1 20 371 https://staging.drfop.org/files/original/9df687fab2e971e5bdb448b8747dc9eb.pdf 78bf41dbabb6870890e75cc378aa3af1 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/1978_01_004.pdf Text Any textual data included in the document <h2>"Should Functional Ambulation Be a Goal for Paraplegic Persons." - Readers' Comments</h2> <p>The <a href="cpo/1977_04_004.asp">above article</a>, which appeared in the last issue of the Newsletter elicited a great number of responses from physicians, orthotists-prosthetists, therapists, and counselors. More than 90 percent of our respondents agreed with Michael Quigley's position that the majority of paraplegic patients should be fitted with lower-limb orthoses despite the fact that use of such orthoses is extremely inefficient. The major reason for providing these orthoses to patients is to either have the patient prove to himself that he will not be able to walk in a normal manner again, or to make sure that every patient has a chance to walk, inasmuch as few patients are able to use orthoses even for transfer purposes or upright mobility.</p> <p>The following comments represent a consensus from our respondents:</p> <h3>Indications For Fitting Paraplegics With Orthoses:</h3> <p>Most respondents agreed that the T₁₀ lesion level seemed to be on the border between a functional ambulator and a non-ambulator. One or-thotist-prosthetist responded that in his area the L1 level is used, as this is the most proximal innervation of the major hip flexors and hip hikers.</p> <p>Margaret Henry, R.P.T., of the Mt. Wilson Center in Maryland stated that the patient must first have abdominal muscles present and have a desire to walk. He is then fitted with trial braces and must be able to complete 200 lattisimus dorsi push-ups before he is fitted with his own braces. This exercise is used to determine if the patient would have the strength and endurance to ambulate functionally.</p> <p>Another therapist stated, "I enjoyed the article and comply with author. However the reasoning behind Cerney's conclusions or Hus-sey's conclusions are faulty. Their conclusions are valid only on the type of braces their patients had and type of training. Study should be qualified!"</p> <p>A rather interesting letter was sent in by Howard V. Mooney, CP. of Burlington, Massachusetts. Mr. Mooney stated that he had no experience with paraplegics but mentioned similar experiences with bilateral, above knee amputations. Mr. Mooney stated "I learned early in the profession that to some there is no such word as 'fail.' " He states that it is his policy to describe the facts and the pitfalls of walking on two above-knee prostheses but if the patient still wants to continue he gives them all the help and encouragement possible.</p> <h3>What Orthotic Designs Do You Recommend For Paraplegic Patients?</h3> <p>The most commonly mentioned design of orthosis is the Scott-Craig KAFO. The respondents preferred this because of the simplicity of design, the lack of a pelvic band, ease of donning, and control of ankle motion. Those readers that did not use the Scott-Craig system preferred plastic molded knee-ankle-foot orthoses or light-weight designs. No one recommended the use of a pelvic band.</p> <p>All respondents were quick to point out the indications for orthoses for children and polio patients differed from that for adult traumatic paraplegic patients.</p> <p>John Glancy, C.O., University of Indiana, Indianapolis feels that rehabilitation practitioners are making a mistake when they assume that present designs of orthoses begin to provide the mechanical aid paraplegics require. Mr. Glancy feels that patient's motivation towards walking is generally poor because they have to work with such inadequate orthotic systems. Mr. Glancy is presently working on a system that uses elastic material as a source of external power and sees this as a possible solution to the problem.</p> <h3>Is It Practical To Expect Ambulation With LSHKAFO's (Bilateral Long Leg Braces With Night Spinal Attachments)?</h3> <p>A resounding "no!" was given by all to this question. One respondent stated that this type of orthosis is too cumbersome and hard to don and that if the patient is so severely involved that he needs this measure of stabilization he undoubtedly lacks adequate muscular and respiratory reserve to ambulate any distance and is better off with a wheelchair. Mr. Robert Penny, C.O. of the Shelby State Community College and Leo Betzelberger, R.P.T. of the VA Spinal Cord Injury Center, Memphis, Tennessee stated that we have had 3000 (conservative) spinal-cord-injury patients as of 1948 and gradually abandoned LASKAFO's as they were just thrown in the closet. We found patients could ambulate up to T₁₀ with KAFO's in parallel bars. Daily living at home negates KAFO's too. We do try to keep them in metal KAFO's for dorsiflexion and ankle protection.</p> <p>Probably the most interesting response on this question came from Frank W. Clippinger, M.D., Duke University Medical Center, Durham, North Carolina. Dr. Clippinger stated "from a purely practical standpoint anyone in their right mind won't bother with this. By locking the trunk to the thighs and the legs to the feet is not standing in the true sense. It is lying down vertically. I think this treats the therapist, orthotist and the doctor but not the patient. The same function can be accomplished using a coffin instead of braces as is perfectly evident in the Egyptian section of any museum."</p> <p>In summary, the vast majority of all respondents felt it was important to give paraplegic persons the chance to stand and ambulate for the many reasons stated above. The term "motivation" ranked very high on everyone's list as one of the major indications for providing orthoses to paraplegic persons. For this reason I think it is proper to finish this synopsis of our readers comments with another quote from Howard Mooney, CP., "Never underestimate the potential of anyone with unlimited motivation."</p> Page Number(s) 4 - 5 Year 1978 Volume 2 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Text Copy Edit 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 "Should Functional Ambulation Be a Goal for Paraplegic Persons." - Readers' Comments https://staging.drfop.org/files/original/30c31f3ab0a1bb7bf6b2fed3d44ab98e.pdf 1b4c13b6fe4572542d88a4b6b1765e21 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/1977_03_001.pdf Text Any textual data included in the document <h2>"The Geriatric Amputees" - Results of the Questionnaire</h2> <p>There were twenty-three replies by mail to the questionnaire on management of lower-limb geriatric amputees that appeared in the Spring 1977 issue of the NEWSLETTER. Ten were signed by prosthetists, five came from M.D.'s and two from therapists. The remarks included on the six unsigned forms appear to have come from prosthetists.</p> <p>The raw results, question-by-question, are shown below:</p> <ol> <li> <p class="kapow"><b>Should the prosthesis weigh less than conventional prostheses?</b></p> <p class="kapow"><i>PROSTHETISTS</i></p> <blockquote> <p class="kapow">AK yes: 15, No: 1<br />BK yes: 14, No: 2</p> </blockquote> <p class="kapow">Comments made by the prosthetists:</p> <ul> <li> <p>They cannot be made too light.</p> </li> <li> <p>We use endoskeletal AK set ups and light feet as often as possible to reduce weight.</p> </li> <li> <p>Yes. Unless "conventional" prostheses are already very light. BK's should weigh between 1 1/2 - 3 lbs. and AK's from 4 1/2 — 6 1/2 lbs. Decreases energy consumption, eases suspension. Soon, however, new materials and techniques should allow all prostheses to weigh about the same. Major difference for geriatrics is not weight but socket comfort and cost.</p> </li> <li> <p>A major complaint from the geriatric patient is the weight of the prosthesis.</p> </li> <li> <p>In most cases conventional prostheses are prescribed and the geriatric patient has trouble with them usually because of the weight. But age and strength are the difference.</p> </li> <li> <p>This is debatable, each case should be considered individually. I feel that most geriatric males would prefer a conventional prothesis.</p> </li> <li> <p>As much weight as you can knock off the better. The old story of the leg being so light that in a strong wind it is hard to control, just a tale.</p> </li> <li> <p>Whenever possible, a light-weight prosthesis is desirable for geriatric patients.</p> </li> <li> <p>Patients' resources less and need for strength not important,</p> </li> <li> <p>I do not feel that this is a very major issue as far as function is concerned. Most patients complain about weight early but those who do function do not continue these complaints,</p> </li> <li> <p>It is generally desirable that prostheses be as light as possible.</p> </li> <li> <p>Light limbs seem to be tolerated much more than the heavy limb.</p> </li> <li> <p>An attempt is always made to maintain lightness in all prostheses, however, especially AK geriatrics who are fighting quite a lever arm in regard to weight.</p> </li> <li> <p>The decrease in energy out-put during ambulation is very important for the geriatric amputee. Decrease in weight decreases energy out-put which in turn decreases the stress on the cardiovascular system.</p> </li> <li> <p>Even where a geriatric has not experienced an amputation, there is loss of muscular strength. This is the primary-reason for a lighter prosthesis.</p> </li> </ul> <p><i>PHYSICIANS</i></p> <p>AK Yes: 5, No: 1<br />BK Yes: 4, No: 2</p> <ul> <li> <p>If the geriatric amputee is unable to manage the conventional prosthesis, making a lighter limb increases his difficulties when walking in a high wind or deep snow. In these cases I fit the geriatric amputee with an articulated peg leg invariably with a successful result.</p> </li> <li> <p>Initially they do quite well, however, a lighter, especially AK prosthesis would help.</p> </li> <li> <p>I think <em>all</em> prostheses should weigh less, particularly for geriatrics. The prosthetists should go to extra lengths to thin out the shell of exoskeletal limbs as thin as possible and consistent with durability. This is just not done enough with the shins of AK and BK prostheses.</p> </li> <li> <p>If there is sensory loss, a heavier prosthesis for sensory feedback may be necessary.</p> </li> </ul> <p><i>THERAPISTS</i></p> <ul> <li> <p>One therapist felt that both the AK and BK prosthesis should weigh less than the conventional and commented that "Patients seem to prefer an extremely lightweight prosthesis." The other therapist did not check any of the boxes but wrote in "Individualized Adjustment" and commented that "A neurophysiological functional evaluation should determine if the patient responds better to heavier or lighter sensory bombardment."</p> </li> </ul> <p style="margin-left: auto; margin-right: auto;"><i>DISCUSSION</i></p> <p>The great majority of clinicians seem to feel that lower-limb prostheses that weigh less than those generally available are desirable for the older patient.</p> </li> <li> <p><b>What type of knee do you generally use for above-knee cases?</b></p> <p style="text-align: center;"><i>PROSTHETISTS</i></p> <table style="border-style: none; width: 338px; margin-left: auto; margin-right: auto;" height="120"> <tbody> <tr> <td>Manual lock</td> <td>6</td> </tr> <tr> <td>Weight-bearing (Safety Knee)</td> <td>10</td> </tr> <tr> <td>Other (please specify)</td> <td>11</td> </tr> </tbody> </table> <p>Prosthetists' comments were as follows:</p> <p><i>Manual Lock:</i></p> <ul> <li> <p>Treatment for the dysvascular amputee should always be separated from geriatric amputees with other causes for amputation at Rancho, well over 90 percent of amputations are secondary to vascular problems. Manual lock knees have cut down PT time by two weeks, and, combined with an adjustable socket, have made it possible to convert nearly all of our dysvascular AK's into prosthesis wearers and more importantly, they use them.</p> </li> <li> <p>At our clinic either the adjustable AK "Rancho design" or conventional AK have locking knees.</p> </li> <li> <p>We have not been pleased with the various "safety" knees. The only really useful one is the SHS — we do not use it for geriatric patients, but it's the best.</p> </li> <li> <p>Balsa Lock knee, wherever possible, light weight foot with soft heel. Polypropylene joint and band (where stump is long)</p> </li> </ul> <p><i>Weight-Bearing (Safety-Knee):</i></p> <ul> <li> <p>The friction lock type of knee will work for 80% of the AK's.</p> </li> <li> <p>The weight-bearing knee seems to be the most easily managed by elderly amputees.</p> </li> <li> <p>Manual lock knees only when safety knee is inadequate.</p> </li> <li> <p>I prefer endoskeletal.</p> </li> <li> <p>About 90% of our geriatric patients are fitted with friction locking knees and 10% are fitted with manual locks.</p> </li> <li> <p>Aside from poorer musculature, the evidence of less proprioception illustrates that the AK geriatric has difficulty knowing where his knee and foot are. Only in extreme severe muscular weakness is a manual lock prescribed.</p> </li> </ul> <p class="kapow"><i>Manual lock &amp; Weight-bearing (Safety) Knee:</i></p> <p class="kapow">Varies with patient need.</p> <p class="kapow"><i>All three types marked:</i></p> <ul> <li> <p>Depends on needs of the patient and his ability to control the knee with his own efforts, as well as his expected level of performance.</p> </li> </ul> <p><i>Other:</i></p> <ul> <li> <p>Constant friction knee for the elderly. Not much maintenance problem. Variable gait is not an important factor. Mauch S-N-S for the younger amputee.</p> </li> </ul> <p><i>None Marked:</i></p> <ul> <li> <p>My approach is to evaluate each person individually. Our primary knee is the Bock Safety knee, relying primarily upon alignment stability and fast plantar flexion of S/A foot. I use Kolman only when absolutely necessary due to noise problems.</p> </li> </ul> <p style="text-align: center;"><i>PHYSICIANS</i></p> <table style="border-style: none; width: 390px; margin-left: auto; margin-right: auto;" height="116"> <tbody> <tr> <td>Manual lock</td> <td>2</td> </tr> <tr> <td>Weight-bearing (Safety Knee)</td> <td>3</td> </tr> <tr> <td>Other (please specify)</td> <td>0</td> </tr> </tbody> </table> <p>The physicians comments were as follows:</p> <p><i>Manual Lock:</i></p> <ul> <li> <p>Bock Geriatric. Most often. Weight-bearing (Safety) knee, seldom. Often knee lock with option to give constant friction if open, as a trial.</p> </li> <li> <p>Safety is very important. There is more energy required to operate a safety knee (Bock). I reserve it for the younger amputee.</p> </li> </ul> <p><i>Weight-Bearing Safety Knee:</i></p> <ul> <li> <p>We need a manual lock that is sturdier than the Bock geriatric knee. Ideally someone should manufacture a lock that could be placed on the outside of the prosthesis so that if patient finally confident enough with free knee after practice he could remove it.</p> </li> <li> <p>I usually use the Otto Bock Safety knee which stands use by the geriatric amputee well. However, have run into breakdown problems with this knee in my younger patients.</p> </li> </ul> <p><i>THERAPISTS</i></p> <p>The comments from the two therapists were:</p> <ul> <li> <p>Knee usually depends on patient's functional demands, equipment cost, prosthetist convenience in non-standard set-ups in that order.</p> </li> <li> <p>My training is deficient in the prosthesis — but excellent in observation of physiological response.</p> </li> </ul> <p><i>DISCUSSION</i></p> <p>Opinion on use of manual lock versus the weight-bearing (Safety) knee is slightly in favor of the weight-bearing (Safety) knee. Certainly the weight-bearing units provide more function and better appearance when they can be used. It is gratifying to find that so many prosthetists and physicians are being successful with the more functional units.</p> </li> <li> <p><b>In your opinion is the use of stubbies for bilateral AK cases desirable?</b></p> <p>PROSTHETISTS</p> <p>Yes: 7<br />No: 8<br />No experience: 1</p> <ul> <li> <p>No, Have not used them for 5 years — patients would not wear them after six months.</p> </li> <li> <p>No. We have used them, however, the cases were to prove to the patient the difficult task it is to master bilateral AK prostheses. The stubbie is a substitute but not a good one.</p> </li> <li> <p>No. Much trouble and expense for very little benefit. Most should not be fit at all. If fit, shorten slightly but include knee joints for sitting purposes. Stubbies cause problems in wheelchairs, look horrible and do not convert non-users of prostheses into users.</p> </li> <li> <p>No. In most cases the bilateral AK patient has had extensive vascular surgery and scars in abdomen and scarpas are too much of a problem.</p> </li> <li> <p>No. Most would rather sit in a wheelchair.</p> </li> <li> <p>No. We have not had the occasion to use them. Geriatric amputees, with therapy, are able to use light-weight prostheses with weight bearing knees.</p> </li> <li> <p>No. We've tried stubbies in a few cases where we thought the patient could eventually go to regular legs. A better idea is pylons — you can adjust them. No one uses stubbies permanently — a wheelchair is much more functional.</p> </li> <li> <p>No. Stubbies make patients look like "freaks", they think. Patients are more functional in wheelchairs.</p> </li> <li> <p>Yes. Only if there is a good P.T. program.</p> </li> <li> <p>Yes. To permit A.D.L. in the home — We have 2 cases of short A.K.'s who did so well they demanded full length prostheses and did fair.</p> </li> <li> <p>Yes. As temporaries to define the patient's functional potential both to him and to the clinic team.</p> </li> <li> <p>Yes. If bilateral amputation occurs simultaneously.</p> </li> <li> <p>Yes. It is a way to allow an individual independence and mobility without the problems of knee control.</p> </li> <li> <p>Yes. There are amputees that can walk with stubbies and not walk with bilateral A/K prostheses therefore it is desirable in obtaining an accurate assessment of prosthetic potential.</p> </li> <li> <p>Yes. Bilateral stubbies offer safety that no AK with knees can offer. The CG is closer to the earth, and there is less weight to be manipulated. I would recommend stubbies for the desirable active AK.</p> </li> <li> <p>No opinion. I have no experience in this area.</p> </li> </ul> <p><i>PHYSICIANS</i></p> <p>Three physicians were opposed to the use of stubbies and two felt that their use is indicated.</p> <p>The physician's comments were:</p> <ul> <li> <p>No. Stubbies are unsightly ugly things, besides (they) cost as much as prostheses. I very seldom prescribe bilateral AK prostheses to geriatric patients. The few knees I did, the prosthesis ended up in the closet. However, an occasional patient may do well, however, when the prostheses are made several inches shorter than patient's original height. Each patient is pretested with pylons.</p> </li> <li> <p>No. I do not believe in fitting bilateral AK's with vascular disease. If young and vigorous and traumatic — and candidate for limited walking with bilateral AK prostheses — should be fitted with full length.</p> </li> <li> <p>No. Not in the geriatric, but useful in young adults.</p> </li> <li> <p>Yes. Useful around the house if patient wants them. Cosmesis bad. Useful for training.</p> </li> <li> <p>Yes. I regard this as an essential if the bilateral amputee is to learn to walk satisfactorily.</p> </li> </ul> <p><i>THERAPISTS</i></p> <p>Both therapists felt that use of stubbies is desirable. Their comments were:</p> <ul> <li> <p>Yes. Stubbies are desirable to demonstrate to most patients that the amount of energy expended is usually not worth the effort, from a functional point of view.</p> </li> <li> <p>Yes. Any reasonably balanced device helps maintain balance and muscle strength. Prevention of disuse atrophy.</p> </li> </ul> <p><i>DISCUSSION</i></p> <p>The respondents were almost equally divided on the issue of stubbies, and without exception each respondent offered a comment. The comments seem to indicate that in spite of drawbacks stubbies can be used successfully in certain settings, and that a careful, thorough evaluation of this procedure is needed.</p> </li> <li> <p><b>In your opinion, is immediate postsurgical fitting of prostheses desirable for geriatric cases?</b></p> <p><i>PROSTHETISTS</i></p> <p>Eleven prosthetists felt that immediate postsurgical fitting is indicated for geriatric patients; five felt that the procedure was contraindicated, while one felt that it would probably be useful if orthopaedic surgeons performed the amputations.</p> <p>Their comments are as follows:</p> <ul> <li> <p>Yes. We only recommend a rigid dressing. Only after wound healing has been ascertained do we apply a pylon.</p> </li> <li> <p>Yes. If there is a good P.T. program; otherwise only the rigid dressing should be used.</p> </li> <li> <p>Yes. This treatment doesn't allow the geratric amputee to become comfortable in a wheelchair thus losing strength and endurance.</p> </li> <li> <p>Yes. The PT Department starts working with the patient within 24 hours and the chances are (that) contractures and depression won't occur.</p> </li> <li> <p>Yes. BK's only. AK's too much trouble for benefit accrued.</p> </li> <li> <p>Yes. Immediate fitting is good for everyone. But its hard to do — hard to supervise, takes a lot of effort so its not done.</p> </li> <li> <p>Yes. For below-knee patients who have the ability to coordinate the post surgical dressing and pylon.</p> </li> <li> <p>Yes. I feel immediate post surgical fittings minimize loss of strength which is very critical in the geriatric cases.</p> </li> <li> <p>Yes. I.P.S. fittings are desirable for any amputee, aside from trauma cases. The less muscle tone the geriatric loses the better his chances are of becoming a successful prosthetic candidate with I.P.S.F. This is possible.</p> </li> <li> <p>No. The results I have witnessed have been mostly unfavorable. Perhaps if the orthopedic surgeons did more of the amputations it would be more advisable.</p> </li> <li> <p>No. Rigid dressings for BK's should be used for 10-14 days then a temporary prosthesis for 2-4 weeks. Immediate post-surgical fittings encourage too much activity and it is too hard to control the stress the patient is placing on the wound.</p> </li> <li> <p>No. We never use immediate postsurgical fitting. Stumps should be healed before shrinkage is attempted. After stump is healed, we use laminated plastic sockets on temporary units for definitive shrinking.</p> </li> <li> <p>No. Low tolerance.</p> </li> <li> <p>(Nothing marked) It depends on the patient's prior medical history. We would not recommend it for diabetic patients.</p> </li> </ul> <p><i>PHYSICIANS</i></p> <p>Two physicians felt that immediate postsurgical fitting had a place in management of geriatric patients; two felt otherwise; and one had no experience on which to base an opinion.</p> <p>Their comments were:</p> <ul> <li> <p>Yes, <em>If</em> you have full team approach including nurses who fully understand principle. Otherwise early temporary fitting with good control of stump edema may be second best alternative. Two months is still a <em>long</em> delay.</p> </li> <li> <p>Yes. I do not feel that a differentiation need be made unless there are other conflicting medical factors, e.g. heart disease.</p> </li> <li> <p>No. But I prefer rigid dressings with early fitting when wound is fully healed.</p> </li> <li> <p>No. No benefits except psychological, and many dangers. Use of cast is OK in many cases, but adding prosthesis courts disaster.</p> </li> <li> <p>(Nothing marked) I cannot express an opinion since in our institution immediate post surgical fitting is not being done at all.</p> </li> </ul> <p><i>THERAPISTS</i></p> <p>Both therapists felt that immediate post surgical fitting is useful.</p> <p>Their comments were:</p> <ul> <li> <p>Yes, . . . but please see abstract of article to be published in American Journal of Surgery {<em>which will be publishing in a future issue. Ed</em>.). I feel that very few people now are using the prosthesis on an immediate basis, but our prospective study well documents the value of the rigid dressing in the postoperative care of the BK amputee.</p> </li> <li> <p>Yes. Normal physiology maintained at maximum potential.</p> </li> </ul> <p><i>DISCUSSION</i></p> <p>The replies to this question indicate that the use of a rigid dressing is used widely and that immediate postsurgical fitting is used more than is generally expected. Perhaps the reports on the study at Iowa will encourage others to adopt these advanced techniques. Other clinics with experience should publish results of their clinical program.</p> </li> <li> <p><b>In your opinion what is needed to improve the function of geriatric amputees?</b></p> <p>All of the respondents commented on this question.</p> <p>Their comments were as follows:</p> <p><i>PROSTHETISTS</i></p> <ul> <li> <p>The lightest prosthesis with the safety factor at the knee system (being) the main factor.</p> </li> <li> <p>A better method of suspending the AK prosthesis. Total suction does not work, rigid pelvic belt is a fair substitute, but (is) heavy. Something better is needed.</p> </li> <li> <p>Vascular surgery is often indicated but compounds our fitting problems. After several surgical procedures — physiologically and psychologically the patients require more professional service — let us all hope that more orthopedists would become more involved in amputation surgery.</p> </li> <li> <p>An adjustable BK socket that is permanent. It can be fit(ted) instead of a "temporary" and will adjust throughout the "maturing" process. (It) will save time, as patient can adjust it and since a temporary is not needed, it will save dollars. Most physicians are looking for a cheap geriatric prosthesis, although they will state "light duty" or "lightweight" or "sitting prosthesis."</p> </li> <li> <p>I believe the prosthetic components that we have now are all we need: However the P.T. program needs to be reevaluated.</p> </li> <li> <p>Better pre-op and initial post-op care.</p> </li> <li> <p>This is where the total team is so very necessary. Pre-surgical consultation, pre-prosthetic care and post prosthetic training and followup. Outpatient care for the amputee is practically overlooked by the doctors and the subsidizing agencies, the insurance companies, Medicare and Medicaid. The patient can only receive adequate care as an inpatient. Usually his funding is exhausted by the time he is ready for prosthetic fitting.</p> </li> <li> <p>A lightweight single axis foot. More training for surgeons (general and vascular) to give the patient a chance for a BK, when the problem is in the toes or ankle; also teach them how to bevel and round the tibia.</p> </li> <li> <p>Articles such as this help spread information that geriatric patients can utilize a prosthesis. Motivation is an important factor. Two days ago we fitted a 91-year-old man with a prosthesis and his initial attempts have been excellent.</p> </li> <li> <p>Lighter prostheses, greater emphasis on use of temporaries in early phase of rehabilitation.</p> </li> <li> <p>Quicker fabrication and more adjustable prostheses. We use Polysar sockets and pylons. We can make adjustments easily and get (out) the prosthesis quickly.</p> </li> <li> <p>The limiting factors in geriatric amputees are motivation, coordination, and endurance. The therapist has the best chance to do something about these things.</p> </li> <li> <p>Patient compliance and patience with the amputee.</p> </li> <li> <p>Better post-surgical physical therapy. Some method to decrease the long periods of inactivity and confinement to a bed prior to amputation.</p> </li> </ul> <p>Follow-up programs.</p> <ol> <li> <p>Successful therapy program (before and after fitting)</p> </li> <li> <p>A competent prosthetist — follow-up necessary</p> </li> <li> <p>A sound instillation of confidence to the geriatric</p> </li> <li> <p>A good exoskeletal safety knee (needs) to be developed.</p> </li> </ol> <p><i>PHYSICIANS</i></p> <ul> <li> <p>Enthusiastic team work and total care of the patient to include medical, socioeconomic and vocational aspects.</p> </li> <li> <p>Immediate referral to a rehabilitation department to teach necessary conditioning exercise, range of motion exercise to prevent contracture and stump conditioning.</p> </li> <li> <p>More interest and concern of plight of elderly person with vascular disease by surgeons in particular, but also by physicians in general. And I don't mean simply interest in the pathophysicology and surgical approaches to arteriosclerosis.</p> </li> <li> <p>Improved sensory feedback</p> </li> <li> <p>Improved training procedures</p> </li> <li> <p>Improved knowledge of what the patient <em>really </em>needs</p> </li> </ul> <p><i>THERAPISTS</i></p> <p>My concern is the bracing needed for C.V.A.'s. Our suggestion to our Medical Chief of Staff is to invite your representative to hold a seminar in our hospital.</p> <p>Generally we need to sell the success of fitting the geriatric AK from the standpoint of requiring less in terms of third-party paid institutionalization or purchased services. An AK patient on a walker is much easier to deal with than a one-legged wheelchair-bound patient. In short, we need to emphasize the 4 successes of 10 attempts, and demonstrate this success in a cost-effective manner. This is the only language cost conscious bureaucrats will understand. Additionally, many patients report positive attributes of independence in gait, so they "don't have to depend on or bother their family or friends." At the same time, we need to strive to improve our care package so as to raise the percentage of AK's who become independent with their prostheses.</p> </li> </ol> <p><i>SUPPLEMENTARY DATA</i></p> <p>To augment the data provided by the 23 questionnaires returned through the mail, prosthetists attending the instructional course in molded plastics sponsored by the American Academy of Orthotists and Prosthetists and held in Kansas City, Missouri, July 15-16, 1977, were asked to fill out the questionnaire. Forty-one did so. The results are given below:</p> <ol> <li> <p>Should the prosthesis weigh less than conventional prostheses?</p> <p>AK Yes: 41 No: 0 No mark: 0<br />BK Yes: 39 No: 0 No mark: 2</p> </li> <li> <p>What type of knee lock do you generally use for above-knee cases?</p> <table style="border-style: none; width: 402px; margin-left: auto; margin-right: auto;" height="116"> <tbody> <tr> <td>Manual lock:</td> <td>15</td> </tr> <tr> <td>Weight-bearing (Safety Knee):</td> <td>22</td> </tr> <tr> <td>Other:</td> <td>3</td> </tr> <tr> <td>No mark:</td> <td>5</td> </tr> </tbody> </table> <br /> <p>(Four people marked two places. Most of the 5 not marked made some kind of comment.)</p> </li> <li> <p>In your opinion is the use of stubbies for bilateral AK cases desirable?</p> <table style="border-style: none; width: 401px; margin-left: auto; margin-right: auto;" height="123"> <tbody> <tr> <td style="text-align: left;">Yes:</td> <td style="text-align: left;">21</td> </tr> <tr style="text-align: left;"> <td>No:</td> <td>19</td> </tr> <tr style="text-align: left;"> <td>No mark:</td> <td>2</td> </tr> </tbody> </table> <br /> <p>(One person checked both yes and no.)</p> </li> <li> <p>In your opinion is immediate postsurgical fitting of prostheses desirable for geriatric cases?</p> <table style="border-style: none; width: 400px; margin-left: auto; margin-right: auto;" height="121"> <tbody> <tr> <td>Yes:</td> <td>25</td> </tr> <tr> <td>No:</td> <td>14</td> </tr> <tr> <td>No mark:</td> <td>2</td> </tr> </tbody> </table> </li> <li> <p>In your opinion what is needed to improve the function of geriatric amputees?</p> <ul> <li> <p class="kapow">Improved knees and feet of lighter weight.</p> </li> <li> <p>In hospital prosthetic facilities so therapists and prosthetists could give combined and closer supervision to walking training, etc.</p> </li> <li> <p>Suspension in geriatrics seems to cause weight and cosmetic problems.</p> </li> <li> <p>A good pre-prosthetic program, a qualified P.T. and a well fitting lightweight prosthesis.</p> </li> <li> <p>Proper post surgical supervision and gait training with prosthesis. Lighter prosthesis that is more comfortable.</p> </li> <li> <p>A good sound Rehabilitation program: 1. Good Amputation; 2. Good prosthesis; 3. Good P.T.</p> </li> <li> <p>Simple donning procedures — less weight, uncomplicated mechanics to understand.</p> </li> <li> <p>Closer observation and good rehabilitation work after surgery so the patient will have the best chance possible of becoming self-sufficient.</p> </li> <li> <p>Reduced weight/energy consumption.</p> </li> <li> <p>Getting them in better physical condition prior to prosthetic fitting.</p> </li> <li> <p>Better physical therapy and PT follow-up.</p> </li> <li> <p>Better materials other than plaster, transparent materials perhaps, lighter weight, orthoplast possibly.</p> </li> <li> <p>More the patients can do for themselves, less care needed by other people.</p> </li> <li> <p>Feather weight prostheses, and 2) team approach management.</p> </li> <li> <p>You can put a safety knee and a two way ankle.</p> </li> <li> <p>(I don't know) I have been fitting AK prosthesis for only a year therefore the above information may not be of value due to my personal lack of experience.</p> </li> <li> <p>Lighter materials.</p> </li> <li> <p>Better communication between the doctor, therapist, prosthetist and patient.</p> </li> <li> <p>Most patients need one person, as overseer, who can control his rehab program, — a coordinator.</p> </li> <li> <p>Immediate post-operative fitting.</p> </li> <li> <p>Lighter prosthesis.</p> </li> <li> <p>Increased physical therapy, —early as possible.</p> </li> <li> <p>More lighter and durable prosthesis and exercise.</p> </li> <li> <p>Exercise.</p> </li> <li> <p>Lighter weight and a more positive attitude about age and life in the future.</p> </li> <li> <p>Proper instruction in wrapping, exercise, etc.</p> </li> </ul> </li> </ol> <p><i>DISCUSSION</i></p> <p>The supplementary data agrees remarkably well with that received through the mail, and only reinforces any conclusions that can be reached from the information supplied by the original 23 respondents.</p> <p>It seems that geriatric patients are receiving considerable attention throughout the country and while the results are good considerable refinement in devices and techniques will be welcomed. Reduction in weight of artificial legs for all levels of amputation through the lower limb seems to be indicated, and improved knee control units are needed by above-knee (and hip-disarticulation) cases. The use of stubbies certainly needs clarification, probably through a well-ordered study.</p> Page Number(s) 1 - 5 Year 1977 Volume 1 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource "The Geriatric Amputees" - Results of the Questionnaire https://staging.drfop.org/files/original/a4f59375f598279295c7fa943e156114.pdf 38aeeeab3d42cf740c3e04155a23deb3 https://staging.drfop.org/files/original/e9b5c21d0675e1f7f78eeae1cab0bf9b.jpg 4a5774b4db78fc684a6a1a7c148f1652 https://staging.drfop.org/files/original/179a4b1fdbe7af47f8671ad8dfc3b633.jpg 8d23f991b42aaa11f4865388aa37f444 https://staging.drfop.org/files/original/9e2dbd2dfdbf18308f14c16deffde187.jpg 516724a853eb79700fcc8b01fd9f4d84 https://staging.drfop.org/files/original/1ab8a3dcf922e1807accda3da54464e0.jpg 9a39560b010e50dd6076068288acd2a6 https://staging.drfop.org/files/original/8048c3cccd316e71ba2b766352368f1c.jpg e4881b396eb266d26e006c1872396510 https://staging.drfop.org/files/original/408763c312b92eca57665f96ace6e393.jpg f061728c01505d148eeca0704ad78939 https://staging.drfop.org/files/original/5539898a198c7a2106d020b39fbb42c9.jpg 7c5b6091748cc36c772f24eaec77668d https://staging.drfop.org/files/original/0fcd332e5c3c16557b9d2e6c049ab526.jpg 70ce52088e0c35f7c9c26b4762c38040 https://staging.drfop.org/files/original/4055a7a2c59d5a522d1e6cf32a0024af.jpg 64c5a270fedf2bd0199cd04498816491 https://staging.drfop.org/files/original/3ae56f5fbb8bf7c542f880fa056513da.jpg 3870cc3795e9a198097bd24bce53b023 https://staging.drfop.org/files/original/315fe14538fad0ed846aa9c5779de2f4.jpg a38b7afdc54124fb2c4fdfaa676a7eb4 https://staging.drfop.org/files/original/f0655872a5389e27f34b64a4975e5f09.jpg 0324b1ddac21e26db1e4d683035350a4 https://staging.drfop.org/files/original/8dc1c46b125a02cfeaac768c7a8b3ff9.jpg 8d644d9b4b557aa4e149b1a298c9728d https://staging.drfop.org/files/original/bc33be62f16216b29a7eefb543073589.jpg eec0b67878c0c03d1f20ca9558e7d867 https://staging.drfop.org/files/original/6741c4989a97f0face9bfbec1b477e07.jpg 6ee4529dba31e6b50c907a3dd975d190 https://staging.drfop.org/files/original/9f8219b9d8441382f6dcedfb9b985f4e.jpg e45df92748138be34e0abfdcfa199ecd https://staging.drfop.org/files/original/4988df0c10cb9d476fd01c9cd3d02880.jpg f3a2809feeb174dec5bc561ff1952898 https://staging.drfop.org/files/original/8d2b6ba0f09f64fc07ef921be89bd5bb.jpg 07fd87bdc0fe603f9a655fd89e76b987 https://staging.drfop.org/files/original/0307da51d6e620c88a84df6a0b08adde.jpg 231b3dc0a2ed2ee57dfe1165c2a9a695 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_01_001.pdf Year 1970 Volume 14 Issue 1 Page Number(s) 1 - 52 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>1970 Limb Prosthetics</h2> <h5>A. Bennet Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>Loss of limb has been a problem as long as man has been in existence. Even some prehistoric men must have survived crushing injuries resulting in amputation, and certainly some children were born with congenitally deformed limbs, with effects equivalent to those of amputation. In 1958 the Smithsonian Institution reported the discovery of a skull dating back about 45,000 years of a person who, it was deduced, must have been an arm amputee, because of the way his teeth had been used to compensate for lack of limb. Leg amputees must have compensated partly for their loss by the use of crude crutches and, in some instances, by the use of peg legs fashioned from forked sticks or tree branches (<b>Fig. 1</b> and <b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Mosaic from the Cathedral of Lescar, France, depicts an amputee supported at the knee by a wooden pylon. Some authorities place this in the Gallo-Roman era. From Putti, V., <i>Historic Artificial Limbs, </i>1930. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Pen drawing of a fragment of antique vase unearthed near Paris in 1862 which shows a figure whose missing limb is replaced by a pylon with a forked end. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The earliest known record of a prosthesis being used by man was made by the famous Greek historian, Herodotus. His classic <i>History, </i>written about 484 B.C., contains the story of the Persian soldier, Hegesistratus, who, when imprisoned in stocks by the enemy, escaped by cutting off part of his foot, and replaced it later with a wooden version.</p> <p>A number of ancient prostheses have been displayed in museums in various parts of the world. The oldest known is an artificial leg unearthed from a tomb in Capua in 1858, thought to have been made about 300 B.C., the period of the Samnite Wars. Constructed of copper and wood, the Capua leg was destroyed when the Museum of the Royal College of Surgeons was bombed during World War II. The Alt-Ruppin hand (<b>Fig. 3</b>), recovered along the Rhine River in 1863, and other artificial limbs of the 15th century are on display at the Stibbert Museum in Florence. Most of these ancient devices were the work of armorers. Made of iron, these early prostheses were used by knights to conceal loss of limbs as a result of battle, and a number of the warriors are reported to have returned successfully to their former occupation. Effective as they werefor their intended use, these specialized devices could not have been of much use to any group other than the knights, and the civilian amputees for the most part must have had to rely upon the pylon and other makeshift prostheses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Alt-Ruppin Hand (circa 1400). The thumb is rigid; the fingers move in pairs and are sprung by the buttons at the base of the palm; the wrist is hinged. From Putti, V., <i>Chir. d. org di movimento, </i>1924-25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the use of ligatures was set forth by Hippocrates, the practice was lost during the Dark Ages, and surgeons during that period and for centuries after stopped bleeding by either crushing the stump or dipping it in boiling oil. When Ambroise Pare, a surgeon in the French Army, reintroduced the use of ligatures in 1529, a new era for amputation surgery and prostheses began. Armed with a more successful technique, surgeons were more willing to employ amputation as a life-saving measure and, indeed, the rate of survival must have been much higher. The practice of amputation received another impetus with the introduction of the tourniquet by Morel in 1674, and removal of limbs is said to have become the most common surgical procedure in Europe. This in turn led to an increase in interest in artificial limbs. Pare, as well as contributing much in the way of surgical procedures, devised a number of Limb designs for his patients. His leg (<b>Fig. 4</b>) for amputation through the thigh is the first known to employ articulated joints. Another surgeon, Verduin, introduced in 1696 the first known limb for below-knee amputees that permitted freedom of the knee joint (<b>Fig. 5</b>), in concept much like the thigh-corset type of below-knee limb still used by many today. Yet, for reasons unknown, the Verduin prosthesis dropped from sight until it was reintroduced by Serre in 1826 and, until recently, was the most popular type of below-knee prosthesis used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Artificial leg invented by Ambroise Pare (middle sixteenth century). From Pare A., <i>Oeuvres Completes, </i>Paris, 1840. From the copy in the National Library of Medicine. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Verduin Leg (1696). From MacDonald, J., <i>Amer.J. Surg., </i>1905. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After Pare's above-knee prosthesis, which was constructed of heavy metals, the next real advance seems to be the use of wood, introduced in 1800 by James Potts of London. Consisting of a wooden shank and socket, a steel knee joint, and an articulated foot, the Potts invention (<b>Fig. 6</b>) was equipped with artificial tendons connecting the knee and the ankle, thereby coordinating toe lift with knee flexion. It was made famous partly because it was used by the Marquis of Anglesea after he lost a leg at the Battle of Waterloo. Thus it came to be known as the "Anglesea leg." With some modifications the Anglesea leg was introduced into the United States in 1839. Many refinements to the original design were incorporated by American limb fitters and in time the wooden above-knee leg became known as the "American leg."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Anglesea Leg (1800). Below knee at left, above knee at right. Knee, ankle, and foot are articulated. From Bigg, H., <i>Orthopraxy, </i>1877. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The American Civil War produced large numbers of amputees and consequently created a great interest in artificial limbs, no doubt inspired partly by the fact that the federal and state governments paid for limbs for amputees who had seen war service.</p> <p>J. E. Hanger, one of the first Southerners to lose a leg in the Civil War, replaced the cords in the so-called American leg with rubber bumpers about the ankle joint, a design used almost universally until rather recently. Many patents on artificial limbs were issued between the time of the Civil War and the turn of the century, but few of the designs seem to have had must lasting impact.</p> <p>During this period, with the availability of chloroform and ether as anesthetics, surgical procedures were greatly improved, and more functional amputation stumps were produced by design rather than by fortuity.</p> <p>World War I stirred some interest in artificial limbs and amputation surgery but, because the American casualty list was relatively small, this interest soon waned and, because of the economic depression of the Thirties, some observers think, very little progress was made in the field of limb prosthetics between the two World Wars. Perhaps the most significant contributions were the doctrines set forth and emphasized by Thomas and Haddan,<a></a> a prosthetist-surgeon team from Denver-that fit and alignment of the prosthesis were the most critical factors in the success of any limb and that much better end results could be expected if prosthetists and physicians worked together.</p> <p>Early in 1945, the National Academy of Sciences, at the request of the Surgeon General of the Army, initiated a research program in prosthetics<a></a>. The initial reaction of the research personnel was that the development of a few mechanical contrivances would solve the problem. However, it soon became evident that much more must be known about biomechanics and other matters before real progress could be made.<a></a> Devices and techniques based on fundamental data have materially changed the practice of prosthetics during the past 15 years. However, the best conceivable prosthesis is but a poor substitute for a live limb of flesh and blood, and so the research program is still continuing. Fiscal support for research and development by some 30 laboratories is provided by the Veterans Administration, the Social and Rehabilitation Service, the National Institutes of Health, the Children's Bureau, the Department of the Army, and the Navy Department.</p> <p>The overall program is coordinated by the Committee on Prosthetics Research and Development of the National Academy of Sciences. The committee publishes twice a year the journal <i>Artificial Limbs</i> and serves as an information center, not only in limb prosthetics but for orthotics as well.</p> <p>In England and Europe, research in artificial limbs was resumed after World War II at Queen Mary's Hospital, Roe-hampton, London, by the Ministry of Health, and a new program was started in Russia. The "thalidomide tragedy" of 1959-60 gave incentive for governments to support research, and now there are effective programs in Canada, Denmark, Holland, Scotland, and Sweden, and the studies in England and Germany have been greatly expanded. Under Public Law 480, the United States supports prosthetics research in a number of foreign countries.</p> <p>Soon after the close of World War II, the Artificial Limb Manufacturers Association, which had been formed during World War I, engaged the services of a professional staff to coordinate more effectively the efforts of individual prosthetists. Known today as the American Orthotic and Prosthetic Association,<a style="text-decoration:none;">*</a> this organization consists of some 500 limb and brace shops, and plays a large part in keeping individual prosthetists and orthotists advised of the latest trends and developments in prosthetics and orthotics.</p> <p>In 1949, upon the recommendation of the association, the American Board for Certification in Orthotics and Prosthetics, Inc.,<a style="text-decoration:none;">*</a> was established to ensure that prosthetists and orthotists met certain standards of excellence, much in the manner that certain physicians' specialty associations are conducted. Examinations are held annually for those desiring to be certified. In addition to certifying individuals as being qualified to practice, the American Board for Certification approves individual shops, or facilities, as being satisfactory to serve the needs of amputees and other categories of the disabled requiring mechanical aids. Certified prosthetists wear badges and shops display the symbol of certification (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Symbol of certification by the American Board for Certification in Orthotics and Prosthetics, Inc. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The research program, with the cooperation of the prosthetists, has introduced a sufficient number of new devices and techniques to modify virtually every aspect of the practice of prosthetics. To reduce the time lag between research and widespread application, facilities have been established within the medical schools of three universities for short-term courses in special aspects of prosthetics. Courses are offered to each member of the prosthetics-clinic team-the physician, the therapist, and the prosthetist. Also, special courses are offered to vocational rehabilitation counselors and administrative personnel concerned with the welfare of amputees.</p> <p>Short-term, continuing-education courses are offered by the University of California, Los Angeles, Northwestern University, and New York University. Two-year courses in prosthetics are offered by Cerritos Junior College (Norwalk, Calif.) and Chicago City College, and a four-year course is available at New York University.</p> <p>Prior to 1957, medical schools offered little in the way of training in prosthetics to doctors and therapists. To encourage the inclusion of prosthetics in medical and paramedical curricula, the National Academy of Sciences organized the Committee on Prosthetics Education and Information, and as a result of the efforts of this group, many schools have adopted courses in prosthetics at both undergraduate and graduate levels.</p> <p>Today, there are more than 400 amputee-clinic teams in operation throughout the United States. Each state, with assistance from the Social and Rehabilitation Service, carries out programs that provide the devices and training required to return the amputee to gainful employment. The Children's Bureau, working through a number of states, has made it possible for child amputees to receive the benefit of the latest advances in prosthetics. The Veterans Administration provides all eligible veterans with artificial limbs. If the amputation is related to his military service, the beneficiary receives medical care and prostheses for the remainder of his life. The Public Health Service, through its hospitals, provides limbs and care to members of the Coast Guard and to qualified persons who have been engaged in the maritime service.</p> <p>In July 1965, the 89th Congress passed Public Law 89-97, the Medicare bill, which includes provision for artificial limbs at essentially no cost for persons 65 years of age and over. The bill also assists individual states in providing artificial limbs for persons who are medically indigent at any age. A number of states have enacted legislation to take advantage of the offer by the federal government.</p> <p>In addition to the government agencies that are concerned with the amputee, there are several hundred rehabilitation centers throughout the United States that assist amputees, especially those advanced in age, in obtaining the services needed for them to return to a more normal life.</p> <p>Thus, through the cooperative efforts of government and private groups, considerable progress has been made in the practice of prosthetics, and there is little need for an amputee to go without a prosthesis.</p> <h3>Reasons for Amputation</h3> <p>Amputation may be the result of an accident, or may be necessary as a lifesaving measure to arrest a disease. A small but significant percentage of individuals are born without a limb or limbs, or with defective limbs that require amputation or fitting (like that of an amputee).</p> <p>In some accidents, a part or all of the limb may be completely removed; in other cases, the limb may be crushed to such an extent that it is impossible to restore sufficient blood supply necessary for healing. Sometimes, broken bones cannot be made to heal, and amputation is necessary. Accidents that cause a disruption in the nervous system and paralysis in a limb may also be cause for amputation, even though the limb itself is not injured. The object of amputation in such a case is to improve function by substituting an artificial limb for a completely useless though otherwise healthy member. Amputation of paralyzed limbs is not performed very often, but has in some cases proven to be very beneficial. Accidents involving automobiles, farm machinery, and firearms seem to account for most traumatic amputations. Freezing, electrical burns, and the misuse of power tools also account for many amputations.</p> <p>Improved medical and surgical procedures introduced in recent years have resulted in the preservation of many limbs that would have been amputated. Infection, once a cause of a high fraction of amputations, can usually be controlled with antibiotics. Newer methods of vessel and nerve suturing make it possible to save limbs that would have had to be amputated some years ago. Highly qualified surgical teams have demonstrated during the last few years that it is possible to replace a completely severed limb.</p> <p>Diseases that may make amputation necessary fall into one of three main categories: vascular, or circulatory, disorders, cancer, and infection. The diseases that cause circulatory problems most often are arteriosclerosis, or hardening of the arteries, diabetes mellitus, and Buerger's disease. In these cases, not enough blood circulates through the limb to permit body cells to replace themselves, and unless the limb or part of it is removed, the patient cannot be expected to live very long. In nearly all these cases, the leg is affected because it is the member of the body farthest from the heart and, in accordance with the principles of hydraulics, blood pressure in the leg is lower than in any other part of the body. Vascular disorders are, of course, much more prevalent among older persons. Considerable research is being undertaken to determine the cause of vascular disorders so that amputation for these reasons may at least be reduced if not eliminated, but at the present time vascular disorders are the cause of a large number of lower-extremity amputations.</p> <p>In many cases, amputation of part or all of a limb has arrested a malignant or cancerous condition. In view of present knowledge, the entire limb is usually removed. Malignancy may affect either the arms or legs. Much time and effort are being spent to develop cures for the various types of cancer.</p> <p>Since the introduction of antibiotic drugs, infection has been less and less the cause for amputation. Moreover, even though amputation may be necessary, control of the infection may allow the amputation to be performed at a lower level than would otherwise be the case.</p> <p>"Thalidomide babies" born between 1958 and 1961 have been given extensive press coverage; however, thalidomide is by no means the sole cause of congenital malformations. Absence of all or part of a limb at birth is not an uncommon occurrence. Many factors seem to be involved in such occurrences, but what these factors are is not clear. The most frequent case is absence of most of the left forearm, which occurs slightly more often in girls than in boys. However, all sorts of combinations occur, including complete absence of all four extremities. Sometimes intermediate parts such as the thigh or upper arm are missing, but the other parts of the extremity are present, usually somewhat malformed. In such cases, amputation may be indicated; however, even a weak, malformed part is sometimes worth preserving if sensation is present and the partial member is capable of controlling some part of the prosthesis. Extensive studies are being carried out to determine the reasons for congenital malformations.</p> <p>As far as it can be determined, there are approximately 311,000 amputees in the United States, exclusive of those patients residing in institutions. There are about six lower-extremity amputees for every upper-extremity amputee.</p> <h3>Losses Incurred</h3> <p>Many of the limitations resulting from amputation are obvious, others less so. An amputation through the lower extremity makes standing and locomotion without the use of an artificial leg or crutches difficult and impracticable except for very short periods. Even when an artificial leg is used, the loss of joints and the surrounding tissues, and consequently loss of the ability to sense position, is felt keenly. The sense of touch of the absent portion is also lost, but in the case of the lower-extremity amputee, this is not quite as important as it might seem, because the varying pressure occurring between the stump and the socket indicates external loading. In the upper-extremity amputee, sense of touch is more important.</p> <p>Most lower-extremity amputees cannot bear the total weight of the body on the end of the stump, and other parts of the anatomy must be found for support.</p> <p>Muscles attached at each end to bones are responsible for movement of the arms and legs. Upon a signal from the nervous system, muscle tissue will contract, thus producing a force which can move a bone about its joint (<b>Fig. 8</b>). Because muscle force can be produced only by contraction, each muscle group has an opposing muscle group so that movement in two directions can take place. This arrangement also permits a joint to be held stable in any one of a vast number of positions for relatively long periods of time. How much a muscle can contract is dependent upon its length, and the amount of force that can be generated is dependent upon its circumference.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Schematic drawing of muscular action on skeletal system. The motion shown here is flexion, or bending, of the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Muscles that activate the limbs must of course pass over at least one joint to provide a sort of pulley action; some pass over two. Thus, some muscles are known as one-joint muscles, others as two-joint muscles. When muscles are severed completely, they can no longer transmit force to the bone and, when not used, wither away or atrophy. It will be seen later that these facts are very important in the rehabilitation of amputees.</p> <h3>Types of Amputation</h3> <p>Amputations are generally classified according to the level at which they are performed (<b>Fig. 9</b>). Some amputations levels are referred to by the name of the surgeon credited with developing the amputation technique used. The general rule in selecting the site of amputation is to save all length that is medically possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Classification of amputation by level. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>LOWER-EXTREMITY AMPUTATIONS</h4> <p><i>Syme's Amputation</i></p> <p>Developed about 1842 by James Syme, a leading Scottish surgeon, the Syme amputation leaves the long bones of the shank (the tibia and fibula) virtually intact, only a small portion at the very end being removed (<b>Fig. 10</b>)<a></a> (The tissues of the heel, which are ideally suited to withstand high pressures, are preserved, and this, in combination with the long bones, usually permits the patient to bear the full weight of his body on the end of the stump. Because the amputation stump is nearly as long as the unaffected limb, a person with Syme's amputation can usually get about the house without a prosthesis, even though normal foot and ankle action has been lost. Atrophy of the severed muscles that were formerly attached to bones in the foot to provide ankle action results in a stump with a bulbous end which, though not of the most pleasing appearance, is quite an advantage in holding the prosthesis in place.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Excellent Syme stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since its introduction, Syme's operation has been looked upon with both favor and disfavor by surgeons. It seems to be the consensus now that "the Syme" should be performed in preference to an amputation at a higher level, if possible. In the case of most women, though, "the Syme" is undesirable because of the difficulty of providing a prosthesis that matches the shape of the other leg.</p> <p><i>Below-Knee Amputations</i></p> <p>Any amputation above the Syme level and below the knee joint is known as a below-knee amputation. Because circulatory troubles have often developed in long below-knee stumps, and because the muscles that activate the shank are attached at a level close to the knee joint, the below-knee amputation is usually performed at the junction of the upper and middle third sections (<b>Fig. 11</b>). Thus, nearly full use of the knee is retained-an important factor in obtaining a gait of nearly normal appearance. However, it is rare for a below-knee amputee to bear a significant amount of weight on the end of the stump; therefore, the design of prostheses must provide for weight-bearing through other areas. Several types of surgical procedures have been employed to obtain weight-bearing through the end of the below-knee stump, but none has found widespread use.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical, well-formed, right below-knee stump. <i>Courtesy Veterans Administration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Knee-Bearing Amputations</i></p> <p>Complete removal of the lower leg, or shank, is known as a knee disarticulation. When the operation is performed properly, the result is an efficient, though bulbous, stump (<b>Fig. 12</b>), capable of carrying the weight-bearing forces through the end.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Typical knee-disarticulation stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Unfortunately, the length causes some problems in providing an efficient prosthesis because the space used normally to house the mechanism needed to control the artificial shank properly is occupied by the end of the stump. Nevertheless, excellent prostheses can be provided the knee-disarticulation case.</p> <p>Several amputation techniques have been devised in an attempt to overcome the problems posed by the length and shape of the true knee-disarticulation stump. The Gritti-Stokes procedure entails placing the kneecap, or patella, directly over the end of the femur after it has been cut off about two inches above the end. When the operation is performed properly, excellent results are obtained, but extreme skill and expert postsurgical care are required. Variations of the Gritti-Stokes amputation have been introduced from time to time but have never been used widely.</p> <p><i>Above-Knee Amputations</i></p> <p>Amputations through the thigh are among the most common (<b>Fig. 13</b>). Because of the high pressures exerted on the soft tissues by the cut end of the bone, total body weight cannot be taken through the end of the stump but can be accommodated through the ischium, that part of the pelvis upon which a person normally sits.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Typical well-formed above-knee stump. <i>Courtesy Veterans Administration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Hip Disarticulation and Hemipelvectomy</i></p> <p>A true hip disarticulation (<b>Fig. 14</b>) involves removal of the entire femur, but, whenever feasible, the surgeon leaves as much of the upper portion of the femur as possible, in order to provide additional stabilization between the prosthesis and the wearer, even though no additional function can be expected over the true hip disarticulation.<a></a> Both types of stump are provided with the same type of prosthesis. With slight modification, the same type of prosthesis can be used by the hemipelvectomy patient, that is, when half of the pelvis has been removed. It is surprising how well hip-disarticulation and hemi-pelvectomy patients have been able to function when fitted with the newer type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Patient with true hip-disarticulation amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>UPPER-EXTREMITY AMPUTATIONS</h4> <p><i>Partial-Hand Amputations</i></p> <p>If sensation is present, the surgeon will save any functional part of the hand in lieu of disarticulation at the wrist. Any method of obtaining some form of grasp, or prehension, is preferable to the best prosthesis. If the result is unsightly, the stump can be covered with a plastic glove, lifelike in appearance, for those occasions when the wearer is willing to sacrifice function for appearance. Many prosthetists have developed special appliances for partial-hand amputations that permit more function than any of the artificial hands and hooks yet devised and, at the same time, permit the patient to make full use of the sensation remaining in the stump. Such devices are usually individually designed and fitted.</p> <p><i>Wrist Disarticulation</i></p> <p>Removal of the hand at the wrist joint was once condemned because it was thought to be too difficult to fit so as to yield more function than a shorter forearm stump. However, with plastic sockets based on anatomical and physiological principles, the wrist-disarticulation case can now be fitted so that most of the pronation-supination of the forearm-an important function of the upper extremity- can be used. In the case of the wrist disarticulation (<b>Fig. 15</b>), nearly all the normal forearm pronation-supination is present. Range of pronation-supination decreases rapidly as length of stump decreases; when 60 per cent of the forearm is lost, no pronation-supination is possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. A good wrist-disarticulation stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Amputations Through the Forearm</i></p> <p>Amputations through the forearm are commonly referred to as below-elbow amputations, and are classified as long, short, and very short, depending upon the length of stump (<b>Fig. 9</b>). Stumps longer than 55 per cent of total forearm length are considered long, between 35 and 55 per cent as short, and less than 35 per cent as very short.</p> <p>Long stumps retain the rotation function in proportion to length; long and short stumps without complications possess full range of elbow motion and full power about the elbow, but often very short stumps are limited in both power and motion about the elbow. Devices and techniques have been developed to make full use of all functions remaining in the stump.</p> <p><i>Disarticulation at the Elbow</i></p> <p>Disarticulation at the elbow consists of removal of the forearm, resulting in a slightly bulbous stump (<b>Fig. 16</b>), but usually one with good end-weight-bearing characteristics. The long bulbous end, while presenting some fitting problems, permits good stability between socket and stump and thus allows use of nearly all the rotation normally present in the upper arm-a function much appreciated by the amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Amputation through the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Above-Elbow Amputation</i></p> <p>Any amputation through the upper arm is generally referred to as an above-elbow amputation (<b>Fig. 9</b>). In practice, stumps in which less that 30 per cent of the humerus remains are treated as shoulder-disarticu-lation cases; those with more than 90 per cent of the humerus remaining are fitted as elbow-disarticulation cases.</p> <p><i>Shoulder Disarticulation and Forequarter Amputation</i></p> <p>Removal of the entire arm is known as shoulder disarticulation, but, whenever feasible, the surgeon will leave intact as much of the humerus as possible, to provide stability between the stump and the socket (<b>Fig. 17</b>). When it becomes necessary to remove the clavicle and scapula, the operation is known as a forequarter, or interscapulothoracic, amputation. The very short above-elbow, the shoulder-disarticulation, and the forequarter cases are all provided with essentially the same type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. A true shoulder disarticulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Postsurgical Period</h3> <p>The period between the time of surgery and time of fitting the prosthesis is an important one if a good functional stump, and thus the most efficient use of a prosthesis, is to be obtained. The surgeon and others on his hospital staff will do everything possible to ensure the best results, but ideal results require the wholehearted cooperation of the patient.</p> <p>It is not unnatural for the patient to feel extremely depressed during the first few days after surgery, but after he becomes aware of the possibilities of recovery, the outlook becomes brighter, and he generally enters cooperatively into the rehabilitation phase.</p> <p>It has been generally agreed through the years that the earlier a patient could be fitted, the easier would be the rehabilitation process. However, until a few years ago, virtually no patients were provided with a prosthesis before six weeks after amputation, and such cases were rare - the average time probably being closer to four months.</p> <p>With the advent of improved cast-taking methods, and temporary legs in which alignment can be easily adjusted, Duke University, about 1960, began an experiment to determine the earliest practical time after surgery for providing amputees with limbs. By 1963, it had been shown clearly that it was not only practical but desirable to fit a temporary, but well-fitted limb as soon as the sutures were removed, some two to three weeks after surgery. In 1963, Dr. Marian Weiss of Poland, in an address in Copenhagen, reported success with fitting amputees immediately after surgery while the patient was still anesthetized, and beginning ambulation training the day afterward.<a></a> Dr. Weiss's work stimulated similar work in this country, notably at the University of California, San Francisco; the Oakland Naval Hospital; the Prosthetics Research Study, Seattle, Washington; Duke University; the University of Miami; Marquette University; and New York University. Records on several thousand patients of all types have shown immediate postsurgical fitting of prostheses to be the method of choice when possible. Healing seems to be accelerated; postsurgical pain is greatly alleviated; contractures are prevented from developing; phantom pain seems to be virtually nonexistent; fewer psychological problems seem to ensue; and patients are returned to work or home at a much earlier date than seemed possible only a few years ago.</p> <p>The procedure consists essentially of providing a rigid plaster dressing over the stump which serves as a socket, and the use of an adjustable leg which can be removed and reinstalled easily (<b>Fig. 18</b>).<a></a> The cast-socket is left in place for 10 to 12 days, during which ambulation is encouraged. At the end of this time, the cast-socket is removed, the stitches are usually taken out, and a new cast-socket is provided immediately. The original prosthetic unit is replaced and realigned. The second cast-socket is left in place for eight to ten days, at which time a new cast can be taken for the permanent, or definitive, prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Schematic cross section showing the major elements of a prosthesis as applied immediately following surgery to a below-knee amputee. The suture line, silk dressing, and drain are not shown. The fluffed gauze does not extend beyond the area indicated in "A." <i>Inset: </i>A below-knee amputee fitted with the immediate postsurgical prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Special courses in immediate postsurgical fitting and early fitting are being offered to qualified prosthetics clinic teams by Northwestern University, the University of California at Los Angeles, and New York University.</p> <h4>CONTRACTURES</h4> <p>When immediate postsurgical fitting is employed, there is little opportunity for contractures to develop. When these procedures are not used, it is most important to avoid the development of muscle contractures. They can be prevented easily, but it is most difficult, and sometimes impossible, to correct them. At first, exercises are administered by a therapist or nurse; later, the patient is instructed concerning the type and amount of exercise that should be undertaken. The patient is also instructed in the methods and amount of massage that should be given the stump to aid in the reduction of the stump size. Further, to aid shrinkage, cotton-elastic bandages are wrapped around the stump (<b>Fig. 19</b>) and worn continuously until a prosthesis is fitted. The bandage is removed and reapplied at regular intervals-four times during the day and at bedtime. It is most important that a clean bandage is available for use each day.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Compression wrap for above-knee amputation. The wrap of elastic bandage aids in shrinking the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee is taught to apply the bandage unless it is physically impossible for him to do so, in which case some member of his family must be taught the proper method for use at home.</p> <p>To reduce the possibility of contractures, the lower-extremity stump must not be propped upon pillows. Wheelchairs should be used as little as possible; crutch walking is preferred, but the above-knee stump must not be allowed to rest on the crutch handle (<b>Fig. 20</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Actions to be avoided by lower-extremity amputees during the immediate postoperative period. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>THE PHANTOM SENSATION</h4> <p>After amputation, the patient almost always has the sensation that the missing part is still present. The exact cause of this is as yet unknown. The phantom sensation usually recedes to the point where it occurs only infrequently or disappears entirely, especially if a prosthesis is used. In a large percentage of cases, moderate pain may accompany the phantom sensation, but in general this too eventually disappears entirely or occurs only infrequently. In a small percentage of cases, severe phantom pain persists to the point where medical treatment is necessary.<a></a></p> <h4>DEFINITIONS</h4> <p><i>Preparatory Prosthesis</i></p> <p>A cosmetically unfinished functional replacement for an amputated extremity, fitted and aligned in accordance with sound biomechanical principles, which is worn for a limited period of time to expedite prosthetic wear and use and to aid in the evaluation of amputee adjustment.</p> <p><i>Pylon</i></p> <p>A rigid supporting member, usually tubular, that is attached to the socket or knee unit of a prosthesis. The lower end of the pylon should be connected to a foot-ankle assembly.</p> <p><i>Rigid Dressing</i></p> <p>A plaster stump wrap, usually applied in the operating or recovery room immediately following operation for the purpose of controlling edema and pain. It is preferably shaped in accordance with the basic patellar-tendon-bearing (PTB) or quadrilateral designs, but is not necessarily so.</p> <p><i>Immediate Postsurgical Prosthetic Fitting</i></p> <p>A procedure wherein a functional socket, designed for weight-bearing and walking, is fitted to the patient immediately after operation in the operating or recovery room, or at some time prior to removal of sutures. As distinct from the rigid dressing, referred to above, this socket should be shaped in accordance with the basic PTB or quadrilateral design; it incorporates provision for easy attachment and detachment of a pylon and foot-ankle assembly.</p> <p><i>Early Prosthetic Fitting</i></p> <p>A procedure wherein a preparatory prosthesis, as defined above, is provided for the amputee immediately following removal of sutures.</p> <p><i>Permanent Prosthesis</i></p> <p>A replacement for a missing limb, which meets accepted checkout standards for comfort, fit, alignment, function, appearance, and durability.</p> <h3>Prostheses for Various Types of Amputation</h3> <p>Much time and attention have been devoted to the development of mechanical component, such as knee and ankle units, for artificial limbs, yet by far the most important factors affecting the successful use of a prosthesis are the fit of the socket ot the stump and the alignment of the vairous parts of the limb in relation to the stump and other parts of the body.</p> <p>Thus, though many parts of a prosthesis may be mass-produced, it is necessary for each limb to be assembled in correct alignment and fitted to the stump to meet the individual requirements of the intended user. To make and fit artificial limbs properly requires a complete understanding of anatomical and physiological principles and of mechanics; craftsmanship and artistic ability are also required.</p> <p>In general, an artificial limb should be as light as possible and still withstand the loads imposed upon it. In the United States, willow and woods of similar characteristics have formed the basis of construction for more limbs than any other material, although aluminum, leather-and-steel combinations, and fiber have been used widely. Today, plastic laminates so popular in small-boat construction form the basis for construction of most artificial limbs. Some artificial legs are made of wood, and occasionally leather is used for sockets, but the trend is toward the plastic laminates. They are light in weight, easy to keep clean, and do not absorb perspiration. They may be molded easily and rapidly over contours such as those found on a plaster model of a stump. Plastic laminates can be made extremely rigid or with any degree of flexibility required in artificial-limb construction.</p> <p>A procedure for making a porous plastic laminate has been developed for use when perspiration presents a difficult problem. A new material, synthetic balata, which can be molded directly over the stump, is now being used in some clinics, primarily to form temporary prostheses.</p> <p>As in the case of the tailor making a suit, the first step in fabrication of a prosthesis is to take the necessary measurements for a good fit. If the socket is to be fabricated of a plastic laminate, an impression of the stump is made. Most often this is accomplished by wrapping the stump with a wet plaster-of-paris bandage and allowing it to dry, as a physician does in applying a cast when a bone is broken (<b>Fig. 21</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Steps in the fabrication of a plastic prosthesis for a below-knee amputation: <i>A, </i>taking the plaster cast of the stump; <i>B, </i>pouring plaster in the cast to obtain model of the stump; C, introducing plastic resin into fabric pulled over the model to form the plastic-laminate socket; <i>D, </i>the plastic-laminate socket mounted on an adjustable shank for walking trials; <i>E, </i>a wooden shank block inserted in place of the adjustable shank after proper alignment has been obtained; <i>F</i>, the prosthesis after the shank has been shaped. To reduce weight to a minimum, the shank is hollowed out and the exterior covered with a plastic laminate. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A number of devices have been introduced in recent years to aid the prosthe-tist in obtaining accurate casts rapidly.<a></a> Most use an apparatus that permits the patient to absorb some of the weight-bearing load through the affected side while the cast is being formed (<b>Fig. 22</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Special jig developed by the Veterans Administration Prosthetics Center to facilitate casting above-knee stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast, or wrap, is removed from the stump and filled with a plaster-of-paris solution to form an exact model of the stump which-after being modified to provide relief for any tender spots, to ensure that weight will be taken in the proper places, and to take full advantage of the remaining musculature-can be used for molding a plastic-laminate socket. Often a "check" socket of cloth impregnated with beeswax is made over the model and tried on the stump to determine the correctness of the modifications.</p> <p>For upper-extremity cases, the socket is attached to the rest of the prosthesis, and a harness is fabricated and installed for operation of the various parts of the artificial arm. For the lower-extremity case, the socket is fastened temporarily to an adjustable, or temporary, leg for walking trials (<b>Fig. 23</b>). With this device, the prosthetist can easily adjust the alignment until both he and the amputee are satisfied that the optimum arrangement has been reached. A prosthesis can now be made, incorporating the same alignment achieved with the adjustable leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Using the above-knee adjustable leg and alignment duplication jig. <i>Top, </i>adjusting the adjustable leg during walking trials; <i>center, </i>the socket and adjustable leg in the alignment duplication jig; <i>bottom, </i>replacement of the adjustable leg with a permanent knee and shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A more refined procedure uses the "Staros-Gardner" coupling (<b>Fig. 24</b>) <a></a>. Not only is the need for the alignment jig eliminated, but in the case of above-knee fittings the alignment adjustments can be made with the knee unit that is to be used permanently, an important factor when sophisticated knee units are used because the present adjustable leg is available with only a single-axis, constant-friction joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Adjustable coupling used for alignment of artificial legs. This unit was designed by the Veterans Administration Prosthetics Center and is suitable for below-knee as well as above-knee legs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An even more refined procedure consists of using one of the adjustable pylon types of prostheses that were originally designed for use in immediate postsurgical fitting. These units are strong enough and sufficiently inexpensive so they can form part of the permanent, or definitive, prosthesis (<b>Fig. 25</b> and <b>Fig. 26</b>). A light, removable, cosmetic cover is used over the pylon. This arrangement permits the prosthetist to change alignment easily at any time. An added feature of the VAPC above-knee "standard" pylon is provision for inter-changeability of a number of knee units, ranging from the simple constant-friction unit to complex hydraulic units. Thus, the patient may try a number of different methods of knee control, at little expense, in order to determine which meets his needs the best.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. An adjustable below-knee pylon with cosmetic cover. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. An adjustable above-knee prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>There are many kinds of artificial limbs available for each type of amputation, and much has been written concerning the necessity for prescribing limbs to meet the needs of each individual. This of course is particularly true in the case of persons in special or arduous occupations, or with certain medical problems, but limbs for a given type of amputation actually vary to only a small degree. Following are descriptions of the artificial limbs most commonly used in the United States today.</p> <h4>LOWER-EXTREMITY PROSTHESES</h4> <p><i>Prostheses for Syme's Amputation</i></p> <p>Perhaps the major reason Syme's amputation was held in such disfavor in some quarters was the difficulty in providing a comfortable, sufficiently strong prosthesis with a neat appearance. The short distance between the end of the stump and the floor made it extremely difficult to provide for ankle motion needed. Most Syme prostheses were made of leather reinforced with steel side bars, resulting in an ungainly appearance. Research workers at the Prosthetic Services Centre at the Department of Veterans Affairs of Canada were quick to realize that the use of the proper plastic laminate might solve many of the problems long associated with the Syme prosthesis. After a good deal of experimentation, the Canadians developed a model in 1955 which, with a few variations, is used almost universally in both Canada and the United States today (<b>Fig. 27</b>)<a></a>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. The Syme prosthesis adopted by the Canadian Department of Veterans Affairs. The posterior opening extends the length of the shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Necessary ankle action is provided by making the heel of the foot of sponge rubber. The socket is made entirely of a plastic laminate. A full-length cutout in the rear permits entry of the bulbous stump. When the cutout is replaced and held in place by straps, the bulbous stump holds the prosthesis in place. In the American version (<b>Fig. 28</b>), a window-type cutout is used on the side because calculations show that smaller stress concentrations are present with such an arrangement. An increasing number of prosthetists have been using a double-wall socket with an expandable inner wall in order to eliminate the need for the window.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Two views of the Canadian-type Syme prosthesis as modified by the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In those cases where, for poor surgery or other reasons, full body weight cannot be tolerated on the end of the stump, provisions can be made to transfer all or part of the load to the area just below the kneecap.<a></a> </p> <p><i>Prostheses for Below-Knee Amputations</i></p> <p>Until recently, most below-knee amputees were fitted with wooden prostheses carved out by hand (<b>Fig. 29</b>). A good portion of the body weight was carried on a leather thigh corset, or lacer, attached to the shank and socket by means of steel hinges. The shape of the corset and upper hinges also held the prosthesis to the stump. The distal, or lower, end of the socket was invariably left open. Other versions of this prosthesis used aluminum, fiber, or molded leather as the materials for construction of the shank and socket, but the basic principle was the same. Many thousands of below-knee amputees have gotten along well with this type of prosthesis, but there are many disadvantages. Because the human knee joint is not a simple, single-axis hinge joint (<b>Fig. 30</b>), relative motion is bound to occur between the prosthesis and the stump and thigh during knee motion when single-jointed side hinges are used, resulting in some chafing and irritation. To date it has not been possible to devise a hinge to overcome this difficulty. Edema, or accumulation of fluid, was often present at the lower end of the stump. Most of these prostheses were exceedingly heavy, especially those made of wood.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Below-knee prosthesis with wood socket-shank, thigh corset, and steel side bars. <i>Courtesy Veterans Administration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Section through the medial condyles of the femur and tibia. The center of curvature is shown for three parts of the articular surface. As gliding occurs in the joint, the instant center moves along the curve connecting these three centers. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In an attempt to overcome these difficulties, the Biomechanics Laboratory of the University of California, in 1958, designed what is known as the patellar-tendon-bear-ing (PTB) below-knee prosthesis (<b>Fig. 31</b>). In the PTB prosthesis no lacer and side hinges are used, all of the weight being taken through the stump by making the socket high enough to cover all the tendon below the patella, or kneecap.<a></a> The patellar tendon is an unusually inelastic tissue which is not unduly affected by pressure. The sides of the socket are also made much higher than has usually been the practice in the past, in order to give stability against side loads. The socket is made of molded plastic laminate that provides an intimate fit over the entire area of the socket, and is lined with a thin layer of sponge rubber and leather. Because it is rare for a below-knee stump to bear much pressure on its lower end, care is taken to see that only a very slight amount is present in that area. This feature has been a big factor in eliminating the edema problem in many instances. The PTB prosthesis is generally suspended by means of a simple cuff, or strap, around the thigh just above the kneecap, but sometimes a strap from the prosthesis to a belt around the waist is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Cutaway view of the patellar-tendon-bearing leg for below-knee amputees. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A number of variations have been introduced during the past few years which make the PTB even more versatile. Many prosthetists feel that not only can many of the problems associated with perspiration be ameliorated by elimination of the soft inner liner, but that a better physiological fit can be obtained with the "hard socket" PTB. Two methods of eliminating the suspension have been introduced from Europe. From France, there is the "pro-these tibiale a emboitage supracondylien," popularly known as the PTS, in which the proximal border extends above the patella anteriorally and the femoral condyles medially and laterally (<b>Fig. 32</b>). Not only does this arrangement eliminate the need for other means of suspension, but it also provides a certain amount of mediolateral stability when required. Another means for eliminating the need for suspension straps was introduced from Germany, known as the wedge-suspension system. In this variation, a molded removable plastisol wedge is inserted between the wall of the proximal area of the socket and the area of the stump along the medial condyles of the femur (<b>Fig. 33</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. A below-knee amputee wearing a PTS-socket prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. The supracondylar-wedge suspension method. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In an effort to develop a socket that would permit the stump to bear the optimum amount of the weight load over its distal end, the University of California designed the air-cushion socket, consisting of a rigid outer socket and an elastic inner sleeve (<b>Fig. 34</b>). Stump support is provided by the tension of the sleeve and by compression of the air between the sleeve and socket. Nearly all of these innovations are compatible with each other, and the Committee on Prosthetics Research and Development has prepared a chart for use by clinical teams in prescribing for the below-knee amputee (<b>Fig. 35</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Cutaway view of the air-cushion socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the PTB socket has been made, it is installed on a special adjustable leg (<b>Fig. 36</b>) or one of the newer pylons (<b>Fig. 37</b>) so that the prosthetist can try various alignment combinations with ease. When both prosthetist and patient are satisfied, the leg is completed, utilizing the alignment determined with the adjustable unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Trial below-knee adjustable leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Below-knee pylon-type prostheses that can be used for fitting immediately after surgery. <i>A, </i>Hosmer Postoperative Pylon; <i>B, </i>Northwestern Pylon (Hosmer); C, Veterans Administration Prosthetics Center (VAPC) "Standard" Pylon; <i>D, </i>Canadian "Instant" Prosthesis (Hosmer); <i>E, </i>U.S. Manufacturing Co. Pylon; <i>F, </i>Finnie-Jig (Arthur Finnieston Co.), <i>Courtesy of Veterans Administration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The shank for the definitive prosthesis is usually made of wood reinforced with plastic laminate. When the new light pylons are used, a cosmetic cover is often provided. The foot prescribed in most instances is the SACH (solid-ankle, cushion-heel) design, but any other type may be used.</p> <p>It is now general practice in many areas to prescribe the PTB prosthesis in most new cases and in many old ones, and if side hinges and a corset are indicated later, these can be added.</p> <p>Stumps as short as two and one-half inches have been fitted successfully with the PTB prosthesis.</p> <p>In special cases such as extreme flexion contracture, the so-called kneeling-knee, or bent-knee, prosthesis may be indicated. The prosthesis used is similar to that used for the knee-disarticulation case.</p> <p><i>Prostheses for the Knee-Disarticulation and Other Knee-Bearing Cases</i></p> <p>Because of the bulbous shape of the true knee-disarticulation stump, it is not possible to use a wooden socket of the type used on the tapered above-knee stump. To allow entry of the bulbous end, a socket is molded of leather to conform to the stump, and is provided with a lengthwise anterior cutout that can be laced to hold the socket in position (<b>Fig. 38</b>). The length of the knee-disarticulation and supracondylar stump makes it difficult to install any of the present knee units designed for above-knee prostheses; therefore, heavy-duty below-knee joints are generally used. Most prosthetists try to provide some control of the shank during the swing phase of walking by inserting nylon washers between the mating surfaces of the joint to provide friction and by using checkstraps. Some prosthetists in the past have installed commercially available piston-type hydraulic swing-phase control units (<b>Fig. 39</b>), a procedure that requires extreme care to achieve the proper result. To make this task easier, the Hosmer Corporation has recently made available a special boring fixture for use in installing the Hosmer-DuPaCo hydraulic knee unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Typical knee-disarticulation prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. DuPaCo swing-phase control unit installed in a knee-bearing prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for Above-Knee Cases</i></p> <p>The articulated above-knee leg is in effect a compound pendulum actuated by the thigh stump. If the knee joint is perfectly free to rotate when force is applied, the effects of inertia and gravity tend to make the shank rotate too far backward and slam into extension as it rotates forward, except at a very slow rate of walking. The method most used today to permit an increase in walking speed is the introduction of some restraint in the form of mechanical friction about the knee joint. The limitation imposed by constant mechanical friction is that for each setting there is only one speed that produces a natural-appearing gait. When restraint is provided in the form of hydraulic resistance, a much wider range of cadence can be obtained, without introducing into the gait pattern awkward and unnatural motions.</p> <p>In recent years, a number of hydraulic units have been made available for control of the shank during the swing phase. Among them are the DuPaCo, the Henschke-Mauch Type S<a style="text-decoration:none;">*</a> (<b>Fig. 40</b>), and the Hydra-Knee. These units are all of the piston-cylinder type, provide for swing-phase control only, and are designed so that they can be incorporated into the more conventional leg structures. The Hydra-Cadence leg (<b>Fig. 41</b>), a complete knee-shin-foot unit, in addition to providing swing-phase control hydraulically, uses the hydraulic system to control ankle action in concert with knee motion. After the knee is flexed 20 degrees, the toe of the foot is lifted as the knee is flexed further, thereby giving more clearance between the foot and the floor as the leg swings through.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. The Henschke-Mauch Type S hydraulic unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. The Hydra-Cadence leg without cosmetic cover. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Throughout the past century, much time and effort have been spent in providing an automatic brake or lock at the knee in order to provide stability during the stance phase and to reduce the possibility of stumbling. Stability during the stance phase can be obtained by aligning the leg so that the axis of the knee is behind the hip and ankle axes. For most above-knee amputees in good health, such an arrangement has been quite satisfactory, but an automatic knee brake is indicated for the weaker or infirm patients.</p> <p>When an automatic brake is indicated, the Bock, the "Vari-Gait" 100, and the Mortensen knee units (<b>Fig. 42</b>) are the ones most generally used. All are actuated upon contact of the heel with the ground. The Bock and Vari-Gait units can be used with almost any type of foot, while a foot of special design is necessary when the Mortensen mechanism is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42/ Some examples of weight-actuated knee units. <i>A, </i>Bock "Safety-knee"; <i>B, </i>Vari-Gait knee; C, Mortensen leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The most sophisticated stance-phase control unit is the Henschke-Mauch Type S-N-S hydraulic unit. It has been thoroughly evaluated by the Veterans Administration and is now available commercially. The Type S-N-S unit contains the same swing-phase control device as the Type S and in addition provides a braking action about the knee when there is a tendency to buckle. The braking action is brought about by the attitude of a pendulum which in turn is controlled by the inertia forces in the shank. The "S" and "S-N-S" units are interchangeable.</p> <p>A number of methods for suspending the above-knee leg are available. For younger, healthy patients, the suction socket (<b>Fig. 43</b>A) has generally been the method of choice. In this design, the socket is simply fitted tightly enough to retain sufficient negative pressure, or suction, between the stump and the bottom of the socket when the leg is off the ground. Special air valves are used to control the amount of negative pressure created so as not to cause discomfort. No stump sock is worn with the suction socket. A major advantage of this type of suspension is the freedom of motion permitted the wearer, thus allowing the use of all the remaining musculature of the stump. Another important advantage is the decreased amount of piston action between stump and socket. Additional comfort is also obtained by elimination of all straps and belts.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Above-knee sockets and methods of suspension: <i>A, </i>total-contact suction socket; <i>B, </i>above-knee leg with Silesian bandage for suspension; C, above-knee leg with pelvic belt for suspension. Most above-knee sockets have a quadrilateral-shaped upper portion as shown. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In some cases, additional suspension is provided by adding a Silesian bandage (<b>Fig. 43</b>B), a light belt attached to the socket in such a way that there is very little restriction of motion of the various parts of the body.</p> <p>Patients with weak stumps and most of those with very short stumps often will require a pelvic belt connected to the socket by means of a "hip" joint (<b>Fig. 43</b>C). Because the connecting joint cannot be placed to coincide with the normal joint, certain motions are restricted. Pelvic-belt suspension is generally indicated for the older patient because of the problems encountered in donning the suction socket, especially that of bending over to remove the donning sock.</p> <p>Shoulder straps, at one time the standard method of suspending above-knee prostheses are still sometimes indicated for the elderly patient.</p> <p>Prior to the introduction of the suction socket into the United States soon after the close of World War II, virtually all above-knee sockets had a conical-shaped interior and were known as plug fits, most of the weight being borne along the sides of the stump. Such a design does not permit the remaining musculature to perform to its full capabilities. In the development of the suction socket, a design known as the quadrilateral socket (see <b>Fig. 43</b>) evolved, and it now is virtually the standard for above-knee sockets, regardless of the type of suspension used. When the pelvic belt or suspender straps are used, the socket is fitted somewhat looser than in the case of the suction socket, and the stump sock is generally worn to reduce skin irritation from the pumping action of the loose socket. A good part of the body weight is taken on the ischium, that part which assumes the load when an individual is sitting.</p> <p>The quadrilateral socket, because of the method employed to permit full use of the remaining muscles, does not resemble the shape of the stump, but, as the name implies, is more rectangular in shape. Until recently, the standard method of fitting a quadrilateral socket called for no contact over the lower end of the stump, a hollow space being left in this area. Although this method was quite successful, there remained a number of cases that persistently developed ulcers or edema over the end of the stump. Experiments involving the use of slight pressure over the stump end led to the development of what is known as the plastic total-contact socket<a></a> (<b>Fig. 43</b>A). As the name implies, the socket is in contact with the entire surface of the stump. In taking some pressure over the end of the stump, the pressure on the ischial area is reduced, thereby providing more comfort to the patient. It also appears that the pressure over the end of the stump helps circulation and improves proprioception. Today the total-contact socket is the method of choice for use by above-knee amputees.</p> <p>In fitting the wooden above-knee prosthesis, the prosthetist carves the interior of the socket, using measurements of the stump as a guide. When a satisfactory fit has been achieved the socket is usually mounted on an adjustable leg for alignment trial, after which the wooden shank and the knee are substituted for the adjustable unit, and the leg is finished by applying a thin layer of plastic laminate over the shank and the thigh piece.</p> <p>In the case of the total-contact socket, the prosthetist obtains a plaster cast of the stump, usually with the aid of a special casting jig (see <b>Fig. 22</b>), and thus obtains a model of the stump over which the plastic socket can be formed.</p> <p>Special adjustable pylon-type legs are available for fitting immediately after surgery, or use as a temporary leg. Provisions are made for all necessary adjustments, and a manually operated knee lock is provided for use by infirm patients.</p> <p><i>Prostheses for Hip-Disarticulation and Hemipeluectomy Cases</i></p> <p>A prosthesis (<b>Fig. 44</b>) developed by the Canadian Department of Veterans Affairs in 1954, and modified slightly through the years, is used almost universally. In the Canadian design, a plastic-laminate socket is used, and the "hip" joint is placed on the front surface in such a position that, when used with an elastic strap connecting the rear end of the socket to a point on the shank ahead of the femur, stability during standing and walking can be achieved without the use of a lock at the hip joint. The location of the hip joint in the Canadian design also facilitates sitting, a real problem in earlier designs.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Hip-disarticulation prosthesis, known as the Canadian type because its principle was originally conceived by workers at the Department of Veterans Affairs of Canada. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A constant-friction knee unit is most often used with the hip-disarticulation prosthesis, but some prosthetists have reported successful use of hydraulic knee units.</p> <p>The hemipelvectomy patient is provided with the same type of prosthesis, but the socket design is altered to allow for the loss of part of the pelvis.</p> <h4>Upper-Extremity Prostheses <a></a></h4> <p>The major role of the human arm is to place the hand where it can function and to transport objects held in the hand. The energy for operation of the hand-substitute in upper-extremity prostheses is generally derived from relative motion between two parts of the body. Energy for operation of the elbow joint, when necessary, can be obtained in the same way. The stump, of course, is also a source of energy for control of the prosthesis in all except the shoulder-disarticulation and forequarter cases. Force and motion can be obtained through a cable connected between the device to be operated and a harness across the chest or shoulders.</p> <p>In recent years artificial arms powered by electricity and by compressed gas have received considerable publicity. An artificial hand powered by electricity and controlled by electrical signals from muscles was developed first in Russia for below-elbow amputees. Versions of the Russian design are manufactured in England, Canada, Germany, and elsewhere. However, the below-elbow patient, of all the types of upper-extremity amputees, is the least handicapped and therefore is less in need of sophisticated devices. The devices are expensive, and in their present state of development seem to offer no real advantage over the simpler conventional devices. The real need is for powered devices for patients with amputations above the elbow and higher.</p> <p>A number of electrically powered elbow units are now being tested, including the so-called Boston Arm, but none are available for general clinical use. To date, no truly satisfactory method of controlling externally powered prostheses has been developed. A good deal of effort is being made both in the United States and abroad to overcome the control problem <a></a>.</p> <p>Sockets for artificial arms are usually made of plastic laminate formed over a modified plaster model of the stump. Synthetic balata, which is molded directly over the stump, is now being used in a few centers.</p> <p><i>Hand Substitutes</i>-<i>Terminal Devices</i></p> <p>All upper-extremity prostheses for amputation at the wrist level and above have in common the problem of selection of the terminal device, a term applied to artificial hands and substitute devices such as hooks. In some areas of the world, there is a tendency to supply the arm amputee with a number of devices, each designed for a specific task such as eating, shaving, hair grooming, etc. In the United States, such an approach has been considered too clumsy, and opinion has been that the terminal device should be designed so that most upper-extremity amputees can perform the activities of daily living with a single device, or at most with two devices.</p> <p>The so-called split hooks are much more functional than any artificial hand devised to date. The arm amputee must rely heavily upon visual cues in handling objects, and the hook offers more visibility. The hook also offers more prehension facility and can be more easily introduced into and withdrawn from pockets than a device in the form of a hand. Therefore, the hook is used in manual occupations and those avocations requiring manual dexterity. When extensive contact with the public is necessary and for social occasions, the hand is of course generally preferred. Many amputees have both types of devices, using each as the occasion warrants.</p> <p>Two basic types of mechanisms have been developed for terminal-device operation—voluntary-opening and voluntary-closing. In the former, tension on the control cable opens the fingers against an elastic force; in the latter, tension in the control cable closes the fingers against an elastic force. Each type of mechanism has its advantages and disadvantages, neither being superior to the other when used in a wide range of activities. Both hands and hooks are available with either type of mechanism.</p> <p>The major types of terminal devices are shown in <b>Fig. 45</b> and <b>Fig. 46</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Voluntary-closing terminal devices. <i>A, </i>APRL-Sierra Hand; <i>left, </i>cutaway view showing mechanism; <i>right, </i>assembled hand without cosmetic glove; <i>B, </i>APRL-Sierra Hook. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Voluntary-opening terminal devices. The wide range of models offered by the D. W. Dorrance Company includes sizes and designs for all ages. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Wrist-Disarticulation Case</i></p> <p>One of the problems in fitting the wrist disarticulation in the past has been to keep the overall length of the prosthesis commensurate with the normal arm. The development of very short wrist units, especially for wrist-disarticulation cases, has materially reduced this problem. However, these units are available in only the screw, or thread, type and cannot be obtained in the bayonet type which lesds itself to quick interchange of terminal devices.</p> <p>The socket for the wrist-disarticulation case need not extend the full length of the forearm, and is fitted somewhat loosely at the upper, or proximal, end to permit the wrist to rotate. A simple figure-eight harness and Bowden cable are used to operate the terminal device (<b>Fig. 47</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Typical methods of fitting below-elbow amputees with medium to long stumps. <i>Top, </i>the figure-eight, ring-type harness is most generally used. Where possible, flexible leather hinges and open biceps cuff or pad are used. When more stability between socket and stump is required, rigid (metal) hinges and closed cuffs can be used <i>(A </i>and <i>B). C </i>shows fabric straps that are used for suspension in lieu of a leather billet. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Long Below-Elbow Case</i></p> <p>The prosthesis for the long below-elbow case is essentially the same as that for the wrist-disarticulation patient except that the quick-disconnect wrist unit can be used when desired.</p> <p><i>Prostheses for the Short Below-Elbow Case</i></p> <p>The socket for the short below-elbow stump, where there is no residual rotation of the forearm, is usually fitted snugly to the entire stump, and rigid hinges connecting the socket to a cuff about the upper arm are often used to provide additional stability. Either the figure-eight harness or the chest-strap harness may be used, the latter being preferred when heavy-duty work is required, since it tends to spread the loads involved in lifting over a broader area than is the case with the figure-eight design.</p> <p>A wrist-flexion unit, which permits the terminal device to be tilted in toward the body for more effective use, can be provided in the short below-elbow prosthesis, but it is seldom prescribed for unilateral cases.</p> <p><i>Prostheses for the Very Short Below-Elbow Case</i></p> <p>Often the very short below-elbow amputee cannot control the prosthesis of the short below-elbow type through the full range of motion, either because of a muscle contracture or because the stump is too short to provide the necessary leverage.</p> <p>When a contracture is present that limits the range of motion of the stump, a "split-socket" and "step-up" hinge may be used. With this arrangement of levers and gears, movement of the stump through one degree causes the prosthetic forearm to move through two degrees; thus, a stump that has only about half the normal range of motion can drive the forearm through the desired 135 degrees. However, when the step-up hinge is used, twice the normal force is required. When the stump is incapable of supplying the force required, it can be assisted by employing the "dual-control" harness, wherein force in the terminal-device control cable is diverted to help lift the forearm. When the elbow stump is very short or has a very limited range of motion, an elbow lock operated by stump motion is employed to obtain elbow function.</p> <p>Recently, a number of prosthetists have reported success in fitting very short be-low-elbow cases with an arm which is bent to give a certain amount of preflex-ion. This type of fitting, which was developed in Münster, West Germany, eliminates the necessity for using the rather clumsy step-up hinges and split socket, thus providing improved prosthetic control without a disadvantageous force feedback. Furthermore, the harness is not necessary for suspension of the prosthesis. The maximum forearm flexion may be limited to about 100 degrees, but this does not appear to be a significant disadvantage to unilateral amputees (<b>Fig. 48</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Comparison of split socket and Miinster-type fitting of short below-elbow case. <i>A, </i>split socket and step-up hinge provides 140 deg of forearm flexion; <i>B, </i>Münster-type fitting permits less forearm flexion but enables the amputee to carry considerably greater weight with flexed prosthesis unsupported by harness. <i>Courtesy New York University College of Engineering Prosthetic and Orthotic Research.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Elbow-Disarticulation Case</i></p> <p>Because of the length of the elbow-disarticulation stump, the elbow-locking mechanism is installed on the outside of the socket. Otherwise the prosthesis and harnessing methods (<b>Fig. 49</b>) are identical to those applied to the above-elbow case.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Typical prosthesis for the elbow-disarticulation case. The chest-strap harness with shoulder saddle is shown here, but the above-elbow figure-eight is also used. See Figure 50. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Above-Elbow Case</i></p> <p>For the above-elbow prosthesis to operate efficiently, it is necessary that a lock be provided in the elbow joint, and it is, of course, preferable that the lock is engaged and disengaged without resorting to the use of the other hand or pressing the locking actuator against an external object such as a table or chair.</p> <p>Several elbow units that can be locked and unlocked alternately by the same motion are available. This action is usually accomplished by the relative motion between the prosthesis and the body when the shoulder is depressed slightly and the arm is extended somewhat. The motion required is so slight that with practice the amputee can accomplish the action without being noticed. These elbow units contain a turntable above the elbow axis that permits the forearm to be positioned with respect to the humerus, supplementing the normal rotation remaining in the upper arm and thus allowing the prosthesis to be used more easily close to the midline of the body.</p> <p>The elbow units described above are available with an adjustable coil spring to assist in flexing the elbow when this is desired. The flexion-assist device may be added or removed without affecting the other operating characteristics.</p> <p>The socket of the above-elbow prosthesis covers the entire surface of the stump. The most popular harness used is the figure-eight dual-control design, wherein the terminal-device control cable is also attached to a lever on the forearm so that when the elbow is unlocked, tension in the control cable produces elbow flexion, and when the elbow is locked, the control force is diverted to the terminal device (<b>Fig. 50</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Typical prosthesis for the above-elbow case. The figure-eight harness is shown here but the chest-strap harness with shoulder saddle may also be used. See Figure 49. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The chest-strap harness may also be used in the dual-control configuration.</p> <p><i>Prostheses for the Shoulder-Disarticulation and Forequarter Cases</i></p> <p>Because of the loss of the upper-arm motion as a source of energy for control and operation of the prosthesis, restoration of the most vital functions in the shoul-der-disarticulation case presents a formidable problem; for many years, a prosthesis was provided for this type of amputation only for the sake of appearance. In recent years, however, it has been possible to make available prostheses which provide a limited amount of function (<b>Fig. 51</b>). To date it has not been possible to devise a shoulder joint that can be activated from a harness, but a number of manually operated joints are available. Various harness designs have been employed, but because of the wide variation in the individual cases and the marginal amount of energy available, no standard pattern has developed, each design being made to take full advantage of the remaining potential of the particular patient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. Typical prosthesis for the shoulder-dis-articulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for Bilateral Upper-Extremity Amputees</i></p> <p>Except for the bilateral, shoulder-dis-articulation case, fitting the bilateral case offers few problems not encountered with the unilateral case. The prostheses provided are generally the same as those prescribed for corresponding levels in unilateral cases. Artificial hands are rarely used by bilateral amputees, because hooks afford so much more function. Many bilateral cases find that the wrist-flexion unit, at least on one side, is of value. The harness for each prosthesis may be separated, but it is the general practice to combine the two (<b>Fig. 52</b>). In addition to being neater, this arrangement makes the harness easier for the patient to don unassisted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 52. Harness for the bilateral below-elbow/ above-elbow case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Some prosthetists have claimed success in fitting bilateral shoulder-disarticulation cases with two prostheses. Because of the lack of sufficient sources of energy for control, most cases of this type are provided with a single, functional prosthesis and with a plastic cap over the opposite shoulder, which provides an anchor for the harness and also fills this area to present a better appearance (<b>Fig. 53</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 53. Special harness arrangement for the bilateral shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Learning to Use the Prosthesis</h3> <p>To derive maximum benefit from his prosthesis, the amputee must understand how it functions and learn the best means of controlling it. A patient may be of the opinion that he is getting along very well when, in reality, he could do much better.</p> <p>Use of the prosthesis can best be learned under the supervision of an instructor who has had special training.</p> <p>All amputees using an artificial limb for the first time will need some instruction. In some instances, when a prosthesis is replaced with one of a different design, special instruction will be required. The time required for training depends upon the complexity of the device and the physical condition and degree of coordination of the patient. The time required will vary from a few hours to several weeks. In many instances, amputees themselves have become excellent trainers, but more often such training is given by physical or occupational therapists. Usually, physical therapists instruct lower-extremity patients, and occupational therapists teach upper-extremity cases.</p> <p>During the period of instruction, the trainer is careful to observe any effects the use of the prosthesis has on the patient, especially at points where the prosthesis is in contact with the body. Any changes are reported immediately to the physician in charge.</p> <h4>Lower-Extremity Cases</h4> <p>One of the major goals in training the leg amputee<a></a> is to enable him to walk as gracefully as possible. Training is begun as soon as the amputee is provided with a comfortable prosthesis. In the case of immediate postsurgical fitting,<a></a> training is often begun on the day following surgery and an adjustable leg is used. There is a growing tendency to train lower-extremity amputees on legs with adjustable features, even though they have not been fitted immediately after surgery. Some other goals of training are to teach the patient proper methods of donning the prosthesis, caring for the stump, arising after a fall, and using canes and crutches when necessary. The type of training will, of course, depend upon the level of amputation.</p> <p>A patient with a Syme amputation needs a minimum of training. The average below-knee case will require somewhat more, though usually not a great deal unless other medical problems are present. The training required is usually considerable for patients who have lost the knee joint.</p> <p>The ability to balance oneself is the first prerequisite in learning to walk, and so it is balance that is taught first to the above-knee amputee. Two parallel railings are used to give the patient confidence and to reduce the possibility of falling (<b>Fig. 54</b>). Balancing on both legs is practiced first, then on each leg. Walking in a straight line between the parallel bars is repeated until the patient no longer requires use of the hands for support. Walking in a straight line is practiced until the gait is even and smooth.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 54. Above-knee patient being trained to walk by a physical therapist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a rhythmic gait has been accomplished, more difficult tasks are learned, such as pivoting, turning, negotiating stairs and ramps, and sitting on and arising from the floor.</p> <p>Most unilateral above-knee patients can use their prostheses quite well without the necessity for a cane. However, in the case of short, weak stumps, it may be advisable to employ a cane for additional support and stability. If a cane is necessary, it should be selected to meet the needs of the patient, and it must be used properly if ungainly walking patterns are to be avoided. Canes with curved handles and made from a single piece of wood should be used. The shaft should not show any signs of buckling under the full load of the body weight, and should be just long enough so that the elbow is bent slightly when the bottom of the cane rests near the foot. The cane is used on the side opposite the amputation to help maintain balance, but it is not used to the extent that body weight is centered between the good leg and the cane (<b>Fig. 55</b>). Continued use of the cane in this manner usually results in a limp that is difficult to overcome. It has been found that, for biomechanical reasons, it is helpful for the amputee to carry a briefcase or purse on the side of the amputation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 55. Above-knee patient being taught correct use of cane. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Training The Hip-Disarticulation Cases</i></p> <p>The training of hip-disarticulation cases follows much the same pattern as that of above-knee cases. With the advent of the Canadian-type prosthesis, the training procedure has been considerably simplified. Some special precautions must be taken to avoid stumbling while ascending stairs.</p> <p><i>Special Considerations for Bilateral-Leg Cases</i></p> <p>As would be expected, bilateral-leg cases pose special problems in addition to those of the unilateral cases, and therefore a good deal of time will usually be required in training. Patients with two good below-knee stumps will seldom require canes. Some bilateral above-knee amputees can get along without canes, but as a general rule, at least one cane is required.</p> <h4>Upper-Extremity Cases</h4> <p>The first objective in the training program for upper-extremity amputees is to ensure that the patient can perform the activities encountered in daily living, such as eating, grooming, and toilet care. When this goal has been attained, attention is devoted to any special training that might be required in vocational pursuits (<b>Fig. 56</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 56. Upper-extremity amputees performing vocational tasks. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Before the prosthesis is put to useful purposes, the patient is shown how the various mechanisms are controlled, and is made to practice these motions until they can be performed in a graceful manner and without undue exertion. In general, the arm amputee soon becomes so adept in these procedures that they are carried out without conscious thought. During this period, the functioning of the prosthesis, especially of the harness and control cables, is watched carefully by the instructor and constantly rechecked to ensure maximum performance.</p> <p>Only when the patient has mastered use of the various controls is practice in handling objects and performing activities of daily living undertaken.</p> <h3>Care of the Stump</h3> <p>Even under the most ideal circumstances, the amputation stump, when called upon to operate a prosthesis, is subjected to certain abnormal conditions which, if not compensated for, may lead to physical disorders which make the use of a prosthesis impossible.</p> <p>Lack of ventilation as a result of encasing the stump in a socket with impervious walls causes an accumulation of perspiration and other secretions of glands found in the skin. In addition to the solid matter in the secretions, bacteria will accumulate in the course of a day. Both the solid matter and bacteria can lead to infection, and the solid matter, though it may appear to be insignificant, may result in abrasions and the formation of cysts. For these reasons, cleanliness of the stump and anything that comes in contact with it for any length of time is of the utmost importance, even when sockets of the newer porous plastic laminate are used.</p> <p>Therefore, the stump should be washed thoroughly each day, preferably just before retiring. A soap or detergent containing hexachlorophene, a bacteriostatic agent, is recommended, but strong disinfectants are to be avoided. To be fully effective, the bacteriostatic agent must be used daily. Some six or seven daily applications are necessary before full effectiveness is obtained, and any cessation of this routine lowers the agent's ability to combat the bacteria. A physician who is himself an amputee has suggested that, after an amputee takes a bath, the stump should be dried first, in order to minimize the risk of introducing infection to it by the towel.</p> <p>When the prosthesis is used without a stump sock, the stump should be thoroughly dry, as moisture may cause swelling that will result in rubbing and irritation. For such cases, it is especially desirable for the stump to be cleansed in the evening.</p> <p>The stump sock should receive the same meticulous care as the stump. The socks should be changed daily and washed as soon as they are taken off. In this way, the perspiration salts and other residue are easier to remove. A mild soap and warm water are used to keep shrinkage to a minimum. Woolite (a cold-water soap) and cold water in recent trials have given excellent results. A rubber ball inserted in the "toe" during the drying process ensures retention of shape.</p> <p>Elastic bandages should be washed daily in the same manner as stump socks, but should not be hung up to dry; rather, they should be laid out on a flat surface away from excessive heat and out of the direct rays of the sun. Hanging places unnecessary stresses on the elastic threads, and heat and sunlight accelerate deterioration.</p> <p>It is of the utmost importance that any skin disorder of the stump—no matter how slight—receive prompt attention, because such disorders can rapidly worsen and become disabling. The amputee should see a physician for treatment. He should also see his prosthetist; it may be that adjustment of the prosthesis will eliminate the cause of the disorder. In no case should iodine or any other strong disinfectant be used on the skin of the stump.</p> <p>Sometimes the skin of the stump is rubbed raw by socket friction. When this happens, the skin should be gently washed with a mild toilet soap. After the stump has been rinsed and dried, bacitracin ointment or some other antibacterial agent should be applied, and the area covered with sterile gauze. The prosthesis should be completely dry before it is put on. If such abrasions occur frequently, the prosthetist should be informed. If there is the slightest sign of infection, the amputee should see a physician.</p> <p>Small painless blisters should not be opened; they should be washed gently with a mild soap and left alone. Large, painful blisters should be treated by a physician.</p> <h4>Bandaging the Stump</h4> <p>The stump is usually kept wrapped in an elastic bandage from the time healing permits until the time the prosthesis is delivered. Also, bandaging is recommended when for some reason it is impracticable or impossible for the patient to wear his limb routinely. It is therefore highly desirable for the amputee, or at least one member of his family, to be able to apply the bandages. Many amputees can wrap their stumps unaided and, indeed, prefer to do so. Others prefer, and in some instances require, the help of another person.</p> <p>Recommended methods for applying elastic bandages for below-knee, above-knee, below-elbow, and above-elbow patients are shown in <b>Fig. 57</b>, <b>Fig. 58</b>, and <b>Fig. 59</b>. These illustrations first appeared in a booklet entitled <i>Industrial Amputee Rehabilitation, </i>prepared by Dr. C. O. Bechtol under the sponsorship of Liberty Mutual Insurance Company of Boston.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 57. Recommended method of applying elastic bandage to the below-knee stump. The bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 58. Recommended method of applying elastic bandage to the above-knee stump. The stump is kept in a relaxed position, and the bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 59. Elastic bandages applied properly to upper-extremity stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Care of the Prosthesis</h3> <p>In addition to the care required in keeping the inside of the socket clean, which has been stressed, best results can be obtained only if the prosthesis is maintained in the best operating condition. Like all mechanical devices, artificial limbs can be expected to receive wear and be discarded for a new device, but the length of useful life can be extended materially if reasonable care is taken in its use. An example often quoted is that of two identical automobiles. The car given the maintenance recommended by the manufacturer and operated with care will outlast many times the vehicle given spotty maintenance and operated with disregard for the heavy stresses imposed. So it is with artificial limbs. Some amputees require a new prosthesis every few years or even more often, while others who follow the manufacturer's instructions, apply preventive maintenance practices, and have minor problems corrected without delay have received satisfactory service from their limbs for periods as long as twenty years.</p> <p>Manufacturers' instructions vary with the design of the device. They consist mainly of lubrication practices, and should be followed closely. Too much lubricant can sometimes produce conditions as troublesome as excessive wear. Looseness of joints and fastenings should be corrected as soon as it is detected, for the wear rate increases rapidly under such a condition. Any cracks that appear in supporting structures should be reinforced immediately, in order to avoid complete failure and the necessity for replacement. The foot should be examined weekly for signs of excessive wear.</p> <p>A point often overlooked by leg amputees, but nevertheless one of the factors affecting optimum use of the artificial limb, is the condition of the shoe. Badly worn or improper shoes can alter alignment and therefore have adverse effects on the stability and gait of the wearer. This is a matter that requires especially close attention in the case of child amputees.</p> <p>Hooks and artificial hands should be treated with the same care that the normal hand is given. Because the sensation of feeling is absent in the terminal device, the upper-extremity amputee is all too prone to use hooks to pry and hammer and to handle hot objects that are deleterious to the hook materials. Hands with cosmetic gloves should be washed daily, and of course hot objects and staining materials should be avoided.</p> <h3>Special Considerations in Treatment of Child Amputees<a></a></h3> <p>Only a few years ago, it was seldom that a child amputee was fitted with a prosthesis before school age, and often not until much later. In recent years, experience has shown that fitting at a much earlier age produces more effective results.</p> <p>If there are no complicating factors, children with arm amputations usually should be provided with a passive type of prosthesis soon after they are able to sit alone, which is generally at about six months of age. Certain gross two-handed activities are thus made possible, crawling is facilitated, and the child becomes accustomed to using and wearing the prosthesis and moves easily into using a body-operated prosthesis as his coordination develops soon after his second birthday.</p> <p>Lower-extremity child amputees should be fitted with prostheses as soon as they show signs of wanting to stand. The development of muscular coordination of child amputees is the same as for non-handicapped children, and therefore this phase may take place as early as eight months or as late as twenty or more months.</p> <p>Children, especially when fitted at an early age, almost always adapt readily to prostheses. As the child grows, the artificial limb seems to become a part of him in a manner seldom seen in adults (<b>Fig. 60</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 60. Children with upper-extremity amputations performing two-handed activities. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Except for the very young, children's prostheses follow much the same design as those for the adult group. Special devices and techniques have been developed for initial fitting of infants and problem cases.</p> <p>Regardless of where the child amputee resides, or the extent of his parents' financial resources, he need not go without the treatment and prostheses required to make full use of his potentials. To ensure that such services are available, the Children's Bureau of the Department of Health, Education, and Welfare has assisted a number of states in establishing well-organized child-amputee clinics, and the facilities of those states are available to residents of states where such specialized services are not to be had. There is an agency in each state that can advise the parents of the proper course of action.</p> <p>Most children can be treated on an out-patient basis, but for the more severely handicapped, many of the clinics have facilities for in-patient treatment. The clinic team for children is often augmented by a pediatrician and a social worker, and sometimes by a psychologist.</p> <p>Training very young children is one of the most difficult problems of the clinic team. Although the learning ability of young children may be rapid, their attention span is of such short duration that extreme patience is required. Regardless of the ability of the therapist, successful results cannot be achieved without complete cooperation of the parents. The mental attitude of the parents is reflected in the child, and all too often children have rejected prostheses because the parents, consciously or subconsciously, could not accept the fact that a prosthesis was needed. Parents of children born with a missing or deformed limb often experience a sense of guilt, a feeling that only adds to an already difficult problem. The guilt feeling is unwarranted, inasmuch as the knowledge of the causes of congenital defects—and appropriate preventive measures—is very limited. The recent discovery of the effects of thalidomide suggests that other causes may be found.</p> <p>As a rule, lower-extremity amputees present fewer problems than the upper-extremity cases. It is natural for the child to walk, and almost invariably the lower-extremity patient adapts rather quickly. However, parents should keep close observation of the walking habits of the child, the condition of his stump, and the state of repair of his prosthesis, and above all they should present the child at the clinic at the recommended times. A gradual change in walking habit may indicate that the child has outgrown the prosthesis or that excessive wear of the prosthesis has taken place. Any unusual appearance of the stump should be reported to the physician immediately so that remedial steps may be taken, thereby avoiding more complicated medical problems at a later date. Children give a prosthesis more wear and tear than do adults, and it is important that the prosthesis be examined carefully at regular intervals and needed repairs made as soon as possible—not only to ensure the safety of the child but to avoid the necessity for major repairs at a later date.</p> <p>Many upper-extremity child amputees adapt readily to artificial arms (some even want to sleep with the arm in place), but in many cases the child will need a great deal of encouragement before he will accept the device and make use of it. At first, the unilateral amputee may feel that the prosthesis is a deterrent rather than an aid, but with the proper encouragement, this feeling is reversed.</p> <p>Parents can help by continuing the training given in the clinics. From the beginning, the artificial arm should be worn as much as possible. Young children should be given toys that require two hands for use, and older children should be given household chores that require two-handed activities. In the latter case, not only does the child learn to appreciate the usefulness of the prosthesis, but he also gains a feeling of being a useful member of the family and thus a better mental attitude is created.</p> <p>The child amputee should not be sheltered from the outside world, but should be encouraged to associate with other children and, to the extent that he can, to take part in their activities. Of course there are certain limitations, but the number of activities that can be performed with presently available prostheses is amazing. It goes almost without saying that the child should receive no more special attention than is necessary and should be made to perform the activities of daily living of which he is capable.</p> <p>It has been shown that it is preferable for the child amputee to attend a regular school, rather than one for the handicapped. Most child amputees can and do take their place in society, and the transition from school to work is much easier if they are not shown unnecessary special consideration. Nonhandicapped children soon accept the amputee and make little comment after the initial reaction.</p> <p>Here again, the arm amputee is apt to be faced with the most problems. Some public school officials have hesitated to admit arm amputees wearing hooks, for fear the child may use them as weapons. This attitude is unrealistic. If such incidents have occurred, they are rare indeed. However, arm prostheses should be removed when the child is engaged in body-contact sports such as football.</p> <p>Cleanliness of the stump, prosthesis, and stump sock is just as important for children as for adults. The same procedures as those outlined on pages 43-46 are recommended.</p> <h3>Special Considerations in the Treatment of Elderly Patients</h3> <p>Persons who have had amputations during youth or middle age seldom encounter additional problems in wearing their prostheses as they become older. However, for those patients who have an amputation in later life, many unusual problems are apt to be present. Most amputations in elderly patients are necessary because of circulatory problems, almost always affecting the lower extremity. For many years, the wisdom of fitting such patients with prostheses was debatable, the thought being that the remaining leg, which in most cases was subject to the same circulatory problems as the one removed, would be overtaxed and thus the need for its removal would be hastened. Energy studies in recent years have shown that crutch-walking is more taxing than use of an artificial limb. Experience with rather large numbers of elderly leg amputees has shown that failure of the remaining leg has not been accelerated by use of a prosthesis, and stumps that have been fitted properly have not been troublesome. As a result, more and more elderly patients are benefiting by the use of artificial limbs. A rule of thumb that is used in some clinics to decide whether or not to fit the elderly patient is that, if he can master crutch-walking, he should be fitted. This measure should be used with discretion because, in some instances, patients who could not meet the crutch-walking requirement have become successful wearers of prostheses.</p> <p>The patient should be fitted as soon as possible, to avoid such complications as the development of contractures. The availability of adjustable pylon-type legs and the use of plaster or plastic sockets now makes early fitting practical, and this approach is being adopted by more and more centers. Many geriatric patients have benefited from the immediate postsurgical fitting procedures.</p> <p>Most clinic teams feel that, if the patient can use the prosthesis to make him somewhat independent around the house, the effort is fully warranted.</p> <p>Artificial legs for the older patients, as a rule, should be as light as possible. Except for the most active patients, only a small amount of friction is needed at the knee for control of the shank during the swing phase of walking because the gait is apt to be slow. Suction sockets have rarely been used, because of the effort required in donning them. A quadrilateral-shaped socket is often used with one stump sock and a pelvic belt. Silesian bandages have been used successfully, allowing more freedom of motion and increased comfort.</p> <p>A new approach introduced recently by the University of Miami offers the geriatric amputee the possibility of using a suction socket by reducing the effort required in donning.<a></a> The flexible plastic inner liner, which contains a suction valve, is put on over the stump first, and then the stump and inner liner are inserted into the outer socket of rigid plastic and latched in place.</p> <p>For the elderly below-knee cases, the patellar-tendon-bearing prosthesis is being used quite successfully.</p> <h3>Cineplasty<a></a></h3> <p>In 1896, the Italian surgeon Vanghetti conceived the idea of connecting the control mechanism of a prosthesis directly to a muscle. Several ideas involving the formation of a club-like end or a loop of tendon in the end of a stump muscle were tried out in Italy. Just prior to World War I, the German surgeon Sauerbruch devised a method of producing a skin-lined tunnel through the belly of the muscle. A pin through the tunnel was attached to a control cable, and thus energy for operation of the prosthesis was transferred directly from a muscle group to the control mechanism. With refinements, the Sauerbruch method is available for use today, but it must be used cautiously.</p> <p>Although tunnels have been tried in many muscle groups, the below-elbow amputee is the only type who can be said to benefit truly from the cineplasty procedure. A tunnel properly constructed through the biceps can supply power for operation of a hand or hook, and there need be no harnessing above the level of the tunnel. Thus, the patient is not restricted by a harness, and the terminal device can be operated with the stump in any position. Training the tunneled muscle and care of the tunnel require a great deal of work by the patient; therefore if the cineplasty procedure is to be successful, the patient must be highly motivated.</p> <p>Some female below-elbow amputees have been highly pleased with results from a biceps tunnel, but as a rule, cineplasty does not appeal to women.</p> <p>Cineplasty is not indicated for children. Sufficient energy is not available for proper operation of the prosthesis, and the effects of growth on the tunnel are not known.</p> <p>Tunnels have been tried in the forearm muscles, but the size of these muscles is such that the energy requirements for prosthesis operation are rarely met. While tunnels in the pectoral muscle are capable of developing great power, in the light of present knowledge the disadvantages tend to outweigh the advantages. It is extremely difficult to harness effectively the energy generated, and very little, if any, of the harness can be eliminated. It is true that an additional source of control can be created, but with the devices presently available, little use can be made of this feature.</p> <p>No application for cineplasty has been found in lower-extremity amputation cases.</p> <p>Still another type of cineplasty procedure is the Krukenberg operation, whereby the two bones in the forearm stump are separated and lined with skin to produce a lobster-like claw. The result, though unattractive in appearance, permits the patient to grasp and handle objects without the necessity of a prosthesis. Because sensation is present, the Krukenberg procedure has been found to be most useful for blind bilateral amputees. Although prostheses can be used with Krukenberg stumps when appearance is a factor, the operation has found little favor in the United States.</p> <h3>U.S. Agencies That Assist Amputees</h3> <p>For several centuries at least, governments have traditionally cared for military personnel who received amputations in the course of their duties. But only in recent years, except in isolated cases, has the amputee in civilian life had much assistance in making a comeback. Today, there are available services to meet the needs of every category of amputee. Aside from the humanitarian aspects of such programs, it has been found to be good business to return the amputee to productive employment and, in the case of some of the more debilitated, to provide them with devices and training to take care of themselves.</p> <p>The armed services provide limbs for military personnel who receive amputations while on active duty, and many of these cases are returned to active duty. After the patient has been discharged from military service, the Veterans Administration assumes responsibility for his medical care and prosthesis replacement for the remainder of his life. The U.S. Public Health Service, through its marine hospitals, cares for the prosthetics needs of members of the U.S. Maritime Service.</p> <p>Each state provides some sort of service for child amputees. If sufficient facilities are not available within a state, provisions can be made for treatment in one of the regional centers set up in a number of states with the help and encouragement of the Children's Bureau of the Department of Health, Education, and Welfare. With assistance from the Social and Rehabilitation Service of the Department of Health, Education, and Welfare, every state operates a vocational rehabilitation program designed to help the amputee return to gainful employment. Some of these programs render assistance to housewives as well.</p> <p>The Medicaid and Medicare programs sponsored by the federal government make it possible for the elderly and indigent to be supplied with artificial limbs.</p> <p>Private rehabilitation centers, almost universally nonprofit and sponsored largely by voluntary organizations, greatly augment the state and federal programs.</p> <p>Information concerning rehabilitation centers serving a particular area may be obtained from the International Association of Rehabilitation Facilities, 7979 Old Georgetown Rd., Bethesda, Md., 20014.</p> <!--References Removed--> <p><b>References:</b></p> <ol> <li>Artif. Limbs, 4:2, Autumn 1957.</li> <li>Artif. Limbs, 6:1, April 1961.</li> <li>Artif. Limbs, 6:2, June 1962.</li> <li>Bechtol, Charles 0., and George T. Aitken, <i>Cineplasty, </i>in <i>Orthopaedic appliances atlas, </i>Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>5. Blakeslee, Berton, Ed., <i>The limb-deficient child,</i> University of California Press, Berkeley and Los Angeles, 1963.</li> <li>6. Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., <i>Immediate postsurgical prosthetics in the management of lower-extremity amputees, </i>TR 10-5, Prosthetic and Sensory Aids Service, Veterans Administration, Washington, D.C., April 1967.</li> <li>Committee on Artificial Limbs, National Research Council, Washington, D.C., <i>Terminal research reports on artificial limbs, </i>covering the period from 1 April 1945 through 30 June 1947.</li> <li>Feinstein, Bertram, James C. Luce, and John N. K. Langton, <i>The influence of phantom limbs, </i>in Klopsteg, Wilson, <i>et al., Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Foort, J., <i>Adjustable-brim fitting of the total contact above-knee socket, </i>No. 50, Biomechanics Laboratory, University of California, San Francisco and Berkeley, March 1963,</li> <li>Foort, James, <i>The patellar-tendon-bearing prosthesis for below-knee amputees, a review of technique and criteria, </i>Artif. Limbs, 9:1:4-13, Spring 1965.</li> <li>Hampton, Fred, <i>Suspension casting for below-knee, above-knee, and Syme's amputations, </i>Artif. Limbs, 10:2:5-26, Autumn 1966.</li> <li>Klopsteg, P. E., <i>The functions and activities of the Committee on Artificial Limbs of the National Research Council, </i>J. Bone Joint Surg., 29:538-540, 1947.</li> <li>National Academy of Sciences-National Research Council, <i>The control of external power in upper-extremity rehabilitation, </i>Publication 1352, 1966.</li> <li>Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, <i>A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, </i>Artif. Limbs, 10:1:52 55, Spring 1966.</li> <li>Sinclair, William F., <i>A suction socket for the geriatric above-knee amputee, </i>Artif. Limbs, 13:1:69-71, Spring 1969.</li> <li>Staros, Anthony, <i>Dynamic alignment of artificial legs with the adjustable coupling, </i>Artif. Limbs, 7:1:31-43, Spring 1963.</li> <li>Taylor, Craig L., <i>Control design and prosthetic adaptations to biceps and pectoral cineplasty, </i>in Klopsteg, Wilson, <i>et al., Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Thomas, Atha, and Chester C. Haddan, <i>Amputation prosthesis, </i>Lippincott, Philadelphia, 1945.</li> <li>Vultee, Frederick E., <i>Physical treatment and training of amputees, </i>in <i>Orthopaedic appliances atlas, </i>Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>Weiss, Marian, <i>Neurological implications of fitting artificial limbs immediately after amputation surgery, </i>in Report of Fifth Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences- National Research Council, February 1966.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bechtol, Charles 0., and George T. Aitken, Cineplasty, in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Sinclair, William F., A suction socket for the geriatric above-knee amputee, Artif. Limbs, 13:1:69-71, Spring 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">5. Blakeslee, Berton, Ed., The limb-deficient child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">6. Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Immediate postsurgical prosthetics in the management of lower-extremity amputees, TR 10-5, Prosthetic and Sensory Aids Service, Veterans Administration, Washington, D.C., April 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Vultee, Frederick E., Physical treatment and training of amputees, in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">National Academy of Sciences-National Research Council, The control of external power in upper-extremity rehabilitation, Publication 1352, 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, in Klopsteg, Wilson, et al., Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total contact above-knee socket, No. 50, Biomechanics Laboratory, University of California, San Francisco and Berkeley, March 1963,</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The Type S replaces Model B. It provides the same function but is shorter and lighter.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Artif. Limbs, 6:2, June 1962.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Foort, James, The patellar-tendon-bearing prosthesis for below-knee amputees, a review of technique and criteria, Artif. Limbs, 9:1:4-13, Spring 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, Artif. Limbs, 10:1:52 55, Spring 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Artif. Limbs, 6:1, April 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Staros, Anthony, Dynamic alignment of artificial legs with the adjustable coupling, Artif. Limbs, 7:1:31-43, Spring 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Hampton, Fred, Suspension casting for below-knee, above-knee, and Syme's amputations, Artif. Limbs, 10:2:5-26, Autumn 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, in Klopsteg, Wilson, et al., Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">6. Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Immediate postsurgical prosthetics in the management of lower-extremity amputees, TR 10-5, Prosthetic and Sensory Aids Service, Veterans Administration, Washington, D.C., April 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Weiss, Marian, Neurological implications of fitting artificial limbs immediately after amputation surgery, in Report of Fifth Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences- National Research Council, February 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Artif. Limbs, 4:2, Autumn 1957.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Artif. Limbs, 6:1, April 1961.</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, Artif. Limbs, 10:1:52 55, Spring 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">1440 N St., N.W., Washington. D.C. 20005.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">1440 N St., N.W., Washington. D.C. 20005.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Klopsteg, P. E., The functions and activities of the Committee on Artificial Limbs of the National Research Council, J. Bone Joint Surg., 29:538-540, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Committee on Artificial Limbs, National Research Council, Washington, D.C., Terminal research reports on artificial limbs, covering the period from 1 April 1945 through 30 June 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Thomas, Atha, and Chester C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennet Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Ave., N.W., Washington, D.C. 20418</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-19.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 1970 Limb Prosthetics Creator An entity primarily responsible for making the resource A. Bennet Wilson, Jr. * 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 Videos Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Imported Thumbnail If a thumbnail images was imported for an embedded video, its id is recorded here and the thumbnail is hidden on pages displaying the embedded video itself. https://i.vimeocdn.com/video/1093528281-08fa835c991033c250d4bbc81d340cbbfc2e59e16deb27d9d79e833299264d2f-d_1920x1080 Player html for embedded player to stream video content <iframe src="https://player.vimeo.com/video/500999363?h=7c0c0a4b15&amp;badge=0&amp;autopause=0&amp;player_id=0&amp;app_id=183091" width="1440" height="1080" frameborder="0" allow="autoplay; fullscreen; picture-in-picture" allowfullscreen title="1976 Fitzsimons Army Medical Center Exhibit"></iframe> Duration Length of time involved (seconds, minutes, hours, days, class periods, etc.) 435 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/. 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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/1985_03_013.pdf Text Any textual data included in the document <h2>A Below-Knee Weight-Bearing Pressure-Formed Socket Technique</h2> <h5>Robert F. Hayes, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>I'm pleased that the Academy has requested that I update and rewrite the Below-Knee Weight-Bearing, Pressure-Formed Socket Technique article I originally wrote in 1975. It's hard to believe that ten years have passed since the original publication of this paper.</p> <p>I haven't made any significant changes regarding the principles or application of this procedure, but let's go back to some of the reasons this concept was developed.</p> <p><strong><a href="/files/original/e764f2e58593ada37005d3d671580fcc.jpg">Fig. 1.</a> Place a sheet of plastic wrap, such as Saran, over the patient's stump to keep it clean and to ease removal of the cast.</strong></p> <p>As I explained in the original article, my son was being fitted for ski boots and it occurred to me that we might make use of some of the techniques used by ski boot designers. The ski boot had an inflatable inner bladder. With the foot under weight-bearing, a conforming material similar to certain silicone compounds was injected into the bladder to give a perfect form-fitting in the attitude of weight-bearing. The incentive to apply this technique to limb prosthetics was reinforced while I was casting a below-knee patient who was a dentist. We exchanged thoughts on molds and changes when pressures are applied. Dentists take one mold for a cast which is filled with dental impression cream (similar to alginate). This is applied to the patient under pressure to give a more accurate impression, and then this is filled to form the definitive positive mold.</p> <p>The standard method of fitting a below-knee amputee involves taking a negative cast in a non-weight-bearing condition, forming a positive model, modifying it in size to present dimensions by removing material to create pressure, and applying material to relieve pressure on the stump as appropriate. A socket is then molded over this model with the hope that, with small adjustments, it will fit the patient.</p> <p>Wouldn't it be wiser to develop a socket under pressure that will adjust to and fit the patient, rather than fit the patient to the socket? In trying to answer this question, the procedure described here was developed.</p> <p><strong><a href="/files/original/8d7c38e3e14f7ff5264b9dc030615015.jpg">Fig. 2</a>. Apply cast sock and felt relief pads.</strong><br /><br /><strong><a href="/files/original/3f65a33756d243d9afabd2712fe9240b.jpg">Fig. 3.</a> Using Plaster-of-Paris, wrap the residual limb in the usual manner.</strong><br /><br /><strong><a href="/files/original/c0094ee66e32340329fd3c14ab5fdbf2.jpg">Fig. 4</a>. Remove the tube gauze and felt buildup from the negative cast.</strong><br /><br /><strong><a href="/files/original/11c6bea9e74d7b47e03c2f589c5f3dcc.jpg">Fig. 5.</a> Pour and modify the positive model.</strong><b><br /><br /></b><strong><a href="/files/original/a9f74838bb3d260e38168c79e38c620a.jpg">Fig. 6</a>. Build up the distal end of the positive model at least 1".</strong></p> <h3>The Procedure</h3> <p>Measure the patient in the usual manner. Place a sheet of plastic wrap material, such as Saran, over the patient's stump to keep it clean of indelible pencil, and to make removal of the cast easy. If a wool sock is to be used, apply it, and then apply the plastic wrap. Apply a cast sock or tube gauze over the stump. Bond 1/4" felt over all pressure-sensitive areas: the crest of the tibia and the head of the fibula.</p> <p>Keep in mind that all areas being built up will be filled with alginate to give contact, yet minimizing pressure. There are some prosthetists who have adopted this technique and claim they apply direct pressure over the crest of the tibia. My experiences do not agree with that. In particular, since many of our patients are diabetic with very thin skin, extra caution should be taken to reduce pressure and especially friction over all bony prominences.</p> <p>Using elastic Plaster-of-Paris bandage 4" wide, wrap the stump in the usual manner, and reinforce with 3" or 4" wide regular plaster bandage. Remove the cast and remove the tube gauze and felt buildup from the negative cast.</p> <p>Pour the positive model, remove the negative cast, and modify in the usual manner, but do not touch areas that were covered with felt. Build up the distal end of the positive model at least 1".</p> <p><strong><a href="/files/original/6c3b995cb38a1514af6eaf680994ddd0.jpg">Fig. 7.</a> Set up the transparent check socket for dynamic alignment.</strong><br /><br /><strong><a href="/files/original/4efea2cf8a0ab176b2e02167045bf2c0.jpg">Fig. 8.</a> Pour the alginate and let it escape through the distal holes until the patient is lowered into the socket to the proper level at which time the holes are blocked. The alginate will then escape along the proximal brim of the socket.</strong></p> <p>Make a check socket. This is a perfect application for vacuum-forming. Plaster bandages or laminates can, of course, be used. Drill two holes 1/4" in diameter in the distal end and rough up the inside surface of the socket. For the first fitting, apply the stump sock of choice, and place plastic "wrap" over the stump sock to act as a separator. An invaginated balloon will not work because it adheres to the alginate that is to be used later.</p> <p>Some prosthetists apply the check socket to the patient's bare stump (no socks) for visual inspection. It bothers me to think what happens to the fit of this socket when the prosthesis is finished from this exact mold and the patient applies the usual stump sock of 3-ply or 5-ply. When the check socket is applied on new patients, I recommend using a thin-fitting sock in anticipation of stump atrophy. On seasoned, well-shaped stumps, I use the same sock that the patient usually wears. When using inserts that tend to compress, i.e. Pelite®, you may use a 3-ply and, after several weeks of prosthetic use, the socket should accommodate a 5-ply sock. Of course, there are many factors to be considered, and this is the area where the prosthetist's knowledge and experience will play the major role as to how well his or her patient does.</p> <p>Mix about 1/2 pint of dental impression cream or alginate (which is more economical). Pour about 1/3 of the total amount in the distal part of the socket and, with a spatula, spread the rest around the remaining surface of the socket. It is necessary to work quickly at this point.</p> <p>Place the socket on a fitting stool adjusted for height. Use some sort of pad to prevent slipping and cover the drilled holes in the socket with your thumb and forefinger. Have the patient place his stump in the socket. Let the alginate escape through the distal holes until the patient is lowered into the socket to the proper level, at which time the holes are blocked. Alginate will now escape along the proximal brim of the socket.</p> <p><strong><a href="/files/original/f88f0a978929d9669ad1e8001308498d.jpg">Fig. 9.</a>&nbsp;The completed socket.</strong><br /><br /><strong><a href="/files/original/e1c24db93cdb2a299cab3af1da2f2dc9.jpg">Fig. 10</a>. The completed socket.</strong></p> <p>As soon as the alginate has set up, remove the stump from the socket and immediately fill the socket with plaster. The rigid socket and alginate are removed by using a cast cutter. The mold resulting is a perfectly smooth, pressure-formed, positive mold that can be used in any method of fabrication desired.</p> <p>When this technique is used, patients can be fit with sockets without soft liners.</p> <p>Only a minimal amount of additional time is required. I feel that the technique allows better fitting of "problem" stumps and that it may be used as a routine procedure to advantage, especially in central fabrication systems. Vacuum-forming procedures recently introduced make this approach to fitting even more attractive. We have since switched to clear plastic check sockets for the obvious advantage of visual inspection and also the ability to adjust check socket pressure areas with a heat gun on some plastics. We also now fit the check socket on the adjustable leg, rather than the fitting stool. This better simulates the pressures exerted on the stump by the definitive prosthesis, since we all agree that socket alignment greatly affects the application of pressure.</p> <p>I know that this procedure has been used by many prosthetists in various parts of the country, and I have received many favorable comments about the benefits to the patient. This pleases me because this is the goal of the process. I'm sure that in the future new devices and innovations will continue to add to and improve this concept to even greater benefit of the patient.</p> <strong>*<em><b>Robert F. Hayes, CP.</b></em></strong><em>President of Hayes Prosthetics, Inc., 1309 Riverdale Street, West Springfield, Massachusetts 01089.<br /><br /><br /></em> Page Number(s) 13 - 16 Year 1985 Volume 9 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_03_013/1985_03_013-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Below-Knee Weight-Bearing Pressure-Formed Socket Technique Creator An entity primarily responsible for making the resource Robert F. Hayes, CP. * https://staging.drfop.org/files/original/55a3a7b173a4ea49841968b5b80df860.pdf 30ec3d14f98a7ba60ecf7428947253e5 https://staging.drfop.org/files/original/3fc21ceaa5b19ada556ba3270df45738.jpg 02bb4d6365ac241f87b6773edcb7e0c1 https://staging.drfop.org/files/original/8f618f54353873ee21984ffd68d8d05a.jpg c3e7d29a8e7b778ed3c74a7defb1e58b https://staging.drfop.org/files/original/44447ecd073a0cc7c351cea452163a32.jpg ee515bdf345c39774428067d5ecef159 https://staging.drfop.org/files/original/5b949cda2964dd9764e61908c066bc6f.jpg 760890658c08795998286568770b9a05 https://staging.drfop.org/files/original/12b48da7443410fc2c39aec2a208a4a8.jpg 517767050abb9972fcd7bb791f3c924c https://staging.drfop.org/files/original/c0bda2f49bcde7fbdb45d9aa932572f0.png da19301ad0fdfca7f5f640abb9c3b40b 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/1984_01_009.pdf Text Any textual data included in the document <h2>A Case History: Clinical Indication for Flexible Above-Knee Prosthetic Socket</h2> <h5>Howard Adelglass, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Don Sung Chu, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />H.R. Lehneis, Ph.D., CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>R.W. is a 62 year old male with a 32 year history of insulin dependent diabetes mellitus. He was in a normal state of good health until August, 1982 when he developed gangrene of the first three toes of his left foot. A left femoral popliteal bypass was performed unsuccessfully. He then underwent a left below-knee amputation which also was unsuccessful and, in October, 1982, a left above-knee amputation was done. In December, 1982, he was admitted to the Institute of Rehabilitation Medicine, NYU Medical Center(IRM-NYU) for a prosthetics rehabilitation program. At that time, his stump became infected and dehisced, requiring stump revision.</p> <p>In July, 1983, he was readmitted to IRM-NYU and started on gait training with an AK prosthesis with a semi-suction socket, hip joint and pelvic belt, polycentric knee joint (Lang) and SACH foot (<a href="/files/original/3fc21ceaa5b19ada556ba3270df45738.jpg"><b>Fig. 1</b></a>). During the course of his rehabilitation training, he began complaining of pain at the distal stump. The socket was adjusted numerous times by alternately relieving painful areas distally and placing padding above these areas, but with little success. Subsequently, x-rays taken of the stump revealed a small amount of soft tissue calcification distally with a small spur at the posterior lateral side of the femur (<a href="/files/original/8f618f54353873ee21984ffd68d8d05a.jpg"><b>Fig. 2</b></a>). The patient was started on anti-inflammatory agents which provided a moderate amount of pain relief. However, he still had difficulty ambulating secondary to stump pain.</p> <p>A lateral pad above the distal end was inserted into the prosthesis which relieved some of the pain. However, within a few days, the patient developed a skin breakdown in the left peroneal area, and an erythematous area on the distal stump. The patient was not allowed to wear his prosthesis for 2 1/2 weeks. During this time, a repeat stump x-ray showed a large spur in the posterior lateral side of the distal stump and more soft tissue calcifications on the anterior surface of the stump (<a href="/files/original/44447ecd073a0cc7c351cea452163a32.jpg"><b>Fig. 3</b></a>). Consequently, a new socket was designed to give relief over the distal anterior and posterior stump in order to decrease the pain and improve ambulation.</p> <p>This socket consisted of a vacuum-molded ionomer (Surlyn®) flexible socket contained in plastic laminated socket. There were fenestrations put into the anterior (<a href="/files/original/5b949cda2964dd9764e61908c066bc6f.jpg"><b>Fig. 4</b></a>) and posterior walls (<a href="/files/original/12b48da7443410fc2c39aec2a208a4a8.jpg"><b>Fig. 5</b></a>) of the rigid outer socket, which afforded relief to the area of spur formation and soft tissue calcification. The flexible inner socket was chosen for several reasons :</p> <ol> <li> <p>Flexibility of the socket results in a more comfortable fit and reduces pressure concentration.</p> </li> <li> <p>Its transparency allows direct visualization of the stump, if skin breakdown is a problem, and to monitor pressure areas.</p> </li> <li> <p>It permits quicker heat dissipation because of reduction in socket wall thickness.</p> </li> <li> <p>The socket allows improved sensory feedback, especially while sitting, due to flexibility in fenestrated areas.</p> </li> </ol> <p>The patient tolerated the prosthesis well, however, he still had pain over the anterior distal stump. Thus, new x-rays of the patient were taken while he was wearing the prosthesis to determine if the fenestrations were, in fact, over the spur and the soft tissue calcifications. Because of the design of this socket, it was easy to determine that the fenestrations needed correction.</p> <p>The anterior cut out was then enlarged to better accommodate the soft tissue calcification (<a href="/files/original/c0bda2f49bcde7fbdb45d9aa932572f0.png"><b>Fig. 6</b></a>). This afforded the patient the relief needed. He is presently ambulating independently with a straight cane and the above-knee prosthesis without any pain.</p> <p>In summary, this flexible socket technique allows improved accuracy in fitting not only routine cases, but is especially suited for problem cases as illustrated here.</p> <em><b>*H.R. Lehneis, Ph.D., CPO </b> Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU).</em><br /><br /><em><b>*Don Sung Chu, M.D. </b> Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU).</em><br /><br /><em><b>*Howard Adelglass, M.D. </b> Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU).<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 9 - 11 Year 1984 Volume 8 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-6.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-1.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-2.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-4.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/1984_01_009/1984_01_009-5.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1984_01_009/1984_01_009-3.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Case History: Clinical Indication for Flexible Above-Knee Prosthetic Socket Creator An entity primarily responsible for making the resource Howard Adelglass, M.D. * Don Sung Chu, M.D. * H.R. Lehneis, Ph.D., CPO * https://staging.drfop.org/files/original/48ab984f63ee9944e8e12c1bf86b8f60.pdf eb995e5594f719eb9d7d1ab8a1c490d7 https://staging.drfop.org/files/original/30569f396b331fcb2e12947a520b6ac1.jpg b543805b7c4b513f32d0060281f28c1e https://staging.drfop.org/files/original/0bc95d63b994e86882e4517d2359f830.jpg 0069caac4493054393b8321505a3418b https://staging.drfop.org/files/original/0ac31bbaa9a0a7f0fec072dd32eb01f6.jpg 19f787d2297a18ef0b242b756a3d565c https://staging.drfop.org/files/original/56454d222bdd3468d5eed2e8285140ef.jpg 04a3c0120545162192a92cc89fdd5ea9 https://staging.drfop.org/files/original/b3e026292277cb859e0e3f4e1784de44.jpg 04e4a36aff5d4f3465d4ab2fe4c2eb7e https://staging.drfop.org/files/original/a446473c17f3288b20207e31bf640f91.jpg 3dd944585433639209e6aba1f6d7e02b https://staging.drfop.org/files/original/b4220edb41cf61a457cbce3d8d3a85e0.jpg dad70000c6445e43ad5115934dfa2024 https://staging.drfop.org/files/original/1a34ee9269e75b1fa11438a645cd9358.jpg 2359c6121a81674e01e8e0aa1813a104 https://staging.drfop.org/files/original/3b83b9695f8d5a45b85fa5f3a3ce8226.jpg b08bd2cf52601d42a9580945fdf0d194 https://staging.drfop.org/files/original/5f2a0eb01af4723d6ad1e673e29af358.jpg d7d0dd21ba3d40e30d463c485cd9df31 https://staging.drfop.org/files/original/a17dff824e882e699ea4241bfdbf1846.jpg 509a6217d3f638c8106e4550bf96d6fc https://staging.drfop.org/files/original/c30118b21e4ccd90a540f956aff44c6b.jpg 5f8d71453173a61fea69ddf09fcf2826 https://staging.drfop.org/files/original/5777bdcd4ca4e1a7990e70d71a0df8e7.jpg 312c5c5027c454f6003665d2d9181936 https://staging.drfop.org/files/original/b80f2cd616a14438719aca13ed27bc35.jpg 6b1cc88760e3fbc9d7438c15ca4ca148 https://staging.drfop.org/files/original/343ea7b1198667406303ad4a8eac51f4.jpg 17767ee459c4d8018faba396f8f5c19e https://staging.drfop.org/files/original/963b2539a143b91e55ee0cf19833183e.jpg 76527cfc69d9e0f23e1f447c0cbf9c91 https://staging.drfop.org/files/original/2a72f1972ae1c761efec324edc5046c8.jpg a02cf0378a7b652331dfffc2f591a00e https://staging.drfop.org/files/original/9f3416f8d473f377d1f6f6ac162f7396.jpg 0cae68f411ca1165884fc7275b632e7a DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_01_003.pdf Year 1964 Volume 8 Issue 1 Page Number(s) 3 - 27 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_01_003.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_01_003.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A Hemipelvectomy Prosthesis</h2> <h5>Fred Hampton, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>A Hemipelvectomy amputation involves removal of the entire lower extremity and half of the pelvis, separation generally being effected at the sacroiliac and symphysis pubis joints. Whenever possible the gluteus maximus and oblique abdominal muscles are preserved and usually are sutured together along the lower anterior aspect of the abdominal cavity. Because of disease or trauma, it is often necessary to remove the gluteus maximus, in which case the "stump" consists simply of a skin-covered abdominal cavity. The operative procedure is described and pictured in detail in <i>An Atlas of Amputations </i>by Dr. Donald B. Slocum.<a></a></p> <p>Because there is no longer a skeletal structure on the affected side to assume the forces required during ambulation with a prosthesis, many workers have attempted to design sockets that will transfer weight-bearing loads directly to existing bony structure. Some have tried to use the ischial tuberosity on the unaffected side to support body weight, but with limited success. Others have felt it necessary to extend the socket so that the rib cage can absorb most of the weight-bearing forces, but this arrangement greatly restricts body motion and heat dissipation.</p> <p>However, it has been found that it is entirely feasible for the "stump" to carry the loads if the socket is designed so that the semisolid abdominal mass of the stump is upward and medially toward the somewhat firmer area of the lower rib cage. Sometimes it is possible to utilize the sacrum for some support but relief for the coccyx must be provided because pressure on this sensitive bone almost always results in pain. Some additional support can often be achieved by utilizing the area of the gluteus maximus on the unaffected side.</p> <p>Such support may be achieved by means of a piece of 1-in. Dacron webbing anchored to the inner distal area of the socket so that the anchor point is anterior to the ischial tuberosity on the sound side. The Dacron tape is led from its anchor point in the socket, under the gluteus maximus on the sound side, passing just distal to the trochanter and then diagonally across the anterior of the socket to a buckle (<b>Fig. 1</b>). Because the strap passes across the sound side at the level of the trochanter, it acts as a counterforce to the shearing action of the stump slipping in the socket under weight-bearing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Sketch shows webbing used as additional support to help to stabilize the amputee in the socket during stance phase. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This article describes a method for fitting the hemipelvectomy patient in such a manner that the major loads are carried through the stump. The hemipelvectomy prosthesis incorporates many of the features of the Canadian hip-disarticulation socket, which was fully discussed in the Autumn 1957 issue of <i>Artificial Limbs. </i>However, the opening used for donning the prosthesis has been moved from the anterior portion to the lateral side of the socket. Greater stability is achieved by this arrangement since both the anterior and the posterior sections of the socket can contribute more support.</p> <p>The hip-disarticulation socket utilizes the ischial tuberosity on the amputated side to support the patient in the socket, and the crest of the ilium for suspension of the prosthesis. In the hemipelvectomy case, the skeletal structure is absent and support of the patient in the prosthesis depends upon oblique upward pressure on the stump with an equivalent opposing pressure on the sound side, obtained by the shape of the socket <a></a> (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Hemipelvectomy socket. Arrows indicate pressure applied by the socket to the "stump," upward and medially. Shaded areas indicate bulges produced by the use of hip sticks. The bulges aid in suspension of the prosthesis, in preventing rotation, and serve as guides for correct alignment while donning the prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>During casting, hip sticks (<b>Fig. 3</b>) are used to obtain the desired contours of tissues necessary for good suspension of the prosthesis.<a></a> Casting a patient while suspended in a sling is one method of compressing tissues in an upward oblique direction, resulting in a cast of the desired shape.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Hip sticks. <i>A, </i>two sticks, approximately 14 in. in length, 1 in. in diameter, joined by a piece of 2-in. webbing, adjustable by means of a buckle. <i>B, </i>hip sticks as applied to the "stump" during casting to create relief for the crest of the ilium on the sound side and desired shape of tissues on the amputated side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The hemipelvectomy prosthesis utilizes the principles of alignment of the Canadian-type hip-disarticulation prosthesis. Moreover, the mechanics of the hemipelvectomy prosthesis are essentially the same as those of the hip-disarticulation prosthesis.<a></a></p> <p>New features incorporated in the hemi-pelvectomy prosthesis are: First, silicone foam is used in the socket construction to fill the cavity at the location of the hip joint; silicone foam is nontoxic, easily used, and provides a surface that is not as slippery as the polyester laminates. Second, the attachment for the hip joint is an integral part of the socket. Third, there is an articulated thigh fairing which is lightweight, easily fabricated, allows reduction in the size of the thigh block, and greatly enhances cosmesis in both the sitting and standing positions. Fourth, there is a support strap under the ilium and around the trochanter.</p> <p>The prosthesis includes the use of a single-axis knee and a SACH foot with a very soft heel wedge. This soft heel wedge increases the stability of the prosthesis at heel strike.</p> <h3>Examination of the Amputee</h3> <p>When an amputee with a hemipelvectomy stump is first seen, a visual examination will reveal scar tissue or other surface conditions that may affect the design of the socket. The location of sensitive areas should be noted so that they may receive special treatment if necessary. All hemipelvectomy amputations are not sectioned at the same level; some surgeons leave behind a small amount of the ilium or a small amount of the pubic bone. Palpation of the stump will usually permit determination of any remaining bony structure, but for definitive evaluation an x-ray of the pelvic area is desirable.</p> <p>When all the conditions relative to the amputation are known and recorded on the Prosthetic Information Form (<b>Fig. 4</b>), the prosthetist is ready to proceed with the first step of prosthesis fabrication; namely, production of a model of the stump and adjacent areas.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Prosthetic Information Form. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Casting the Stump</h3> <p>It has been found that a minimum of modifications to the positive model is required if the cast is taken under weight-bearing conditions. To achieve these conditions, a simple adjustable overhead sling is used. The arrangement shown in <b>Fig. 5</b> utilizes existing structure in the laboratory and a tent-rope tension bar to achieve height adjustability, but a number of equally satisfactory designs can be devised.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Adjusting the sling to obtain proper height. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The seat area of the sling may be made with a piece of 6-in. or 8-in. stockinette tied to the rope at both ends. The stockinette should be long enough to clear the outline of the superior brim of the socket.</p> <p>In taking the cast, hip sticks are used to assist in locating and providing relief for the anterosuperior spine of the ilium on the sound side, and to produce a similar impression on the amputated side. This impression assists in suspension of the prosthesis and helps to prevent rotation of the socket on the stump. Materials required for taking the cast are:</p> <table> <tbody> <tr> <td> <p>4-in. or 6-in. plaster bandages</p> </td> <td> <p>Indelible pencil</p> </td></tr> <tr> <td> <p>3-ft. length of 8-in. or 10-in. stockinette    </p> </td> <td> <p>Plumb bob</p> </td></tr> <tr> <td> <p>Two 3-ft. lengths of 1-in webbing</p> </td> <td> <p>Yardstick</p> </td></tr> <tr> <td> <p>Four harness clamps</p> </td> <td> <p>Paper</p> </td></tr> <tr> <td> <p>Container with water</p> </td> <td> <p></p> </td></tr></tbody></table> <h3>Preparation of the Patient</h3> <p>A 3-ft. length of stockinette (8-in. or 10-in. width as required) is pulled up on the amputee until it is quite snug on the sound thigh. Proximally, it should cover half the thorax. The stockinette is secured with 1-in. webbing over the shoulders and should be pulled tight enough to give some support to the stump mass (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Tentative outline of socket drawn on stockinette. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The distal portion of the rib cage and any areas that need relief are outlined with an indelible pencil. The remaining anterosuperior spine of the ilium is located and outlined. The trochanter on the sound side is located and marked.</p> <p>An approximate outline of the socket is drawn (<b>Fig. 6</b>). The anterior distal portion of the outline starts at the pubic ramus and arcs upward along the inguinal crease onthe sound side with clearance for the sartorius muscle, then passes down to a point just superior to the trochanter. The posterior distal portion of the outline passes from the midline of the body to a point just lateral to the ischial tuberosity, then arcs upward to join the anterior line superior to the trochanter. The proximal outline circumscribes the body at the level of the tenth rib.</p> <h4>Sling Orientation</h4> <p>The amputee is seated in the sling after it has been positioned approximately for height. Pressure on the stump should be diagonally upward and toward the opposite shoulder. Therefore, the sling should pass diagonally across the body to the sound side. A piece of 1-in. webbing under the axilla on the sound side will hold the rope away from the neck and face of the amputee.</p> <p>A slot is cut in the sling posteriorly and just superior to the seat area. Another slot is cut opposite this in the anterior section. A piece of 1-in. webbing is pulled through these slots, around the thigh, and clamped together to prevent the seat from sliding on the stump (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Orientation of amputee in sling. Retention strap adjusted just distal to trochanter on sound side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee is instructed to place more weight on the sling than on the sound leg, and the sling is adjusted for height. It is ascertained that the seat area is contacting the remaining ramus.</p> <p>The setting of the hip sticks is checked. The length of the webbing should be adjusted to fit the patient so that the groove for relief of the remaining ilium and a corresponding groove on the amputated side will be in the proper position. The fulcrum of the hip sticks should be slightly posterior to the crest of the ilium to obtain leverage necessary to bring adequate pressure against the proximal posterior portion of the plaster wrap.</p> <h4>Wrapping The Stump</h4> <p>The procedure of wrapping the stump usually requires two people. Except for obese cases, the patient is removed from the sling for application of the plaster wrap. This is done to contain the tissues and so prevent lateral distortion of the stump when weight is reapplied in the sling. An obese amputee, however, should not be removed from the sling. The wrap cast should be made to incorporate the stockinette initially, because it is too difficult to wrap the stump and properly orient the patient back into the sling before the plaster starts to set.</p> <p>The wrap is started at the lateral proximal brim on the sound side and is brought diagonally upwards across the anterior (<b>Fig. 8</b>). Moderate pressure is placed on the wrap, but ridges should be avoided. The stump should be completely wrapped just past the outline previously drawn on the stockinette. Care must be taken to include the trochanter on the sound side. While the wrap is still wet, the amputee is positioned back in the sling, and the ropes are adjusted until he is standing erect, with at least equal weight being borne on the amputated side.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Beginning diagonal wrap of stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The webbing of the hip sticks is placed across the back of the patient and under the stockinette sling, if it is bridging. The sticks should slant diagonally down just medial to the anterosuperior spine of the ilium on the sound side and a corresponding position on the amputated side. The crest of the ilium on the sound side is palpated by hand to ensure that the hip sticks are not impinging on the anterosuperior spine of the ilium. When the hip sticks are in the correct position, they are held with sufficient pressure to ensure adequate relief. At the same time, an oblique upward pressure is exerted to the lateral distal area of the stump and a counterforce is applied on the opposite ilium. This condition is maintained until the plaster is set. The hip sticks are removed, and the cast is reinforced with additional bandages over the sling. The wrap should touch the remaining ramus, and a portion of the gluteus on the sound side should be included.</p> <p>The trochanter is marked (<b>Fig. 9</b>), and the amputee is removed from the sling.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Locating trochanter on sound side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient is then placed on a table with the stump toward the near side of the table. The gap between the plaster cast and the patient's abdomen is checked to determine if alteration to the wrap is required to contain the viscera and ensure an intimate fit to the socket (<b>Fig. 10</b>). The plaster wrap is cut from the proximal to the distal rim just medial to the socket section. The gap, if there is one, is eliminated by pushing the cast down to meet the abdomen, care being taken not to squeeze the cast mediolaterally and so disturb the placement of the bulge caused by the hip sticks on the sound side (<b>Fig. 11</b>). One side of the cut is covered with vaseline to a depth of approximately 4 in. to facilitate removal of the cast.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Checking the gap between the cast and the patient. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Closing the gap by downward pressure. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A panel of plaster-of-Paris bandages approximately 8 in. wide is formed and laid across the front of the cast, the cast being held in the desired position. Lines to relocate the position of the panel and the cast are drawn, and the cast is secured on the patient by means of a web belt. This will prevent the cast from spreading when the amputee stands and will result in more accurate datum lines.</p> <p>With the amputee standing, the cast is checked for lit and comfort.</p> <h4>Reference Lines</h4> <p>To provide datum lines for alignment of the prosthesis, vertical reference lines are marked on the cast at this time.</p> <p>The amputee should stand erect using an adjustable support under the cast. The spine should be straight and the shoulders level and at right angles to the line of progression.</p> <p>A plumb bob is suspended from the sternum (<b>Fig. 12</b>), and a vertical line is drawn on the cast. A plumb bob is suspended from the spine, and a vertical line is marked on the cast. A plumb bob is suspended from tinder the axilla to bisect the trochanter on the sound side, and the line is drawn on the cast.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Use of plumb bob to obtain reference lines on cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast is removed from the amputee and, after being cut down to the outline previously drawn on the stockinette, is used as a check socket. It should be checked for support and comfort under weight-bearing while the amputee is standing, for pressure on the rib cage, and for clearance of the sound leg while the amputee is sitting. The area of the coccyx should be checked, also the area providing relief for the anterosuperior spine of the ilium on the sound side.</p> <p><b>Pouring the Plaster Positive Model</b></p> <p>The common method of forming the plaster positive model is to pour the negative cast full of a plaster slurry. A mixture of plaster and vermiculite in equal proportions results in a lighter model and one that is quite easy to work. A slush, or hollow model, may be used, but care should be taken to make the model thick enough for it to withstand the pressures involved when lamination is carried out.</p> <p>The leg opening is closed, and the cast is reinforced with plaster bandages. A separator such as vaseline or silicone spray is applied to the inside of the cast.</p> <p>The reference lines are reestablished if they were covered by the reinforcement.</p> <p>A sheet of paper large enough to extend beyond the cast is laid out and divided into four equal parts by means of two perpendicular lines. The cast is placed on the paper so that the vertical reference lines on the cast coincide with and are vertical to the lines on the paper. The cast is secured in this position by blocking it up with plaster.</p> <p>After the plaster has been poured into the cast to form the positive model, a pipe is inserted not only to provide for ease of handling but also to act as a pathway for the air to be drawn out of the laminate by a vacuum pump. A paper cup is installed on the pipe, as shown in <b>Fig. 13</b>, to keep plaster from clogging holes that have been drilled in the pipe to allow the passage of air. The pipe is inserted so that it is aligned with the vertical reference lines; thus it can be used as a reference line when the negative mold has been removed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Setting pipe vertically using vertical lines on cast as reference. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Location of the Hip Joint</h3> <p>Before any modifications to the positive model are undertaken, a buildup is made so that the finished socket will contain a flat area suitable for installation of the hip joint. Instructions given here are for the so-called Northwestern hip joint,<a style="text-decoration:none;">*</a> a unit which provides for alignment adjustment.</p> <p>The hip joint should be placed laterally to provide adequate clearance in the crotch area, placed well forward to ensure adequate stability during the stance phase of walking, and high enough so that the extension stop does not interfere with sitting.</p> <p>If the hip joint is placed too far to the rear, the amputee will be insecure, the joint will interfere with sitting, and more energy will be expended in walking. If it is placed too far forward, the prosthetic knee will extend past the normal knee when the patient is seated. This condition can be partially alleviated by shortening the thigh and lengthening the shank. However, a compromise in the location of the joint is essential.</p> <p>Location of the hip joint in approximately the optimum position may be achieved by the following method:</p> <blockquote><p>Before the positive model is removed from the cast, a reference trochanter, the point on the cast directly opposite the trochanter on the sound side, is established. By means of a height gauge, the trochanter mark on the cast is transposed to a point vertical to the layout line on the opposite side. A point on the surface of the cast 1 1/2 in. vertically below this point is marked. Through this last mark, a line is drawn on the cast at an angle of 45 deg. A useful aid for this is a piece of wood approximately 1 in. thick, cut on an angle of 45 deg. (<b>Fig. 14</b>). In scribing the line, the pencil must be held flat on the 45-deg. surface. All reference lines from the cast are cut through to the positive model by use of an awl. When the cast is removed, the lines are marked on the model with an indelible pencil.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Scribing 45-deg. line on cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /></blockquote> <p>An outline of the socket is drawn on the model. Heretofore, it has been the common practice to cut the anterior portion of the socket to allow entry and exit of the torso. Experiments at the Northwestern University Prosthetics Research Center have shown that more stability between patient and socket can be achieved if the opening is made on the lateral wall.</p> <h3>Modification of the Positive Model</h3> <p>To provide additional relief for the antero-superior spine of the ilium on the sound side, a skived piece of leather or a plaster buildup 1/4 in. thick on the positive model should be adequate.</p> <p>The anterior section of the model usually has a ridge caused by overlapping during the casting procedure. This ridge should be eliminated by removal of plaster. If there is a large bulge posteriorly in the gluteal area, the bulge should be reduced by removal of plaster. Sometimes the angle of the lateral wall will continue to the ramus. If this is apparent, the distal seat area may be modified and flattened slightly by removal of plaster in order to minimize slipping. Any other ridges should be removed, and the entire model should be smoothed with files, wire screen, or sandpaper. A good finish may be obtained by wet sanding with a piece of Wetordry Fabricut.</p> <p>Moisture must be contained in a new model to prevent the PVA bag used as a separator from becoming wrinkled. Application of a sealer, such as Ambroid or parting lacquer, will serve to retain moisture.</p> <p>Leather tongues used at the closure of the socket will deteriorate from sweat. A molded flexible polyester tongue is more durable and sanitary. It should be formed to the model before the flare is added to ensure a smooth transition from the tongue to the socket surface. The tongue is made by laminating four staggered pieces of nylon stockinette across the proposed opening with a flexible mixture of polyester resin (60 per cent Laminac 4134 to 40 per cent Laminac 4110 is an adequate mix). After the tongue has set, it should be trimmed to the desired shape and taped to the model.</p> <p>The outline of the socket on the model is built up to provide a flare with a radius of approximately 3/4 in. The buildup is accomplished by folding a piece of 4-in. plaster bandage lengthwise approximately seven times, wetting it, and laying it on the outline as a beading. The plaster bandage is formed over the tongue to provide a lateral opening at least 1 in. wide. The beading is formed to the desired flare and smoothed with plaster (<b>Fig. 15</b>). The flare should be coated with Ambroid or parting lacquer.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Construction of flaring. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The model is now inverted and mounted in a vise with the sagittal plane vertical. The mounting pipe should be set at an angle of 45 deg. to the horizontal, with the anterior surface of the model upward (<b>Fig. 16</b>). The 45-deg. line on the model should now be vertical, and it should be extended past the flare, both proximally and distally.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Positioning joint on positive model using 45-deg. line as reference. (Model is held in vise at 45-deg. angle, so 45-deg. line, previously scribed, is now vertical.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The configuration of many hemipelvectomy sockets will not allow sufficient clearance for the joint in the crotch area. To allow the joint to be placed more laterally and to provide a flat area for mounting the joint, it is necessary to build up the positive model with rigid poly-urethane foam.</p> <p>The principal considerations in planning the joint location are: First, the flat area must be large enough to receive the mounting plate (about 2 3/4 in. in diameter). Second, the flat area will be horizontal when the model is mounted at the 45-deg. angle. Third, usually the axial center of the joint is somewhat anterior to the 45-deg. line. (It should be kept as close as possible to the line, but the joint must not be permitted to interfere with the sitting position.) Fourth, in most hemipelvectomy sockets, the joint will project beyond the lateral edge of the socket, but it should not project further from the midline of the body than the corresponding joint of the sound leg.</p> <p>Cardboard is formed on the positive model to form the buildup for the joint location and to allow for contours that will blend well with the socket. Polyurethane foam (Pelron 4-lb. density No. 9664<a style="text-decoration:none;">*</a>) is mixed and poured into the cardboard form (<b>Fig. 17</b>). As the foam is being shaped, care should be taken to shape the area immediately medial to the joint to permit full adjustment of the joint. <b>Fig. 18</b> shows the completed buildup on the positive model for the location of the hip joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Pouring polyurethane foam into cardboard form. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Anterior view of positive model showing flat area necessary to receive hip joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Socket Fabrication</h3> <p>Although it is not necessary to use any specific laminating procedure, the vacuum technique described in this article is presented as one that has produced consistently good results in the Northwestern University Prosthetics Research Center.<a></a> </p> <p>Radial suction grooves are cut with a sharp knife from the crest of the flare on the positive model to the cup, or approximately eight 1/8-in. holes are drilled through the model into the cup, the holes being so situated as to ensure the evacuation of air from undercuts.</p> <p>A thin smear of vaseline or motor oil is applied over the sealed surfaces of the model and the polyurethane foam buildup. (Caution: Ambroid should not be applied to the polyurethane foam; the thinner in the Ambroid will soften the foam.) A light plaster slurry is used to blend the edges of the foam into the contours of the socket. A light plaster wash is then applied to the foam and allowed to dry. Ambroid, then vaseline or oil, may be applied to facilitate pulling the PVA separator over the model.</p> <p>A tailored PVA bag is pulled down over the positive model. One end is gathered and tied over the area of the sound leg. The other end is taped tightly around the pipe. Three or four holes are punched in the bag near the cup.</p> <p>Fabric is applied as follows:</p> <ul> <li>1 layer 1/2-oz. Dacron felt.</li> <li>1 layer nylon stockinette.</li> <li>7 layers of glass cloth over the joint and seat areas. The pieces of cloth should be of varying size to produce a gradual transition in rigidity.</li> <li>1 layer Dacron felt over all.</li> <li>5 layers of nylon stockinette pulled on tight and tied to the pipe. A PVA bag is pulled down over the layup and taped tightly to the pipe.</li> </ul> <p>Resin, in an appropriate amount, should be prepared in the proportion of 80 per cent rigid Laminac 4110 to 20 per cent flexible Laminac 4134. ATC catalyst-2 per cent of the weight of the resin mixture is added and spatulated thoroughly. Appropriate pigment, amounting to about 2 per cent of the weight of the resin mixture, should be added: 12 drops of Nauga-tuck # 3 promoter results in approximately 20 min. working time. This will vary according to temperature and humidity.</p> <p>One method of impregnating the fabric with the resin is to pour the resin into the top of the outer PVA bag and "string" the resin downward, working it into the layup, especially into the reinforced seat area, to obtain complete saturation. After the resin has been "strung" into the layup, the vacuum is applied and a head of resin is maintained at the top to prevent air from being sucked into the laminate. Insofar as possible, air is excluded from the top of the PVA bag, and the bag is tied off tightly at the top.</p> <p>Another method is to apply vacuum prior to "stringing" the resin into the layup. In this procedure, the resin is poured into the top of the PVA bag, which is then tied off and vacuum is applied. The resin is then "strung" down into the layup.</p> <p>In both procedures, the hands must be used to force the resin from undercuts, considerable "stringing" downward must be done to remove bubbles, and "stringing" upward to remove excess resin.</p> <p>Low negative pressure should be maintained until the plastic has set (<b>Fig. 19</b>). Excessive vacuum will pull the resin from the laminate, causing "starving."<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. View of laminate of socket using vacuum technique. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Removal of Socket from Positive Model and Replacement of Polyurethane Foam Buildup with Silicone Foam</h3> <p>With the flare as a guide, a Stryker cast cutter is used to cut through the laminate along the outline of the socket. If a molded tongue has been attached to the positive model, care should be taken when making the cut on the lateral side. It is prudent to leave a little extra laminate for subsequent trimming.</p> <p>The polyurethane buildup for the location of the hip joint is removed from the positive model. The positive model is smoothed in this area, and a thin smear of vaseline is applied. A piece of lightweight stockinette is stretched over this part of the model and stapled in place.</p> <p>Using the back plate as a template, three 1/4-in. holes are drilled. The center hole is drilled with a 1/2-in. drill. The back plate is mounted in the socket with two bolts and nuts. The bolts should not be cut.</p> <p>The socket is replaced on the stump model and secured tightly with a web belt or friction tape (<b>Fig. 20</b>). It is in position for the injection of silicone rubber through the 1/2-in. center hole in order to provide support for the amputee over the area of the hip joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Socket replaced on stockinette-covered cast preparatory to injection of foam. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In choosing the silicone rubber to be used, it should be remembered that Silastic 386 Foam Elastomer is relatively soft and may not be capable of supporting the weight of the amputee, while Silastic 385 Elastomer forms a solid rubber which will, if used by itself, add considerable weight to the prosthesis. Accordingly, a mixture of 70 per cent by weight of 386 with 30 per cent by weight of 385 is recommended. This is poured into a caulking gun. The 386 catalyst-6 per cent by weight of the mixture-is added, and the mixture is spatu-lated for 25 seconds. Because of the small amount of catalyst, the viscosity of the Silastic, and the shape of the chamber of the caulking gun, it is very difficult to get a homogeneous mix if spatulated by hand. A mixing rod should be formed that can be used in conjunction with a 1/4-in. electric drill. A rotary up and down movement should be used, mixing for 25 seconds. It is then injected through the center hole of the spherical plate to fill the socket cavity (<b>Fig. 21</b>). The mixture will expand approximately four times its volume during foaming. If necessary, more of the same mixture is added until the cavity is filled.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Injection of silicone foam through center hole of spherical plate. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket is removed from the cast. The silicone pad is removed and the nuts are removed from the two bolts. The spherical plate is attached to the socket with three 1/4-in. flat head bolts. The bolts should be locked tight with a locking compound. The bolts are threaded into the spherical plate with a screwdriver, but they should be tightened with vise grip pliers applied to the protruding threaded portion of the bolt. If this spherical plate is not tightened sufficiently, movement and noise will result. The bolts should then be cut and ground to maintain the spherical contour (<b>Fig. 22</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Socket with spherical plate attached. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The edges of the socket are sanded and buffed to provide a smooth radius.</p> <p>For fitting purposes, the foam pad is secured in the socket by means of friction tape. It can be glued to the socket when the prosthesis is being completed. The edges of cloth reinforcement on the foam should be trimmed, and the surface coated with a skin of Medical Silastic S-5391 Elastomer (<b>Fig. 23</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. View of silicone foam pad with stockinette reinforcement. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Layout of Thigh Block</h3> <p>One method of determining the configuration of the thigh block is as follows:</p> <ol> <li>On a large piece of paper, line A is drawn to represent the length of the foot (<b>Fig. 24</b>). The distance from the end of the heel to the center of the ankle bolt is measured and marked on line A.</li><li>Line B is drawn perpendicular lo line A from the point representing the foot attachment bolt. The length of this line is the distance from the ischial tuberosity to the floor.</li><li>On line B a point is located equal to the height of the medial tibial plateau (MTP) plus 1 1/4 in. for adults. The location of the hip joint often causes the prosthetic knee lo protrude beyond the sound knee when the patient is in the sitting position unless the thigh is shortened and the shin is lengthened. Therefore, 1 1/4 in. is added to the dimension between the floor and the MTP.</li><li>Two inches above this point a 6-in. line is drawn to represent the attachment plate of an adjustable leg. This line is drawn 3 1/2 in. anterior of and 2 1/2<i> </i>in. posterior of line B.</li><li>A line is drawn at right angles to line B at its topmost point. This line, D, represents the height of the level of the seat of the ischium from the floor.</li><li>From a point 1 in. behind the heel, line E is drawn to intersect the prosthetic knee center (PKC) and the horizontal line D.</li><li>The socket is superimposed on the layout, with the joint attached and in a neutral position. The inner edge of the socket must fall on line D and the hip joint center must pass through line E.</li><li>The hip joint is adjusted so that the angle of the straps with line D is 73 deg. in order to maintain the 45 deg. originally planned for the placement of the hip joint.</li><li>The position of the side straps is marked and outlined, line F, and also the offset for the shoulder of the straps, line G.</li><li>There should be 1/4 in. of wood anterior to the hip joint. Therefore, from a point 1/4 in. anterior to the shoulder of the side strap outline, a line should be drawn connecting with the anterior end of the socket attachment plate line. (Angle <i>a </i>in <b>Fig. 24</b> is the flexion angle.)</li><li>From a point 1/4 in. posterior to the shoulder of the side strap outline, a line is drawn to form the posterior outline of the thigh block. Often, this is not a direct connection with the posterior end of the socket attachment plate line, as this would not provide sufficient thickness of wood for screws at the attachment plate of the adjustable leg.</li><li>An anterior view is drawn of the thigh section in which the proximal center point is offset the equivalent of the distance from the center of the artificial hip joint to the vertical support line on the prosthesis, less 1 in. (distance H in lower part of <b>Fig. 24</b>). This establishes the approximate angle of adduction needed in the thigh block. The objective is to place the artificial foot in the approximate amount of adduction.</li><li>The thigh block, of correct length, is positioned with the lateral side up and angle <i>a, </i>obtained from step 10 above, is inscribed upon it.</li><li>The thigh block is positioned with the posterior side up. A goniometer is placed with one arm parallel to the lateral side of the posterior wall; the other arm, set in the angle required, should lie across the posterior wall and connect with the flexion angle previously established. If the adduction required is excessive, it is sometimes necessary to bend the side straps. A bend of approximately 8 deg. is usually sufficient. Care must be taken not to produce nicks and notches in the side straps which may cause premature fracture.</li><li>The table of the saw is set at the adduction angle and a cut is made along the flexion line.</li><li>The hip joint is centered on the thigh block, and the width of the straps is marked. The outline of the straps should be left showing after the excess wood has been cut away. Enough wood must be left for the socket attachment plate. Care must be taken that the distance between joints is accurately reproduced on the thigh block, otherwise binding will result when the joint is assembled and shimming will become necessary.</li><li>The joint is clamped to the thigh block. After the two indicated 1/4-in. holes have been drilled, the joint is bolted to the thigh block.</li></ol> <h3>Bench Alignment of Prosthesis</h3> <p>Two general rules to be followed in the bench alignment of the prosthesis are: First, the socket should be the correct height above the floor, with the transposed point of the ischium directly over the center of the foot. Second, the knee should be set in slight hyper-extension so that a straight line drawn through the hip joint intersects the floor about 1 to 1 1/2 in. behind the heel.</p> <p>It is recommended that a SACH foot with a soft heel wedge be used. A knee extension aid is important; it is provided by a piece of 1-in. elastic which also functions as a stride length control. This is adapted for temporary use on the adjustable leg by mounting a piece of leather on the socket approximately 2 in. behind the hip joint in such a way that the elastic strap can pass through the attachment. For a woman, the extension aid is built into the knee mechanism and the socket bias strap is secured to the distal thigh block. One end of the elastic is screwed to the shin 2 in. down from the PKC, and the other end of the elastic is secured by a buckle mounted in the corresponding position on the other side of the shin. A keeper of 1/2-in. Dacron webbing, with a buckle, is positioned about 1 1/2 in. proximal to the knee bolt. This keeper should be adjusted so that it holds the bias strap anterior to the knee bolt center when the patient is standing and walking but allows it to pass posterior to the knee bolt center when the patient is sitting.</p> <p>Velcro offers a convenient method of closure for the lateral opening of the socket (<b>Fig. 25</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Arrangement of closure straps using Velcro. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the prosthesis is assembled, the axes of the hip joint and of the knee joint should be essentially parallel to the floor and at right angles to the line of progression.</p> <h3>Static and Dynamic Alignment</h3> <p>Satisfactory suspension of the prosthesis often depends upon the proper application of the socket (<b>Fig. 26</b>). The stump should be forced as far laterally as possible and the closure straps should be tightened alternately until the amputee is well supported. The ischial support strap should be secured last. The relief provided by the socket for the an-terosuperior spine of the ilium on the sound side is a useful guide in orienting the socket to the patient. The socket should then be checked for fit and comfort under weight bearing in the areas of the ramus, the coccyx, and the rib cage. Lateral stability of the socket should be evaluated by supporting the prosthesis against a chair and asking the patient to raise his good leg without leaning over the prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Socket mounted on adjustable leg preparatory to dynamic alignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The alignment line from hip center through PKC to a point behind the heel should be verified for stability. It should be ascertained that the height of the prosthesis is correct; that the extension bias strap is forward of the PKC; that there is no friction in the knee joint; and that the bumper and stop are in contact. The patient should not be in a forced position of lordosis, and the socket should not exert pressure proximally in the back. If either of these conditions exists, the bumper is contacting the stop too soon and the socket should be tilted backward by means of the adjustable hip joint. If the bumper is not in contact with the stop, correction should be made by adjustment of the hip joint.</p> <p>The amputee should then sit upright in a hard chair, and the anterior distal portion of the socket should be inspected for clearance of the thigh. If the amputee tends to lean to the amputated side, the exterior gluteal area of the socket should be built up with foam for support and to improve cosmesis. It should be ascertained that there is no pressure between the proximal edge of the socket and the rib cage; that the thigh block clears the chair; that the shank is vertical; that the prosthetic knee axis does not protrude excessively beyond the normal knee center; that toe-out is approximately correct; and that the extension bias strap is holding the shank in flexion.</p> <p>In training the amputee to walk, he should be impressed with the importance of standing upright by holding his hands parallel to or slightly posterior to the long axis of his body. If he leans forward to watch his feet, the hip bumper will not contact the stop, making it impossible to propel the leg forward. He should alternately bear his weight on the prosthesis and then lift it clear of the floor. To initiate flexion of the knee, the amputee should be instructed to "scoop" his stump and pelvis forward and flex his spine. This should be jepeated a few times and the bias strap ad-rusted to obtain the proper stride length.</p> <p>The amputee should be instructed to take a few steps. If the knee appears unstable just after heel contact, the durometer of the heel wedge should be checked, and it should be determined whether the shank is reaching full extension; whether the knee is in some hyper-extension; whether the hip joint is contacting the stop before the foot is flat on the floor; and whether the alignment line runs correctly from the center of the hip joint through the center of the knee joint to 1 1/2 in. behind the heel of the shoe. To eliminate medial or lateral whip, rotational adjustments are necessary at the knee or hip axis.</p> <p>Many amputees wear a stump sock, which decreases the friction between the patient and the socket during the stance phase and loses some of the socket's support. To increase the friction, it is sometimes advantageous to line the lateral aspect of the socket with a rubber material or with horsehide.</p> <p>If toe clearance is still a problem, the length of the prosthesis should be reduced. The hemipelvectomy amputee will tend to vault on the sound foot to increase the clearance of the prosthesis. This tendency should be minimized as much as possible, but it must be remembered that the patient cannot "hike" his pelvis on the amputated side since there is no remaining skeletal structure. Where obesity is a problem, it is sometimes necessary to use a shoulder strap to aid suspension.</p> <p>If the patient experiences rotational instability in the socket, a "teardrop" cutout on the lateral aspect of the socket will help to alleviate the problem and to aid suspension. The cutout should be approximately 2 in. wide at the lateral proximal edge of the socket and extend three-quarters of the length of the socket (<b>Fig. 27</b>). The foam insert in the socket should be removed before the panel is cut out. The edges of the panel should be sanded smooth to prevent cracking. A strap and buckle or Velcro should be attached proxi-mally for closure of the cutout. When the prosthesis is donned, this strap should be loose and should be tightened last.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Teardrop opening in socket on amputated side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Duplicating and Finishing</h3> <p>For duplicating and finishing, the socket is removed and the duplicating jig is used; excess wood is removed from the thigh block and the block is faired into the knee; the knee, thigh, and shin sections are laminated; the keeper for the extension bias strap and all straps and buckles are riveted; and the prosthesis is reassembled (<b>Fig. 28</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Finished thigh block in reassembled prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Thigh Fairing</h3> <p>The chief purpose of the thigh fairing is to compensate for the differences in circumference between the thigh block and the sound leg, both in standing and in sitting. This must be done without impairing the function of the prosthesis.</p> <p>A light, articulated fairing has been developed at the Northwestern University Prosthetics Research Center. It utilizes a piece of 1/32-in. light aluminum alloy, 1/8-in. Kemblo rubber, and lightweight horsehide, with Velcro for closing. It is pivoted distally by two screws just superior to the knee bolt and fastened proximally by a snap fastener to the anterior wall of the socket.</p> <p>A piece of cardboard is used to make a pattern for the aluminum (<b>Fig. 29</b>). Distally, it should be wide enough to receive the pivot screws approximately l 1/2 in. superior to and vertical to the knee bolt center. Anteriorly, it forms an upward arc. To allow the pivot action, the posterior section is open and the anterior proximal section is cut away so that the socket can be fully flexed without touching the cardboard. The posterior medial and lateral edges govern the amount of anterior displacement of the fairing in the sitting position and the fullness of the thigh in the standing position. In the sitting position, both edges should be in full contact with the seat of the chair (<b>Fig. 30</b>). The cardboard pattern should fit close to the anterior thigh block in the standing position and should be cut and formed to allow the medial and lateral contours of the Kemblo rubber fairing to blend in with the contours of the socket (<b>Fig. 31</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Cardboard used as template for metal portion of thigh fairing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Template shown on prosthesis in sitting position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Contouring rubber portion of thigh fairing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the aluminum has been cut out, it is formed to the desired shape and attached with a screw to the knee. A sheet of 1/8-in. Kemblo rubber is wrapped around the metal to obtain the desired fullness (<b>Fig. 32</b>). The Kemblo should be long enough to start at the distal end of the aluminum and fair in proximally to the contours of the socket. The distal edge is skived to blend in with the metal form. The anterior proximal edge of the Kemblo should come up to meet the socket in the sitting position. The posterior proximal edge should meet the socket during the stance phase. The Kemblo is glued to the aluminum form.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Open view of completed thigh fairing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Kemblo rubber is covered with lightweight horsehide, and the leather is rolled over the edges of the rubber.</p> <p>The fairing is attached to the socket anteriorly by means of a snap fastener. The leather continues from the medial and lateral sides to produce a triangle anteriorly with enough slack to allow displacement of the fairing in the sitting position. In the standing position, the attachment should return the fairing and eliminate any slack in the attachment area.</p> <h4>Acknowledgments</h4> <p>For valuable assistance in the development of this prosthesis (<b>Fig. 33</b>) and for help in the preparation of this article, I am most grateful to Colin A. McLaurin, B.A.Sc, Robert G. Thompson, M.D., H. Blair Hanger, C.P., Edwin A. Bonk, Mary Farnan, Walter Horiuchi, and Paula Hamilton.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. View of finished prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Schematic drawing (not to scale) for layout of thigh block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Lyquist, Eric, <i>Canadian-type plastic socket for a hemipelvectomy, </i>Artificial Limbs, Autumn 1958, pp. 130-132.</li> <li>McLaurin, Colin A., and Fred Hampton, .4 <i>method of taking hip disarticulation casts using hip sticks, </i>Orthop. &amp; Pros. Appl. J., June 1960, pp. 71-77.</li> <li>McLaurin, Colin A., and Fred Hampton, <i>Fabricating hip disarticulation sockets using the vacuum method, </i>Orthop. &amp; Pros. Appl. J., June 1960, pp. 66-70.</li> <li>Radcliffe, Charles W., <i>The biomechanics of the Canadian-type hip-disarticulation prosthesis, </i>Artificial Limbs, Autumn 1957, pp. 29-38.</li> <li>Slocum, Donald B., <i>An atlas of amputations, </i>C V. Mosby Co., St. Louis, Mo, 1949, pp. 244-249.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">At sea level, the atmosphere will support a column of mercury 30 in. high. Most vacuum gauges, therefore, are calibrated in inches of mercury (in. Hg.), reading from 0 to 30. 10 in. Hg. negative pressure means 10 in. of mercury below atmospheric pressure.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">McLaurin, Colin A., and Fred Hampton, Fabricating hip disarticulation sockets using the vacuum method, Orthop. &amp;Pros. Appl. J., June 1960, pp. 66-70.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Pelron Corp., Lyons, Ill.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">NHJ-100, Hosmer Corp., Santa Clara, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., The biomechanics of the Canadian-type hip-disarticulation prosthesis, Artificial Limbs, Autumn 1957, pp. 29-38.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">McLaurin, Colin A., and Fred Hampton, .4 method of taking hip disarticulation casts using hip sticks, Orthop. &amp;Pros. Appl. J., June 1960, pp. 71-77.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Lyquist, Eric, Canadian-type plastic socket for a hemipelvectomy, Artificial Limbs, Autumn 1958, pp. 130-132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Slocum, Donald B., An atlas of amputations, C V. Mosby Co., St. Louis, Mo, 1949, pp. 244-249.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Fred Hampton, C.P. </b></td></tr><tr><td class="clsTextSmall">Assistant Project Director, Northwestern University Prosthetics Research Center.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-05.jpg Figure 7 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-06.jpg Figure 8 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-07.jpg Figure 9 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-08.jpg Figure 10 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-09.jpg Figure 11 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-10.jpg Figure 12 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-11.jpg Figure 13 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-12.jpg Figure 14 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-13.jpg Figure 15 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Hemipelvectomy Prosthesis Creator An entity primarily responsible for making the resource Fred Hampton, C.P. * https://staging.drfop.org/files/original/06f6f74cd10bc2ee26ce0685431872f2.jpg a8da2dd297edbf8190bce6c70291735a 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 Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. URL www.altso.org Address 401 Park Avenue South, 10th Floor City New York State/Province New York Countries Served USA Regions: Africa, Middle East, Asia, South AmericaCountries: Afghanistan, Bangladesh, Cambodia, Colombia, India, Indonesia, Nepal, Pakistan, SomalilandSpecific cities, regions, or groups of people: children with limb disabilities in the developing worldAge Group: ChildrenFees Charged: No Postal Code 10016 Phone 212.683.8805 Fax 212.683.8813 Email info@altso.org Organization Type Including ID and tax status Non-profit Tax ID 02-0594709 Not-for-profit Type 501(c)(3) Services Provided Prosthetic Fitting, Orthotic Fitting, Prosthetic Fabrication, Orthotic Fabrication, Medical / Surgical Care, Rehabilitation / Training Need I Financial Assistance Need II Materials, Components, and Equipment Need III Materials, Components, and Equipment: New, Equipment Additional Info & Comments Since 2003, ALTSO has been partnering with local treatment providers in Africa, Asia and Latin America to bring free orthopedic care to children in need. To learn more about ALTSO's mission or about how to get involved, please visit www.altso.org.Specific needs include: financial assistance and prosthetic supplies/equipment and raw materials.All donations and contributions, both monetary and in kind, are acknowledged as tax deductible donations to the full extent permitted by law, upon receipt. Memorials, honorariums, charitable annuities and sponsorships are graciously accepted. Facebook Page <a href="https://www.facebook.com/alegtostandon" target="_blank" rel="noopener">https://www.facebook.com/alegtostandon</a> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Leg To Stand On https://staging.drfop.org/files/original/02af16250516ded97985a715859e1d48.pdf 65d14eece6f79ba597a6dae38a00de2a https://staging.drfop.org/files/original/e39a0401f8bbfac0d7ecc2b81b69051f.jpg 8d0aee0aac22824b626b3f8d2b09410b https://staging.drfop.org/files/original/ec0662366f6e7d988cba99c4979f2001.jpg 107421598388ffad0c304b8ffb5f9550 https://staging.drfop.org/files/original/1270e5e0a05e215c9e3ce92571815ce9.jpg 1c1fe45517ca27d04646ba18f75d20c9 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_01_053.pdf Year 1970 Volume 14 Issue 1 Page Number(s) 53 - 64 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_01_053.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_01_053.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A Material for Direct Forming of Prosthetic Sockets</h2> <h5>A. Bennett Wilson, Jr. <br /></h5> <p>For a number of years, prosthetics research groups have been attempting to develop a method of forming sockets directly on amputation stumps, in order to reduce the time required to produce a satisfactory socket and to eliminate the messy working conditions inherent in the use of plaster of paris.<a></a></p> <p>Direct forming requires a material that: (<i>a</i>) is plastic at temperatures moderately above ambient, but which requires reasonably high temperatures for subsequent softening; <i>(b) </i>is easily handled under conditions found in most limb shops; (<i>c</i>) exhibits minimum creep or deformation under normal loads, even at temperatures slightly above body temperature; (<i>d</i>) is nontoxic; and (<i>e</i>) has a reasonable strength-to-weight ratio.</p> <p>Recently, research and development groups in Canada and the United States have developed successful techniques for direct forming of some types of sockets by using a synthetic balata, Polysar<a style="text-decoration:none;">*</a> X-414.</p> <p>Polysar X-414 has been found to possess the properties most essential for direct forming: (a) it becomes plastic at temperatures between 160 and 180 deg F; <i>(b) </i>it can be applied to the amputation stump within a minute or two after heating; (c) it remains reasonably plastic after its surface temperature drops 20 to 30 deg; <i>(d) </i>after it cools and becomes nonplastic, it maintains its shape, even under stress and subsequent heating to temperatures of 120 deg F; and (e) it can be reheated and reformed to permit socket modification after fabrication. In the plastic state, it exhibits cohesive properties which facilitate fabrication. It yields a slightly flexible socket which is considered desirable by most patients, and it is practical to use all conventional components and accessories with Polysar X-414.</p> <p>Clinical findings indicate that the sockets remain durable, provided they are not exposed to excessive heat <i>(e.g., </i>leaving the prosthesis in the sun, in the trunk of a car on a hot day, or leaning against a house radiator). Also, excessive contact with perspiration may cause erosion of the material in a year's time; however, stump socks normally provide an adequate barrier.</p> <p>The socket-forming procedure is relatively simple. The need for making a plaster-of-paris wrap cast, pouring a positive cast, and modifying the positive cast is eliminated. Thus, not only is fabrication time reduced, but the chance of the errors that are likely to occur when fabricating a socket with conventional materials also is lessened.</p> <h4>Lower-Extremity Sockets</h4> <p>A practical method for direct forming of sockets over the below-knee stump has been developed recently at the Veterans Administration Prosthetics Center. Early attempts included the use of a pneumatic bag over a tube of synthetic rubber to provide the pressure necessary for forming the socket over the stump (<b>Fig. 1</b>) <a></a>, a procedure which worked satisfactorily for bony, mature stumps but which often produced sockets that were too loose when molded over flabby stumps. Further experimentation resulted in a technique in which pressure is provided by wrapping pressure-sensitive tape spirally around the tube of Polysar X-414 and molding it with the hands as the tube cools (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Pneumatic pressure was applied to the softened synthetic rubber to form the socket on the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Direct forming of a below-knee socket with a pressure-sensitive tape wrap and hand molding of the softened synthetic rubber tube. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This method, described in the article beginning on page 57, has proved to be successful in a number of clinics, especially for use in temporary, or preparatory, prostheses. If a pylon is used, the patient can be provided with a well-fitted prosthesis in a very few hours. If subsequent socket modifications are required, they can usually be carried out readily, and if one of the adjustable pylons is used, alignment can be changed easily when required. A satisfactory cosmetic effect (<b>Fig. 3</b>) can be achieved relatively easily, to provide a "permanent" prosthesis. Such a prosthesis has proved to be quite successful as a "permanent" prosthesis for many patients in the old-age group.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. A "permanent" below-knee prosthesis, consisting of a synthetic rubber socket, adjustable pylon, foam-block covering (note cutout for access to the adjustment mechanism), and stocking. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Because of the size of the above-knee socket and the usual need for rather drastic modification of the socket with respect to the shape of the stump, a successful method of molding sockets directly over the above-knee stump has not yet been developed. However, work is continuing at VAPC.</p> <h4>Upper-Extremity Sockets</h4> <p>A technique for satisfactorily forming sockets for permanent prostheses directly over below-elbow stumps has been developed, also at VAPC. Again, extruded tubing of Polysar X-414 is used. All pressure necessary for forming is provided by the prosthetist's hands. Several types of cosmetic coverings are available when further cosmetic treatment is desired. The time required for fabrication of a typical below-elbow prosthesis can be reduced by half. The VAPC technique is described fully in the article beginning on page 65.</p> <p>The Ontario Crippled Children's Centre, Toronto, Canada, has been routinely using Polysar X-414 in fabrication of the open-shoulder, above-elbow socket, described in <i>Artificial Limbs </i>for Autumn 1969. Sockets preformed roughly to the shape required are heated and applied over the stump.</p> <p>The Prosthetics Research Center, Northwestern University, has developed a successful method for forming more conventional above-elbow sockets directly over the stump. An article describing this technique is scheduled for publication in the next issue of <i>Artificial Limbs.</i></p> <h4>Implications</h4> <p>Forming sockets with synthetic balata offers the prosthetist and orthotist the opportunity to provide quicker service to the patient, and also opens up many possibilities for improving the designs of sockets and orthotic components. The use of temporary prostheses can now be made routine, giving the clinic team ample time to determine the optimum prescription for the patient. Errors can be rectified easily, and new ideas can be tried with a minimum expenditure of time. Orthotists are already using synthetic balata for cuffs and molded supports. It is expected that many more uses for this remarkable material will be developed in the future.</p> <p><b>References:</b></p> <ol> <li>Committee on Prosthetics Research and Development, <i>Fracture bracing, </i>A report of a workshop, National Academy of Sciences, Washington, D.C., February 1969. </li> <li>The Staff, Veterans Administration Prosthetics Center, <i>Direct forming of below-knee patellar-tendon-bearing sockets with a thermoplastic material, </i>Orth. and Pros., 23:1:36-61, March 1969.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">The Staff, Veterans Administration Prosthetics Center, Direct forming of below-knee patellar-tendon-bearing sockets with a thermoplastic material, Orth. and Pros., 23:1:36-61, March 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Registered trademark of the Polymer Corporation Limited.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Fracture bracing, A report of a workshop, National Academy of Sciences, Washington, D.C., February 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_01_053/tmp399-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_01_053/tmp399-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_01_053/tmp399-3.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Material for Direct Forming of Prosthetic Sockets Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr.  https://staging.drfop.org/files/original/e52cf9eac794bb9024231c39d7c2f051.pdf 413a609559c66e9af1293680829afbfb https://staging.drfop.org/files/original/166a665a9fc23bfb942fb45a0d328add.jpg c4cee2dc30891c4dbd453a9ff9e9011d https://staging.drfop.org/files/original/dbcd7e754b0a7ca302d6404ea3eb5802.jpg bdcfd7fbb9809d59b822c0d8ec33038f https://staging.drfop.org/files/original/f9037b7cea4f85149601c702a1aa5701.jpg d55cef0a8d268de336576c39f462689a https://staging.drfop.org/files/original/de19e93c24849987f2b78a59293b0356.jpg 1f2ce2deb67ef8d12a9c28e3c40958b6 https://staging.drfop.org/files/original/3f2cc93e4e236d72d78c81efe84fc44a.jpg d7b29c791929c0956a546a4a68f9d629 https://staging.drfop.org/files/original/af1b7b176b3438b5f1ae452d9e41bdf6.jpg dd70ef09a9e9d539df70116c0d4bd9ea DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_02_031.pdf Year 1969 Volume 13 Issue 2 Page Number(s) 31 - 35 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1969_02_031.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_02_031.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A Method for Location of Prosthetic and Orthotic Knee Joints</h2> <h5>Henry F. Gardner <a style="text-decoration:none;">*</a><br />Frank W. Clippinger, JR, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>When it is necessary to use a mechanical knee joint, whether it be in a below-knee prosthesis or a long-leg brace, ideally there should be no relative motion between the patient's limb and the appliance during its use. Because the human knee is not a single-axis joint, analogues of the human knee employing more than one axis of rotation have been developed but none have proven practical, owing largely to bulki-ness, but to some degree to cost. At this time, therefore, we are faced with the problem of determining a method of placing the center of rotation of a single-axis mechanical knee joint with respect to the knee so that the least amount of relative motion will occur between the patient and the appliance.</p> <p>This article describes a method of determining the optimum location of single-axis knee joints, based on data accumulated recently from X-rays and from cadaver dissection.</p> <h3>Functional Characteristics of the Knee</h3> <p>Both the medial and lateral condyles of the femur appear as helical curves, the radii of which become progressively smaller from anterior to posterior. Only a small portion of the surface of the femur is in contact with the tibia at any given moment. Weight, however, is distributed over a larger area by the menisci, which provide smooth contact at any position.</p> <p>The knee structure is stabilized by cruciate and collateral ligaments, which control the range of motion of the joint and the relative positions of the articulating condylar surfaces. Because the medial and lateral condyles of the femur are not the same size, a transverse rotation of the femur takes place as the knee approaches full extension, causing the collateral and cruciate ligaments to tighten, and binding the femur and tibia tightly together in the weight-bearing position. Thus, as the knee begins to flex from the extended position and the femur rolls on the head of the tibia, the medial condyle rotates approximately 15 deg while the lateral condyle rotates approximately 20 deg. Then a slipping or gliding motion begins. Although the total flexion-extension range of the knee is approximately 160 deg, the first 110 deg is the most useful segment for prosthetic application, since this arc includes the full range required for walking (70 deg) and for sitting (100 deg).</p> <p>The numbered references if <b>Fig. 1</b> show the areas and the femoral condyle and the tibial plateau where contact is made successively as the knee is flexed or extended. Points "0" on the femur and tibia indicate the contact relationship between the bones when the knee is in 5 deg hyper-extension. During the first 20 deg of knee flexion, the condylar surfaces of the femur roll posteriorly on the tibia from point "0" to point "1." The greatest migration of the instantaneous center of rotation takes place during the first 15-20 deg of flexion. During the latter portion of the first 20 deg of knee flexion, a progressive sliding begins (between points "1" and "2"). Once the center of rotation reaches point "2," it remains relatively fixed during the remainder of the flexion range. This point is considered to be the optimum location for single-axis mechanical joints, especially if the knee is not permitted to extend fully. However, the usefulness of this point depends on one's ability to locate it by reference to external bony landmarks.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Points of contact between the femoral condyle and the tibial plateau during knee flexion and extension. The majority of translation occurs in the first 15 deg of knee flexion from a position of hyper-extension (point "0"). Successive flexion beyond this point concentrates the point of articulation between points 1 and 6. In prosthetics application, restriction of the knee to 10 deg before full extension confines the instantaneous center of femoral rotation between points 1 and 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>X-ray Studies of the Knee</h3> <p>X-ray studies of knee motion were undertaken in an attempt to find landmarks that had a constant relationship to the optimum center of rotation. Analysis of over 500 X-rays of the knee, such as those shown in <b>Fig. 2</b>, taken in various phases of extension and flexion revealed that the posterior femoral condyles, the posterior tibial condyles, and the posterior border of the head of the fibula are in approximately vertical alignment throughout the useful range of flexion-extension (lines 1, 2, and 3). Although the patella and the anterior fleshy-knee outline appear to recede posteriorly under the tensions exerted by the quadriceps, the posterior aspects of the femoral and tibial condyles and the posterior border of the fibula remain in the same relative posterior vertical alignment.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Typical transverse soft-tissue X-ray views of a normal knee showing the vertical relationship of the posterior borders of the major bony knee segments with the knee in the extended position and in 90 deg of flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Because there is only very thin tissue covering the anterior border of the tibia and the tibial tubercle, they are easily palpable, and therefore should make better reference points than the poples.</p> <h3>Analysis Of The Knee Joint By Diissection</h3> <p>The knee-joint measurements obtained from 21 adult cadavers are given in <b>Table 1</b> and <b>Fig. 3</b>. An analysis of these measurements indicates that the difference between the anterior-posterior measurements of the stump and the actual bone dimensions is approximately 3/4 in. The medio-lateral dimensions vary approximately 3/4 in. between the external measurement and the actual epicondylar width.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Dimensional proportionality of widths at the femoral epicondyles related to the measurements between the tibial tubercle and the posterior border of the fibular head. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Location of Knee Center</h3> <p>Based upon the dimensional relationships shown in <b>Table 1</b> and <b>Fig. 3</b>, a method (<b>Fig. 4</b>) is advanced for locating the approximate functional knee center, using the figures in <b>Table 2</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Steps in locating functional knee center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A. With the patient standing and leg extended, measure the knee width at the condyles.</p> <p>B. With the patient standing, knee flexed and relaxed, locate the posterior border of the fibular head.</p> <p>C. With the patient standing and the knee vertically extended, mark a reference line up the knee and lower thigh.</p> <p>D. With the patient standing, leg unweighted and knee slightly flexed, locate the lateral tibial plateau by pressing into the knee with the thumb.</p> <p>E. Keeping the thumb in position to maintain the exact location as the patient extends the knee, mark the tibial plateau level horizontally.</p> <p>F. Using the applicable figure from <b>Table 2</b>, mark the measurement at the plateau level and extend a line vertically from that point toward the thigh.</p> <p>G. Using the same measurement as in step F, mark the axis reference on the anterior vertical line horizontally.</p> <p>H. To mark the knee center references on the medial side, have the patient sit with the medial aspects of the knees 1/2 in. apart, flexed at 90 deg. Place a straight edge across the patellas. Measure the distance from the straight edge to the lateral reference (step G) and mark the measurement on the medial side (I). Measure the distance of the lateral reference from the floor and mark the measurement on the medial side.</p> <h3>Acknowledgments</h3> <p>Edward Peizer, Ph.D., Chief, Bioengineering Research Service, Veterans Administration Prosthetics Center, assisted the authors in the design and analysis of the knee data. Gabriel Rosenkranz, M.D., Medical Consultant, gave guidance and encouragement.</p> <p><b>References:</b></p> <ol> <li>Berndt, Albert L., and Michael Harty, <i>Trans-chondral fractures (osteochondritis dissecans) of the talus</i>, J. Bone Joint Surg. (Amer.), 41A:5:988-1020, September 1959.</li> <li>Fleer, Bryson, and A. Bennett Wilson, Jr., <i>Construction of the patellar-tendon-bearing below-knee prosthesis</i>, Artif. Limbs. 6:2:25-73, June 1962.</li> <li>Klopsteg, Paul E., Philip D. Wilson, et al., <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Slocum, Donald B., <i>An atlas of amputations</i>, C. V. Mosby Company, St. Louis, 1949.</li> <li>Steindler, Arthur, <i>Kinesiology of the human body under normal and pathological conditions</i>, Charles C Thomas, Springfield, Ill., 1955.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Frank W. Clippinger, JR, M.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Orthopedic Surgery, Duke University Medical Center, Durham, N. C; Chief, Orthopedic and Prosthetic Appliance Clinic Team, Veterans Administration Hospital, Durham, N. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Henry F. Gardner </b></td></tr><tr><td class="clsTextSmall">Technical Assistant to the Director, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York, N. Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_02_031/69autumn-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_02_031/69autumn-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_02_031/69autumn-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_02_031/69autumn-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_02_031/69autumn-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_02_031/69autumn-06.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Method for Location of Prosthetic and Orthotic Knee Joints Creator An entity primarily responsible for making the resource Henry F. Gardner * Frank W. Clippinger, JR, M.D. * https://staging.drfop.org/files/original/848c4d3ac131b5dd1f6aa772c7f8a431.pdf e817c23d305059d5eb0443856e4b4387 https://staging.drfop.org/files/original/36b983688348af4a118989fc5fb897c9.jpg 6cb2b221554b0b485d8fc79981ef09a6 https://staging.drfop.org/files/original/24dfe7339220fe553a1c64a284121f9f.jpg a77726724bb605b1b62088c61fa199fe https://staging.drfop.org/files/original/30555cd9d726c783eed81b24037c5cd4.jpg 9a82f709360468920d35880d9de0a173 https://staging.drfop.org/files/original/426fd84a7ec08befbdd52faee128f558.jpg f857fbf49e56777769bc3f0b1a131af4 https://staging.drfop.org/files/original/b4c608d131a05575666bb7d89f3e757a.jpg dc4cf48f9a16720c6e9c13db8d6428ab https://staging.drfop.org/files/original/ee370f1cc7c95a6fe60c95c4f0819351.jpg df2aa330418617744cac4fc848f4db40 https://staging.drfop.org/files/original/1ec16330c2317e239c81f3dca00e95eb.jpg 4cf2e1cb947b42839a66044354310fee https://staging.drfop.org/files/original/6b9d52df99dff7d840e2ec6557a4b1ac.jpg 348b4c2cc2203c0a6e6442d32a5dd6da https://staging.drfop.org/files/original/c847a8882afd28e78043d628ef01b4d1.jpg 1191ffe8bde507257ac7dcd9dd61efad DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_02_001.pdf Year 1971 Volume 1 Issue 2 Page Number(s) 1 - 5 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A Method of Early Prosthetics Training for Upper-Extremity Amputees</h2> <h5>Timothy V. Reyburn, MAJ., AMSC <a style="text-decoration:none;">*</a><br /></h5> <p>Over the past ten years, there have been gradual changes in the treatment and training of patients who have had upper-limb amputations.<a></a> This paper discusses early training techniques used over a two-year period at Valley Forge General Hospital on 67 (32 above-elbow and 35 below-elbow) amputees. Thirty-four of the amputees were treated from July 1968 to February 1969, and 33 from February 1969 to July 1970.</p> <p>Prior to February 1969, there was no separate ward for amputees, and each patient was placed on a ward appropriate to his overall disability, rather than according to his amputation. The upper-extremity amputees were pretrained in the leather-laced practice prosthesis with plaster-shell insert. However, this type of practice prosthesis was not fitted to the patient's stump until all wounds had healed and drainage had ceased. Consequently, preprosthetic training was delayed, and unilateral patterns could develop in the interim. When the patient did receive his practice prosthesis, training was initiated, with limited practice periods in occupational therapy for one hour a day. At first, the amputee wore the practice prosthesis only in the clinic. After he had mastered its operation and could tolerate the socket for longer periods, he was allowed to wear it the entire day. The patient was instructed to remove the prosthesis at night and to use the standard stump-wrapping procedure to control edema. A major problem during the training period was the constant separation of the plaster socket from the leather-laced cuff. Also, the functional alignment and the appearance were anything but desirable (<b>Fig. 1</b>). The therapist noted that the patients did not voluntarily wear their practice prostheses outside the supervised clinic environment. It was apparent that a more functional and streamlined type of practice prosthesis was urgently needed. In February 1969, the chief of orthopedics organized a separate amputee service, and a new training plan was initiated. The successful treatment of lower-extremity amputees by a technique in which a rigid dressing and plaster pylons were applied immediately after surgery lead to the hypothesis that a similar procedure might be beneficial for upper-extremity amputees. A practice prosthesis that consisted of a plaster socket with the terminal device and cable attachments embedded within the outer shell was fabricated (<b>Fig. 2</b>). From February 1969 to July 1970, 30 patients were fitted with the device (three amputees could not be fitted, because of transfer, infection, etc.). Their ages were between 19 and 39; the average age was 22 years.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. A leather-laced practice prosthesis with plaster-shell insert. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Adapted above- and below-elbow practice prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The key to a successful practice prosthesis is a firm, nonconstrictive, well-made socket. Both the above- and below-elbow sockets must be formed firmly and evenly to control swelling and to forestall blisters from developing by movement of the stump within a poorly fitting socket. Fabrication of the plaster-of-paris socket and prosthesis is relatively easy, and the procedure is basically the same for both above- and below-elbow prostheses.</p> <p>For the below-elbow socket, a layer of stockinet is pulled over the stump (<b>Fig. 3</b>) and extended two or three inches above the elbow, which allows for a fold and a trim on the proximal end. The distal end of the stockinet is cut and folded smoothly over the stump. Double thicknesses of three-inch plaster roll are thoroughly soaked and placed lengthwise on the stump. An area is left open ventrally to allow room for maximum flexion of the forearm. Circular, non-constricting, single-thickness wraps are then applied (<b>Fig. 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The first layer of stockinet applied to a below-elbow stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Application of plaster to the below-elbow stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For an above-elbow socket, the stump is completely covered with stockinet. The distal end of the stockinet is cut and folded smoothly over the stump. Double thicknesses of three-inch plaster roll are thoroughly soaked and placed lengthwise on the stump (<b>Fig. 5</b>). Each strip is ended three or four inches distal to the axilla to facilitate removal of the piaster socket. Circular, nonconstricting, single-thickness wraps are then applied. The lateral proximal apex is reinforced in order to provide a firm base for attachment of the lateral harness buckle.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Plaster being applied over the stockinet. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Aluminum struts are attached to the prosthetic appliance and plastered into the socket (<b>Fig. 6</b>). When the socket is finished, a figure-eight harness with a Northwestern ring is fitted to the patient, and a terminal device is attached to the practice prosthesis. All of the cable, base-plate, and harness connections are adjusted for each patient. Once the connections are attached and in proper alignment, the patient is trained to operate the practice prosthesis (<b>Fig. 7</b>). Additional sockets are fabricated if stump shrinkage exceeds the thickness of two single-ply stump socks. This basic prosthesis is used by the patient until he receives his final prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Affixing aluminum struts and a terminal device to the plaster socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. A below-elbow amputee learns to operate the terminal device on a practice prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Because these prostheses have proved so acceptable to the amputees, a plaster socket is fitted immediately upon the patient's admission. A below-elbow amputee can be fitted and can start to use his prosthesis all in the same day. An above-elbow amputee, if not ready for a practice prosthesis, is fitted with a plaster-shell socket and figure-eight harness (<b>Fig. 8</b>). Anterior and posterior elastic straps are attached to the plaster shell to provide an even upward pressure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. An above-elbow amputee fitted with a plaster shell with figure-eight harness and Northwestern ring. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The plaster shell replaces the standard elastic wrap and provides an exercise modality for the patient. The protection provided by the hard plaster shell and the non-constricting but firm pressure against the patient's stump are superior to that provided by an elastic-bandage wrap. An elastic bandage, when wrapped properly, is firm distally and becomes less and less firm proximally. The wrap is thus very unstable, and it readily falls off. The plaster shell provides a more constant pressure, and the elastic straps can be adjusted easily.</p> <p>Once the patient masters his practice prosthesis, he is assigned to a work-therapy job, which usually is related to his future vocational interest. The ability to use his prosthesis on the job convinces the patient that he can function normally, which is another step in preparing the man for his permanent prosthesis and eventual discharge. If the patient cannot perform a certain function with his prosthesis, a therapist shows him how to solve the problem. The ability to hold grain sacks, handle meat knives, and lift pails are just a few of the everyday tasks that can be taught in work-therapy assignments.</p> <p>At this point in his rehabilitation, the patient receives a thirty-day leave. It is during this period that the amputee can really give his prosthesis a workout, by wearing it around the house and using it while doing repair work or mechanical tasks. Completely relying on his prosthesis is the best way for him to work out any problems in its operation. He learns what works best for him, and this knowledge is of great value when he is sent to the prosthetist for the fitting of the permanent prosthesis. After the patient receives his permanent prosthesis, he needs no further training; he can operate it with maximum efficiency, and all that is needed is a final check-out. After minor pressure points and alignment problems are adjusted, the patient is ready for discharge.</p> <p>If necessary, amputees can be fitted while their stumps were still open and in traction. The importance of skin traction cannot be overemphasized; 75 percent of the amputees received for treatment needed some type of skin traction before being fitted.</p> <p>The skin-traction weight is removed, and the traction ties are folded back over the stump end. Another stockinet is then pulled over the skin traction, and a plaster socket is fabricated over both.</p> <p>Although at first only the less open stumps were fitted in this manner, the method was so successful that we used it on grossly open stumps, and the fittings were accomplished without difficulty (<b>Fig. 9</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Stump ready for fitting with practice prosthesis and traction still maintained. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Training sessions in occupational therapy with the practice prosthesis are a tremendous boost to the patient's well-being. After the training session, he removes the prosthesis, reties the traction, and attaches the traction weights. As skin coverage and healing improve, skin-traction time becomes less, and practice-prosthesis-wearing time increases.</p> <h3>Discussion</h3> <p>Acceptance of the permanent prosthesis by the 30 patients fitted after February 1969, and their functional use of it, was evaluated. The degree of acceptance and functional use decreased as the level of amputation increased, with positive acceptance of the long below-elbow prosthesis and a gradual rejection of the shoulder-dis-articulation prosthesis. Every patient was given and trained with an APRL (Army Prosthetic Research Laboratory) hand. Two of the 30 patients preferred the APRL hand to the hook; both of these had shoulder disarticulations.</p> <p>The post-February 1969 patients were fitted three to four weeks earlier than the pre-February 1969 patients. Duration of hospitalization remained about the same, but the post-February 1969 patients were on work therapy and were productive three to four weeks earlier.</p> <p>Ease of fabrication and patients' acceptance of the streamlined practice prosthesis were noted. The patients' stumps tolerated the hard-shell sockets without difficulty.</p> <p>Early fitting over open stumps and over skin traction is possible. Edema is reduced and the stump is desensitized while the patient uses his prosthesis.</p> <p>Rehabilitating the upper-extremity amputee to normal activities as soon as possible requires a total team approach. Close coordination among the physicians, nurses, physical therapists, occupational therapists, and prosthetists is necessary. If everyone on the team understands the problems of the upper-extremity amputee, then all can work together in directing and guiding his treatment.</p> <p><b>References:</b></p> <ol> <li>Bailey, Ronald B., <i>An upper extremity prosthetic training arm</i>, Amer. J. Occup. Ther. 24:5:357-359, July-August 1970.</li> <li>Burgess, Ernest M., Robert L. Romano, and Joseph H. Zettl, <i>The Management of Lower-Extremity Amputations</i>, TR 10-6, Prosthetic and Sensory Aids Service, Veterans Administration, August 1969, p. 11.</li> <li>Sarmiento, Augusto, Newton C. McCollough III, Edward M. Williams, and William F. Sinclair, <i>Immediate postsurgical prosthetics fitting in the management of upper-extremity amputees</i>, Artif. Limbs 12:1:14-19, Spring 1968.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bailey, Ronald B., An upper extremity prosthetic training arm, Amer. J. Occup. Ther. 24:5:357-359, July-August 1970.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Robert L. Romano, and Joseph H. Zettl, The Management of Lower-Extremity Amputations, TR 10-6, Prosthetic and Sensory Aids Service, Veterans Administration, August 1969, p. 11.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, Newton C. McCollough III, Edward M. Williams, and William F. Sinclair, Immediate postsurgical prosthetics fitting in the management of upper-extremity amputees, Artif. Limbs 12:1:14-19, Spring 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Timothy V. Reyburn, MAJ., AMSC </b></td></tr><tr><td class="clsTextSmall">Now Chief of Occupational Therapy, Fort Riley, Kans. 66442.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-9.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 A Method of Early Prosthetics Training for Upper-Extremity Amputees Creator An entity primarily responsible for making the resource Timothy V. Reyburn, MAJ., AMSC * https://staging.drfop.org/files/original/4e183acf56bb242b877abe71bad0c82c.pdf 2d5fb2193aba4c56fe7e72e3aa738711 https://staging.drfop.org/files/original/f35dbf1ec5058164a5372c266853ed58.jpeg b93e3a485fb5fa30970f58cb3c3f97b4 https://staging.drfop.org/files/original/84f9510431f05aafdee61cf4a63a6e60.jpg 815e14879134606d06e3dec6ad49473c https://staging.drfop.org/files/original/2bf778e75bd7f9b6cdd9a04374f57fee.jpg 0ce17c62d2456956432115616f913c64 https://staging.drfop.org/files/original/bf19e271aafb1c9ff9bb542af0b93338.jpg d3e8c2de5e80c1498f33a82414e7bcb3 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_01_011.pdf Text Any textual data included in the document <h2>A Modified Hemipelvectomy Socket</h2> <h5>Peter A. Ockenfels, CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>This paper is to demonstrate a modified design for a hemipelvectomy type of prosthetic socket, which was designed for an endoskeletal system prosthesis.</p> <p>The patient, a 28-year old white male, while involved in the operation of heavy equipment in May of 1978, experienced severe crushing type injuries. The injuries required a hemipelvectomy amputation on the right side, and due to peroneal nerve injuries, the function of the left lower limb was limited. For the purpose of this paper, however, only the hemipelvectomy socket design, which is different and special due to the presence of a colostomy, which needed to be fitted into the prosthetic receptacle, will be discussed.</p> <p>The patient's first prosthesis was designed in the usual fashion with the colostomy inside the prosthetic socket. This restricted drainage into the colostomy device. The patient needed to remove his prosthetic socket during the day in order to relieve pressure and dispose of the accumulated waste.</p> <p>In considering the design of a new prosthesis, it was felt that an anterior or a lateral opening on the opposite side was inadequate and non-functional since the colostomy opening could not be maintained in one particular area at all times. Thus, a lateral opening was provided on the amputated side. A flexible tongue allows the socket to expand as the patient dons his prosthesis (<a href="/files/original/f35dbf1ec5058164a5372c266853ed58.jpeg"><b>Fig. 1</b></a>). A single Velcro strap (<a href="/files/original/84f9510431f05aafdee61cf4a63a6e60.jpg"><b>Fig. 2</b></a>) secures the prosthesis, and the colostomy opening is maintained in a permanent position while standing (<a href="/files/original/2bf778e75bd7f9b6cdd9a04374f57fee.jpg"><b>Fig. 3</b></a>), as well as sitting (<a href="/files/original/bf19e271aafb1c9ff9bb542af0b93338.jpg"><b>Fig. 4</b></a>).<br /><br /><em><b>*Peter A. Ockenfels, CPO </b> American Orthotic &amp;Prosthetic Laboratory, Inc., Columbus, OH</em></p> Page Number(s) 11 - 11 Year 1983 Volume 7 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1983_01_011/1983_01_011-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1983_01_011/1983_01_011-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1983_01_011/1983_01_011-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 4 http://www.oandplibrary.org/cpo/images/1983_01_011/1983_01_011-4.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Modified Hemipelvectomy Socket Creator An entity primarily responsible for making the resource Peter A. Ockenfels, CPO * https://staging.drfop.org/files/original/0fd16e6b909f7130aea2a750ca50a40a.pdf 853cb1beca60fbae264611089e78bb36 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/1984_04_005.pdf Text Any textual data included in the document <h2>A Need for Information</h2> <h5>Kent Smith&nbsp;</h5> <p>April 6, 1971. My wife and I were eagerly anticipating the birth of our second child. I accompanied her to the hospital in suburban Chicago. It had been a normal pregnancy, much like the pregnancy two years earlier when our daughter was born. Shortly after midnight the joyous moment arrived. The doctor came to the father's waiting room; he was not smiling. Our son was born with a birth defect known as spina bifida. As we look back on that moment, we've realized how much the birth of our son Stephen has affected our lives.</p> <p>As a news writer/producer for a major television station in Chicago, I had access to a great deal of information. I had been trained to ask the right question, investigate the story thoroughly, and report both sides equally.</p> <p>My wife had received her education in library science and enjoyed the research involved in establishing a library and developing good reference systems. Nowhere in our professional experience had either of us come across information on the birth defect spina bifida, nor were we to realize how difficult it would be to get the information that should be so readily available to new parents of a spina bifida child.</p> <p>Parents find themselves very vulnerable after having given birth to a child with spina bifida. The hospital and medical staff appeared intimidating. We knew little about birth defects in general and nothing about our own child's specific needs. We looked to the "experts" whom we hoped would help.</p> <p>Our first attempt to get information was through the local chapter of the March of Dimes. Their personnel were courteous, sympathetic to our needs, but could not answer specific questions on how other families were coping with a child with spina bifida. We tried to gain understanding on a variety of terms. How did it affect our Stephen? Were we unique with this problem? What was the outlook for our son's future? Those questions went unanswered, although we did receive some pages copied directly from a well-known book on birth defects.</p> <p>Good friends stood by us trying to provide a sympathetic ear. They couldn't answer questions, but wanted to do the best for our family, even encouraging us to look at places where our child could be placed and be raised in a loving atmosphere; then we could go on with our own lives. This only frustrated us, for we wanted to help our son, who—by some quirk of fate—had problems that we knew were serious but we didn't understand. He was part of our family and we wanted to provide him with the best medical care available.</p> <p>As parents, we had to depend on others for guidance. The most obvious person to turn to is the family physician. Clearly, new parents of a disabled child need information on the disability and its treatment, as well as the names of agencies and support groups available to assist the family unit. Other parents who have faced the same situation can share their knowledge and give comfort and assistance.</p> <p>My wife and I were steered to a support group of parents and adults with spina bifida. This group met every month at the hospital. Our physician had been working with this parent group. Although he could not share the parental experience of raising a handicapped child, he respected the support that was freely given by parents "sharing their experiences." From our point of view, it was the best medicine that he could provide. It gave us hope that our son might make advances similar to other children.</p> <p>Information is the key to knowledgeable parents raising their children with spina bifida. My wife and I became active in this parent support group to learn more about the birth defect. From those adults with spina bifida we learned some problems they had faced and how we could help our son.</p> <p>Our involvement with a national organization wasn't something we planned, it evolved. In 1979, I was asked to establish a central office to provide information to new parents and be a resource to chapters consisting of parents, adults, and professionals in many cities. Under a letter of agreement with my employer, the American Broadcasting Company, I took a year's leave of absence to establish the office. I've never gone back to ABC.</p> <p>The leadership of Spina Bifida Association of America (SBAA) comes from the active participation of adults with spina bifida and parents working together. When SBAA was formed as a volunteer group in 1972, the greatest need was to provide printed information written in lay language. Today, the Association has 11 booklets directed to educators, new parents, adults with spina bifida, and to children. As a journalist, I was able to work with the writers in developing a distribution system that now has over 50,000 pieces of literature circulated each year.</p> <p>One concern we have is the misinformation that others continue to tell new parents regarding the current treatment or the lack of potential of people born with the birth defect today. In 1979, the SBAA established a policy that encourages early evaluation and medical/surgical treatment of every infant with spina bifida, and recommends that the evaluation be performed by professionals experienced in that care and treatment.</p> <p>Improved medical treatment within the last 25 years minimizes the disabling effects of spina bifida. Recent statistics from major treatment centers in New York, Pittsburgh, Chicago, Seattle, and elsewhere indicate that approximately 90 percent of those infants born today with spina bifida can lead a competitive life with some adjustments for physical disabilities.</p> <p>The majority of infants who receive aggressive treatment early do not suffer mental retardation. Lack of bowel and bladder control can be dealt with and should not take the "opportunity for life" away from the child. Some amount of paralysis often occurs, but the degree of involvement varies widely and cannot be determined at birth.</p> <p>The SBAA also sponsors an Adoption Referral program which offers a viable alternative to parents who feel unprepared to raise a child with a disability. The program has placed 70 babies in loving homes and has a waiting list of parents willing to take infants with spina bifida.</p> <p>During these last five years I have met hundreds of parents with similar stories, all with a commitment to provide information to a new parent who, like each of us, needed someone or some group to answer questions. The adults with spina bifida hold challenging jobs, and in general make worthwhile contributions to society. They have devised innovative ways in which to overcome their disabilities. Each represents a realistic goal which our child born with this birth defect can hope to achieve.</p> <p>If you would like further information on Spina Bifida and our Association, please call 1-800-621-3141.</p> Page Number(s) 5 - 6 Year 1984 Volume 8 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Need for Information Creator An entity primarily responsible for making the resource Kent Smith  https://staging.drfop.org/files/original/78226bca3eceb612d7d8db7908b1afea.pdf 17ea92cb6ada6610f2fbaf86eea54a0f https://staging.drfop.org/files/original/261df725d54dd7f063e4c1480fe2b3d3.jpg e794ee1f0b5fff92c69ded224bd3aa44 https://staging.drfop.org/files/original/5dfcfa64de6eb114dc3fd23266ad039f.jpg 154d7c1efbfef010c8ffd5299e701802 https://staging.drfop.org/files/original/26f6f61c5da43145a36acf58b1b84714.jpg 710d554f2eca75d9ec64650b02660da0 https://staging.drfop.org/files/original/11c9646efd2d9c0d69c2c465b47da84c.jpg d2191235871cd29462432969c2b36907 https://staging.drfop.org/files/original/db60e11c55d82008b2c099fe8ebda7ea.jpg 92cd2270b0e64d666d64407d4727ea18 https://staging.drfop.org/files/original/52834292f43677d81a9dc47f6f0f8db8.jpg da920604014ba63f1c778df76f95429d https://staging.drfop.org/files/original/f25fe005117d51ad9f0f54b235e228b3.jpg 2b8bb51f1b1e51f6d17abf901bde4539 https://staging.drfop.org/files/original/77e0f06a236e310a84838dc1ae8ea654.jpg b54a96a32abe60f41a30de18539467e7 https://staging.drfop.org/files/original/717dfa7fc8a884e6add25d763cbec268.jpg ac4508fff3afb9d1e91dc55704c0ecd5 https://staging.drfop.org/files/original/9833ca023913ff88aa0624da3d7d60eb.jpg ee895b1e9c8002f8f13bd6e78e37fcef https://staging.drfop.org/files/original/016bae82750ffc63db29627f435b81be.jpg 49366f88c3c52085520c43c8c7d454eb https://staging.drfop.org/files/original/7aec942c558625876ab59a8cbfa191da.jpg 2d09d1494909a8173317549ba8eaaff0 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_02_068.pdf Year 1970 Volume 14 Issue 2 Page Number(s) 68 - 80 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_02_068.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_02_068.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A New Approach to Patient Analysis for Orthotic Prescription- Part I: The Lower Extremity</h2> <h5>Newton C. Mccollough III. M.D. <a style="text-decoration:none;">*</a><br />Charles M. Fryer. MA. <a style="text-decoration:none;">*</a><br />John Glancy, CO. <a style="text-decoration:none;">*</a><br /></h5> <p>There is little question that the field of orthotics has taken a back seat to prosthetics in modern times, and perhaps for good reason. The needs of the amputee are more immediate and obvious, and the wars of the past thirty years have yielded untold numbers of young men in their prime whose productivity depended upon satisfactory functional restoration of their missing limbs. Medicine, engineering, and the prosthetic profession have responded to the needs of the amputee through extensive research and development, widespread educational programs, improved fabrication and fitting techniques, and better delivery of services. The field of orthotics remains in comparative disarray with more limited, though no less sophisticated, research activities, few educational endeavors, and little improvement upon local fabrication and delivery services over the past fifty years.</p> <p>Much of the blame for this rather distressing state of affairs must be laid to the physician, whose approach to orthotic prescription has been somewhat less than scientific. More often than not, little thought is given to analyzing specific biomechanical defects present in an extremity with the aim of translating them into an appropriate mechanical substitute. Even when this is done, all too often the device that is prescribed impairs to some degree the normal biomechanical functions which coexist in the same extremity. For example, a long leg brace prescribed for genu recurvatum may also limit normal functioning of the subtalar joint. Much of the physician's casual approach to orthotic prescription stems from a relatively sparse education in orthotic principles, but an even greater deficiency is the failure to relate well-known biomechanical principles to the mechanical substitute, or orthosis. Therein lies the trap, for without this awareness, prescriptions will continue to reach the orthotist calling for simply a "short leg brace" or a "long leg brace," and thus there is no stimulation for new or improved design criteria for orthotic components and systems.</p> <p>There is little doubt that the great advances which have been made in prosthetics in recent years have resulted primarily from a systematic appraisal of normal human posture and locomotion, with resultant attempts to duplicate not only the missing anatomy but also the biomechanical functions of the extremity. The problem in orthotics is somewhat different: specific functional losses must be substituted for in the presence of intact anatomy, and the variety of functional losses which may be present in a given extremity necessitates correspondingly varied design criteria. It is apparent, therefore, that an initial step in developing a rational approach to orthotic design and prescription would be some means of systematically analyzing the biomechani-cal losses in an impaired extremity. Once properly identified, these losses could then be matched against specific components or component systems to substitute for the functions lost. In addition, such an analysis might point up certain areas or functions for which truly satisfactory components are not available, and thus it might serve as a stimulus for future design and development.</p> <p>Recognizing the need for a more organized and systematic approach to orthotic prescription as a part of current efforts to revise volume 1 of the <i>Orthopaedic Appliances Atlas, </i>the Committee on Orthotics and Prosthetics of the American Academy of Orthopaedic Surgeons appointed an ad hoc committee for the development of a lower-extremity analysis form. In essence, this article represents a report of that committee, whose work commenced two years ago. During the development of the form, workshops were held periodically with the parent committee, together with representatives of the American Orthotic and Prosthetic Association, the Veterans Administration Prosthetics Center, and the Committee on Prosthetics Research and Development of the National Research Council. The form underwent periodic revision as it was applied to patients with a variety of disabilities, utilizing several clinics. The most recent and final application of the lower-extremity analysis form was in conjunction with the Workshop Panel on Lower-Extremity Orthotics held at Rancho Los Amigos Hospital in Downey, California, in March 1970. Its applicability to the evaluation of lower-extremity disability is now felt to be such as to warrant description for more widespread usage.</p> <h4>Lower-Extremity Analysis Form</h4> <p>The form consists of four pages of appropriate size for insertion into the patient's hospital chart. The first page <b>Fig. 1</b> contains spaces for patient data, including the diagnosis and a summary of major impairments existing in one or both extremities. At the bottom of the first page there is a legend for symbols to be used on the extremity diagrams. The second and third pages <b>Fig. 2</b>,<b>Fig. 3</b> contain skeletal outlines of the right and left lower extremities, respectively, in the sagittal, coronal, and transverse planes. Overlying the major joints are shaded areas, representing the normal ranges of joint motion within a circle divided into thirty-degree segments. Similar smaller circles overlie the mid-shafts of the long bones for diagraming angular, rotational, or translational deformities of the femur and tibia. The fourth page <b>Fig. 4</b> includes spaces for summarizing the functional disability, and for orthotic recommendations based upon this summary.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Front sheet of patient analysis form, including summary of major impairments and legend. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Second page of patient analysis form, with diagram of right lower extremity. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Third page of patient analysis form, with diagram of left lower extremity. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Fourth page of patient analysis form provides space for summary of patient's functional disability and for the orthotic recommendation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Instructions for Use</i></p> <p>Most of the "Major Impairments" portion of the form is self-explanatory. "Abnormal bone and joint" conditions may include such entities as osteoporosis, Paget's disease, and coxa vara. "Muscle" may be normal, flaccid, or spastic, but a space is provided for description of rarer disorders such as muscular dystrophy and fibrosis of muscle. Under the heading of "ligament," check boxes are provided to indicate abnormal laxity of the major ligaments of the knee and ankle. The sections on "sensation," "skin," and "vascular" impairments cover considerations which may influence orthotic design, and are self-explanatory.</p> <p>"Balance" is either normal or impaired, and if impaired, the following definitions are applicable: "mild" impairment is compatible with independent ambulation; "moderate" impairment is compatible with ambulation utilizing external support; and "severe" impairment indicates the need for maximal support or personal assistance in ambulation.</p> <p>"Extremity shortening" is recorded as follows: ischial tuberosity to sole of heel, ischial tuberosity to medial tibial plateau, and medial tibial plateau to sole of heel.</p> <p>In leg-length discrepancies exceeding one-half inch, X-ray studies of leg length may be indicated, and an appropriate space is provided for this measurement.</p> <p><i>Legend and Extremity Diagrams</i></p> <p>Two terms must first be defined:</p> <ol> <li><i>"Translatory motion"</i> is motion in which all points of the distal segment move in the same direction, with the paths of all points being exactly alike in shape and distance traversed <b>Fig. 5</b>.</li><li><i>"Rotary motion"</i> is motion of a distal segment in which one point in the distal segment or in its (imaginary) extension always remains fixed <b>Fig. 6</b>.</li></ol> <p>The symbols described in the legend are used in conjunction with the right-and left-extremity diagrams according to the following rules:</p> <ol> <li><b>Recording motion:</b> The degrees of rotary motion or centimeters of translatory motion are to be obtained from passive manipulation, and are to reflect passive (not active) motion at the site being examined. In the lower extremity, joints are to be observed during weight-bearing, and if the degree of joint excursion is greater under conditions of loading than under passive manipulation, this figure is diagramed rather than the smaller figure (e.g., recurvatum of the knee). <ul><li><i>Translatory motion:</i> Linear arrows horizontally placed below the circle indicate the presence of (abnormal) translatory motion at one or more of the six designated levels of the lower extremity listed on the left side of the form. The head of the arrow always points in the direction of displacement of the distal segment relative to the proximal segment. Linear arrows vertically placed on the right side of the circle indicate(abnormal) translatory motion along the vertical axis at the site indicated.</li> <li><i>Rotary motion:</i> Normal ranges of rotary motion about joints are preshaded on the diagram. Abnormal rotary motion, either as limited or excess motion, is indicated by double-headed arrows placed outside and concentric to the circle, to indicate the extent of available motion present in the affected joint. In certain instances, it may be more meaningful to use two double-headed arrows in order to describe the range of motion to either side of the neutral joint axis, rather than a single arrow which describes the total range of motion present. If one head of an arrow fails to reach the preshaded margin, limitation of joint motion is denoted. Conversely, if one head of an arrow projects beyond the preshaded margin, excess motion is designated. Numbers in degrees are placed adjacent to the arrows to indicate the arc described. In addition, radial lines drawn from the center of the circle and passing through its perimeter at the tips of the double-headed arrow are to be used for more graphic representation of the arc of available motion. At sites where rotary motion does not occur (e.g., fracture site, or knee joint in the coronal plane), the presence of abnormal rotary motion is similarly designated by a double-headed arrow with adjacent numerical value in degrees.</li> <li><i>Fixed position:</i> Double radial arrows indicate a fixed joint position, and describe in degrees the deviation from the neutral joint position. Horizontal or vertical double arrows indicate a fixed joint position in a translatory sense, and the extent of abnormal translation is indicated in centimeters adjacent to the arrow (e.g.,subluxation of the tibia in a hemophiliac knee).<br /></li></ul></li><li><b>Muscle dysfunction: </b> <ul><li><i>Flaccid muscle:</i> Flaccid muscle is designated as such under the section on major impairments. Muscle-group strength, not individual muscle strength, is determined by conventional means on the examining table, and the letter grade corresponding to volitional force is recorded adjacent to the skeletal outline at the proper location for each muscle group. The letter grades correspond to the standard muscle-grading system used in poliomyelitis. No symbol is used if muscle strength is normal.</li> <li><i>Spastic muscle: </i>Spastic muscle is designated as such under the section on major impairments. It is further identified in the legend as "SP." The letter grade (e.g., SP_MO) for muscle-group tone, not individual muscles, is to be placed adjacent to the skeletal outline at the proper location for each muscle group. Spastic-muscle estimates are to be made with the patient in the functional position for the lower extremity, i.e., observation during standing and walking. The subletter grades for spastic muscle are as follows:<br /> "M" indicates a mild degree of spasticity;<br /> "MO" indicates a moderate degree of spasticity sufficient for useful holding quality;<br /> "S" indicates severe spasticity, obstructive in terms of function.<br /> In certain instances, muscle groups in a patient with spastic paralysis may be more appropriately graded according to volitional force, e.g., dorsiflexion of the foot in a hemiplegic.<br /></li></ul></li><li><b>Recording fracture or bone deformity: </b> All translatory or rotary motions at the fracture on the shaft of a long bone are diagramed on the circle located</li></ol> <p>The technique of completing the analysis forms for specific lower-extremity disabilities is shown in <b>Fig. 7</b>,<b>Fig. 8</b>,<b>Fig. 9</b>,<b>Fig. 10</b>,<b>Fig. 11</b>,<b>Fig. 12</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Record for patient with left hemiplegia. Information given on front sheet includes spastic muscle picture with inversion deformity of foot, mild loss of proprioception, venous stasis in left leg, and mild impairment of balance. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Diagram of patient E.L.'s left lower extremity. Muscles which are not normal are designated by letter grade. Muscles which are not spastic clinically and which possess volitional control are designated by conventional letter grading. The diagram illustrates presence of good hip flexors, extensors, and abductors, good knee extensors, fair knee flexors and foot invertors, poor foot dorsi flexors, zero foot evertors, and mild calf spasticity. There is 15° of hyperextension at the knee, and the heel cord is tight, limiting dorsiflexion of the foot to neutral. The presence of edema from the knee to the foot is also noted at the mid-shaft of each bone. The actual fracture site is indicated by the fracture symbol. All bony deformities such as valgus angulation of the shaft are likewise diagramed on the circle located at the center of the shaft, regardless of the position of the angular deformity. The location of the angular deformity is designated by circling the appropriate level on the left side of the chart. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Summary of the patient's functional limb disability, and the orthotic recommendation based upon that summary. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Record for patient with residual poliomyelitis affecting his left lower extremity. Information given indicates flaccid paralysis with severe atrophy, laxity of the medial collateral ligament of the knee, and 1 3/4 in. shortening of the left lower extremity. In addition, the patient had an old supracondylar fracture of the femur and a previous triple arthrodesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Diagram of patient W.S.'s left lower extremity. In addition to showing the letter grades for muscle-group strength, the diagram also shows 20° of hyperextension at the knee, 15° of valgus instability of the knee, 15° of external tibial torsion, limitation of dorsiflexion at the ankle, abnormal inversion and eversion at the ankle, and a fixed position of the subtalar joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Summary of patient W.S.'s functional limb disability, and the orthotic recommendation based upon that summary. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Discussion</h4> <p>The stated purpose of developing a patient analysis form of this type is to organize a systematic approach to orthotic prescription. In addition, through stimulation of a careful appraisal of biomechani-ical faults in a given extremity, it may also serve as a basis for identifying certain areas in need of new or further design and development. It is also viewed as a valuable teaching tool for students of orthotics at both the technician and physician levels. Most importantly, it may serve as a common ground upon which both the orthotist and the physician can meet to work out satisfactory solutions to bracing problems. (Sample copies of the form are available from the CPRD office).</p> <p>As a further step in making such an analysis form more meaningful to orthotists and physicians, a list of available lower-extremity orthotic components is currently being compiled in such a way as to categorize these components by their biomechanical function. Ideally then, one might diagra-matically plot the biomechanical losses present in a limb and then select a mechanical device from the appropriate category to substitute for the lost function. In this way, the orthotic prescription can evolve as a carefully thought-out combination of specific components to create a suitable orthotic system for the deficient limb.</p> <p>A revitalized approach to orthotics is urgently needed. According to a recent estimate, there are 3,370,000 orthotic patients in the United States as opposed to 311,000 amputees, or ten times as many patients who need orthoses as need prostheses <i>(1). </i>Little that is new has been done for many of these patients until very recently. Several research centers in the United States and Canada are engaged in sophisticated and promising orthotic research. Unfortunately, by and large, the products of this research have not yet reached the masses of handicapped people. Stimulation of new approaches to mechanical design at the local level must be achieved through close and meaningful collaboration between physician and orthotist. It is hoped that the material presented in this article will be an initial step toward that goal.</p> <p>Work is currently being done on a similar approach to the upper extremity and the spine. These areas will be the subjects of future reports.</p> <h4>Acknowledgements</h4> <p>The authors wish to express special appreciation to Dr. George T. Aitken, former chairman of the American Academy of Orthopaedic Surgeons Committee on Prosthetics and Orthotics; Dr. Robert Keagy; Mr. A. Bennett Wilson, Jr.; Mr. Anthony Staros; and Dr. Edward Peizer for their specific contributions to this work.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> FIg. 5. "Translatory motion": motion in which all points of the distal segment move in the same direction, with the paths of all points being exactly alike in shape and in distance traversed. In all three examples, the pathways between original position "A" and final position "B" of four arbitrarily selected points in each figure are each exactly alike in direction, form, and distance traversed. Note that the long axes of the figures also remain parallel throughout the "translation" from A to B. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. "Rotary motion": motion of a distal segment in which one point in the segment, or in its (imaginary) extension, always remains fixed. The axis "O," in each of the three examples, represents a point in the figure (or as in "III" in its imaginary extension) that always remains fixed in position when the body "rotates" from position "A" to position "B." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Committee on Prosthetics Research and Development, <i>Report of the Seventh Workshop Panel on Lower-Extremity Orthotics of the </i><a><i>Subcom.it-</i></a><i>tee on. Design and Development, </i>National Research Council-National Academy of Sciences, March 1970.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>John Glancy, CO. </b></td></tr><tr><td class="clsTextSmall">Orthotic Division, Indiana University Medical Center, Indianapolis, Ind. 46207.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles M. Fryer. MA. </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetic-Orthotic Center, Northwestern University Medical Center, Chicago, Ill. 60611.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Newton C. Mccollough III. M.D. </b></td></tr><tr><td class="clsTextSmall">Assistant Professor of Orthopaedics, Associate Director of Rehabilitation, University of Miami School of Medicine, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-07.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-08.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-09.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-10.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-11.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-12.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-05.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-06.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A New Approach to Patient Analysis for Orthotic Prescription- Part I: The Lower Extremity Creator An entity primarily responsible for making the resource Newton C. Mccollough III. M.D. * Charles M. Fryer. MA. * John Glancy, CO. * https://staging.drfop.org/files/original/934d9d58cdc431c9e0221d32ee8fe951.pdf 9ab98303a3e42383d5edd757b0da7d06 https://staging.drfop.org/files/original/9a0943f435a6d9fe4ed610d2caba0b86.jpg b20aa7224fab12563b41462c3dd6fe20 https://staging.drfop.org/files/original/ac1c440073b39ee145136d5d5c0f8990.jpg caadd7555cef407c05e9e41c66a61ecb 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/1987_02_079.pdf Text Any textual data included in the document <h2>A New Look at the RGO Protocol</h2> <h5>Lou Ekus, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Linda McHugh, R.P.T.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>The L.S.U. Reciprocal Gait Orthosis (RGO) is an orthotic device that gives structural stability to the patient with lower trunk and lower limb paralysis while allowing, through a cable coupling system, reciprocal hip joint motion for ambulation. The device has been used at the Shriners Hospital in Springfield, Massachusetts since December, 1980. Our experience with the Reciprocal Gait Orthosis has led us to a simplified approach in the selection, fitting, and training of patients suitable for fitting with this device.</p> <h3>Patient Distribution</h3> <p>Sixteen fittings with the Reciprocal Gait Orthosis have been reviewed for this article. Seven of these children were under the age of four years at the time of their first fitting, with a total of 12 children under the age of eight at the time of first fitting. All 12 children were discharged from the hospital using the orthosis effectively. One child in this group later rejected the orthosis because he was able to ambulate with bilateral knee-ankle-foot orthoses and felt the Reciprocal Gait Orthosis was too much bracing. Out of this group, the remaining 11 children are currently community ambulators and wear the orthosis for most of the day.</p> <p>In addition to these 12 children, we have four young adults who are fit with the Reciprocal Gait Orthosis. Three of them were 13 years old at the initial fitting. Two of these children were discharged from the hospital using the orthosis effectively and are currently household ambulators. The last of the 13 year olds rejected the brace due to an extreme fear of the upright position. Our last fitting was done on a 21 year old male with severe hip and knee flexion contractures. This patient had a tremendous desire to ambulate and so the fitting was attempted. However, after numerous fittings and adjustments, the attempt was abandoned as a result of the severity of his contractures.</p> <h3>Protocol</h3> <p>Our first patient was fit with a reciprocator in December, 1980. Subsequently, 12 children were fit following the general guidelines established by Louisiana State University. In November, 1985, we developed our own written protocol. The protocol was extremely specific, outlining prerequisites before fitting with the Reciprocal Gait Orthosis. The protocol included such criteria as, 1) hip and knees free of flexion contractures greater than 20 degrees, 2) patient required to demonstrate independent mobility in a parapodium, and 3) parents required to admit children for training.</p> <p>After a review of our series up to that point, we realized that few of the patients actually met 100 percent of the criteria in our existing protocol, and yet our success rate was quite high. After a further review of the fittings was done, a revised protocol was written and instituted in June, 1986. Our new protocol for fitting with the Reciprocal Gait Orthosis is outlined below:</p> <ol> <li> <p>Parents and child will watch a video prepared by the hospital showing the fitting and training process for the Reciprocal Gait Orthosis.</p> </li> <li> <p>A team meeting will be held prior to admission with parents and child, physical therapist, orthotist, nurse, social service representative, and physician. At this meeting, goals are set for admission and parents are given the opportunity to ask any member of the team questions that they might have. The child's abilities will be discussed, including a) ability to stand and move in the parapodium, b) emotional and cognitive ability to tolerate training, c) upper extremity strength, and d) any existing joint contractures and their influence on fitting and training.</p> </li> <li> <p>Goals will be set, regarding a) cooperation for training, b) balance and confidence with movement, c) quality of mobility, d) independency in transfers, and e)&nbsp;donning and doffing of the orthosis.</p> </li> </ol> <p>Following fitting and dynamic alignment of the Reciprocal Gait Orthosis, gait training begins. It includes 1) momentary standing balance, 2) training on the parallel bars (patient instructed to "shift weight" and "push back"), 3) progression to a rollator walker when consistent orthotic control, good balance, and even stride length are demonstrated in parallel bars, and 4) progression to Loftstrand crutches when improved independence in balance is achieved and the patient is cognitively able to use them.</p> <p>Three weeks into training, a second team meeting is held. Each goal is addressed and the team determines the best way to continue training based on the reassessed goals.</p> <p>At discharge, the patient will 1) ambulate with the walker, 2) exhibit consistent control in step length, balance and stability, 3) exhibit good standing balance, and 4) be able to negotiate a ramp.</p> <h3>Fitting Problems</h3> <p>Without a doubt, the most consistent problem we've seen in fitting the Reciprocal Gait Orthosis is existing hip, knee, and ankle contractures. We have fit patients with significant contractures of these joints and have accommodated for the contractures in alignment by wedging the shoes (<a href="http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-1.jpg"><b>Fig. 1</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-2.jpg"><b>Fig. 2</b></a>). Our intention is to enable the child to exhibit effective ambulation and then to consider joint releases when possible.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-1.jpg"><strong>Figure 1. Front view of patient showing extensive pre-existing contractures and shoe wedging to accommodate the contractures.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-2.jpg"><strong>Figure 2. Lateral view.</strong></a><br /> <p>We have seen, in a few cases, where it is difficult for the patient to comprehend that pushing back will advance the leg. To make this concept more easily understood in the early stages of training, the hip joints are flexed slightly more than usual to allow the patient to grasp this concept easily. This usually makes standing balance impossible. However, after a day or two, the orthosis can be extended and standing balance can be addressed. We found this to be an extremely useful tool in expediting the initial stages of training.</p> <h3>Early Intervention</h3> <p>Taking into consideration the importance of upper limb strength, preservation of range of motion, and weight control before fitting a patient with the reciprocating orthosis, it is easy to see the importance of early intervention in cases of congenital deficiency. Through our myelodysplasia clinic, we are able to follow the patients on an ongoing basis from birth to insure continuing follow up in these areas. It is also possible to insure the delivery of an infant Stander at the appropriate time. The clinic also gives us the opportunity to observe the child in the Stander or parapodium. Mobility in these devices is a good indication of motivation, balance, and the child's awareness of his body moving through space. The myelodysplasia clinic gives us an invaluable opportunity to insure that all of the prerequisites are being nurtured and that we can initiate a fitting with the Reciprocating Gait Orthosis at the appropriate time.</p> <h3>Results</h3> <p>Included in our series of 16 patients are 12 children who are community ambulators. In addition, two children are ambulatory in their household or for short distances, and two rejected the Reciprocal Gait Orthosis as their means of mobility. The age of initial fitting for these children spanned two years to 21 years, with children under the age of eight all being community ambulators.</p> <h3>Conclusion</h3> <p>Clearly, the results demonstrate the importance of both early intervention and early fitting with the Reciprocal Gait Orthosis. We hope that children with congenital paraplegia who initiate ambulation with a Reciprocal Gait Orthosis at an early age will continue to be ambulatory further into adult life than those who have used knee-ankle-foot orthoses in the past. In conclusion, we would like to propose the idea that, based on experience with our protocol, the fitting and training of a child using the Reciprocal Gait Orthosis is no more difficult than other bracing modalities and can be approached with the same ease.</p> <p><b>References:</b></p> <ol> <li>Douglas, R., P. Larson, R. Ambrosia, and R. McCall, "The LSU Reciprocation-Gait Orthosis," <i>Orthopedics</i>, Vol. 6, No. 7, July, 1983, pp. 834-838.</li> <li>McCall, R., R. Douglas, and N. Rightor, "Surgical Treatment in Patients with Myelodysplasia Before Using the LSU Reciprocation Gait System," <i>Orthopedics</i>, Vol. 6, No. 7, July, 1983, pp. 843-848.</li> <li>Shanks, K., "LSU Reciprocating Gait Orthosis," Durr-Fillauer Medical, Inc.</li> <li><a href="http://www.acpoc.org/library/1985_03_046a.asp">Ekus, L., "Reciprocator Orthosis: A Protocol," <i>ACPOC</i>, April, 1985.</a></li> </ol> <p><em><b>*Linda McHugh, R.P.T. </b> Linda McHugh, R.P.T. is also with Shriners Hospital for Crippled Children.</em></p> <p><em><b>*Lou Ekus, C.P.O. </b> Lou Ekus, C.P.O. is Director of Orthotics and Prosthetics at Shriners Hospital for Crippled Children, 516 Carew Street, Springfield, Massachusetts 01104.</em></p> <div style="width: 400px;"></div> Page Number(s) 79 - 81 Year 1987 Volume 11 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-2.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/. 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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_01_019.pdf Text Any textual data included in the document <h2>A Partial Foot Prosthesis for the Transmetatarsal Level</h2> <h5>Jack N. Collins, C.P.O.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>Traditionally prosthetists and orthotists have faced the problem of partial foot amputations with the skills, materials, and observations gained from past experiences or from others in the field. The author is not aware of any extensive research in prosthetics for partial foot amputations. Attempts to provide a suitable prosthesis have ranged from a simple toe filler with arch support, to an ankle immobilizer at P.T.B, level, and lace-on fillers of many descriptions. In the author's observation, any prosthesis that goes above the ankle results in the buildup of unwanted forces.</p> <p>The late Charles Childs, C.P.O.,<a></a> made the greatest breakthrough in partial foot prostheses. I attended his seminar in late 1978 and was very impressed with the entire approach demonstrated, especially the cosmesis and fit at shoe level height. Unfortunately, after a few weeks wear, the rubber material used in the fabrication of the prosthesis did not retain its shape and support against the extreme forces exerted in walking. The forces developed on the short lever arm, the foot, in walking are greater than at any other level of amputation. These forces applied in walking and running are not confined to the plantar surface of the residual foot, but are transmitted in part to the entire surface of the prosthesis. In turn, some of these forces are applied to whatever footwear is worn. Thus, the footwear applies a resistant force to the prosthetic appliance, quite often to the detriment of the appliance and the residual foot.</p> <p>It must be stated at this point that the prosthesis about to be described has not been evaluated with foot amputations at the Lisfranc or Chopart level, but only on transmetatarsal level. And from our limited experience, developed over the past 7 to 8 years, a mid-trans-metatarsal amputation presents fewer problems in toe-off than amputations at a greater or lesser length. With this in mind, the evaluation, casting, and fabrication techniques used will be described.</p> <h3>Evaluation, Casting and Fabrication</h3> <p>Evaluation is made in routine manner, for amputation level, range of motion at ankle, contractures, cut bone covering, abrasions, callosities and sensitive areas.</p> <p>With patient seated in a chair, invaginate a casting balloon over the residual foot with a short piece of plastic tubing on the dorsum of the foot. Mark with indelible pencil all boney prominences, callosities and sensitive areas (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-01.jpg"><b>Fig. 1</b></a>). Very carefully roll on a 4" roll of plaster in a manner to cover the entire foot to the inferior edge of the lateral malleoli and with a thickness sufficient to retain its shape on removal. While the plaster is still soft, have the patient place his foot on the floor, with the knee at 90°, foot in neutral position (not in valgus), and with the weight of the leg on the plaster. Make marks with indelible pencil on the cast at 90° across the plastic tube. With a cast saw cut down the tube to remove the cast. If care is taken in applying the plaster, you will have a very smooth and detailed cast on removal (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-02.jpg"><b>Fig. 2</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-01.jpg"><strong>Figure 1. Foot ready for casting with casting balloon and plastic tubing in place.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-02.jpg"><strong>Figure 2. Cast removed</strong></a><br /> <p>Close the cast carefully with plaster wrap, apply the release agent, and pour the cast with mandrel in place about 45° to vertical. This makes it easier to apply P.V.A. and stockinette. Remove the plaster wrap from the model.</p> <p>Very little modification should be necessary. Add about 1/8" plaster buildup over the boney prominence at the distal end and over any callosities or other sensitive areas. It is not necessary to modify as in the U.C.B.L. Shoe Insert casting method. Using a Scarpas knife, remove about 3/16" to 1/4" plaster from the plantar surface 1/2" proximal to the metatarsal ends, the width of the metatarsals, and taper in the direction of the heel about 1" to 1 1/2" depending on the size of the foot. The anterior edge of cut should have a 5/16" radius (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-03.jpg"><b>Fig. 3</b></a>). Dry or seal the model.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-03.jpg"><strong>Figure 3. Modified positive model</strong></a><br /> <p>Pull on one layer of nylon stockinette to allow for the patient's sock. Pull the P.V.A. over cast for vacuum. Tailor a piece of 1 oz. Dacron felt to cover the plantar surface. The felt should extend over the anterior distal end, laterally to cover the base of the 5th metatarsal, and medially to cover the scaphoid prominences. Sew one end each of four lengths of nylon stockinette and pull on the model with the Dacron felt in place. On heavier more active patients, one layer of woven glass reinforcement is added between the felt and stockinette. When pulling on the stockinette, take care not to pull out the stretch of the stockinette. The stretch needs to be retained in the silicone laminated areas to allow donning. Take two 4" P.V.A. sleeves and cut 12" long pieces from the small end of each to make feeder tubes. Apply a 6" moist P.V.A. sleeve to the model so as to give a smooth surface all over. Do not tie off the ends, but do dry with a heat gun. Use a tongue depressor to push the small end of one of the feeder tubes under the P.V.A sleeve at the heel of the model. The tube should be about 3/8" from the plantar surface of the heel. In the same manner, position the remaining feeder tube under the P.V.A. sleeve over the dorsum of the model. The tube should be about 3/8" from the proximal edge.</p> <p>Roll a 1" wide by 6" long piece of 1/16" thick polyethylene into a funnel and place in the open end of one of the tubes (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-04.jpg"><b>Fig. 4</b></a>). Mix 80 grams of Dow Corning 382 silicone with 2 or 3 drops of appropriate color and catalyze as directed by Dow Corning, pour into the funnel and very carefully squeeze into the stockinette. On the dorsum of the foot, laminate the section the shoe lace will cover, or a little more area. Squeeze with your finger tips to get a thorough and even penetration working the Silastic, laterally, and distally down to, but not onto the plantar surface. Working with the fingers gives better penetration without spreading the resin to unwanted areas. After this has cured, repeat in the same manner posteriorally. The posterior portion should extend distally down the back of the heel to the sole and anteriorally along the proximal trimline for a width of 1" distal of the trimline so that it meets the posterior border of the anterior lamination medially and laterally (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-05.jpg"><b>Fig. 5</b></a>). When the posterior portion has cured and both feeder tubes have been removed, tie off the pipe end of the 6" P.V.A. sleeve and pour in 150 grams of 4110 Laminae that has been catalyzed and pigmented. Saturate the remaining lamination and maintain it under a vacuum until cured. While the polyester is still warm, trim to the shoe top level and remove the prosthesis from model (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-06.jpg"><b>Fig. 6A</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-07.jpg"><b>Fig. 6B</b></a>). The prosthesis is now ready for fitting.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-04.jpg"><strong>Figure 4. Completed layup with P.V.A. sleeve and feeder tubes in place</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-05.jpg"><strong>Figure 5. Initial phase of lamination. Dorsum and proximal border of socket have been laminated with Dow Corning 382 Silastic.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-06.jpg"><strong>Figure 6A. Socket completed and removed from model, medial view</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-07.jpg"><strong>Figure 6B. Lateral view</strong></a><br /> <p>In weight bearing, check for comfort, undue pressure, and position of the foot. More than likely it is in some valgus, as any foot amputated proximal to the head of the first metatarsal loses its medial support. With small wooden wedges, you can determine the amount of posting needed under the distal end of the first metatarsal to hold the foot in a neutral position. When this has been done, mix a small amount of thickened polyester and add it to the distal plantar surface of the first metatarsal area to establish the desired position. When comfort and fit have been achieved, the prosthesis is ready to be completed.</p> <p>Obtain a shoe from the patient for foot sizing. Take a plaster wrap of the distal portion of an appropriately sized S.A.C.H. foot. When the plaster on the S.A.C.H. foot has cured, remove it from the foot, and inspect the inside for smoothness. Fill any voids and smooth nicely. Dry the plaster and paint the inside with ambroid or celluloid. Spray the inside of the toe cast with silicone release agent.</p> <p>Rivet with two #12 copper rivets, all" long by 1 1/2" wide .0035 thick blued steel spring, that has been shaped to the contour of the inside surface of the shoe sole, to the plantar surface of the socket. Shear off the distal portion of the spring so it ends about 1" from the toe. Drill a hole for a #12 copper rivet and rivet on a small "U" shaped piece of leather to act as an anchor for the silicone toe piece (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-08.jpg"><b>Fig. 7</b></a>). Drill 1/2" hole in the distal plantar surface of the toe cast. Wipe the anterior surface of the prosthesis with acetone. It must be clean. Fit the plaster shell over the spring and anterior portion of the prosthesis as far proximal as necessary to obtain proper foot length. Be sure the spring or leather anchor does not come in contact with the inside of the plaster mold. When properly positioned, solidly tape the plaster wrap to the prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-09.jpg"><b>Fig. 8</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-10.jpg"><b>Fig. 9</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-08.jpg"><strong>Figure 7. Socket with toe spring and leather anchor rivetted in place</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-09.jpg"><strong>Figure 8. Socket and plaster toe mold</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-10.jpg"><strong>Figure 9. Toe mold taped in place</strong></a><br /> <p>Mix 65 grams of Dow Corning #382, 5 grams Dow Corning Q74290 Prosthetic Foam, and 2 or 3 drops of appropriate pigment. Catalyze and pour slowly into the 1/2" hole in the toe. Stand the assembly on the back of the heel, toe up, and support it in this position until foamed and cured. When the foam has cured, carefully use a thin instrument to pry the silicone toe gently loose from the plaster. It should come off with little effort. Depending on the smoothness of your plaster toe mold, the release agent used, and the foam mixture, the prosthesis should be very presentable (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-11.jpg"><b>Fig. 10</b></a>). If it is rough and has air holes, sand it smooth and paint on a coat of Pigmented Dow Corning #382.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-11.jpg"><strong>Figure 10. The completed prosthesis</strong></a><br /> <h3>Summary</h3> <p>The rigid control of the residual foot, yet flexible entry and toe off, together with good patient acceptance, cosmesis, and wearibility makes this type prosthesis our choice in the prosthetic management of transmetatarsal amputations. We call this the C.O.S.I. Partial Foot Prosthesis (Collins Orthopedic Service, Inc.).</p> <h3>Addendum</h3> <p>It is the author's opinion that Lisfranc and Chopart level amputations could be approached in a similar manner by extending the distal support and point of toe off to a more normal position. However, this opinion is not based on personal experience with using the C.O.S.I. Partial Foot Prosthesis to fit these level amputations. This would require some thought and quite a bit more effort in the lamination procedure.</p> <p><b>References:</b></p> <ol> <li>Childs, Charles, Pacific Orthotic and Prosthetic Services, 111 East First Street, Medford, Oregon 97535.</li> </ol> <em><b>*Jack N. Collins, C.P.O. </b> Jack N. Collins, C.P.O., is with Collins Orthopedic Service, Inc. 2875 Joyce Street, Fayetteville, Arkansas 72703.<br /><br /><br /></em> Page Number(s) 19 - 23 Year 1988 Volume 12 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 FIGURE 6A http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-06.jpg FIGURE 6B http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-07.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-08.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-09.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-10.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-11.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 A Partial Foot Prosthesis for the Transmetatarsal Level Creator An entity primarily responsible for making the resource Jack N. Collins, C.P.O. * https://staging.drfop.org/files/original/33ac5f83c3b345c7f45c737170f43aa0.pdf 7e4f270c0b93c37ded6218cb290d8afb 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/1984_04_003.pdf Text Any textual data included in the document <h2>A Personal Experience</h2> <h5>Cynthia L. Cuchna&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Most people would say, "It would be terrible to be born with a birth defect." Well, I know firsthand that it really isn't so terrible. I have been blessed with family and friends who have not let me feel that my disability should get in the way of reaching my goals. My parents have never let me use my handicap as a way of getting out of responsibilities. I have the same responsibilities around the house as my sisters and if I don't take care of them I am equally disciplined just as my sisters would be if they didn't do their share of the work. I feel my oldest sister, Sherri, has helped me the most in believing that I am just as capable as anyone else in doing things for myself. If I would ask her to get me a book or a glass of water or something, Sherri would probably say something like, "Get it yourself, you aren't helpless!" I wouldn't want it any other way between us.</p> <p>People have asked me if I feel my sisters are allowed to go more places and do more things than me. I don't feel that I've missed out on any of the experiences my sisters have had. I go to football games, movies, go shopping, and go to the local disco just like my sisters.</p> <p>The only problem I have is that most of my friends live too far away from me to just "drop by" whenever they feel like it. My friends are my classmates from the high school I had to attend, which is outside my local school district and is the only school in the county capable of handling my special problems. We can't even call one another very often because it is long distance.</p> <p>Hospitals have been a vey important part of my life, since I was in and out of them quite frequently when I was young. I never really minded going into the hospital because the doctors and nurses were always nice and I knew they would take good care of me. Along with hospitals comes bills. Our family has never been eligible for financial aid because my parents always made "too much money." I know that at times it has been tough for my parents to make ends meet because I am such an "expensive kid." Sometimes I feel guilty about having my parents pay such big bills just because of me.</p> <p>I have been in braces ever since I was four years old. I know that they have helped me considerably, but I often have negative feelings about my braces. There was a time when I was unable to wear my braces due to pressure sores. I like being out of them because my clothes weren't torn by the locks on my braces and I liked getting dressed faster. I thought I looked prettier without all of that plastic and metal sticking out of my clothes. I am finally starting to realize that I look better in them because they make me straighter. I don't look like I'm a "pretzel" when I'm in them. I have greater mobility in them, which enables me to do things and go places that I couldn't in my wheelchair. Even though the negative feelings may resurface in the future, I plan on wearing my braces a lot more than I have for the past two years.</p> <p>When I go out to a movie or go shopping, sometimes people stare at me. This has never really bothered me. It just shows me that they are interested in my disability and are curious to see how my braces, crutches and/or wheelchair works. I especially like it when little children come up to me and ask, "What happened to you?" I am glad that children aren't afraid to ask questions. I wish that adults would open up and ask, because I would be more than willing to tell them about anything they would want to know.</p> <p>My plans for the future are to graduate from college with a degree in psychology. I think that I would like to be a school psychologist because I love children. I know that the road ahead will have some rough spots, but I know that I can make it with the love and support of my family behind me.</p> <em><strong><b>*Cynthia L. Cuchna </b></strong>Cynthia Cuchna was born with spina bifida on March 21, 1966. Now she is 18 years old and is entering her first year of college.<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 3 - 4 Year 1984 Volume 8 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Personal Experience Creator An entity primarily responsible for making the resource Cynthia L. Cuchna * https://staging.drfop.org/files/original/57984a195780837231c3d47547393acc.pdf 11789779a85e2b709280689bf0e71309 https://staging.drfop.org/files/original/229e5d0143847fe4a628fb14ddec46e4.jpg be7e746d002f06941f613b3ffcdfe220 https://staging.drfop.org/files/original/c42e1a9caf2711b34235fffd340b847a.jpg b9f313905f981a7b1b591b553ac76025 https://staging.drfop.org/files/original/65483353f040cfd3076c229f9103ba79.jpg f7f25aeeda8fcb9417fcb2a3f14480d5 https://staging.drfop.org/files/original/48332643526aa1b923893a54d16f1d14.jpg 6fdbc24c287659b506d32920ab794a07 https://staging.drfop.org/files/original/2bfcb2f521edd120186e036fda6d7d8f.jpg 6ecc7fab73b16908b5797aa5757d6bfd 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/1987_02_066.pdf Text Any textual data included in the document <h2>A Physiologic Rationale for Orthotic Prescription in Paraplegia</h2> <h5>Robert L. Waters, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Leslie Miller, R.P.T.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>A difficult clinical decision to be made when treating a paraplegic patient is deciding if walking is a realistic goal, if orthoses should be prescribed, and what the functional outcome will be. It has been demonstrated that the energy expenditure for paraplegics, utilizing a crutch assisted swing-through gait pattern, is markedly elevated. Many patients have learned to walk with crutches and orthoses, but discontinued their use after discharge from a rehabilitation center.<a></a> Studies of other forms of bracing also reveal elevated energy expenditure.<a></a></p> <p>In this review, we will describe the indications for prescribing ankle-foot orthoses and knee-ankle-foot orthoses. We will then outline the criteria used at Rancho Los Amigos Medical Center to determine whether or not a paraplegic is a candidate for ambulation. These criteria are based on the results of energy expenditure measurements of 150 patients with traumatic paraplegia.<a></a> Further investigation of the data collected revealed that the proprioception level or pattern seemed a reliable indicator of which patients would achieve ambulation, while muscle function seemed to determine the quality of their ambulation. These results have helped us to develop guidelines for projecting the functional outcome of ambulation of paraplegics.</p> <h3>Orthotic Prescription</h3> <p>The goal of orthotic management in paraplegia is to provide the external support necessary to compensate for the motor and sensory deficits. Joint range of motion, muscle strength, proprioception, sensation, and spasticity are evaluated when determining the orthotic prescription.</p> <p><i>Knee-Ankle-Foot Orthosis (KAFO)</i></p> <p>Quadriceps strength less than "Fair+" on manual muscle testing is the most common indication for a KAFO. The KAFO is locked at the knee while walking. Although some patients with less than "Fair+ " strength are able to ambulate a short distance without a locked knee (knee stabilization), knee instability usually occurs after a few steps. The exception is the patient with severe quadriceps spasticity which maintains the knee in extension, eliminating the need for external support.</p> <p>Another indication for a KAFO is impaired or absent knee proprioception. The lack of proprioception can result in knee instability even when the quadriceps strength is "Fair+" or greater, as the patient is unable to monitor joint position. If light touch sensation is present on the front of the thigh, a KAFO which allows knee flexion is usually sufficient to control the knee. The anterior stop of the knee mechanism limits extension at 180 degrees and the patient feels pressure from the anterior thigh cuff. In this regard, the brace serves as a transducer that converts proprioception (which is not perceived) into pressure (which is perceived).</p> <p>The final indication for extending bracing above the knee is a severe hyperextension thrust during stance. Paraplegics whose gait is characterized by a hyperextension thrust may develop ligamentous instability, due to attenuation of the posterior cruciate ligament and posterior knee capsule resulting in hyperextension deformity.</p> <p>Range of motion at the hip from 0 degrees of extension to 110 degrees of flexion should be present. In the absence of hip extensor muscles, full hip extension range is necessary to allow the patient to lean backwards and move the center of gravity of the trunk posterior to the hip joint (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-1.jpg"><b>Fig. 1</b></a>). Hip flexion to 110 degrees, with the knee extended, enables the patient to come to standing with locked KAFO's and rise from the ground after a fall. Full knee extension is required for optimal fit.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-1.jpg"><strong>Figure 1. Standing posture.</strong></a><br /> <p>Ten degrees of dorsiflexion at the ankle is the minimum necessary for unassisted upright balance (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-1.jpg"><b>Fig. 1</b></a>). Normal proprioception in at least one hip also facilitates unassisted standing.</p> <p>Inability to meet the joint range requirements described above commonly occurs and is most often due to spasticity or contracture. If satisfactory orthotic fit and posture cannot be achieved, a physical therapy regime that includes stretching exercises or serial casting is often successful when spasticity is mild and the deformity is not longstanding. When severe spasticity or deformity is present, or the deformity has been present for an extended time, the patient should be referred to an orthopedic surgeon.</p> <p>Good trunk strength is necessary to maintain an erect posture in the standing position without excessive weight bearing in the arms. High level paraplegics without adequate trunk strength must exert a strong upwards force by the arms throughout the entire gait cycle to prevent forward collapse and accomplish forward progression. This contributes to the high energy demand. (All swing-through gait candidates are required to perform 50 consecutive dips on parallel bars to insure they have sufficient upper extremity strength and endurance.)</p> <p><i>Ankle-Foot Orthosis (AFO)</i></p> <p>Quadriceps strength greater than "Fair" should be present to stabilize the knee if an AFO is prescribed. The patient must also have adequate hip flexion strength to swing the leg forward to achieve a reciprocal gait pattern. The indications for AFO are numerous and include any or all of the following: plantarflexion strength less than "Good," dorsiflexion strength less than "Fair," impaired ankle proprioception, and moderate to severe plantar-flexion spasticity.</p> <p>During normal walking, the plantarflexors are active during the stance phase of gait to prevent excessive forward advancement of the tibia. As a result of forward momentum, the knee passively extends as the body advances forward over the stabilized tibia, and the demand placed on the quadriceps is minimal. Customary manual muscle testing methods fail to place a sufficient load on the plantarflexors to evaluate the force required during gait. The strength required to provide ankle and knee stability is present in patients who can perform 15 to 20 toe raises on one leg. Failure to provide adequate orthotic stabilization of the ankle in patients with inadequate plantarflexion strength may result in ankle instability and knee instability, if the quadriceps and/or hip extension strength is also inadequate.</p> <p>Knee wobble can be a sign of impaired ankle proprioception and/or weakness. This can be eliminated by an AFO with a rigid ankle or anterior ankle stop, which provides distal stability and kinesthetic information via the calf cuff.</p> <p>An AFO may be utilized to hold the ankle in the neutral position when dorsiflexion strength is impaired or there is excessive plantarflexion spasticity. When spasticity is severe, it may not be possible to maintain the foot in neutral, and the patient should be referred to an orthopedic surgeon if non-operative measures prove inadequate.</p> <p>When the ankle is held in a rigid orthosis, ankle stability is gained during midstance. However, a forward thrust is imposed, forcing the knee into flexion at the moment of heel contact. (This knee flexion torque is generated because the rigidly immobilized ankle rotates forward about the point of heel contact.) During normal gait, this torque is avoided by ankle plantarflexion, minimizing the effect of the heel lever.</p> <p>There are two courses of action available to provide ankle stability during stance, while still maintaining knee stability at heel strike. If the patient has "Fair+ " or better ankle dorsiflexion strength and intact proprioception, we fit a metal AFO with a double adjustable ankle joint. A set screw in the anterior channel provides an adjustable stop that prevents excessive dorsiflexion. The posterior stop is left open to allow free ankle plantarflexion. Springs can be added posteriorly if dorsiflexion strength is less than "Fair+." The advantage gained is that restriction of motion during terminal stance is maintained while the normal plantarflexion motion during heel contact is preserved, avoiding the undesired knee flexion torque. If the patient has less than "Fair" dorsiflexors or absent proprioception at the ankle, then the ankle is locked and either metal or plastic is used. To avoid the excessive knee flexion torque when the AFO is locked, the heel of the shoe is undercut. This decreases the heel lever and, thus, the knee flexion torque.</p> <h3>Orthosis Weight</h3> <p>Weight is an important factor to some patients, as is the availability of joint motion of the orthotic system. Plastic, because of its potential to be lighter than metal, is sometimes preferable. For the patient with weak hip flexors, efforts to minimize weight are warranted since any extra weight at the end of the limb will make it more difficult to lift the foot and advance the leg. Lehneis, et al.<a></a> found that improving orthotic stability at the ankle reduces energy costs. It follows, then, that in any orthotic design, stability (control about a joint) should not be sacrificed merely to achieve lighter weight.</p> <h3>Exercise Physiology</h3> <p>It is necessary to understand several fundamental principles of exercise physiology to interpret the results of energy expenditure measurements in paraplegic patients.<a></a> The use of oxygen consumption is based on the fact that during sustained exercise, most of the ATP for muscle contraction is generated by aerobic metabolic pathways. After several minutes of exercising at a constant submaximal workload, the rate of oxygen consumption rises until it reaches a level sufficient to meet the metabolic demands of the exercising muscle. Measurement of the rate of oxygen consumption at this time reflects the energy cost of the activity and indicates the exercise intensity. The oxygen cost per meter walked determines the efficiency of ambulation.</p> <p>The principle fuels for aerobic metabolism are carbohydrates and fats. The oxidation of glucose can be summarized by the following equation:</p> <p>GLUCOSE + 36 ADP + 6 O₂ --&gt; 6 CO₂ + 44 H₂O + 36 ATP</p> <p>During exercise, the extent to which anaerobic pathways contribute to the production of energy depends upon the intensity of the effort. In mild to moderate exercise (approximately 50 percent of the maximal aerobic capacity for untrained individuals), the oxygen supplied to the tissue for the aerobic energy producing reactions is usually sufficient to meet energy requirements. During more strenuous exercise, anaerobic oxidation processes also occurs.</p> <p>The amount of energy that can be produced by anaerobic means is limited. Nineteen times more energy is produced by the aerobic oxidation than by anaerobic oxidation. Also, accumulation of lactate in muscle and blood leads to acidosis, limiting the extent to which intense exercise can be performed. From a practical standpoint, anaerobic oxidation provides an extra supply of energy for sudden bursts of strenuous effort, but these pathways cannot be routinely utilized for a prolonged time. In contrast, when exercise is performed below anaerobic threshold, an individual can sustain exercise for many hours without exhaustion.</p> <h3>Maximal Aerobic Capacity</h3> <p>The maximal aerobic capacity (VO₂ max) is the single best indicator of physical work capacity and fitness. It measures the individual's maximum energy production capability. Generally, an individual is able to reach the VO₂ maximum within two to three minutes of instituting strenuous exercise. Any disorder of the respiratory-cardiovascular muscle or metabolic systems that restricts the supply of oxygen to the muscle decreases the VO₂ max. A physical conditioning program can increase aerobic capacity by several processes which include improving cardiac output, increasing the capacity of the muscle to extract oxygen from the blood, increasing the level of hemoglobin, and increasing the muscle mass. On the other hand, the maximal aerobic capacity can be reduced due to blood loss, paralysis, surgery, negative nitrogen balance, or bed rest.<a></a> The important clinical implication is that the paraplegic patient is usually severely deconditioned as a consequence of the injury. The prescription of orthoses and a walking program should not be initiated until the patient has sufficient strength and maximal aerobic capacity to meet the required energy demand. The deconditioned paraplegic patient will respond to a physical conditioning program just as an able bodied subject with respect to increased strength, endurance, and maximal aerobic capacity.<a></a></p> <p>In able bodied subjects, the VO₂ max also depends on the type of exercise. During lower limb exercise, the VO₂ max is greater than the VO₂ max for the upper limbs. Since paraplegic patients rely on the upper extremities to walk with the aid of crutches, their energy production capability is inherently limited. The problem in paraplegics is further compounded by the effects of the spinal injury. The upper extremity VO₂ max for paraplegics is lower than for able bodied subjects, presumably due to the effects of paralysis and interruption of the autonomic neurological pathways which regulate blood flow and cause venous pooling in the lower extremities.<a></a> For the typical adult male paraplegic, we establish a VO₂ max of 20 ml/kg-min during upper arm cranking as the minimal criteria acceptable for entering gait training if a swing-through crutch assisted gait pattern will be required.</p> <h3>Energy Expenditure</h3> <p><i>Wheeling Versus Normal Walking</i></p> <p>On a hard, level surface paraplegic wheelchair use is as efficient as normal walking. A comparison of the data in <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg"><b>Fig. 2</b></a> indicates that when propelling a chair around a 60.5 meter circular track, the speed was almost as fast as normal walking (72 versus 80 m/min).<a></a> The oxygen rate was approximately the same (11.5 versus 11.9 ml/kg/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg"><b>Fig. 3</b></a>), as was the oxygen cost (.16 versus .15 ml/kg/ min). The heart rate was higher in paraplegics using the wheelchair than in normal walking (123 versus 100 BPM) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg"><b>Fig. 4</b></a>). As previously mentioned, this relates to the lower upper maximal aerobic capacity in paraplegics during arm exercise. From a clinical standpoint, it may be concluded that the wheelchair is a highly efficient means of transportation whose speed and energy requirements are comparable to that of normal walking.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg"><strong>Figure 2. Average velocity in normal subjects and in patients using wheelchairs or orthoses.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg"><strong>Figure 3. Rate of oxygen consumption in normal subjects and in patients using wheelchairs or orthoses.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg"><strong>Figure 4. Heart rate in normal subjects and in patients using wheelchairs or orthoses.</strong></a><br /> <p><i>Swing Through Gait</i></p> <p>Crutch walking with a swing-through gait requires the arms and shoulder girdle to lift the entire weight of the body and swing it forward with each step. The average speed in paraplegics trained to use a swing-through crutch assisted gait was 64 percent lower than normal walking (20 versus 80 m/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg"><b>Fig. 2</b></a>); the rate of oxygen consumption was 38 percent greater (16.5 versus 11.9 ml/kg/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg"><b>Fig. 3</b></a>); the oxygen cost was 560 percent greater (.84 versus .15 ml/kg/min); and the heart rate was increased 46 percent (145 versus 99 BPM) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg"><b>Fig. 4</b></a>).<a></a> This rate of energy expenditure requires most of the aerobic capacity of the typical adult male paraplegic with a complete T12 lesion and is well above the anaerobic threshold. The extreme exertion required for a swing-through gait demands a greater intensity of physical effort than a normal individual customarily expends on sports activity such as recreational jogging. Consequently, it is not surprising that while the athletic paraplegic may be willing to expend this level of exertion for recreational purposes, he is unwilling to sustain these efforts for normal activities of daily living. Even those patients, who are physiologically capable of sustaining the intense physical effort of a swing-through gait for a sustained time period to travel longer distances, find tachypnea (rapid breathing), tachycardia (rapid heart rate), and hidrosis (sweating), unacceptable for routine activities of daily living.</p> <p>We believe that the highly motivated paraplegic who is willing to exercise strenuously should not be discouraged from walking, but a more realistic approach should be taken for the average patient. The average patient should be given walking training and bilateral knee-ankle-foot orthoses only if walking is necessary for psychological reasons, for purposes of exercise, or because of architectural barriers in the living environment. It should be clearly explained that the wheelchair should be considered as the primary means of mobility.</p> <p>We have tested three patients with "Fair+" hip flexors who used bilateral KAFO's and preferred a reciprocal gait pattern.<a></a> Interestingly, the effort expended by these patients was just as great as in swing-through gait (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg"><b>Fig. 2</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg"><b>Fig. 3</b></a>, and <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg"><b>Fig. 4</b></a>).</p> <p><i>Energy Expenditure: Reciprocal Gait</i></p> <p>In a review of spinal cord injured patients, Hussey and Stauffer found that those patients who were able to walk in the community had pelvic control with at least "Fair" hip flexor strength and at least "Fair" extensor strength in one knee so that a maximum of one KAFO was required, enabling the patient to achieve a reciprocal gait pattern.<a></a> Having "Fair+" or greater quadriceps strength sufficient to stabilize one knee eliminates the need for one KAFO and enables the patient to walk with a crutch assisted reciprocal gait pattern at a rate of energy expenditure and heart rate that are significantly below that required for a swing-through gait pattern (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg"><b>Fig. 3</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg"><b>Fig. 4</b></a>). Surprisingly, we found no difference in the speed and rate of energy expenditure in patients with one free knee or two free knees and requiring bracing only below the knee (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg"><b>Fig. 2</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg"><b>Fig. 3</b></a>).</p> <p>Nevertheless, paraplegics who have intact hip flexion and knee extension bilaterally require orthoses only below the knees, and those who use a reciprocal crutch assisted gait pattern are still severely impaired (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg"><b>Fig. 2</b>,</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg"><b>Fig. 3</b>,</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg"><b>Fig. 4</b></a>). Compared to normal walking, the rate of oxygen expenditure is 20 percent greater (16.3 versus 11.9 ml/kg/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg"><b>Fig. 3</b></a>), the heart rate 31 percent greater (131 versus 100 BPM) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg"><b>Fig. 4</b></a>), and the speed 67 percent slower (80 versus 20 m/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg"><b>Fig. 2</b></a>).<a></a> The typical paraplegic who uses crutches and a reciprocal gait still exerts a force of 25 to 50 percent of total body weight on the crutches with each step, accounting for the increased rate of energy expenditure. The only spinal cord injured patients we have tested whose energy expenditure during walking does not exceed normal values are those patients with minimal involvement who have intact sacral function (in addition to lumbar function) and a sufficient hip abductor and extensor strength to maintain an erect posture without crutches.</p> <p>The average distances necessary to perform different daily living activities are listed in <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-5.jpg"><b>Fig. 5</b></a> and were obtained from numerous measurements made in different types of urban areas in Los Angeles.<a></a> Since the average speed of walking in low lumbar paraplegics who used bilateral ankle-foot orthoses and a reciprocal crutch assisted gait pattern was only 26 m/min, it would take more than five minutes to travel 150 meters. Because five minutes of walking will require a strenuous effort, it is apparent why even the typical low lumbar paraplegic is a limited walker outside the home and is not able to routinely ambulate comfortably for activities which require walking a longer distance. In this regard, clinicians are justified in prescribing a wheelchair to any spinal injury patient who requires crutch assistance. The patients should be encouraged to use the wheelchair as necessary and be reassured that reliance on the wheelchair, when necessary, should not be considered a failure.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-5.jpg"><strong>Figure 5. Average distances necessary to perform customary activities of daily living.</strong></a><br /> <p><b>References:</b></p> <ol> <li>Aastrand, P.O. and K. Rodahl, <i>Textbook Work Physiology</i>, Ed. 2, McGraw-Hill, Inc., New York, 1977.</li> <li>Cerny, K., R. Waters, H. Hislop and J. Perry, "Walking and Wheelchair Energetics in Persons with Paraplegia," <i>Physical Therapy</i>, 60:1133-1139, 1980.</li> <li>Clinkingbeard, J.R., J.W. Gersten, and D. Hoehn, "Energy Cost of Ambulation in the Traumatic Paraplegic," <i>American Journal of Physical Medicine</i>, 43:157-165, 1964.</li> <li>Gordon, E.E., "Physiological Approach to Ambulation in Paraplegia," <i>JAMA</i>, 161:686-688, 1956.</li> <li>Huang, C.T., A.B. McEachran, K.V. Kuhlemeier, M.J. DeVivo, and P.R. Fine, "Prescriptive Arm Ergometry to Optimize Muscular Endurance in Acutely Injured Paraplegic Patients," <i>Arch. Phys. Med. Rehab.</i>, 64:578-582, 1983.</li> <li>Hussey, R.W. and E.S. Stauffer, "Spinal Cord Injury: Requirements for Ambulation," <i>Arch. Phys. Med. Rehab.</i>, 54:544-547, 1973.</li> <li>Lehneis, H.R., E. Bergofsky, and W. Fresina, "Energy Expenditure with Advanced Lower Limb Orthoses and with Conventional Braces," <i>Arch. Phys. Med. Rehab.</i>, 57:20, 1976.</li> <li>Lerner-Frankiel, M.B., S. Vargas, M. Brown, L. Krusell, and W. Schoneberger, "Functional Community Ambulation: What Are Your Criteria?" <i>Clin. Man. in Phys. Ther.</i>, 6:12-15, 1986.</li> <li>Waters, R.L., H.J. Hislop, J. Perry, and D. Antonelli, "Energetics: Application to the Study and Management of Locomotor Disabilities," <i>Orthop. Clin. North America</i>, 9:351-377, 1978.</li> <li>Waters, R.L. and B.R. Lunsford, "The Energy Cost of Paraplegic Locomotion," <i>Journal of Bone Joint Surgery</i>, 67A: 1245-1250, 1985.</li> <li>Wolf, E. and A. Magora, "Orthostatic and Ergomet-ric Evaluation of Cord-injured Patients," <i>Scandinavian Journal of Rehabilitation Medicine</i>, 8:93-96, 1976.</li> </ol> <em><b>*Leslie Miller, R.P.T. </b> Leslie Miller, R.P.T. is a spinal cord injury clinical specialist at Rancho Los Amigos Medical Center.</em><br /><br /><em><b>*Robert L. Waters, M.D. </b> Robert L. Waters, M.D. is Chairman of the Department of Surgery at Rancho Los Amigos Medical Center, HB-121, 7601 E. Imperial Highway, Downey, California 90242.<br /><br /><br /></em> Page Number(s) 66 - 73 Year 1987 Volume 11 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 5 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-5.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Physiologic Rationale for Orthotic Prescription in Paraplegia Creator An entity primarily responsible for making the resource Robert L. Waters, M.D. * Leslie Miller, R.P.T. * https://staging.drfop.org/files/original/ef9c33fd77b148aa90de4a15eba38d63.pdf 6b120f4df1e3a107e3d3c68bef3540f9 https://staging.drfop.org/files/original/aecc71c9f63ca3de9635b49186ef0fe2.jpg ee0dd270acf130106c5b30ef3f556f83 https://staging.drfop.org/files/original/9c3a89cb7f7730cd4c6b56b7590d7391.jpg f4cec16ef9035d5921c41f90ca28bcd6 https://staging.drfop.org/files/original/b5fd66a485fcb7d48eb30a63f5504417.jpg 5b69122a27795a14bcb9a1cb7a594a03 https://staging.drfop.org/files/original/17d159b930dfb31d71d62c5ee691ba0d.jpg 2a72b8f6ae90f2e9e1524ac5f30529c3 https://staging.drfop.org/files/original/eb00ea2eaae4f210b268d565e63c7e0d.jpg 54fc0b54bbd8edad785ea19df297b698 https://staging.drfop.org/files/original/640dd4eb6ba2ed2b6c98f608c29c713b.jpg b9543354d744c53f2572778988313b32 https://staging.drfop.org/files/original/b2d38ec808677879975c23042b055df4.jpg aa1d9e01ee14c6de2fde688835090f3a https://staging.drfop.org/files/original/3bb75593aa89a50b825f8368f7f92b73.jpg 347a553c959fa12bd1f4978f9eecf597 https://staging.drfop.org/files/original/d9d8ecde312bfe6431d3e6d17c56d6cb.jpg aec588355a2ba508857a04c899f7bb26 https://staging.drfop.org/files/original/9464bc47067b808f2c144ad6714d4c83.jpg ba3630b2632efa359fc9d1889de8e90d https://staging.drfop.org/files/original/3fbbfc9c24383b1570eb5768ffc83c89.jpg 1798118642ea00b00689a5bfed53f585 https://staging.drfop.org/files/original/5270bfa0fa18365e770ebb78a42d2436.jpg 91718b4d11f9d8da1db4a041219b78b1 https://staging.drfop.org/files/original/4fe6516dbb0072232e7634731bd5069e.jpg 954bd4f2762fc59a0fd590821ab51073 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_005.pdf Year 1963 Volume 7 Issue 1 Page Number(s) 5 - 10 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_01_005.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_005.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A Preliminary Report on the Amputee Census</h2> <h5>Harold W. Glattly, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>What is the magnitude of the amputee population of the United States? What is the composition of this group of physically handicapped individuals in terms of their sex, ages, and sites of amputation? What proportion of amputations is caused by disease? By trauma? By tumor? The answers to these questions are today more a matter of opinion than of documented fact since statistics relating to amputees that are based on large numbers of cases collected from all states of the Union have never heretofore been available.</p> <p>In the interest of developing certain basic descriptive data concerning the amputee population of the United States, the Amputee Census was initiated in October 1961 as a joint project of the Committee on Prosthetics Education and Information and the American Orthotics and Prosthetics Association. The rationale of utilizing the limb facilities of this country as the data source for the Census is based upon the assumption that a relatively high percentage of new amputees visit these shops for the purpose of being fitted with a prosthetic device. It is believed that this percentage is materially higher today than it was in 1946, at which time a federally sponsored prosthetics research program was initiated. Since that date there has been a very marked improvement in the function and comfort of prostheses, and amputees who formerly were unable to pay for a replacement device now find that there are several Government agencies to assist them. These include the federally supported State Bureaus of Vocational Rehabilitation, the Children's Bureau, the Veterans Administration, and the Workmen's Compensation programs. It has been variously estimated by both surgeons and prosthetists that between 80 and 90 per cent of all new amputees desire a prosthesis. It is hoped that some spot checks can be made in a few large medical centers to document this estimate.</p> <p>The project title, Amputee Census, is strictly speaking a misnomer (although it is a concise expression of the hoped-for result), since no national or regional head count of amputees is involved. In that only new amputee cases are included in this study, it will be possible to establish annual rates of amputation by age and cause. By applying life-expectancy tables to these rates, it is hoped to develop information that will bear upon the size of our amputee population. For example, it is obvious that there is a very wide disparity in the life expectancy of a 55-year-old man in good health who loses a limb by reason of an accident as compared with a man of the same age who suffers an amputation of his leg as the result of vascular disease. This quantitative study will not be undertaken until the census has been completed in the fall of 1964.</p> <p> Two simple data-collection forms were devised that can be executed in a matter of minutes by limbshop personnel ( <b>Fig. 1</b> and <b>Fig. 2</b> ). The participating limbshops were provided with bound books of these serially numbered forms. The books consist of original data slips that are retained by the facilities and carbon copies in the form of self-addressed and stamped postcards to be mailed to the National Academy of Sciences. It will be noted in <b>Fig. 1</b> and <b>Fig. 2</b> that the upper left-hand corners of the data cards are blocked out. It is in this space that the name of the amputee appears on the original forms retained by the facilities. Since the cards are serially numbered, it will be possible at some future time to identify certain types of amputees for further study. In the upper right-hand corner is a symbol consisting of three capital letters that identify each facility. The code to these symbols is known only to the staff of CPEI, and the limbshops have been assured that no information concerning their volume of cases will be disclosed to anyone. ( <b>Fig. 3</b> , <b>Fig. 4</b> , <b>Fig. 5</b> , <b>Fig. 6</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1. Amputee Census Card No. 1. Data form for single amputations and multiple amputations that result from a single cause at the same time.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2. Amputee Census Card No. 2. Data form for multiple amputations that occur serially at different times from the same or different causes.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig 4</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 5. Actual case numbers in each decade of life.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The participating facilities were instructed to fill out a card on each new amputee case for whom an original prosthetic device of some type was provided. Amputees furnished with a replacement for a worn-out or otherwise unusable limb are not recorded in this study. The card shown in ( <b>Fig. 1</b> ) is used for single amputations and for multiple amputations that occur simultaneously from a single cause. The card shown in ( <b>Fig. 2</b> ) is prepared for those cases that have had more than one amputation at separate times from either the same or different causes. Examples of this type of case include: </p> <ol> <li>An individual who is a left, below-knee amputee due to an injury who, years later, becomes a right. above-knee amputee due to vascular disease.</li><li>An individual who is a left, below-knee amputee due to vascular disease and is converted into an above-knee case a year later.</li></ol> <p> Since this card amounted to only three per cent of the total data forms received, an analysis of these cases will not be accomplished until the end of the project. ( <b>Fig. 7</b> , <b>Fig. 8</b> , <b>Fig. 9</b> , <b>Fig. 10</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 7</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 10. Actual case numbers in each decade of life.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The following data items are entered on the census forms:</p> <ul> <li>State of Residence.</li> <li>Age.</li> <li>Sex.</li> <li>Date of Amputation.</li> <li>Date Prosthesis Furnished.</li> <li>Site of Amputation:</li> <li>Upper Extremity:<ul> <li>(SD) Shoulder disarticulation (includes fore-quarter cases and very short above-elbow stumps that require fitting as an SD).</li> <li>(AE) Above elbow.</li> <li>(E) Elbow disarticulation.</li> <li>(BE) Below elbow.</li> <li>(W) Wrist disarticulation.</li> </ul></li> <li>Lower Extremity:<ul> <li>(HD) Hip disarticulation (includes hemipelvec-tomies and above-knee stumps so short that they must be fitted as an HD).</li> <li>(AK) Above knee.</li> <li>(KB) Knee-bearing (includes knee disarticulations, Gritti-Stokes, etc.).</li> <li>(BK) Below knee.</li> <li>(S) Syme's operation or ankle disarticulation. (Partial-hand and partial-foot amputations are not included in the census.)</li> </ul></li> <li>Cause of Amputation:<ul> <li>Trauma-amputations due to physical and thermal injuries.</li> <li>Disease-amputations due to vascular diseases and infections.</li> <li>Tumor-refers to all types of growths for which an amputation is performed.</li> <li>Congenital-only cases that are fitted with a prosthesis are included. The type of prosthesis is used to determine the level of "amputation." It is recognized that the data card is not appropriate for certain types of congenital amputees.</li> </ul></li> </ul> <p>The statistical material that is presented in this preliminary report on the Amputee Census is based upon the data forms received from the prosthetics facilities during the 16-month period from October 1, 1961, through January 31, 1963. During this time, 8,416 new cases were reported. This sampling of the amputee population of the U. S. is sufficiently large so that the distribution by sex, age, side of amputation, levels of amputation, and causes of these new amputations is already well established. This conclusion is based upon the fact that the percentages presented in this report are almost identical to those that were obtained from an analysis of the first 5,000 cases. It is thus possible in this initial census report to present in graphic and tabular form (Figs. 3-13) a simple description of the group of individuals upon whom amputations are presently being performed. The following comments and observations on this statistical material are noteworthy: ( <b>Fig. 11</b> , <b>Fig. 12</b> , <b>Fig. 13</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11. Actual case numbers in each decade of life.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12. Actual case numbers in each decade of life.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 13</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The disparity in the amputation rates for males and females is due primarily to the facts that: <ol> <li> Amputations in males by reason of injury are nine times as frequent as in females. This is due to the vocational and avocational hazards to which males are more liable ( <b>Fig. 8</b> ). </li><li> Amputations in males by reason of disease are 2.6 times as frequent as in females ( <b>Fig. 8</b> ). </li></ol> </li><li> Amputations due to tumor are roughly comparable between the sexes ( <b>Fig. 8</b> ). </li><li> Congenital deformities of the extremities that are fitted with prostheses occur with almost equal frequency in males and females ( <b>Fig. 8</b> ) </li><li> There is no significant difference in the incidence of left- and right-sided amputations in either the upper or lower extremities ( <b>Fig. 7</b> ). </li><li> There is a surprisingly large number of lower-extremity amputees over 70 years of age who are being fitted with prostheses. In this series, they number 1,020, or 13.2 per cent, of the total number of reported cases. It will be noted that there are four who are over 90 years of age ( <b>Fig. 5</b> ). </li><li> The incidence of malignancy resulting in amputation is fairly constant for individuals between 21-60 years of age. The decade 11-20 years has an indicated rate of twice that of any other ten-year period ( <b>Fig. 12</b> , <b>Fig. 13</b> ). </li><li>In this series there were 162 cases of multiple amputations that occurred from the same cause at the same time. Twenty-two were bilateral upper-extremity cases, 132 were bilateral lower-extremity amputations, and eight involved one upper and one lower extremity.</li><li>During the 16-month report period there were 1,798 cases of below-knee amputations for disease. It is believed that the vast majority of this group falls into the vascular insufficiency category. During this same period there were 2,520 cases due to disease in which the initial amputation was above the knee. There is no reason to doubt but that similar numbers of below-knee and above-knee amputations for vascular disease have been performed in years past during comparable periods of time. Although theoretically the site of amputation in vascular disease is based on the level of vascular sufficiency in the extremity, it may be that too many surgeons are overly concerned with the possibility that amputations at the below-knee level will later require re-amputation above the knee. This possibility is suggested by the fact that in this series there were only 12 instances in which below-knee amputations due to disease were re-amputated at a later date. This is an extremely low incidence, considering the number of below-knee amputations that are performed annually for vascular conditions. A clinical study may be needed that is designed to define better the criteria that bear upon the decision as to the level of amputation in cases of lower-extremity vascular disease. The advantages of preserving the knee joint are obvious, especially in the older age group.</li><li>The reader must recognize that the foregoing statistical material relates only to new amputee cases. The statistics are not valid for the amputee population at large due to the wide variation in the life expectancy of various types of amputees.</li></ol> <h4>Acknowledgments</h4> <p>The Committee on Prosthetics Education and Information wish to express their appreciation to the owners and managers of the participating prosthetics facilities who made this study possible and to the officers, directors, and staff of the American Orthotics and Prosthetics Association for their full cooperation in this project.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Harold W. Glattly, M.D. </b></td></tr><tr><td class="clsTextSmall">Executive Secretary, Committee on Prosthetics Education and Information of the Division of Medical Sciences, NAS-NRC. This Committee is jointly supported by the Training Division, Vocational Rehabilitation Administration, Department of Health, Education, and Welfare, and the Prosthetic and Sensory Aids Service, Veterans Administration.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-2.jpg Figure 2 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-3.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-4.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-5.jpg Figure 5 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-6.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-7.jpg Figure 7 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-11.jpg Figure 8 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-10.jpg Figure 9 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-8.jpg Figure 10 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-9.jpg Figure 11 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-12.jpg Figure 12 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-13.jpg Figure 13 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-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 A Preliminary Report on the Amputee Census Creator An entity primarily responsible for making the resource Harold W. Glattly, M.D. * https://staging.drfop.org/files/original/809ea89a32d4d8e36fa8e6385772fa3a.pdf 3ee99a2bf09bacedf1558f9b28f4ed07 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/1978_02_001.pdf Text Any textual data included in the document <h2>A Proposal for Delivery of Externally Powered Upper-Limb Prostheses</h2> <h5>Michael J. Quigley, C.P.O.&nbsp;</h5> <p>Prepared by the American Academy of Othotists and Prothetists, 1444 N St., N.W., Washington, D.C. 20005. Editor: A. Bennett Wilson, Jr., B.S. M.E.; Managing Editor: Brian A. Mastro, B.A.; Editorial Board: Joseph M. Cestaro, C.P.O., Charles H. Epps, Jr., M.D., Robert B. Peterson, R.P.T.</p> <p>There are about 322,000 amputees in the United States today. Of this number, approximately 9,000 people have upper-arm amputations and 16,000 have forearm amputations. Many arm amputees choose not to wear a prosthesis for three major reasons; 1) lack of sensory feedback, 2) poor function and 3) poor cosmesis.</p> <p>Unfortunately, the vast majority of physicians, therapists, and prosthetists seem to believe that new amputees should always be provided a hook first, and a hand later, if the hook is accepted. Nearly all patients, however, want a hand first and dread the thought of using a hook for obvious cosmetic and psychological reasons. In a great number of cases, the hook and prosthesis are rejected due to the undue amount of attention attracted to the wearer.</p> <p>Body powered mechanical hands are heavy, cumbersome, and far less functional than hooks. The same amount of harnessing and body power is required to control these hands as with the hooks. The cosmetic gloves that cover these hands are easily stained, torn, and discolored. The major indication for prosthetic hands has been for unilateral amputees who are engaged in light-duty work and are very conscious of cosmesis.</p> <p>The introduction of the VA- Northwestern University, Otto Bock, Variety Village, and other powered hands and elbows for prostheses should change the dismal attitude concerning prosthetic hands. These prostheses are extremely cosmetic, and require very little body motion and little or no harnessing to control the hand. The hand can be controlled easily whether the wearer is reaching for something over his head or behind him, which was previously very difficult. Powered prostheses are of greatest value for patients with high amputations, whether they are unilateral or bilateral. These patients are normally present complicated problems because they lack the muscle power and leverage to control mechanical prostheses, but they can easily control powered prostheses by myoelectric or switch controls.</p> <p>Powered prostheses have received a very cool reception in the United States due to a number of factors; the cost of the prostheses is high- four to five times that of conventional prostheses-and therefore many third-party payers refuse to pay for them. The prosthetist fitting an externally powered prosthesis must be well trained in order to evaluate myoelectric potentials and to properly fit and maintain the prosthesis. As most prosthetists have no background in electronics, more than a short orientation course is required. Even after thorough training is obtained, the prosthetist may only see two or three patients per year requiring these types of prostheses, and therefore much of the information will be forgotten. In many cases, components that were intended to be modular in concept and simply plugged in need to be reworked or redistribued around on the socket in order to accommodate a long or non-standard type of amputation. In a study conducted by the Veterans Administration 18 prosthetists were involved in an evaluation of powered prostheses. All prosthetists were given a one-to-two-week course by the VA on myoelectric prostheses and patients were referred to them through VA clinics for fittings. Despite all this education, prosthetist errors were responsible for more malfunctions than any other cause. Faced with all of the above facts plus the fact that the cosmetic glove is still a problem, most prosthetists chose not to handle externally powered prostheses. Further, since such a small percentage of the amputee population can be fitted with this type of prosthesis, most prosthetists find it impractical to invest the great amount of time and money for education and equipment before they can provide satisfactory service.</p> <p>It has been shown that in areas where prosthetists learned enough about powered prostheses to be able to properly fit and maintain them, the prostheses received wide acceptance. John Billock, C.P.O., in Warren, Ohio uses a number of different powered prosthesis systems, including hybrid models using components of different systems on severely disabled upper-limb amputees that are referred from all over the Midwest. William Sauter at Ontario Crippled Childrens Center has also proven the practicality of powered systems on adults and children. In each area, however, institutional support has been the determining factor. Mr. Billock's success was achieved after years of participation in the research program at Northwestern University and Mr. Sauter's work is done in a large Rehabilitation Center. Similarly, the Bock system is used in Minneapolis due to a great amount of support from the Germany-based Otto Bock Company to its United States headquarters in Minneapolis. The Otto Bock Company is presently offering a free one-week course on the basic below-elbow system, and plans future courses on advanced powered components.</p> <p>We are faced with the situation that powered upper-limb prostheses are presently available but are not used for the many reasons stated previously. How do we solve the service delivery problem, particularly for the more severely disabled upper-limb amputee? I suggest that specialized fitting centers are the best solution to the problem. Such centers can be privately owned or located in an institution. The advantage of this system is that the prosthetist would see enough patients to become truly expert in the area of powered prostheses, and could well afford the expense of taking all relevent courses or preceptorships and obtaining the necessary staff and equipment.</p> <p>I have visited one such center in Warren, Ohio, which is owned by John Billock, C.P.O. Mr. Billock and his staff at Warren Orthotics and Prosthetics Restoration Laboratory fit three to four powered upper-limb prostheses per month, including all levels of amputation. His staff includes a full time electrical engineer and an electronics technician. There are enough equipment and spare parts available so that essentially all maintenance is carried out on the scene, which avoids long delays when repairs are done elsewhere. Patient referrals are mostly from the Midwest and East Coast, although patients from the West Coast are not uncommon. One patient being seen during my visit had a right shoulder disarticulation and a left above-elbow amputation and was being fitted with powered hands, elbows and wrist rotators controlled by switches. Components from at least three manufacturers had to be made compatible in the ten-month long project.</p> <p>I feel that a total of four centers in the United States could adequately handle the patient load. The average prosthetist with a good understanding of powered prostheses will be able to treat most unilateral below-elbow patients, so referrals to a powered prosthesis center will usually be for more difficult cases. It will be important for private centers to be closely allied with a rehabilitation center, as these patients will require therapy, counseling, and other services while the prosthetic services are being performed.</p> <p>It seems obvious to me that powered prostheses will be more common than body powered designs within the next twenty years, and it is time now to establish an efficient service delivery system.</p> Page Number(s) 1 - 2 Year 1978 Volume 2 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 A Proposal for Delivery of Externally Powered Upper-Limb Prostheses Creator An entity primarily responsible for making the resource Michael J. Quigley, C.P.O.