bearing, rigid, molded AFO. As standard AFO's are commonplace items in any orthotic practice, detailed discussion in this context serves no purpose. However, the need for rigidity should be emphasized. The lower vertical trimlines need to be anterior to the malleoli, and carbon composite inserts can be used if necessary. Our chosen design for bivalved, weight bearing, rigid, molded AFO's is that described by Wilson, Stills, and Pritham<a></a> with the addition of a higher posterior trimline in the popliteal area, similar to that in a below-knee prosthesis. The reduction in the range of knee flexion as a result of this higher posterior trim is a minor sacrifice for a major gain in reduction in pain. We purposely try to avoid the use of the term PTB orthosis because of its erroneous weight-bearing implications. The patella tendon is identified by mild modification of the positive model in this anatomical region, similar to but much less aggressive than in a so called "PTB" prothesis. However, there is little concentrated weight-bearing in this area; the goal of weight-bearing is equal distribution throughout the entire part of the lower leg contained within the orthosis. Perhaps the most accurate prosthetic acronym describing the weight-bearing goals of the bivalved, weight-bearing, rigid, molded AFO, is the "total surface bearing" concept. In the case of an intact lower limb as is encountered in orthotics, modification of the term "to maximum surface bearing" seems appropriate. None of our patients requiring rigid AFO's has required SACH (solid-ankle cushion-heel) and rocker sole shoe modifications. We do recommend the use of shoes with soft soles constructed of Vibram® or crepe. <h3>Shoes for Arthritic Patients</h3> Proper shoes are a vital component of orthotic management of the arthritic foot. As was stated earlier, some foot orthotic objectives can be attained with shoes of poor quality or integrity. However, properly designed and fitted shoes can only enhance the best designed and fabricated foot or ankle-foot orthoses. Our large arthritic patient population at the University of Virginia has allowed us to recommend and fit a wide variety of accommodative shoes. As we gained experience, it became apparent that we could rely on a minimum inventory of shoe types or designs. I refrain from the use of the descriptor "style" because there may be several "styles" available within a shoe design category. The categories of "design" that I refer to could be listed and described as follows: <ol> <li> Thermo adjustable shoes </li> <li> Extra depth shoes </li> <li> Running shoes. </li> </ol> Thermo Adjustable Shoes <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-8.jpg">Figure 8. View of various shoes useful in the management of patients with arthritis affecting the feet and ankles.</a> This shoe type or design is made primarily of Dermaplast®, which is a heat shrinkable Plastizote®. Known as Apex Ambulators®, there are two styles available: #1201, the simplest and most accommodative, and #1273, a more cosmetic version of the first style. Style #1201 is of black Dermaplast™ with a thin outer fabric covering, crepe wedge soles, Velcro® lap closure (eases donning for those arthritics with hand involvement), and removable Plastizote® insole. There is no heel counter reinforcement. The indications for this type of shoe is last resort, severe deformities, especially in the dorsal aspect of the foot, that are difficult or impossible to accommodate in shoes of firmer and less adjustable materials. Examples of such deformities are severe hammer toes, severe hallux valgus, and/or nodules on the dorsum of the feet or toes. This shoe is fitted slightly large and then heated while on the patient's foot (with protection by socks, of course). The application of heat causes the Dermaplast® to shrink and mold to the patient's foot shape, thus accommodating the severe deformity. The shoe upper material of Plastizote® and fabric is very soft and forgiving to such deformities. In all cases, we replace the removable Plastizote® insoles with molded PVC-Pelite™ foot orthoses. The other style of Apex Ambulators® thermo adjustable shoes, #1273, is very similar to that described above. The major difference is the outer covering of the uppers, which in this second style is thin, pliable leather. This shoe is more cosmetically appealing to most patients because the leather uppers allow the choice of four colors, (the catalogue number varies with color variations). It has slightly more integrity than the #1201 style, including a moderately reinforced heel counter. It also has a removable tongue, which is secured in place with Velcro®, a feature that enhances its adjustability. It is available with either lace or Velcro® loop back closure. Accommodation of deformities can be accomplished either by heating and shrinking a loose fit as with the #1201's above or by fitting the shoes to the proper size and then stretching the uppers with shoe stretching tools over areas of deformity. Extra Depth Shoes Extra Depth® shoes are offered by several manufacturers and provide greater depth throughout the entire shoe. This depth is ideal for accommodating molded foot or ankle foot orthoses designed for arthritic foot deformities. Extra depth shoes, like molded AFO's, are a familiar item in any orthotic practice, and therefore do not necessitate detailed discussion. However, there are two important considerations regarding their application to arthritic patients: (1) the shoe style selected should be made of very soft leather, preferably calfskin or deerskin, as these leathers are most easily spot stretched to accommodate deformities, and are the most forgiving to areas of inflammation; (2) adequate width in the forefoot or toebox of the shoe cannot be overemphasized. The extra depth shoes that we recommend for our arthritic patients are manufactured and distributed by Alden Shoe Company and P.W. Minor. The designs and styles vary in leather utilized, closure (lace or Velcro®), and amount of heel counter reinforcement. All have soft crepe soles and uppers that can be modified for deformities with relative ease using shoe stretching tools and equipment. Running Shoes Running or jogging shoes should be familiar to orthotists and patients alike. Their application to patients with arthritic foot problems stem from three of their characteristics: (1) they are acceptable to many patients who do not accept the "lack of style" of other appropriate shoes; (2) most utilize separate, removable insoles, which when removed, allow adequate room for use of molded foot or ankle foot orthoses; and (3) most are very light in weight. Problems we have encountered with running shoes include seams in the dorsal aspect of the toe box, making spot stretching difficult or impossible, and construction of vinyl or other synthetic materials which also make stretching difficult or less successful. <h3>Conclusion and Results</h3> An experience based protocol for orthotic management of the arthritic foot has been described. This experience is based on over 300 arthritic patients who required orthotic management by our service since 1985. Seven patients have been fit with eight bivalve, weight-bearing rigid, molded AFO's (one bilateral). One of these seven patients benefitted from a rigid, molded AFO on his lesser involved lower extremity. The remaining patients have been managed with custom molded PVC Pelite™ foot orthoses. Many of the patients fit with PVC Pelite™ foot orthoses were successfully converted from direct molded Plastizote® shoe inserts. Through routine follow up and chart reviews, we have found less than a three percent rejection rate; more important, we have found more active patients who enjoy a better quality of life. <h3>Appendix</h3> Alden Shoe Company, Taunton Street, P.O. Box 617, Middleborough, Massachusetts 02346. Apex Ambulators, Apex Foot Products, 330 Phillips Avenue, S. Hackensack, New Jersey 07606. PPT, The Langer Biomechanics Group, 21 East Industry Court, Deer Park, New York 11729. PVC Pelite™, Durr-Fillauer Medical, Inc., Orthopedic Division, P.O. Box 5189, Chattanooga, Tennessee 37406. P.W. Minor Extra Depth Shoe Co., 3 Treadeasy Avenue, Batavia, New York 14020. References: <ol> <li>Carlson, J. Martin, and Gene Berglund, "An Effective Orthotic Design for Controlling the Unstable Subtalar Joint," Orthotics and Prosthetics, 33:1, March, 1979, pp. 39-49.</li> <li>Guerra, J. and D. Resnick, "Arthridities Affecting the Foot and Ankle-Pathology and Treatment. The Relationship Between Foot and Ankle Deformity and Disease Duration in Fifty Patients," Foot and Ankle, 2:6, 1982, pp. 325-331.</li> <li>Portwood, Margaret M., "The Foot and Ankle in Rheumatic Disorders," Principles of Physical Medicine and Rehabilitation in the Musculoskeletal Diseases, Grune and Stratton, 1986, Chapter 19, pp. 489-513.</li> <li>Short, C.L., W. Bauer, W.E. Reynolds, In Rheumatic Arthritis, Harvard University Press, Cambridge, 1957, pp. 194-195.</li> <li>Tillman, K., The Rheumatic Foot: Diagnosis, Pathomechanics, and Treatment, Stuttgart, Georg Thieme Publishers, Boston, PSG Publishing Co., 1979, pp. 3-61.</li> <li>Vaino, K., "The Rheumatoid Foot: A Clinical Study With Pathologic and Roentgenological Comments," Ann. Chir. Gynaecol. 45 (Suppl), 1956, pp. 1-107.</li> <li>Wilson, A. Bennett, Jr., David Condie, Charles Pritham, and Melvin Stills, Lower-Limb Orthotics, A Manual, First Edition, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Temple University, Drexel University.</li> </ol> *C. Michael Schuch, C.P.O. C. Michael Schuch, C.P.O., is an Assistant Professor in Orthopaedics and Rehabilitation and Associate Director of Prosthetics, Orthotics, and Rehabilitation Engineering Services at the University of Virginia Medical Center, Box 467, Charlottesville, Virginia 22908. 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Title A name given to the resource Orthotic Management of the Arthritic Foot Creator An entity primarily responsible for making the resource C. 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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/1988_02_044.pdf Text Any textual data included in the document <h2>Clinical Analysis of Foot Problems</h2> <h5>Karen S. Seale, M.D. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> Orthotists are vital members of the foot care team. Their expertise and special interests in materials and biomechanics add a unique dimension to the management of foot problems. It is hoped that the principles of clinical assessment of foot problems set forth in this article will foster even greater interest in and understanding of the pathophysiology of foot problems. The purposes of this article are threefold: <ol> <li> To familiarize the orthotist with the general concepts of clinical analysis of the foot. </li> <li> To assist the orthotist in designing the most appropriate orthosis based on clinical assessment of the problem. </li> <li> To give examples of clinical analysis of the following common foot problems for which an orthotic treatment may be prescribed: <ol> <li> Heel pain </li> <li> Pes planus </li> <li> Metatarsalgia </li> <li> Ankle instability </li> </ol> </li> </ol> <h3>Discussion</h3> Clinical analysis of the foot consists of obtaining a pertinent history and performing a physical examination of the lower extremity. The medical history is an opportunity to gather as much information as possible by asking the patient to describe the pain, problem, or deformity. Specific information is sought by asking about the type of pain, its duration, onset (whether insidious or abrupt), location of the pain, and activities that help or aggravate the pain (such as rest, walking, or wearing or removing certain shoes). Physical examination involves inspection, palpation, and manipulation. Observe the patient, first with and then without his typical footwear, both standing and walking, with arms hanging freely at the sides. The patient should be observed from the front and from the back. With the patient seated at a height comfortable for the examiner and the shoes removed, palpation and manipulation can be performed. Palpation is not intended to inflict pain, but rather to identify areas of discomfort. For example, applying direct pressure in the center of the heel pad may cause discomfort in a patient with "heel spur" syndrome. In addition to palpation, manipulation is used to assess range of motion of the various joints and to determine the biomechanical relationships of the component parts of the lower extremity. Although a description of a comprehensive foot examination is beyond the scope of this paper, clinical analysis of four common foot problems is included in the next section. <h3>Heel Pain</h3> A very common clinical problem for which shoe modifications may be prescribed is heel pain. Although many causes of heel pain exist, common etiologies include, (1) fat pad atrophy, (2) plantar fascitis or "heel spur" syndrome, and (3) neuritis of the medial calcaneal or lateral plantar nerves. Atrophy of the fat pad is particularly common among older individuals who will complain of localized pain about the heel brought on by walking, especially in hard soled shoes. Varying degrees of fat atrophy of the metatarsal area as well as the heel pad are observed on physical examination and the underlying tubercle of the calcaneous can be readily palpated. The key to successful shoe modification in treating this condition is to increase the padding beneath the heel. The onset of chronic heel pain due to plantar fascitis or "heel spur" syndrome may be either acute or insidious. It is often most severe upon arising in the morning, but improves after a period of "warming up." However, it may worsen if the patient remains on his feet during the day or with intermittent periods of rest and activity. The patient is usually tender to palpation at the origin of the plantar fascia on the plantar tubercle of the calcaneus and about one centimeter distally (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-1.jpg">Fig. 1a</a>). The principles of shoe modification management are soft soles, relief in the center of the heel, and a soft arch support to better distribute the weight and relieve the painful heel area. <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-1.jpg">Figure 1A. Point of tenderness in patient with plantar fascitis.</a> Neurologic causes of heel pain include neuritis and/or compression of the medial calcaneal nerve, the lateral plantar nerve, or the nerve to the abductor digiti quinti, which is a branch of the lateral plantar nerve.<a></a> The pain is usually not well localized as with plantar fascitis, but tends to be diffuse. On physical examination tenderness may be found on the medial aspect of the heel over the origin of the abductor hallucis (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-2.jpg">Fig. 1b</a>). Occasionally, the examiner can elicit pain or tingling along the medial aspect of the heel with light tapping or pressure in this area. For these patients, an orthosis which limits excessive pronation, and thereby decreases the pull of the abductor hallucis across the nerves, is useful. <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-2.jpg">Figure 1B. Point of tenderness in patient with neuritis of medial calcaneal and/or lateral plantar nerve. </a> <h3>Pes Planus</h3> Pes planus, or flat foot, is a descriptive term indicating the loss of height of the medial arch, but is a more complex entity than the name implies. There are many causes of symptomatic flat feet, including posterior tibial tendon rupture, Charcot joint degeneration secondary to neuropathy, rheumatoid arthritis, and generalized ligamentous laxity.<a></a> The specific complaints vary depending on the etiology, but in general, pes planus leads to diffuse aching of the foot and early fatigue. Patients with inflammation or early rupture of the posterior tibial tendon will note pain on the medial aspect of the foot and ankle early on, but as significant deformity develops, pain occurs on the lateral aspect of the hindfoot due to impingement of the fibula against the valgus-tilted calcaneus.<a></a> The rheumatoid patient may have a great deal of diffuse pain, whereas the patient with Charcot joint degeneration secondary to neuropathy may have little or no pain in the presence of very severe deformity. Pes planus is best observed seen while the patient is standing. One notes the decrease in the medial arch height, the increase in forefoot abduction and external rotation as well as the presence of heel valgus (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-3.jpg">Fig. 2a</a>). Observations, made from behind as the patient walks, are (1) the excessive external rotation of the foot relative to the line of progression, and (2) the lack of significant heel inversion motion from foot flat to heel lift. <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-3.jpg">Figure 2A. Note loss of longitudinal arch, with the excessive forefoot abduction and external rotation.</a> Further biomechanical evaluation is performed by sitting in front of the seated patient to observe the relationships of the hindfoot to the leg and of the forefoot to the hindfoot. The subtalar joint motion is assessed by grasping the heel and tilting it laterally (into valgus or eversion) and then medially (into varus or inversion). Not infrequently, the patient with pes planus will demonstrate excessive eversion, greater than the normal excursion of 10°. The foot is then placed in its "neutral position," which is the point at which the calcaneus is centered under the tibia and the talar head is adequately covered by the tarsal navicular. This is done by the examiner's holding the heel in alignment with the long axis of the tibia or in a few degrees of valgus and then adducting the forefoot approximately halfway between maximum forefoot abduction and maximum adduction. The position of the plantar aspect of the forefoot relative to the perpendicular axis of the tibia is noted. There is usually a component of forefoot varus which means the plantar aspect of the foot is facing medially (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg">Fig. 2b</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg">Figure 2B. Forefoot varus-plantar aspect of foot facing medially.</a> The principles of orthotic management of pes planus include correcting the valgus tilt of the calcaneous, providing a medial arch support, and posting of the first ray to control the hyper-pronation. <h3>Metatarsalgia</h3> Metatarsalgia is pain in the forefoot area for which a wide variety of etiologies have been identified. For the purposes of this article, which is aimed at the practicing orthotist dealing with foot problems, the discussion will be limited to the following: <ul> <li> Fat pad atrophy </li> <li> Sesamoiditis </li> <li> Disorders of the lesser metatarsophalangeal joints </li> <li> Interdigital neuroma </li> <li> Rheumatoid arthritis </li> <li> Pes cavus </li> </ul> Fat Pad Atrophy As in heel pad atrophy, the soft tissue padding under the metatarsal heads may become atrophied with age, causing diffuse pain under the metatarsal heads due to the lack of sufficient padding for shock attentuation. The patient may complain of pain especially when walking on a hard floor without shoes. The atrophy is apparent on general inspection; palpation reveals the prominence of the metatarsal heads plantarly. The patient may be tender to palpation directly under the metatarsal heads. Soft soled shoes and soft inner soles with metatarsal pads proximal to the metatarsal heads are beneficial modalities. Sesamoiditis Patients with inflammation of the sesamoids of the first metatarsophalangeal joint will complain of well localized pain on the medial aspect of the foot just proximal to the first metatarsal head upon weight bearing. There may be a history of repeated jumping or running on the balls of the feet or of a crush injury due to a heavy object falling on the foot. The patient may walk by rolling his foot into supination and inversion, thus bearing the majority of the weight on the lateral border of the foot. Palpation directly over the involved sesamoid will cause localized tenderness beneath either the tibial or the fibular sesamoid (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg">Fig. 3a</a>). Look for associated edema and swelling under and around the first metatarsal head. Passive extension of the first metatarsophalangeal joint will aggravate the pain. Placing the patient in low heeled shoes with padding devices which relieve weight bearing under the first metatarsal head are indicated. <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg">Figure 3A. Area of point tenderness of fibular sesamoiditis.</a> Disorders of the Lesser Metatarsal Joints Disorders such as subluxation or dislocation, isolated synovitis, or Freiberg's disease can cause pain limited to a single metatarsophalangeal joint.<a></a> The onset of pain may be insidious and there may or may not be a history of trauma associated with the onset of pain. The patient is usually able to point to the involved area. Pain can be elicited upon palpation of the involved joint and with passive manipulation. Synovial thickening may be appreciated when comparing the thickness of the involved joint to the normal joint of the opposite foot. Interdigital Neuroma The well localized pain associated with an interdigital, or Morton's, neuroma is caused by a thickening of the soft tissues surrounding the common digital nerves on the plantar aspect of the foot and occurs most frequently between the third and fourth metatarsal heads. This entity occurs frequently in women and probably results from the repeated trauma to the metatarsal region caused by the wearing of high heeled shoes. The patient is usually able to point out the area of maximum pain on the plantar aspect of the foot, pain which occasionally radiates to the toes, and which is worse with weight bearing when wearing snug, thin soled shoes. Removing the shoes and massaging the foot usually affords some temporary relief. The physical examination will be normal to inspection, but upon palpation pain can be elicited by squeezing the soft tissues between the involved metatarsal heads. This is done by using the thumb and forefinger of one hand to simultaneously press from dorsal and plantar while compressing all the metatarsal heads medially and laterally with the opposite hand (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-5.jpg">Fig. 3b</a>). Occasionally, the enlarged nerve tissue can actually be felt to roll between the finger and the thumb. <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-5.jpg">Figure 3B. Technique for eliciting tenderness of interdigital neuroma between third and fourth metatarsal heads.</a> Keeping the pressure off the involved area with a metatarsal support proximal to the metatarsal heads and eliminating snug, high heeled shoes can be helpful in decreasing the pain. Rheumatoid Arthritis The typical advanced deformities of rheumatoid arthritis causing metatarsalgia are hallux valgus with lateral deviation and dorsal dislocation of the lesser metatarsophalangeal joints. This results in the distal displacement of the plantar fat pad, thus leaving the metatarsal heads displaced plantarly with insufficient fat pad coverage (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-7.jpg">Fig. 3c</a> and <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-8.jpg">Fig. 3d</a>). Broad, soft soled shoes with an adequate height of the toe box to accommodate the deformities are necessary. Providing a soft, total contact insert with metatarsal padding proximal to the prominent metatarsal heads is helpful in decreasing the weight born by the metatarsal heads and more evenly distributing the weight across the sole of the foot. <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-7.jpg">Figure 3C. Typical forefoot deformities of rheumatoid arthritis-hallux valgus and dorsal dislocation of metatarsalphalangeal joints (plantar view).</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-8.jpg">Figure 3D. Typical forefoot deformities of rheumatoid arthritis-hallux valgus and dorsal dislocation of metatarsalphalangeal joints (lateral view).</a> Pes Cavus A common complaint of the person with pes cavus, or a high arch, foot deformity is metatarsalgia. The elevated arch results in greater weight being borne on the metatarsal heads. The cavus foot is more rigid and, thus, has less shock attentuation capability than the normal, more supple foot. Metatarsalgia can be worsened in the presence of clawing of the toes, which involves hyperextension of the metatarsophalangeal joints, thus making the metatarsal heads even more prominent plantarly. The deformity can best be appreciated on physical exam by watching the patient in a standing position. In addition to the elevated longitudinal arch, heel varus may be noted. Plantar flexion of the first ray may be present and can be seen by viewing the foot anteriorly with the patient seated. Stabilize the calcaneus in alignment with the tibia and note the level of the plantar aspect of the first metatarsal head relative to the others. The patient with metatarsalgia secondary to pes cavus may benefit from a soft arch support to increase the weight bearing surface of the foot and to improve shock attenuation. <h3>Ankle Instability</h3> Ankle instability may be the result of lateral ligamentous laxity, a varus heel, or a varus an-gulated tibia.<a></a> A patient with lateral ligamentous laxity of the ankle may give a history of having initially sustained an ankle sprain secondary to significant ankle trauma followed by recurrent sprains with minimal or no trauma. The wearing of high heeled shoes worsens the tendency of recurrent ankle sprains as this further throws the foot into supination. Ligamentous laxity causing ankle instability can usually be demonstrated by the "lateral talar tilt" test. The ankle is stress tested both in dorsiflexion, to test the calcaneofibular ligament, and in plantarflexion, to test the anterior talofibular ligament. The tibia is held stationary as the examiner applies pressure on the lateral aspect of the hindfoot in a medial direction (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-9.jpg">Fig. 4</a>). The ankle, which lacks adequate ligamentous support, will tilt medially indicating instability. <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-9.jpg">Figure 4. "Lateral talar tilt" test for ankle instability.</a> The presence of heel varus can be appreciated by viewing the patient from behind as he stands with shoes removed. It will be noted that the calcaneous is medial to the longitudinal axis of the tibia. Upon manipulation of subtalar joint motion, there may be decreased eversion of the calcaneous relative to inversion. A person who had a varus angulated tibia, either from a congenital deformity or secondary to a tibia fracture which has united in varus, may also experience ankle instability. With such malalignment, the biomechanical forces pass lateral to the center of the calcaneous. Observing the standing patient from the front, the examiner will note that an imaginary plumb line dropped from the center of the patella will fall lateral to the center of the ankle on the affected side. A lateral heel and sole wedge tilts the hind-foot into slight valgus to help prevent recurrent ankle instability. <h3>Summary</h3> The principles of clinical assessment of four common clinical problems for which orthotic treatments are prescribed have been discussed. The information gained from the medical history and physical examination used in clinical assessment of foot problems can aid the ortho-tist in improving his or her effectiveness as a vital member of the foot care team. References: <ol> <li>Baxter, Donald E., "The Evaluation and Treatment of Forefoot Problems in the Athlete" (Unpublished manuscript).</li> <li>Baxter, Donald E. and C. Mark Thigpen, "Heel Pain-Operative Results," Foot & Ankle, 5:1, 1984, pp. 16-25.</li> <li>Johnson, Kenneth, "Tibialis Posterior Tendon Rupture," Clinical Orthopaedics & Related Research, 166, 1983, pp. 143-150.</li> <li>Mann, Roger A., "Biomechanical Approach to the Treatment of Foot Problems," Foot & Ankle, 2:4, 1982, pp. 205-212.</li> <li>Mann, Roger A., "Metatarsalgia," Postgraduate Medicine, 75:5, 1984, pp. 150-167.</li> <li>Mann, Roger A. Surgery of the Foot, The C.V. Mosby Co., 1986.</li> </ol> *Karen S. Seale, M.D. Karen S. Seale, M.D. is assistant professor in the Department of Orthopedics, University of Arkansas Medical School Center Page Number(s) 44 - 50 Year 1988 Volume 12 Issue 2 Figure 1 FIGURE 1A http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-1.jpg FIGURE 1B http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-2.jpg Figure 2 FIGURE 2A http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-3.jpg FIGURE 2B http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg Figure 3 FIGURE 3A http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-5.jpg FIGURE 3B http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-6.jpg FIGURE 3C http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-7.jpg FIGURE 3D http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-8.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-9.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review 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 Analysis of Foot Problems Creator An entity primarily responsible for making the resource Karen S. Seale, M.D. *