2 20 371 https://staging.drfop.org/files/original/99ea32a0e2c94d4c7589431c1ce25157.pdf 2e7fbc0fa2eb0306b0ca796e5ddda33f https://staging.drfop.org/files/original/db98a4319f901a5df31650f9d7aaafee.jpg 0fa803d29cb641dc7320e3d9a863936f https://staging.drfop.org/files/original/64d9411b67eb520fc954e715926b9298.jpg 726bcec99286d9cecafabb7eb8dc978d https://staging.drfop.org/files/original/16c6695c898c94d3672358c548efdb97.jpg 79d67a4e4d9d172c26b6a84ae56bf6d9 https://staging.drfop.org/files/original/52576dcdb3ac9adc947bf94d02d02a39.jpg ea6217584377d64348133ea09815076b https://staging.drfop.org/files/original/58f2050e89cae296d63c129ffca2499c.jpg e164595194dd9613126ebed26bc18d6f https://staging.drfop.org/files/original/e2bcd7e4954572b656575f76c6af042f.jpg a1cd131317ea4a80a7ff5fa68bb4b971 https://staging.drfop.org/files/original/ab3796e5b9f95a10bab6a6a4709fa759.jpg 929d3223aba1e1b2a7483eeebec5b0cd https://staging.drfop.org/files/original/c6047dac85ad7f0f42b9c09184f5c29b.jpg 65c71a86ab2789401328078e47ef9466 https://staging.drfop.org/files/original/ecf16ce9b6a02f16a28b7068eae7fa6a.jpg bfd62cca40c1d6ea9aa12468949eb70a https://staging.drfop.org/files/original/f517f80846ccc5574405da3e9e1627c2.jpg fde37795ae610a1848e2baff68929c95 https://staging.drfop.org/files/original/f762ec99d412e60f2d8d35ce9d55db87.jpg e26a637f131da62ed04ac2a515036959 https://staging.drfop.org/files/original/b166d882aab8ca9bff2a7ca99b8d8045.jpg 5dfee50cca7846001283b3b9c216796f https://staging.drfop.org/files/original/d6e1c536ddb7878b64b3bb95f1c31c0f.jpg c09e884e976731eb2d27af842c9614ad https://staging.drfop.org/files/original/c751d02f21559b315e9457299166cfeb.jpg 8d9e303bb98ad2f59b8056e9ffca5dca DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_02_001.pdf Year 1970 Volume 14 Issue 2 Page Number(s) 1 - 18 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_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_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>The Prosthetics and Orthotics Program</h2> <h5>A. Bennett Wilson. Jr. <a style="text-decoration:none;">*</a><br /></h5> <p> Early in 1945, at the request of the Surgeon General of the Army, the National Research Council sponsored a conference of surgeons, engineers, physicists, and prosthetists to consider the feasibility of effecting improvements in artificial limbs<a></a>. Conclusions that emerged from the conference were that virtually no organized research of significance had been conducted in the field of limb prosthetics, and that application of technology already in existence should produce improved devices. </p> <p> Organization of Research Program</p> <p>Subsequently, at the request of the surgeon general, the NRC established the Committee on Prosthetic Devices (later the Committee on Artificial Limbs) to organize a research program<a></a>. (The members of the Committee on Prosthetic Devices were: Paul E. Klopsteg, Ph.D., Chairman; Harold R. Conn, M.D.; Roy D. McClure, M.D.; Robert R. McMath, D.Sc; Mieth Maeser; Paul B. Magnuson, M.D.; Edmond M. Wagner; and Philip D. Wilson, M.D. Consultants: Robert S. Allen and Charles F. Kettering.) Subcontracts were entered into with sixteen universities, industrial laboratories, and foundations: </p> <ul> <li>Adel Precision Products Corp., Burbank, Calif. </li><li>Armour Research Foundation, Chicago, Ill. </li><li>C. C. Bradley and Sons, Inc., Syracuse, N.Y. (Catranis, Inc.) </li><li> Goodyear Tire and Rubber Co., Akron, Ohio </li><li>A. J. Hosmer Corp., Los Angeles, Calif. </li><li>International Business Machines Corp., Endicott, N.Y. </li><li> Mellon Institute of Industrial Research, Pittsburgh, Pa. </li> <li> National Research and Manufacturing Co., San Diego, Calif. </li> <li> Northrop Aircraft, Inc., Hawthorne, Calif. </li> <li> Northwestern University, Evanston, Ill. </li> <li> Research Institute Foundation, Detroit, Mich. </li> <li> Sierra Engineering Co., Sierra Madre, Calif. </li> <li> United States Plywood Corp., New Rochelle, N.Y. </li> <li> University of California, Berkeley and San Francisco, and Los Angeles </li> <li> Vard, Inc., Pasadena, Calif. </li> </ul> <p> Funds were initially supplied by the Office of Scientific Research and Development. With the impending disestablishment of OSRD shortly after World War II, the Office of the Surgeon General of the Army for a short time assumed fiscal responsibility for the program. Then, for fiscal year 1947, the Army and the Veterans Administration shared the support. The Army, the Navy, and the Veterans Administration cooperated by establishing laboratories within their own organizations. </p> <p> In some laboratories, development of components and application of new materials was begun, but it soon became clear to the committee that more knowledge of the patients' requirements was needed if significant progress was to be made. This in turn required a more detailed knowledge of the biomechanics of human extremities, and thus projects in this area were started. Also, anthropometric data were obtained with the idea of selecting rationally a series of standard sizes of components. </p> <p> The activities of the various groups were initially coordinated by the Committee on Artificial Limbs, and considerable progress was made during the first two years. By the spring of 1947, the committee felt that it had completed its task of establishing an organized program and suggested that contracts between the government and the research laboratories be made directly, and that the committee be reconstituted as an advisory group to the sponsoring agency. At that time, the majority of service-connected amputees had been discharged from the armed forces, and their medical care had become the responsibility of the Veterans Administration. Therefore, new contracts were effected between the VA and those laboratories in which promising developments were identifiable (1947: Catranis, Inc.; Northrop Aircraft, Inc.; University of California, Berkeley and San Francisco, and Los Angeles; 1948: New York University.) At the request of the VA, the NRC established the Advisory Committee on Artificial Limbs to continue the coordination and the correlation of the program. The Army, the Navy, and the VA continued to operate their own laboratories. </p> <p> The general feeling at the beginning of the program was that the solution to the problem of providing better prostheses lay in developing new devices, and rapid advances were made by applying new materials and fabrication methods. It was apparent, however, that fit, suspension, and control were at least as important as components were in the successful use of an artificial limb, and perhaps even more so. Letters of inquiry were sent by the committee early in its history to all known limb manufacturers, and one of the first subcontracts was made with the Research Institute Foundation, a laboratory operated by the Orthopedic Appliance and Limb Manufacturers Association. </p> <p> In the spring of 1946, arrangements were made with certain prosthetists to fit experimental suction-socket above-knee limbs, with cooperation from local surgeons and assistance from the committee staff. Studies to establish the principles of socket configuration, fitting, and alignment were initiated as supplements to the existing projects. Both fitting and harnessing of artificial arms were studied at other projects. </p> <h4> Public Law 729 </h4> <p> In 1948, the Eightieth Congress, recognizing the need for continuity in a program of this kind, passed Public Law 729, which authorized the expenditure of $1,000,000 annually for research in limb prosthetics and sensory aids (amended by P.L. 85-56, Eighty-fifth Congress, to remove the $1,000,000 limitation). The Veterans Administration was designated as the appropriate agency for the administration of the funds, and the Administrator of Veterans Affairs was authorized and encouraged to make the results of the proposed program widely available, so that all disabled persons might benefit. </p> <h4> Suction-Socket "Schools" </h4> <p> By October 1948, experience in a number of experimental settings indicated that the suction socket provided significant advantages over other methods of fitting and suspension for above-knee amputations, and that the technique should be released for general use. Because of the many factors which enter into the successful application of the suction socket, however, the publication of a teaching manual was not considered sufficient to ensure success. Therefore, with the assistance of the Orthopedic Appliance and Limb Manufacturers Association (now the American Orthotic and Prosthetic Association) and a distinguished group of surgeons, the NRC organized a series of regional workshops to teach surgeons and prosthetists the proper application of the suction socket. The University of California at Berkeley was assigned the initial responsibility for this program. The regional workshops were continued under VA auspices with cooperation of OALMA through 1952, by which time it was felt that the suction-socket technique had become established. During the entire program, approximately forty workshops were held. </p> <h4> Prosthetics Education Program </h4> <p> Through the findings of the UCLA case study and other endeavors, a considerable body of knowledge in upper-extremity prosthetics had been accumulated by 1952. Hence, the development was undertaken of a medium through which knowledge about the greatly improved devices and techniques that were available could be disseminated throughout the nation. Since the new developments involved the use of plastic laminates for all upper-extremity amputation levels, the time required for thorough instruction in fabrication of prostheses ruled out the use of regional teaching sessions. The Veterans Administration therefore financed the organization and operation of the Prosthetics Education Program at the University of California at Los Angeles. Following a pilot school in 1952 for teams from the Chicago area, participation in the UCLA cources was ultimately extended to surgeons, physicians, occupational and physical therapists, and prosthetists from all over the United States. Prosthetists attended for six weeks; they were joined by the therapists for the last two weeks, and by the physicians and surgeons for the final week, during which these disciplines worked together as a clinic team. </p> <p> The upper-extremity courses proved to be extremely popular and very successful. During the initial, intensive phase of the program (1953-55), 12 courses were conducted. As a result of these efforts, personnel constituting 75 specialized amputee clinics, and representing 30 states and the District of Columbia, were trained. Twenty-eight of these clinics were held at Veterans Administration installations, while 47 were at other public and private institutions. Concomitant with the upper-extremity education program, the VA funded a nationwide field study, conducted by New York University, to assess the value not only of specific devices but also of the treatment program taught at the schools. This study gathered much useful information and also served to reinforce the instructional material. </p> <p> This combined education-research program not only served to introduce new improved concepts in the management of upper-extremity amputees, but also was a tremendous stimulus to the formation of amputee clinics and clinic teams throughout the nation. Today, more than 400 amputee clinics staffed with trained personnel are in operation in the United States. This treatment concept has also spread to other countries throughout the world. </p> <p> The education program at UCLA proved to be so successful that the VA sponsored the establishment of a similar education program at New York University in 1956 to meet the needs of clinic personnel. Subsequently, the Vocational Rehabilitation Administration funded an additional prosthetics school at Northwestern University in 1959. As new devices and techniques emerged from the research program, additional courses were developed at all three schools, so that today every aspect of amputee management is covered. </p> <h4> Present Program Organization</h4> <p> By 1953, the Advisory Committee on Artificial Limbs recognized that child amputees had special problems, and began to work with the Michigan Crippled Children Commission to determine what might be done to solve some of these problems. The Children's Bureau supported the establishment of several research centers, and in 1955 the committee created the Subcommittee on Child Prosthetics Problems. </p> <p> From the beginning, the committee had felt that much of the experience gained in research in limb prosthetics was applicable to the field of orthopedic bracing, but it recognized that problems in orthotics were even more complex. Therefore, work was initially concentrated on prosthetics. About 1960, the Committee on Prosthetics Research and Development took steps to assist in the development of improved orthotic devices and techniques. At the present time, an active program in orthotics, supplementary and complementary to the prosthetics program, is under way. </p> <p> In 1966, at the request of the Veterans Administration, CPRD formed the Subcommittee on Sensory Aids to advise the VA concerning its research program in that area. The subcommittee also serves the Social and Rehabilitation Service in the same capacity. </p> <p> Prior to 1954, most of the research, development, and education activities in prosthetics and orthotics in the United States were supported by the Veterans Administration. In 1954, Congress enacted the Vocational Rehabilitation Act, which for the first time authorized the Office of Vocational Rehabilitation (later the Vocational Rehabilitation Administration and now the Social and Rehabilitation Service of the Department of Health, Education, and Welfare) to support research and education in rehabilitation. The prosthetics and orthotics research and education programs of the VRA were initiated gradually, beginning in 1955-a significant milestone being the assumption of the fiscal responsibility for the three prosthetics schools. </p> <p> Today the Veterans Administration, the Social and Rehabilitation Service, the Maternal and Child Health Service, and, to a limited extent, the National Institutes of Health, all support extramural research in these fields. The VA, the Army, and the Navy also operate research and development laboratories as part of their respective organizational endeavors. </p> <p> The VA, SRS, and MCHS support the Committee on Prosthetics Research and Development, which is responsible for correlating the various research projects and for advising the interested governmental agencies on matters related to prosthetics and orthotics. The VA and SRS also support the Committee on Prosthetic-Orthotic Education of the Division of Medical Sciences, National Academy of Sciences—National Research Council. CPOE's activities are directed toward the stimulation of educational programs for medical and paramedical personnel. </p> <p> Laboratories supported by the VA, SRS, MCHS, the Army, and the Navy, and their areas of interest, are listed at the end of this article. </p> <h4> Accomplishments </h4> <p> As a result of the research program, virtually every aspect of the management of amputees has been changed and improved. A similar program has now been initiated in orthotics, with the findings of the prosthetics program already strongly influencing research and clinical practice in orthotics. </p> <h4> Fundamental Studies </h4> <p> The fundamental studies supported originally by the VA, supplemented later by support from SRS and NIH mainly at the University of California at Berkeley and at Los Angeles<a></a>, have widely increased our knowledge about human locomotion, phantom pain, the functions of the upper extremities, the properties of voluntary muscle, and energy consumption. These studies not only have provided the basis for most of the new designs that have emerged from the research program but also have proven to be a stimulus to others to investigate the basic principles underlying the neuromuscular system. It is anticipated that fundamental studies will continue to contribute to the total research effort. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical force-plate results for a normal subject during level walking, illustrative of the information obtained in fundamental studies. (From Klopsteg, Wilson, et at., "Human Limbs and Their Substitutes,'' p. 453.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Fitting, Alignment, and Harnessing Techniques </h4> <p> Prior to the research program, it was the general surgical practice to amputate at certain specified levels, referred to as "sites of election." Most lower-extremity amputations resulted either in below-knee stumps that were six inches or shorter, or, in the case of above-knee amputations, in stumps no longer than two-thirds the length of the original thigh. Similar circumstances prevailed for upper-extremity amputations. The primary reason for these surgical practices was the lack of satisfactory techniques for fitting the longer stumps, especially those involving disarticulation, despite the fact that, in most cases, the longer the stump, the more functional it is. Improved techniques have now been developed for fitting stumps at all levels, and surgeons have been encouraged to save all length medically feasible. <b>Fig. 2</b>,<b>Fig. 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Force-length measurement of a biceps tunnel. (From "Human Limbs and Their Substitutes," p. 328.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Total-tension I, passive P, and developed-tension ? curves for flexor muscles of the human forearm. (From "Human Limbs and Their Substitutes," p. 328.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> New approaches to alignment based on biomechanics have been established for most amputation levels. New devices to aid in achieving optimum alignment have been devised and made available commercially. Descriptions of the new alignment principles, techniques, and instruments have been widely published, and their application is stressed in the Prosthetics Education Program. <b>Fig. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. A quadrilateral, total-contact socket developed for above-knee amputees under the program at University of California, Los Angeles. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> As an outcome of biomechanical analyses, new lower-extremity socket designs have been developed for all levels of amputation. The new socket designs have revolutionized fitting practices not only in the United States but also throughout the world. <b>Fig. 5</b>,<b>Fig. 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The figure-eight, ring-type harness for below-elbow amputees developed at Northwestern University. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The prosthesis for a Syme's amputation developed by the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> New harnessing techniques for upper-extremity prostheses, also based on biomechanical analyses, have been developed and made available for general use. </p> <p> Not only have the new fitting, alignment, and harnessing techniques provided the patient with increased function and comfort, but they also are easier for the prosthetist to apply than the older methods. <b>Fig. 7</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The casting jig for above-knee stumps developed by the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Among the more significant techniques developed under the program are: the plastic Syme prosthesis, the patellar-tendon-bearing below-knee prosthesis and its variations, the quadrilateral total-contact above-knee socket (with or without suction suspension), the Canadian-type hip-disarticulation and hemipelvectomy prostheses, and various plastic-socket designs for upper-extremity amputations. </p> <h4> Devices </h4> <p> A large number of mechanical components have been developed to provide additional or improved functions. While most of the designs have involved individual components, each was planned in relation to the total prosthesis. Hence, these new items can be used in various combinations to meet the needs of each individual patient. Noteworthy examples among the components developed through the research program are: the harness-operated elbow lock, the APRL voluntary-closing hand and hook, the Northrop 2-load hook, voluntary-opening hand sizes 1-5, the SACH foot, the Henschke-Mauch "Hydraulik" knee units, the Hosmer-DuPaCo "Hermes" unit, and the UCB pneumatic knee unit. <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. 8. The Henschke-Mauch "Hydraulik" knee unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The APRL-Sierra Model 44C artificial hand (without glove). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. The Northrop Model C elbow unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The Multiplex above-knee pylon-type prosthesis. Various knee-control devices are interchangeable when this unit is used. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. A below-knee prosthesis fabricated of synthetic balata, with a cosmetic cover, developed by the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Clinic-Team Concept </h4> <p> As a planned objective of the VA research program, the clinic-team concept was introduced and encouraged as the preferred method of amputee management. The results achieved have fully established the validity of this concept in providing superior service to the amputee and in promoting more successful use of prostheses. Today, utilization of the amputee clinic team is standard practice in the VA, and many state agencies have followed the lead of the VA by insisting that their patients be treated by a clinic team. Moreover, as a result of the VA experience, the Children's Bureau has encouraged the establishment of more than twenty specialized clinics throughout the United States to serve child amputees. <b>Fig. 13</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Steps in the clinic-team procedure. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Specifications and Checkout Procedures</h4> <p> In the course of the research program, specifications for manufactured components have been developed. The Veterans Administration Prosthetics Center in New York City regularly checks components against the specifications in order to insure that quality is being maintained. This procedure not only insures the provision of safe, durable devices to veterans, but also helps to keep the quality of the devices used by others at a high level. </p> <p> Procedures designed to assure that the total prosthesis is adequately constructed, fitted, and aligned have been developed for the use of clinic teams. These "checkout" procedures are modified as new devices and techniques become available, and have been of great assistance in raising the quality of amputee management. </p> <h4> Reduction in Rehabilitation Time </h4> <p> As a result of the introduction of immediate postoperative fitting procedures<a></a>and early fitting procedures, a substantial reduction in the time between amputation and return to home and job has been effected. The use of a rigid dressing immediately after amputation also helps to reduce edema and pain. </p> <p> At one time it was the rule in many hospitals, once the decision was made to remove part of a limb because of peripheral vascular disease, to amputate through the thigh because of the better blood supply in that region. Various studies have shown, however, that the knee joints in peripheral vascular cases can, with judicious care, be saved. As a result of these studies, rehabilitation time for many geriatric cases has been reduced even further. Indeed, the probability of rehabilitation itself can be markedly increased. </p> <h4> Reduction in Costs </h4> <p> The Veterans Administration has shown that, because of improved devices and procedures for fitting and aligning prostheses, artificial limbs were lasting twice as long in 1968 as they were in 1948. Although the average cost of artificial limbs increased 116.5% during that period, the increased "life" reduced the cost per year per eligible amputee veteran to about the same as it was in 1948.<a></a> </p> <p> In addition to an effective reduction in the cost of the devices, repair, maintenance, and clinic visits were also reduced substantially. There has been no discernible increase in the number of prosthetists in the United States over the past 20 years, yet the number of patients being served has increased considerably during that period, owing to the increase in the general population and to an increase in the number of amputations because of peripheral vascular disease in a population surviving to greater ages. </p> <h4> Dissemination of Information </h4> <p> <i>Prosthetics Education Program</i> </p> <p> The Prosthetics Education Programs originally established by the VA for training its clinic teams have proven to be extremely successful. The short-term courses have made possible the rapid and effective introduction to clinic teams of the new devices and techniques developed by the research program. </p> <p> Since the Prosthetics Education Program was organized in 1953, over 15,000 students have attended the courses offered by the three participating schools-New York University, Northwestern University, and the University of California at Los Angeles. </p> <p> <i>Degree and Associate in Arts Programs</i> </p> <p> Historically, the provision of educational opportunities in a given discipline has tended to create a demand for further education. This phenomenon has also been true of prosthetists and ortho-tists, and has led to the establishment of longer-term courses at several institutions. <b>Fig. 14</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. A typical laboratory scene in prosthetics-orthotics education. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> New York University undertook the most ambitious venture by establishing, in 1964, a four-year curriculum in prosthetics and orthotics leading to the Bachelor of Science degree. Two-year courses leading to the degree of Associate in Arts in prosthetics were begun at Chicago City Junior College (1965) and Cerritos College (1964). </p> <p> These expanding educational endeavors, plus numerous additional offerings such as the certificate course at UCLA and the technicians course at Delgado College, have raised the standard of prosthetics- orthotics practice at all levels, and have exerted a steady upward pressure on the requirements for certification. </p> <p> <i>Publications</i> </p> <p> From the beginning of the research program, it has been the policy of the sponsoring agencies to make new information available as it is developed to those concerned with the welfare of the amputee. This program, which has involved both periodic and special reports,<a></a> was financed initially by the Veterans Administration. SRS and the MCHS have since added their support. </p> <p> <i>Artificial Limbs, </i>a semiannual journal, was created in 1953 to provide a vehicle for dissemination of timely information, primarily to clinic-team personnel. Publication and distribution of the journal is the responsibility of the Committee on Prosthetics Research and Development, and it is mailed gratis to more than 4300 physicians, surgeons, therapists, pros-thetists, and research personnel. </p> <p> In 1961, the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development inaugurated the publication of the <i>Inter-Clinic Information Bulletin, </i>a monthly bulletin which serves as a vehicle for the exchange of information between child amputee clinics. The material for each issue is provided on a regularly scheduled basis by the 29 clinics affiliated with the SCPP's cooperative research program. More than 2500 copies of the ICIB are distributed gratis each month to interested individuals and institutions in the United States and abroad. </p> <p> In 1964, the Prosthetic and Sensory Aids Service of the VA began publication of its own semiannual journal, the <i>Bulletin of Prosthetics Research, </i>which is designed primarily to meet the needs of PSAS and covers a wide range of topics. It is available from the Superintendent of Documents of the U.S. Government Printing Office. Typically, some 2300 copies of each issue are sold, in addition to an official distribution of 3500 copies. </p> <p> In 1954, <i>Human Limbs and Their Substitutes<a></a>, </i>published by McGraw-Hill Book Company, was prepared principally from manuscripts developed by research personnel supported by the VA, and with the collaboration of the Office of the Surgeon General of the Army. This book was essentially a report on the results of the research program up to that time, and contains much basic information. Four thousand copies were printed, and the book had been out of print after 1960 until it was reprinted by the Hafner Publishing Company in 1968. </p> <p> Reports of special conferences organized by the Committee on Prosthetics Research and Development have been prepared in order to provide information useful to others as well as to those attending the meeting.<a></a> </p> <p><b>References:</b></p> <ol> <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. </li> <li>Committee on Artificial Limbs, National Research Council, <i>Terminal research reports on artificial limbs covering the period from 1 April 1945 through 30 June 1947 </i>(to the Office of the Surgeon General of the Army and the U.S. Veterans Administration).</li> <li>Committee on Prosthetics Research and Development, Selected bibliography on limb prosthetics, <i>Artif. Limbs, </i>12:2:42-48, Autumn 1968. </li> <li>Klopsteg, Paul E., Philip D. Wilson, et al., <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954. (Reprint edition, Hafner, 1968) </li> <li>Talley, William H., Prosthetics research-a cost reduction program, an editorial, <i>Bull. Pros. Res. </i>10-10, Fall 1968. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs, </i>Report to the Committee on Artificial Limbs, National Research Council, 1947, two volumes. </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>3.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Selected bibliography on limb prosthetics, Artif. Limbs, 12:2:42-48, Autumn 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., Human limbs and their substitutes, McGraw-Hill, New York, 1954. (Reprint edition, Hafner, 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Selected bibliography on limb prosthetics, Artif. Limbs, 12:2:42-48, Autumn 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Talley, William H., Prosthetics research-a cost reduction program, an editorial, Bull. Pros. Res. 10-10, Fall 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</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. </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">University of California (Berkeley), Prosthetic Devices Research Project, Fundamental studies of human locomotion and other information relating to design of artificial limbs, Report to the Committee on Artificial Limbs, National Research Council, 1947, two volumes. </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">Committee on Artificial Limbs, National Research Council, Terminal research reports on artificial limbs covering the period from 1 April 1945 through 30 June 1947 (to the Office of the Surgeon General of the Army and the U.S. Veterans Administration).</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">Committee on Artificial Limbs, National Research Council, Terminal research reports on artificial limbs covering the period from 1 April 1945 through 30 June 1947 (to the Office of the Surgeon General of the Army and the U.S. Veterans Administration).</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. Bennett Wilson. Jr. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-14.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Prosthetics and Orthotics Program Creator An entity primarily responsible for making the resource A. Bennett Wilson. Jr. * https://staging.drfop.org/files/original/80bd7e168ac76f3973055be7e00862b9.pdf e97318035d3d30c66366bd3b043f7eed DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_01_073.pdf Year 1970 Volume 14 Issue 1 Page Number(s) 73 - 74 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_073.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_01_073.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>Evaluation of Polysar Below-Elbow Fitting </h2> <h5>Clyde M. E. Dolan <br /></h5> <p>The technique of forming sockets directly on below-elbow stumps using Polysar<a style="text-decoration:none;">*</a>, presented in a January 1968 manual by Gennaro Labate and Thomas Pirrello of the Veterans Administration Prosthetics Center, was used to prepare complete prostheses for three amputees, following a demonstration of the technique by VA personnel. The subjects were male, unilateral below-elbow amputees, with stump lengths in the range of 40-60% of the sound-side measurement. Each amputee had previously worn a conventional prosthesis; one had been using a Munster-type fitting immediately prior to wearing the experimental prosthesis.</p> <p>The instructions in the manual were considered by our staff prosthetists to be clear and comprehensive; however, the demonstration of the procedure was particularly helpful. No difficulties were encountered in interpretation or application of the fabrication technique. Each prosthesis was fabricated, from measurement to delivery, in approximately one-half day.</p> <p>At the time of delivery, each synthetic-rubber prosthesis was weighed for comparison with the previously worn conventional product. A staff therapist checked out each prosthesis, and the subject was instructed to wear the arm exclusively during the evaluation period. No special precautionary measures were advised. Initial reactions of the subjects were recorded, with specific reference to weight, cosmesis, the soft foam covering, and comfort.</p> <p>The experimental arms were considerably heavier than the respective conventional arms worn by the subjects. The weights of the complete prostheses (including harness, cable, and APRL hand and glove) were:</p> <table> <tbody> <tr> <td> <p><strong>Subject    </strong></p> </td> <td> <p><strong>Conventional    </strong></p> </td> <td> <p><strong>Experimental    </strong></p> </td> <td> <p><strong>Difference    </strong></p> </td> <td> <p><strong>% Increase    </strong></p> </td></tr> <tr> <td> <p>A</p> </td> <td> <p>788.5 g</p> </td> <td> <p>967.5 g</p> </td> <td> <p>179.0 g</p> </td> <td> <p>22.7</p> </td></tr> <tr> <td> <p>B</p> </td> <td> <p>842.0 g</p> </td> <td> <p>1133.5 g</p> </td> <td> <p>291.5 g</p> </td> <td> <p>34.5</p> </td></tr> <tr> <td> <p>C</p> </td> <td> <p>777.0 g</p> </td> <td> <p>921.5g</p> </td> <td> <p>144.5 g</p> </td> <td> <p>18.7</p> </td></tr></tbody></table> <p>Despite these substantial differences, none of the subjects commented adversely about the weight of the synthetic-rubber prosthesis.</p> <p>Two of the subjects experienced problems related to cosmesis during the initial fitting. The cosmetic cover of Subject B's prosthesis was not sufficiently opaque, and irregularities in the foam underlayer presented an unsatisfactory appearance. This defect was remedied by covering the foam with a layer of Helenca stockinet to improve the color uniformity. Subsequent shifting of this layer caused a wrinkle to develop in the vinyl cover, but this did not disturb the patient.</p> <p>On initial fitting of Subject C's prosthesis, it was apparent that the foam (a 50-50 combination of Silastic 385 and 386) had collapsed in the area proximal to the wrist unit, producing an unsightly configuration. This difficulty was remedied by the use of a somewhat denser foam mixture, one which retained sufficient flexibility to simulate normal flesh turgor but which was nonetheless strong enough to maintain cosmetic shape when the cover was applied.</p> <p>Once those initial problems were solved, all reactions to the soft foam, with a vinyl cover, were highly positive. Initial reactions to the comfort of the experimental sockets were also positive.</p> <p>The three subjects wore the experimental prostheses for periods ranging from two to four months. Only one (Subject A) subsequently experienced problems, and these required that the prosthesis be replaced. It is worth noting that this patient was the one who had previously worn a Miinster-type prosthesis. After wearing the experimental socket for five weeks, he expressed a preference for his previously worn prosthesis in terms of comfort. His socket produced from Polysar had developed embossed ridges caused by the stockinet, which resulted in considerable discomfort and skin irritation. In addition, the socket had deformed, becoming elliptical in the direction of cable pull, which may have contributed to a dermatitis which occurred after that fitting.</p> <p>The other two subjects reported at the close of the period of wear that they preferred the synthetic-rubber fitting to their conventional prosthesis. Subject B reported increased comfort and cosmesis, and also reported greater range of motion, which may be due to slightly lower proximal trim lines and some socket flexibility. Subject C felt that he could wear the prosthesis continuously without discomfort; he found no problem with the weight of the prosthesis and felt "more secure" with the experimental prosthesis than with the previously worn arm.</p> <p>To summarize, the fabrication procedure using Polysar, as demonstrated and as presented in the draft manual, seems to offer advantages in terms of: <i>(a)</i> saving of shop time (the technique requires approximately one-half day, while standard techniques require nearly a full day, not considering curing time), <i>(b)</i>elimination of some opportunities for error through the reduction of the number of steps in the fabrication process, and <i>(c)</i> fabrication of a prosthesis with a soft external surface which simulates normal flesh turgor. Difficulties encountered were: (<i>a</i>) collapse of the foam cover (tending to dent when the sleeve was applied), which may be ameliorated by the use of a denser foam; <i>(b)</i>low opacity of the sleeves, which may be improved by using a dilaminar or a thicker material; (<i>c</i>) weight, which seemed excessive although not noted by the subjects; and (<i>d</i>) possible deformation or embossing of the socket, as noted in the case of Subject A.</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>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> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Evaluation of Polysar Below-Elbow Fitting Creator An entity primarily responsible for making the resource Clyde M. E. Dolan  https://staging.drfop.org/files/original/f705a88b62579919ebd280734cc87c01.pdf b9eacb74fddcfd81decdd065a6705fdd https://staging.drfop.org/files/original/e05b257845dff7213c7f075b57cf5fcc.jpg bd523911342105f9a2128e78a1aeb6cb https://staging.drfop.org/files/original/11cd3f8a84385221430f3e8c6b68d7a8.jpg b96e00d451e355e664197cf1f6c096b8 https://staging.drfop.org/files/original/81be0b0e594f36536b95cc888ea0798a.jpg 23da1b6dc1872b1b5797b235a956b7c7 https://staging.drfop.org/files/original/3791a0eb792a4d25c7f40b60c75e5b2d.jpg bad29a39e144a9990815beb05f7bbdc6 https://staging.drfop.org/files/original/a2c4d5480f72caa73d1807874cb70fce.jpg 8a15ca8c6b8342bd3cf706868a599486 https://staging.drfop.org/files/original/6f0562d37d37b957ceba489c2e2ca39b.jpg 96e365de47b09be1e0e2dd80223633ac https://staging.drfop.org/files/original/b01cfe724a87500df31cadb5038854e7.jpg bddf845abdebf1a394bf9fd15257f9db https://staging.drfop.org/files/original/3de6676506062bef75f71a38287a7578.jpg 2445d12e95b2289f26c3cbd6f2a18c05 https://staging.drfop.org/files/original/74f77a4af134297887250161d208c62c.jpg 8c549b1b71dbc8c982018a1cee1545fb https://staging.drfop.org/files/original/070812cad4152c89454a35f884e2e3e9.jpg 2a7a6bb1dd1ed4f8098878287bc3d4e8 https://staging.drfop.org/files/original/a2fe1d3281087c6ce407dd3a40dd4c21.jpg f1f8ea956fc5d035040e0eefd468e990 https://staging.drfop.org/files/original/5cab3bf9dca0d59b832e1adb6cb078dd.jpg b7419f891e57061df0c34997b04d0bd5 https://staging.drfop.org/files/original/70128bff2c284b7089ab9d7941dd8170.jpg 3cf6e7ffb74689f5ef7610709e4932dd https://staging.drfop.org/files/original/35d21b8cabb98a340036e5d94c747608.jpg 4372e34ed61e9169c31341fc400b42d2 https://staging.drfop.org/files/original/8e48f7a2f951dd4704f7f69bc1d7c09c.jpg e1364dfabd6d579d4acd84dc43569812 https://staging.drfop.org/files/original/53aa38977adfa885dd4446a080079bea.jpg 047c02beb59db92227b8a507b687614f https://staging.drfop.org/files/original/680e550c3416ad1257bf7172cd07a96b.jpg 0dbe82e84dd46cc9172de94cf4cb754c https://staging.drfop.org/files/original/0018b73701a2a03adb1202951eb9890e.jpg 2bd534a213d889b949b9f5e556cdf482 https://staging.drfop.org/files/original/341143f786b503326091116f2cafa449.jpg af22ca80378e8cdccdf571b5f1d5e0ad DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_01_065.pdf Year 1970 Volume 14 Issue 1 Page Number(s) 65 - 72 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_065.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_01_065.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>Direct Forming of Below-Elbow Sockets</h2> <h5>Gennaro Labate <a style="text-decoration:none;">*</a><br />Thomas Pirrello <br /></h5> <p>The following equipment and materials are required for this direct-forming procedure:</p> <ul> <li> Polysar<a style="text-decoration:none;">*</a> X-414 tubing</li> <li> Hot plate (thermostatic control optional)</li> <li> Tote pail and cover (height 22 in.; diameter 10 in.)</li> <li> Rubber casting sleeves</li> <li> Silicone spray</li> <li> Manila folders</li> <li> Pressure-sensitive tape</li> <li> Trichloroethylene</li> <li> Heat gun and adapter</li> <li> Cosmetic covers</li> </ul> <p>All the prosthetics information required to fabricate a conventional socket is necessary for forming a socket with Polysar synthetic rubber.</p> <p> 1. A rubber sleeve that will best conform to the stump is selected. (The three sizes which will accommodate most below-el-bow stumps are 3 in. x 6 in. x 14 in., 3 1/2 in. x 6 in. x 14 in., and 4 in. x 6 in. x 14 in.) The rubber sleeve is pulled snugly over the stump, and the proximal end is fastened with Yates clamps to a figure-eight harness. The sleeve is lubricated generously with silicone spray. <b>Fig. 1</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 2. Tubing whose circumference 2 in. from the distal end is closest to <i>but less than</i> the circumference of the stump is selected. (The three tube sizes which accommodate most below-elbow stumps are 4 3/4 in., 5 1/2 <i></i> in. and 6 1/4 in.) The tubing is cut 3 in. longer than the measurement from the lateral epicondyle to the stump end. The inner surface of the tube is cleaned to remove loose particles. <b>Fig. 2</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 3. The tube is immersed in water heated to approximately 180 deg F. (The tube may float when it is completely soft and ductile.) <b>Fig. 3</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 4. The softened tube is removed from the water and the entire inner surface is lubricated with silicone spray. <b>Fig. 4</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 4.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 5. After the tube has cooled to skin tolerance, it is drawn up on the stump to a point where the proximal brim is about 1 in. above the olecranon. <b>Fig. 5</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 5.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 6. The tube is encircled at the distal end of the stump with nylon cord, and the cord is gently pulled until the tubing conforms to the end of the stump and is completely sealed. <b>Fig. 6</b> </p> <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> 7. The excess tubing is cut off close to the cord. <b>Fig. 7</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 /> <p> 8. The tube is molded on the stump to produce the desired contours. The working time is approximately 5 minutes. <b>Fig. 8</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 9. While the tubing is still soft, a trim line is marked according to the socket plan and the tube is trimmed. The socket is cooled before removing it from the stump: the covered stump is immersed in cold water, and hand and finger pressure are used to maintain the socket contours while it is immersed. <b>Fig. 9</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>10. The socket is removed from the stump and trimmed to its final shape. Large areas requiring reshaping may be resoftened by immersion in hot water. Smaller areas may be softened by use of a heat gun and reshaped on the stump. (When using a heat gun on Polysar X-414, it is advisable to use a conical adapter.)</p> <p> 11. The forearm extension is made over a manila folder formed into a conical tube, incorporating the desired wrist fitting. The length of the tube is equal to the epicon-dyle-to-ulnar-styloid measurement. The tube is adjusted so that the proximal end flares into the socket approximately 3 in. over the distal end. <b>Fig. 10</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 10.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 12. A length of Polysar tubing is cut approximately 2 in. longer than the manila tube and immersed in hot water until soft. <b>Fig. 11</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 13. A section of 2-in. stockinet which is twice the length of the Polysar tube is pulled through the softened tube. <b>Fig. 12</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 14. With the stockinet used as a "pull sleeve," the softened tube is pulled down until the proximal edge overlaps the proximal end of the manila tube by 1 in. The tube extension is cooled by immersion of the entire assembly in cold water. <b>Fig. 13</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 13.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>15. Realignment reference lines are marked on both the socket and the extension, and the extension, manila tube, and wrist fitting are removed.</p> <p>16. The socket surface covered by the extension is sanded lightly, and the socket and the extension are wiped with trichlo-roethylene.</p> <p> 17. The extension tube is replaced on the socket and realigned according to the reference lines. The proximal 3 in. of the extension are heated until soft. <i>(The socket is not allowed to become soft.)</i> The softened end of the extension is compressed until it adheres evenly to the socket, then the socket and extension are immersed in cold water. <b>Fig. 14</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 14.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 18. The epicondyle-to-ulnar-styloid measurement is checked, and the extension is trimmed if necessary. <b>Fig. 15</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 15.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 19. One inch of the distal end of the extension is immersed in hot water until soft. The wrist fitting is inserted into the softened extension and the tube compressed around the wrist fitting with pressure-sensitive tape. The alignment is again checked and adjusted if necessary, and the tube is cooled in cold water. <b>Fig. 16</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 16.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 20. The extension and socket are flared by sanding. The wrist fitting is secured with four 3/8-in. #6 self-tapping pan-head sheet-metal screws. <b>Fig. 17</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 17.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>21. The proximal socket brim is buffed with a felt wheel and wiped with trichlo-roethylene to produce a smooth surface.</p> <h4> <i>Finishing</i> </h4> <p> Below-elbow prostheses fabricated with synthetic-rubber sockets are best finished with prefabricated flexible cosmetic covers. Although the sockets may also be finished by conventional laminating procedures, laminates tend to reduce the yielding property of Polysar X-414, and therefore are not recommended. Three cosmetic coverings are illustrated: contoured vinyl sleeve, armlet stockinet, and tubular rubber sleeve. <b>Fig. 18</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 18.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The contoured vinyl sleeve (A) is pulled over the arm after softening in hot water. The cover is trimmed approximately 1/4 in. above the proximal socket brim. </p> <p> The armlet stockinet <i>(B)</i> is sewn closed at the unfinished end. A small opening in the sewn end is made to accommodate the threaded stud of the terminal device. The armlet is pulled over the prosthesis. (The proximal end is not cut.) </p> <p>The tubular rubber sleeve (C) must be bonded to the prosthesis, as follows.</p> <p> 1. A length of 3-in. stockinet is used as a "pull sleeve." The stockinet is inserted into a rubber sleeve cut one and one-half times the length of the prosthesis. <b>Fig. 19</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 19.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 2. The stockinet is pulled over the prosthesis until the rubber sleeve extends 1 in. past the proximal socket edge. <b>Fig. 20</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 20.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 3. Approximately half of the rubber sleeve is rolled back, and the stockinet is trimmed. <b>Fig. 21</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 21.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 4. The exposed portion of the socket is coated with rubber cement, and the rubber sleeve is unrolled while the cement is still wet. <b>Fig. 22</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 22.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 5. The cementing procedure is repeated at the proximal end after removal of the remaining stockinet. When the cement is completely dry, the excess rubber sleeve is trimmed. <b>Fig. 23</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 23.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> <i>Hinges and Transmission System</i> </h4> <p>Metal or leather joints are aligned and fastened with Speed rivets. All other components are installed in the conventional manner.</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>Footnote</b></td></tr><tr><td class="clsTextSmall">Registered trademark of th ePolymer 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>Gennaro Labate </b></td></tr><tr><td class="clsTextSmall">Veterans Administration Prosthetics Center, New York, N.Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-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 Direct Forming of Below-Elbow Sockets Creator An entity primarily responsible for making the resource Gennaro Labate * Thomas Pirrello  https://staging.drfop.org/files/original/785f66484a457dd5ea36486281669c63.pdf 2a13be21d16b3cba581d0f5c39829307 https://staging.drfop.org/files/original/de0295080d2342091ee8d35f8b9eb492.jpg 67f6018770a74ed03cb90a1fdcf80b22 https://staging.drfop.org/files/original/a2e780143e6e8508bc090f38eec6847b.jpg ce791d7bd02f539672bfd6aafc1c7955 https://staging.drfop.org/files/original/01140c6f2bcd0a25691175b8982667e4.jpg e646a27436a751e896353b213a2dacc9 https://staging.drfop.org/files/original/039eec2639e19736a06618dc61593eb5.jpg 8c7aaa7044354c386391909637bb056e https://staging.drfop.org/files/original/2acaa9f6178a16d99894a0ec19c23ef7.jpg 4a7f9f5704a2518e642edd71b92c8c87 https://staging.drfop.org/files/original/fb289d965166e603e52ef903cea429f0.jpg 5c402e4e8983f7fc34a947dfa7335046 https://staging.drfop.org/files/original/d63440c21a0f69b8b5fb63b022e61190.jpg 66831f497f8cdab5da95d86117ef5763 https://staging.drfop.org/files/original/85b340c5dff8d0a0258af2bdad391640.jpg e637b228d06590314f7d668b4f83decf https://staging.drfop.org/files/original/3db34f12dfb1ec30ad911b4f9f24f9b3.jpg 47a226f4750a71f160e119ae48cff694 https://staging.drfop.org/files/original/20eafe5419c83630cf610007cac7a089.jpg 1863122494926efc5d49d2ad8f203365 https://staging.drfop.org/files/original/874cfc1d92441810888b9aa4c0d9f3ae.jpg da650953df53e1189a6777e2c01b1726 https://staging.drfop.org/files/original/7dc88dda4cf9dc97e0c41a5b9d4df0d9.jpg cad29965382e0be70dcc5c64fea49d17 https://staging.drfop.org/files/original/4ad6c948c583a6f956dd404eb175790b.jpg 78415e090cb4b1a74fd776db498158fb https://staging.drfop.org/files/original/41b685212583f4394899d15ff59a4ff5.jpg a6bbba17a745d1a8aed594e0f6dd0292 https://staging.drfop.org/files/original/65118f6ccc79f81819690361de395d17.jpg 9e265f25fc1297f5a01dd3614e1cd25e https://staging.drfop.org/files/original/194efbb8bfd7cd41bd9e251cf5345c21.jpg cf723eb59e370d89b74acefbeb52cb82 https://staging.drfop.org/files/original/df9ae6774a07620814409dcd6667d120.jpg 47ea548a6ed55d80d656723d22946d5f https://staging.drfop.org/files/original/0ca4197cba7b3be9c1adb317f610eeb7.jpg f97971b37ea237eb8c1ce8cbaef544a9 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_01_057.pdf Year 1970 Volume 14 Issue 1 Page Number(s) 57 - 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_057.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_01_057.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>Direct Forming of Below-Knee PTB Sockets with a Thermoplastic Material</h2> <h5>Anthony Staros <br />Henry F. Gardner <br /></h5> <p> Prior to forming the socket, a careful evaluation of the stump must be made. The usual prosthetics data must be noted, especially any stump characteristics which would require special considerations for socket comfort. </p> <p> With the patient seated, a lightweight cast sock is applied snugly <b>Fig. 1</b> to maintain tension. The top of the sock is clamped to a strap encircling the patient's hips. The strap is made of two halves of mating Velcro for easy adjustment behind the patient's back, and the two free ends are equipped with Yates clamps, which are placed medially and laterally at the top of the sock. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Application of a lightweight cast sock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A strip of 1/4-in. felt, cut to form a tib-ial-crest relief, is positioned from the superior border of the tibial tubercle to <i>and over the end of the stump </i><b>Fig. 2</b>. The portion of the pad over the tubercle is made approximately 1 1/4<i> </i>in. wide, tapering to a 5/8-in. width for the entire length of the tibial crest relief. All edges are carefully skived. If adhesive-backed felt is not available, medical adhesive may be used to attach the pad. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Placement of the relief for the tibial crest. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A second lightweight cast sock is pulled snugly over the tibial relief and fastened in the same manner as the first sock <b>Fig. 3</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Stump with second cast sock applied. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Using the VAPC knee caliper, the anterior-to-posterior knee measurement at the level of the patellar tendon is taken <b>Fig. 4</b>. The medial-to-lateral dimensions of the epicondyles of the femur are measured in the same manner. These dimensions are useful in determining the accuracy of the socket. The maximum depth of the patellar ledge is determined by the A-P measurement. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Measuring stump dimensions with the VAPC caliper. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Socket Forming </h4> <p> A section of Polysar<a style="text-decoration:none;">*</a> X-414 synthetic rubber tubing with a 1/4-in. wall is selected. The diameter of the tubing should be one-third of the mid-stump circumference. The tube length should be approximately one and one-half times the distance measured <i>from the top of the knee to the end of the stump </i><b>Fig. 5</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Determining the proper length of tubing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A section of Helenca stockinet 36 in. long is used to pull the heated tube over the stump. One end of the stockinet is pulled up on the stump as shown in <b>Fig. 6</b>. The other end is passed through the heated tube. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The stockinet in position over the stump for pulling on heated plastic tubing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The inside surface of the tube is thoroughly cleaned to remove all plastic dust. (When heated, the dust would cohere to the inner walls, causing undesirable irregularities.) </p> <p> The dust-free tube is softened by immersing it in water heated to 180 deg F, or just under the boiling point, for four to six minutes. Because the inner walls of the tube would cohere instantly if permitted to touch when heated, <i>the tube is placed on its end in the water container.</i> </p> <p> To facilitate slipping the tube over the knee, the upper half is enlarged by spreading (hands together, palms out). The end of the stockinet hanging from the stump is pulled through the heated tube. The tube is pushed on the end of the stump and carried up over the stump by a continuous pull on the stockinet <b>Fig. 7</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Pulling the heated tube over the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>Twists or folds in the stockinet should be avoided while drawing the stockinet and plastic tube over the stump. </i>The forming pressures which compress the soft thermoplastic produce a slight imprint of the stockinet material on the inner surface of the socket, and any folds or twists in the stockinet will cause undesirable irregularities in the inner socket wall. The top of the stockinet is then clamped in the same manner as the cast socks. </p> <p> The upper socket borders are trimmed with bandage scissors, leaving the posterior borders approximately 1/2<i> </i>in. higher than the required measurement, for later rolling out of the material to form a relief for the hamstrings <b>Fig. 8</b>. The remainder of the socket border is cut transversely above the superior edge of the patella. The lower tube end and the stockinet are trimmed to provide an extension of 3 in. beyond the stump. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Trimming the upper socket borders before molding. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The stump is held relaxed in 5 to 10 degrees of flexion. Starting approximately 1/2<i> </i>in. above the stump end, a snug wrap of 1-in. elastic pressure-sensitive tape is applied over the tube in a continuous anterior-to-medial spiral, with increasing </p> <p> tension approaching the level of the medial tibial flare and continuing over the knee <b>Fig. 9</b>). The tension is controlled best if one steadies the socket while the other wraps half of the circumference. The hands then change functions to wrap the other half of the circumference. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Application of pressure using an elastic pressure-sensitive-tape wrap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The section of soft tubing extending below the stump will tend to sag. This must be prevented by supporting this section until it cools while molding the material. Approximately 10 minutes are required for the material to harden. During this time, the socket is molded to provide freedom over the anterior end of the tibia by massaging the taped surface of the socket to define the tibial crest and medial flares of the tibia <b>Fig. 10</b>. During the molding process, all surface irregularities may be pressed out of the socket. The socket should not be removed from the stump until the thermoplastic is no longer deformable by hand. The tape is removed, and with the knee flexed to at least 90 degrees, the socket is forced from the stump. Later, pressure-sensitive fiberglass or nylon tape may be put on the socket as a circumferential (barrel hoop) reinforcement, usually required only around the proximal brim. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Hand molding to define the medial tibial flare and tibial crest. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The resulting open-end socket will permit easy attachment of the shank. Once the socket extension has been secured to the shank, the end of the socket chamber is filled with foam, or another type of resilient end pad is provided. </p> <h4> Socket Modifications </h4> <p> To modify the socket, heat is focused with a heat gun fitted with a cone <b>Fig. 11</b>. With one hand placed inside the socket against the surface to be modified, heat is directed to the <i>immediate area from close range </i>until the heat is sensed by the fingers through the socket wall. <i>Large areas should not be heated, nor should heat be directed against the socket for a prolonged period of time, because excessive temperature will cause the plastic to boil and discolor. </i>When molding for a pressure point, one finger should press from inside the socket, and the surrounding areas should be supported on the outside of the socket with the fingers of the other hand. After the molded area has cooled sufficiently to retain its shape, the socket should be chilled with cold water or refrigerated for a short interval to reset the plastic. <i>Caution must be exercised to avoid heating the entire socket. The heat should be concentrated on the one spot until the pressure applied with the fingers inside the socket causes the material to yield.</i> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Heat gun with modified cone for control of heated area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A similar procedure is followed to shape the patellar-tendon ledge. For patients who have previously worn prostheses, the A-P measurements obtained by caliper are used to determine the depth of the ledge. For recent amputees, the patellar-tendon ledge is not molded to the maximum depth in one adjustment. Instead, three or more adjustments should be made at intervals of one month until the required A-P dimension is reached. </p> <p> The proximal posterior socket border is heated and rolled out to form a smooth radius for comfortable knee flexion <b>Fig. 12</b>, the border being maintained at approximately the patellar-ledge level. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Rolling out the softened posterior socket wall. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> An adjustable pylon is prepared with a wood socket-attachment block 1 V'2 in. thick and 3 in. in diameter, with a Vi-in. deep circumferential groove at the midpoint of the block. The block is tapered to a slightly smaller diameter around the bottom, then fastened permanently to the pylon with bolts and cement <b>Fig. 13</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. The pylon and socket ready for assembly. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The tube end extending distally from the socket is heated, then fitted over the wood pylon-attachment block, with the groove helping to make a good bond. <i>A 1-in. space between the stump end and the attachment block must be maintained. </i>The tube is taped tightly to the wood block and permitted to cool <b>Fig. 14</b>. Any excess tubing extending below the wood can be trimmed while the plastic is still soft. When hardened, the tube is fastened permanently to the wood block with four screws set at 90-degree angles to one another. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. The heated socket bottom is joined to the pylon with elastic-tape wrap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Suspension </h4> <p> To provide for suspension, the socket can be trimmed at the regular PTB level and a separate cuff used above the knee. Of the several kinds of PTB suspension that can be provided with this socket, suprapatellar-supracondylar suspension is described. </p> <p> The patient is seated in a chair with his knee flexed at approximately 45 degrees, and the stump is covered with two cast socks. The upper socket walls above the level of the upper border of the patella are softened by holding the socket (bottom up) in hot water. When the socket top is heated, the stump is pushed into the socket. The plastic is molded against the thigh over the condyles by wrapping tightly with pressure-sensitive tape and hand molding. </p> <p> After the patient has been fitted and the prosthesis aligned, the bottom of the socket chamber should be foamed to obtain a total-contact fitting. To avoid difficulty in quickly inserting the stump into the socket, the stump is covered with a lightweight sock and a powdered PVA bag. Three 1/8-in. holes are drilled through the lower socket wall at the level at which the stump begins to taper inwardly, away from the socket wall. A foam mixture is prepared and poured into the socket <b>Fig. 15</b>. The patient's stump is inserted into the socket and the patient stands still until the foam has set. The. foam mixture may vary, depending upon the type of stump and condition of the distal tissues. Usually a combination of foam and RTV rubber is used. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Pouring the foam mixture to form the total-contact socket bottom. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Shaping and Finishing</h4> <p> A leg shape can be made from prefabricated sections of semirigid foam, Koroseal Spongex.<a style="text-decoration:none;">*</a> Beginning at the level of the patella, a paper pattern is cut to fit around the socket at this level. The pattern is traced upon one foam section <b>Fig. 16</b>. The foam is carefully sanded to form a hollow for the socket. It is necessary to obtain a tight, gap-free fitting of the foam to the socket; best results are obtained from a slight stretch fit. For this, the foam is heated in an oven at 180 deg F before placement over the socket. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Foam blocks prepared for fitting over the pylon and socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> To cover the remaining part of the pylon, a foam block is cut to correspond to the measurement between the bottom of the foam surrounding the socket and the top of the foot plus 1/4 in. A hole is made through the length of the block large enough to receive the pylon tube. Since the foam is semirigid, the areas for the alignment coupling and ankle plug of the pylon are cut slightly undersize to permit a snug fit about the pylon <b>Fig. 17</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Foam blocks fitted over the socket and pylon and rough-shaped. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A 1/2-in. hole is bored transversely through the foam block to permit entry of a screwdriver to fasten the tube clamp. The two foam sections are <i>not </i>glued together, in order to facilitate removal for alignment adjustments. Compression of the foam block between the socket base and the foot will prevent any movement of the block. </p> <p> The blocks are shaped with a band saw or knife and sanded with a drum or cone sander. For cosmesis, either a flexible poly-urethane coating over the foam or a stocking cover is recommended <b>Fig. 18</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. The prosthesis with a flexible plastic coating over stocking-covered foam. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <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">B.F. Goodrich Co.</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> Figure 1 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-18.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Direct Forming of Below-Knee PTB Sockets with a Thermoplastic Material Creator An entity primarily responsible for making the resource Anthony Staros  Henry F. Gardner  https://staging.drfop.org/files/original/b5321419e7289e34cedd7b3e0cbe4493.pdf 1cb64ea6151a427da372f111e67022a4 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_02_041.pdf Year 1969 Volume 13 Issue 2 Page Number(s) 41 - 42 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_041.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_02_041.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>Clinical Study of the Application of the PTB Air-Cushion Socket</h2> <h5>Eric Lyquist <a style="text-decoration:none;">*</a><br /></h5> <p>From January 1966 to September 1968, the Orthopaedic Hospital in Copenhagen conducted a clinical evaluation study of the patellar-tendon-bearing (PTB) air-cushion socket (see p. 1).</p> <p>The Prosthetic/Orthotic Research Department at the hospital fabricated the sockets, using the casting procedure described by Wilson and Lyquist <a></a> and the fabrication procedures described by Lyquist and his associates<a></a>. These procedures and the results of fitting 45 amputees were published in September 1968.<a style="text-decoration:none;">*</a></p> <p>Forty-five amputees were selected for the test series and fitted with air-cushion sockets. Four patients were eventually dropped from the study, three because of their inability to return for re-examination, and one because of her confinement to a wheelchair as a result of progressive vascular disease.</p> <p>The group of 41 amputees consisted of 30 males and 11 females, with ages ranging from 7 to 74 years (average age: 44).</p> <h3>Clinical Evaluation</h3> <p>Seventeen of the amputees had been satisfied wearers of a PTB prosthesis for at least 12 months. After being fitted with air-cushion sockets, 13 noted improved comfort and function, 3 found no change in comfort and function, and 1 was dissatisfied because of nocturnal stump pain.</p> <p>Seven patients had previously been fitted with the standard type of PTB prosthesis, but satisfactory fittings had never been achieved. With fitting of the air-cushion socket, 4 amputees obtained satisfactory comfort and function. One patient was able to wear a modified air-cushion socket with a soft insert. The remaining 2 had to abandon the socket; both had short stumps (2-1/2 in.) with distal hypersensitivity.</p> <p>Seven amputees had previously worn prostheses, but with complications such as ulcerations and secondary distal edema. Six obtained satisfactory comfort and function with the air-cushion socket, but one who had a short stump (2 in.) and extensive skin transplants was fitted after four weeks with a standard PTB prosthesis.</p> <p>Four amputees had successfully worn conventional BK prostheses for periods of 40, 30, 13, and 6 years. Nonetheless, when fitted with an air-cushion socket, each preferred it to the conventional prosthesis.</p> <p>Of the remaining 6 amputees, 5 had never worn a prosthesis. Two of those had distal edema and ulceration, which healed when an air-cushion socket was applied. Another had stump problems not attributable to the prosthesis, but he managed well with the air-cushion socket. A fourth patient had no stump problems, and successfully wore the socket. One amputee had to be fitted with a different type of prosthesis because his stump was hypersensitive distally and the volume was constantly changing.</p> <h3>Summary</h3> <p>Of the 41 amputees fitted with the air-cushion socket, 36 had previously worn prostheses. In that group, 27 noted increased comfort and function, 4 were considered unchanged, 3 returned to wearing a standard PTB prosthesis, and 1 required fitting with a conventional prosthesis. One amputee had previously been fitted with an air-cushion socket by a private pros-thetist, and got along very well. Of the 5 amputees who had not previously worn a prosthesis, 1 was not successfully fitted, but 4 were able to manage well with the air-cushion socket.</p> <p>At the time of this report, 36 of the 41 amputees evaluated in this study were wearing the air-cushion socket. Although extensive final medical examinations of the entire group have not been completed, it is unlikely that the information resulting from those examinations will differ greatly from the results presented in this report.</p> <p><b>References:</b></p> <ol> <li>Lyquist, E., L. A. Wilson, and C. W. Radcliffe, <i>Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, principles and fabrication procedures</i>, Technical Memorandum, Biomechanics Laboratory, University of California, San Francisco and Berkeley, 1965.</li> <li>Wilson, L. A., and E. Lyquist, <i>Plaster bandage wrap cast</i>, Pros. Int., 3:4-5:3-7, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Prosthetic/Orthotic Research Department technical report (Danish).</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, E., L. A. Wilson, and C. W. Radcliffe, Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, principles and fabrication procedures, Technical Memorandum, Biomechanics Laboratory, University of California, San Francisco and Berkeley, 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>2.</b> </td><td class="clsTextSmall">Wilson, L. A., and E. Lyquist, Plaster bandage wrap cast, Pros. Int., 3:4-5:3-7, 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>Eric Lyquist </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetic/Orthotic Research Department, Orthopaedic Hospital, Copenhagen, Denmark.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> 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 Study of the Application of the PTB Air-Cushion Socket Creator An entity primarily responsible for making the resource Eric Lyquist * https://staging.drfop.org/files/original/5724c58acfdabe747b7c60927a4a24b5.pdf 4a65f44f3c20bce5b481525068819737 https://staging.drfop.org/files/original/8d0af8c9cdc4c818379f8f4094eeec16.jpg 52aaa3f3899a02ce896dc9f5fd82ba1c https://staging.drfop.org/files/original/ace50222cdc84974cc159ef1646c56ad.jpg 784acabf15b2c43c1dadb7ce14e7d49e https://staging.drfop.org/files/original/f101d6c6bc81000f4f4882cccedb60ba.jpg e449ffc3b155c41c90a50c19331e96b7 https://staging.drfop.org/files/original/5c4e1ab1e0cd9ee721de1e4279d2d9e0.jpg db093c4fcf07979d3cd3a7508481c2de DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_02_036.pdf Year 1969 Volume 13 Issue 2 Page Number(s) 36 - 40 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_036.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_02_036.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>Radiographic Evaluation of Stump-Socket Fit</h2> <h5>C. B. Taft <a style="text-decoration:none;">*</a><br /></h5> <p>The critical relationship between accurate fit of a prosthesis and amputee comfort and function constitutes the foundation of all prosthetic fitting. Consequently, one of the most important features of a lower-extremity prosthesis is the distribution of the pressures applied to the stump by the socket. Since World War II, considerable progress has been made in the design of sockets, leading to the widespread use of "total-contact" sockets for amputations at all levels. However, reliable objective information regarding the relationship of the stump to the socket below its proximal brim is masked by the opaqueness of the socket material. The use of conventional materials <i>(e.g., </i>chalk, talcum, clay, and lipstick) to determine the adequacy of fit and the achievement of total contact has proved of limited value in the accurate diagnosis of fitting problems.</p> <p>The use of X-rays as a means of checking stump-socket fit has been discussed by several investigators. <a></a> Conventional X-ray films of the stump in the socket from the front and side under weight-bearing conditions have been of considerable value in determining total contact, fit, and alignment, but the films obtained by conventional techniques do not always reveal a clear demarcation between the soft tissues of the stump and the inner surface of the socket. <a></a> A radiographic method or procedure that would consistently give an adequate visualization of the stump-socket interface would provide valuable information for the physician and for the prosthetist in fitting patients. Such a procedure would also contribute to overall knowledge in this area of prosthetics, and this knowledge would aid in teaching the proper fabrication of sockets.</p> <p>Some preliminary experimental work relevant to the above-stated deficiency, reported by Dr. N. C. McCollough, involved the topical application of an X-ray contrast material to the skin of the stump. <a></a> Two or three coats of a saturated solution of sodium iodide in absolute alcohol were applied to the stump with a sponge and allowed to dry. The usual number of stump socks were then applied, the stump was inserted into the prosthesis, and films were made under weight-bearing conditions in the anteroposterior and lateral projections. The films obtained by this method provided a clear outline of the periphery of the stump, and any lack of total contact was easily recognized.</p> <p>The purposes of the present study were to assess the value of radiopaque materials in the evaluation of stump-socket fit on a broader basis, and to develop a satisfactory procedure for routine clinical use in determining achievement of total contact and in diagnosing pressure problems more accurately.</p> <h3>Sample</h3> <p>The sample for this study consisted of 16 adults (15 males and 1 female), of whom 8 were below-knee and 8 were above-knee amputees. The below-knee prostheses were the patellar-tendon-bearing type, with and without Kemblo inserts. The above-knee prostheses had quadrilateral sockets of various types: wood open end, wood distal air chamber, and plastic total-contact suction socket.</p> <p>Prior to participation in the study, each prospective subject was questioned concerning previous X-ray exposure and allergy to iodine solutions, in order to exclude patients with a history of extensive X-ray exposure or iodine sensitivity. A statement of informed consent was executed by each subject.</p> <h3>Methodology</h3> <p>The study encompassed investigation of the following radiopaque materials and X-ray techniques.</p> <h4>Materials</h4> <ol> <li>Hypaque-M, 90% (Winthrop): An aqueous solution of sodium and meglumine (methylglucamine) diatrizoates, water-soluble organic compounds, used primarily as a contrast medium in studies of the cardiovascular system. Each milliliter supplies 462 mg of iodine.</li><li>Sodium iodide: A saturated solution in absolute alcohol.</li><li>Sodium iodide: A saturated solution (44%) in isopropyl alcohol (70%). Each milliliter supplies 374 mg of iodine.</li></ol> <h4>Procedures</h4> <p>Two or three coats of the contrast medium were applied with a sponge to the entire surface of the stump; the skin was allowed to dry between coats. The procedure was varied by also applying the contrast medium to the inner surface of the socket insert, and by applying lead foil on pressure-sensitive tape to the inner surface of the socket (or socket insert) as a radiopaque marker. The patient then donned his prosthesis, and weight-bearing films were made in the anteroposterior and lateral projections, using either highspeed screens or Kodak Royal Blue Ready-Pack Medical X-ray Film.</p> <p>The X-ray unit used was a Westing-house with an 85-kv peak capacity, and the settings were varied from 100 ma, 1/2sec, 70 kv, 36-in. tube distance, to 100 ma, 1-1/4 sec, 85 kv, 36-in. tube distance, depending on the type of film.</p> <p>Additional films were taken <i>without </i>application of a contrast medium to the stump for half of the subjects. Also, in several instances films were taken while the artificial leg was bearing no weight, <i>i.e., </i>in the mid-swing position.</p> <h3>Results</h3> <p>The techniques used in this study were very satisfactory in providing a definite outline of the periphery of the stump. The films demonstrated a sharp demarcation between the soft tissues of the stump and the inner surface of the insert or socket, thereby clearly indicating the presence or absence of total contact and identifying pressure areas more accurately.</p> <p>With the X-ray equipment used for this study, the optimum settings were determined to be:</p> <p>High-Speed Screens: 100 ma, 75 kv, 1/2sec, 36-in. distance</p> <p>Ready-Pack Film: 100 ma, 85 kv, 1 sec, 36-in. distance</p> <p>Excellent results were obtained with all three of the contrast media, and no significant differences were noted in the films obtained with the three solutions. The saturated solution of sodium iodide in absolute alcohol dries on the skin a little more rapidly than a saturated solution in isopropyl alcohol 70%, but because of Federal regulations, detailed record-keeping is required when absolute alcohol (ethanol) is used. Hypaque-M, 90%, while more expensive than a sodium iodide solution, has the advantage of being commercially available and therefore not requiring the services of a pharmacist for its preparation. Because the iodine compounds are highly water-soluble, they are readily washed off the skin with water after completion of the X-ray exposures. No adverse effects <i>(e.g., </i>skin eruptions) were manifested by any of the patients as a result of these preparations.</p> <p>Application of a contrast medium to the inside of the Kemblo insert (leather backed by rubber) or the inside of the socket (plastic or wood) was not found to be necessary in order to secure satisfactory results. The rubber backing of the Kembio insert and the plastic or wood of the socket are adequately radiopaque for clear demarcation of the inner surface of the prosthesis. The films obtained with the additional step were only marginally superior to those obtained without it, and furthermore, the contrast media tend to stain socket materials, particularly leather.</p> <p>In several instances, lead foil was used successfully as a radiopaque marker of the interface between stump and insert, particularly in cases involving a removable distal-end pad which was not satisfactorily delineated otherwise. This material is available from the Minnesota Mining and Manufacturing Company as Pressure-Sensitive Tape #420-Lead Foil.</p> <p>Examples of films obtained after application of a contrast medium to the stump are shown in <b>Fig. 1</b>, <b>Fig. 2</b>, and <b>Fig. 3</b>. The periphery of the stump is clearly outlined in the films, so that the accuracy of socket fit may be readily determined: whether there is total contact; whether the suitable weight-bearing areas of the stump, such as the patellar tendon, the popliteal space, and the medial and lateral condyles, are being utilized to the best advantage; and whether adequate reliefs have been provided for the head of the fibula and the tibial tubercle.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Left, anteroposterior and right, lateral weight-bearing views of a below-knee stump, coated with contrast material, in a well-fitting PTB socket. Note excellent contact between stump and insert except for small air space posteriorly at distal end. Note also the undesirable space between insert and socket at distal end. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Left, anteroposterior and right, lateral weight-bearing views of a below-knee stump, coated with contrast material, in a poorly fitting PTB socket. Note lack of distal contact and inadequate bearing on the patellar tendon. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Left, anteroposterior and right, lateral weight-bearing views of a below-knee stump, coated with contrast material, in a hard-socket PTS prosthesis with medial condylar wedge. Note that total contact is satisfactory, except for small air spaces at distal end, but the patellar-tendon bar is too high and the posterior brim is insufficiently flared to provide an adequate shelf in the popliteal area. Note also (right) the apparent increased radiodensity in the patellar-tendon weight-bearing area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Inspection of the contrast-medium films for objective indications of stump-socket pressure gradients tentatively suggests, as also remarked upon by McCollough, that areas of compression <i>(e.g., </i>over the patellar tendon) show increased density of the contrast material. An example of this phenomenon is shown in the lateral view of <b>Fig. 3</b>, where increased radiodensity is apparent in the patellar-tendon weight-bearing area.</p> <p>Although X-ray films obtained by routine methods, without the use of a contrast medium, provide considerable useful information about stump-socket fit, they do not always reveal a clear demarcation between the soft tissues and the socket. This observation was confirmed in the present study on comparing films made with and without a contrast medium taken on the same patient, using the same X-ray settings for both series. With few exceptions, the contrast-medium films were superior to the routine films in outlining the periphery of the stump more sharply. An example of this superiority may be seen in comparing the two views in <b>Fig. 4</b>. This improvement in the delineation of the stump-socket interface makes it easier to read the films and eliminates any doubts that may arise concerning the exact relationship between the stump and the socket at various stump levels.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Left, anteroposterior weight-bearing view of an above-knee stump, coated with contrast material, in a plastic hard-end total-contact suction socket. Note clear delineation of the stump-socket interface, showing excellent total contact. Right, conventional anteroposterior weight-bearing view of same stump and socket, using same X-ray settings. Note blurring of stump-socket interface. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>References:</b></p> <ol> <li>Clippinger, Frank W., <i>The temporary patellar tendon bearing limb</i>, Inter-Clinic Inform. Bull., 3:8:5-7, June 1964.</li> <li>Clippinger, Frank W., and Bert R. Titus, <i>A "hard socket" patellar tendon bearing below-knee prosthesis</i>, Inter-Clinic Inform. Bull., 4:10:16-18, August 1965.</li> <li>King, Richard E., <i>X-rays as an adjunct to patellar-tendon-bearing fitting</i>, Inter-Clinic Inform. Bull., 2:6:1-8, April 1963.</li> <li>Lambert, Claude N., <i>Applicability of the patellar tendon bearing prosthesis to skeletally immature amputees</i>, Inter-Clinic Inform. Bull., 3:7:7, May 1964.</li> <li>McCollough, Newton C, and Raymond E. Gilmer, Jr., <i>A method of determining total contact in prostheses</i>, Inter-Clinic Inform. Bull., 6:5:9-13, February 1967.</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>5.</b> </td><td class="clsTextSmall">McCollough, Newton C, and Raymond E. Gilmer, Jr., A method of determining total contact in prostheses, Inter-Clinic Inform. Bull., 6:5:9-13, February 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>5.</b> </td><td class="clsTextSmall">McCollough, Newton C, and Raymond E. Gilmer, Jr., A method of determining total contact in prostheses, Inter-Clinic Inform. Bull., 6:5:9-13, February 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>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Clippinger, Frank W., The temporary patellar tendon bearing limb, Inter-Clinic Inform. Bull., 3:8:5-7, June 1964.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Clippinger, Frank W., and Bert R. Titus, A 'hard socket' patellar tendon bearing below-knee prosthesis, Inter-Clinic Inform. Bull., 4:10:16-18, August 1965.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">King, Richard E., X-rays as an adjunct to patellar-tendon-bearing fitting, Inter-Clinic Inform. Bull., 2:6:1-8, April 1963.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Lambert, Claude N., Applicability of the patellar tendon bearing prosthesis to skeletally immature amputees, Inter-Clinic Inform. Bull., 3:7:7, May 1964.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">McCollough, Newton C, and Raymond E. Gilmer, Jr., A method of determining total contact in prostheses, Inter-Clinic Inform. Bull., 6:5:9-13, February 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>C. B. Taft </b></td></tr><tr><td class="clsTextSmall">Present address: Columbia Medical Center, 630 W. 168th St., New York, N. Y. 10032.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_02_036/69autumn-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_02_036/69autumn-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_02_036/69autumn-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_02_036/69autumn-04.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 Radiographic Evaluation of Stump-Socket Fit Creator An entity primarily responsible for making the resource C. B. Taft * 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/4ebe6c9358e369d2dfcc780525f71744.pdf 01ca7a3bb92c5f91b306060769848ed9 https://staging.drfop.org/files/original/fd2a976afd43f432a91856fbb3542adb.jpg 4cd388f1bb2e5bb5c7d6e8658721feb3 https://staging.drfop.org/files/original/5ea20b480864b5662268ba574fb4df90.jpg 404b82d99bc176c0c3b47905d236e7ef https://staging.drfop.org/files/original/2c56957b9735b01a9f5c9fe75689c927.jpg 57e264451217b8c83f7667a500f4caca https://staging.drfop.org/files/original/0939c6a9623e986d55b567dbe6f9704f.jpg 3da4ca037b4b925d204360e54d41830b https://staging.drfop.org/files/original/83f69a234f7756caf1d51f0b94e4ce93.jpg efc5c9cd7ee1708de022357d15829c4a https://staging.drfop.org/files/original/7b3ddab93a637e18d8e2ceb0c867ea1a.jpg d263fb414ce5d3e085085e28830834eb https://staging.drfop.org/files/original/135a37db3f3673e23afdb5ba5411f6b0.jpg 34b6fbf004c0a0ea762ecccc0a6e38fb https://staging.drfop.org/files/original/38ea4d432e4466c58292d70162ecd0a2.jpg 8150ce6a83ac114ca162be9ae6615263 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_01_049.pdf Year 1969 Volume 13 Issue 1 Page Number(s) 49 - 58 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_01_049.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_01_049.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>Dynamic Structure of the Human Foot</h2> <h5>Herbert Elftman <a style="text-decoration:none;">*</a><br /></h5> <p>The foot is one of the most dynamic structures in the human body. The lively interplay of forces which makes its function possible is easily forgotten and it is too often treated like the graven image of a static structure. The success of modern therapeutic measures in solving other problems has owed much to close cooperation between Nature working from within and assistive devices from without. The forces within the foot can be powerful allies in such a partnership.</p> <p>The human foot acts in concert with the rest of the body during standing and movement. It provides man with his most effective physical contact with the environment and is especially responsible for successful regulation of initial and final contact of the body with the ground. The foot must also provide adjustable support during the characteristic human occupations of manipulating the environment or of simply standing in line.</p> <p>Human bipedality was made possible by the redesign of an ancestral foot with five long toes used for the grasping of the limbs of trees. We still testify to our heritage by having a big toe larger than the rest but no longer opposable. The heel bone was brought down into contact with the ground to provide additional area of support. Each of these changes traded an old advantage for a new one and the barter is still going on.</p> <h3>The Foot in Motion</h3> <p>Walking is more characteristic of human movement than running, since man has substituted cunning in the management of external devices for fast movement of body parts when speed is desired. The foot must constantly adjust to the varying loads imposed upon it. Particularly important are the stresses it must withstand at the initiation of contact with the ground and again at its termination.</p> <h4>Initiation Of Contact</h4> <p>The heel is the first part of the foot to touch the ground in walking. It is consequently entrusted with the delicate mission of gradually bringing the foot to rest on the ground. In running this can be done without the help of the heel since the limb is already in the midst of its backward swing with respect to the body and the ball of the foot can touch the ground at zero velocity.</p> <p>In walking, the advanced leg has barely started its backward swing with respect to the body when the heel touches the ground. The initial velocity of the ankle after contact is only slightly less than that of the hip joint, making heel-roll imperative. As the ankle approaches zero velocity at ball contact, the forward velocity of the hip joint is preserved by ankle and knee flexion (<b>Fig. 1</b>). Failure to do this properly is one of the most common deficiencies of assistive devices.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Forces acting on the foot during two important phases of its activity: (1) completion of heel roll; (2) initiation of rolling off on the hall. From Elftman, 1967. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The normal human heel is specialized for the part it plays in walking. Resilience is supplied by the construction of the connective tissue under the heel. The collagenous fibers are arranged so as to produce cylindrical compartments filled by more fluid tissues. Since the fluid changes volume only slightly in compression, pressure is accommodated by elastic deformation of the surrounding connective tissue. While this elastic deformation is taking place the foot rolls forward on the heel. The character of this movement is determined by the contour of the calcaneous combined with the shape which the heel-pad assumes under pressure. Artificial heels can be of assistance if properly shaped, usually achieved when wear erases original design.</p> <h4>Termination Of Contact</h4> <p>Although the foot moves only slightly in the interval between ball contact and heel rise, it is subjected to constantly changing stresses. As the body moves forward over the ankle until the knee becomes almost straight, tension is built up in the calf muscles in preparation for the critical events which terminate ball and toe contact. In this phase of walking the transformation of the ape foot into a human foot shows its functional worth. With grasping no longer the chief function of the toes, they have been shortened and the connective tissue pad beneath the ball has become stronger. The great toe has lost its opposability and is permanently aligned parallel to the others. This relieves the peroneus longus muscle of its ancestral responsibility of adducting the hallux and enhances the aid which it gives to the tibialis posterior in resisting splaying of the foot. The first metatarsal and its attendant phalanges retain the size which they had attained in the ape. This led to the accentuated use of this toe during push-off and the important role which the flexor hallucis longus plays in terminal contact with the ground.</p> <p>Rolling over the ball of the foot has a function similar to that of the heel but acting in reverse. It must control the gradual acceleration of the ankle so that the lower limb as a whole is moving forward with body speed close to the time at which the advanced heel makes contact and double support begins. Here again knee flexion adjusts the relative velocities of the limb segments and allows the calf muscles to push off the limb as it begins its forward swing.</p> <h4>Control Of Foot Position By Hip And Knee</h4> <p>Primary control of foot position is exercised at the hip joint with assistance from the knee when it is flexed. After the primary position of the foot is determined by these distant factors, fine control is added by joints of ankle and foot. The forces and moments which act on the foot are largely determined by the disposition and accelerations of other parts of the body. The importance of knee and hip joints in controlling the spatial relationships of the foot is emphasized frequently by unwelcome responses in these joints to abnormal stresses in the foot.</p> <h3>Fundamental Architecture of the Foot</h3> <p>The foot consists of 26 bones controlled by 42 muscles and is held together by an almost unbelievable number of ligaments. Fortunately, in the normal performance of its major functions, many of these parts co-operate so closely that an initial workable concept of the foot can be based on very few units. The talus is the uppermost of these. When it is removed, the subtalar part of the foot reveals two major divisions: the calcaneus and, articulating with it by the calcaneocuboid joint, a semirigid constellation of bones terminating in the ball of the foot. This leaves the toes jutting out, to become of importance in activities which require forward extension of the base of support beyond the ball.</p> <h4>The Ankle-Joint Complex</h4> <p>The talus is a bony meniscus which allows the movements of the foot with respect to the shank to be divided between a pair of articulations: the subtalar below and the ankle joint above. Since the same external forces act on both joints, the normal body is interested in their combined movement but the clinician is frequently faced with the results of differential insult.</p> <p>In the ankle joint, normal pressure is transmitted from the tibia to the trochlear surface of the talus and lateral bending moments are resisted, within limits, by the malleoli and ligaments. When the joint is compressed, as in weight bearing, the instant axis is determined by the curvatures of the surfaces in contact at the moment. The classical concept of an invariant axis passing horizontally through the lateral malleolus to emerge just below the medial malleolus has been revised in recent years. Barnett and Napier (1952) have described the difference in curvature between the parts of the talus used as movement progresses. Close and Inman (1952) have emphasized a component of vertical rotation conforming to the curved lateral surface of the talus. Both of these factors are sufficiently variable to require assessment in each individual.</p> <p>Even more variable is the orientation of the axis of the ankle joint with respect to the foot and to the transverse axis of the knee. The situation in any individual can be estimated by observing the position of the malleoli; the results of such measurements recorded by Elftman (1945) are shown in <b>Fig. 2</b>. It is obvious that the orientation of the ankle joint determines the plane in which dorsi- and plantar flexion occur and this influences the amount of movement required in the subtalar joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Range of variation in the orientation of the axis of the ankle joint. Two-thirds of the individuals measured were within the limits shown here. From Elftman, 1945. ties. Indispensable for our ancestors in tree climbing, it is still our chief accommodation to rough terrain. Its large component of vertical rotation gives us the possibility of transverse rotation at the ankle under gravitational control. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The subtalar joint is guided in its movement, when it is under compression, by the areas of contact between the calcaneus and the lower surface of the talus. These surfaces are beautifully sculptured to form parts of a helical or screw-shaped surface. The helix is right-handed in the right foot; the resulting advance of the talus during eversion is important for the control of the transverse tarsal joint, but may be neglected during consideration of the ankle. For this purpose the major axis of the helix, also called the compromise axis, suffices. Its position in one foot is shown in <b>Fig. 3</b>. This axis emerges from the talus so as to pierce the tendon of the tibialis anterior; its other end is variably located on the lateral surface of the calcaneus. The movements about this axis are called inversion and eversion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The instant axis for the combined movement in the upper ankle joint and the subtalar joint lies in the thin disc represented by the dashed circle. Attention is also called to another variable functional feature, the arc of the ball of the foot. From Elftman, 1954. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The obliquity of this axis confers on the subtalar joint its most significant properties. Indispensable for our ancestors in tree climbing, it is still our chief accommodation to rough terrain. Its large component of vertical rotation gives us the possibility of transverse rotation at the ankle under gravitational control.</p> <p>Since the ankle joint and the subtalar joint are not subject to independent regulation, the resultant movement when the two are combined is of greater practical value than the separate components. The location of this resultant axis is indicated in <b>Fig. 3</b>. If the two joint axes actually intersected, the resultant would lie in the plane determined by the two axes. Since they almost intersect, but not quite, the resultant is confined within a thin disc which may be treated as a plane for practical purposes. Once this plane is determined, the problem of substituting new artificial axes for the old ones is simplified.</p> <p>Movement in the ankle-joint complex is controlled by: (1) moments due to the ground reaction; (2) constraints due to joint surfaces and ligaments; and (3) moments produced by the leg muscles which pass over the ankle. The part played by the ankle muscles can be studied quantitatively from the data shown in <b>Fig. 4</b>. This is essentially an oblique section through the ankle oriented so as to include the axes of the ankle joint and the subtalar joint. The lever arms of the muscles with respect to these axes can be read from the diagram; the relative maximum strengths of the muscles are proportional to the areas of the circles which represent them. The resultant moment of various muscle combinations can then be found. Important points to note are: (1) the tibialis anterior is a dorsiflexor and not an in-vertor in this position; (2) the gastrocnemius and soleus are strong invertors as well as plantar flexors; (3) the peroneal muscles are stronger for eversion than for plantar flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Muscular control of the ankle. The figure is essentially a section through the right ankle in the plane of the disc shown in Figure 3 and includes the ankle-joint axis (TC) and subtalar axis (ST). The circles representing the muscles are proportional in area to the physiologic cross sections. The muscles may be identified by their initials, e.g., triceps surae (TS). From Elftman, 1960. The calcaneocuboid joint was described as a saddle-shaped joint by Adolf Fick in 1854; only one other joint of this type is present in man, at the base of the first metacarpal. More than a century elapsed before an adequate description of this joint was provided by Elftman in 1960. For practical purposes a simplified description will suffice. The principal axis (labeled CC in Fig. 5) passes obliquely through the calcaneus in such a fashion that an extension of it would almost intersect the subtalar axis in the neck of the talus. Associated with the major movement of rotation about this axis is a slight translation parallel to the axis. The total movement is known as supination and pronation. The man in the street calls these raising and lowering of the arch. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Transverse Tarsal Joint</h4> <p>The part of the foot which lies immediately in front of the talus and calcaneus forms a semirigid unit articulating with the rear part of the foot by means of two joints, the calcaneocuboid and the talonavicular. Since they act together much of the time, it is convenient to call the combination the transverse tarsal joint.</p> <p>The calcaneocuboid joint was described as a saddle-shaped joint by Adolf Fick in 1854; only one other joint of this type is present in man, at the base of the first metacarpal. More than a century elapsed before an adequate description of this joint was provided by Elftman in 1960. For practical purposes a simplified description will suffice. The principal axis (labeled CC in <b>Fig. 5</b>) passes obliquely through the calcaneus in such a fashion that an extension of it would almost intersect the subtalar axis in the neck of the talus. Associated with the major movement of rotation about this axis is a slight translation parallel to the axis. The total movement is known as supination and pronation. The man in the street calls these raising and lowering of the arch.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Transverse tarsal joint, pronated at left, supinated at right. The joint axes are labeled as follows: AJ, ankle joint; ST, subtalar; CC, calcaneocuboid; TN, talonavicular. When the heel is placed on the ground in the supinated position, inversion in the subtalar joint restores the vertical orientation of the shank and rotates the head of the talus so as to lock the transverse tarsal joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The talonavicular joint is the controlling element in the transverse tarsal joint complex. The head of the talus is a cam of ellipsoidal shape which is not concentric about the subtalar axis but makes a considerable angle with respect to it. As a consequence of this, rotation of the head of the talus during rotation about the subtalar axis changes its orientation, and movement in the transverse tarsal joint ensues to bring the navicular concavity to a conformable position. The important thing to remember is that inversion produces supination and eversion causes pronation. At the extremes of this range of association, the transverse tarsal joint becomes independent of the subtalar in extremely pronated (flat) feet and the subtalar motion can occur alone at extreme supination.</p> <h4>Ball Of The Foot</h4> <p>The structures which allow the heads of the metatarsals to transmit pressure to the ground consist of connective tissue and skin which have been modified in the human foot to spread the pressure in the hope of preventing painful concentrations. When weight is not borne by this region, a transverse metatarsal arch is visible. Even slight pressure is sufficient to bring the heads of the metatarsals in alignment with the ground and the arch disappears. The extreme variability in the lengths of the metatarsals has important consequences for foot action. The distribution of pressure as the heel is raised is very closely dependent on the contour of a line connecting the metatarsal heads, as shown in <b>Fig. 3</b>. Morton (1935) has stressed the difficulties resulting from first metatarsals which are short or have posteriorly located sesamoids. Equally disastrous effects can come from contours which are sharply curved or hairpin in shape.</p> <p>Among a number of variable features in this part of the foot is the extent to which the base of the fifth metatarsal transmits weight to the ground. Another condition, splaying of the foot, can result when the cooperative efforts of the tibialis posterior and the peroneus longus are insufficient to give transverse stability.</p> <h4>Toes</h4> <p>Although human toes can be used for grasping when occasion demands, their customary use is accessory to the ball of the foot which lies behind them. The toes are the anchors for the long flexors which play an important part in managing the ankle-joint complex. By differential contraction of the flexors of the toes it is possible to adjust the distribution of pressure between parts of the ball of the foot. Because of the strength of the big toe and the long flexor attached to it, this part of the foot is usually the last to leave the ground and contributes the final touch to the control of movement.</p> <h3>Control of the Foot by the Heel</h3> <p>When the body rolls forward on the heel until the foot rests on the ground, the position which the foot assumes is determined by the manner in which the calcaneous rolls forward. Proper contouring of the sole of the shoe where the heel nests in it will not only provide assistive forces but will also originate sensory feedback to stimulate better foot alignment.</p> <p>If the heel cup is so constructed that its anteromedial quadrant is elevated, the calcaneus will come to rest with a predetermined amount of inversion about the subtalar axis. This places the contact area of the calcaneus more nearly under the vertical thrust of the body, decreasing its rotational moment. Since the ankle-joint axis strives for a horizontal position, the talus is forced into inversion and this drives the transverse tarsal joint into supination. Sensory feedback, in the course of a few steps, will encourage the hip joint to bring the foot down in a slightly toed-in position, thus restoring the knee joint to its usual orientation.</p> <p>The details of the sculpturing of the heel cup need not be left to chance since the desired conformation of the internal architecture of the foot is almost identical with that which it assumes when the subject stands on an inclined plane. Instant orthotics can be achieved by placing the proper compound in the shoes and having the subject stand in them, with heels supported at a proper elevation, to impress the functional shape.</p> <h3>Measurement of Foot Function</h3> <p>The foot is sandwiched between the pressure of the ground below and the weight and inertia forces of the body above. Since these are the forces to which the foot must accommodate, their measurement assumes primary importance.</p> <p>The total pressure of the ground on the foot and the point at which its resultant is applied can be measured easily when the individual is standing. The only equipment needed consists of three reasonably accurate scales and a ruler. The usefulness of the information which can be obtained should not be underestimated; it is sufficient to tell whether many therapeutic devices achieve their objectives.</p> <p>When the body is in motion, measurement of the ground reaction is more important and becomes more difficult. This can be accomplished by means of force plates, the earliest results of which are shown in <b>Fig. 6</b> from Elftman (1939). From data such as this and photographic determination of the location of joint axes, muscle moments and joint forces can be obtained.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Force plate record of the ground reaction acting on the foot of J. T. Manter during a step described by Elftman, 1939. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In foot problems the distribution of the ground reaction over the foot is frequently of greater interest than its total value. Many interesting methods of making such measurements have been recorded and some are still useful; they have been reviewed by Elftman (1934). Since the distribution of pressure changes in the course of movement, instantaneous recording is of value. This can be accomplished by means of the barograph, introduced by Elftman in 1934. The changes in area of a pressure transducer placed under the foot are recorded photographically. <b>Fig. 7</b> shows two phases of a step; when the pressure is on the ball of the foot the structural characteristics of this region reveal themselves. Calibration of the pressure transducer allows the derivation of quantitative data from the photographic record. In <b>Fig. 8</b> it is even possible to recognize the concentration of pressure under the sesamoid bones beneath the head of the first metatarsal.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Barograph record of the distribution of pressure at two phases of the step. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Load distribution on the human foot during one step of J. T. Manter. (Isobars at 4 lb. per sq. in.) The records made on the original barograph and published in Elftman, 1934, were measured after calibration of the pressure transducer. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>References:</b></p> <ol> <li>Abramson, E., <i>Zur Kenntnis der Mechanik des Mit-telfusses</i>, Skand. Arch. Physiol., 51:175-234, 1927.</li> <li>Berlemont, M., <i>Notre experience de I'appareillage precoce des amputes des membres in-ferieurs aux Etablissements Helio-Marins de Berck</i>, Ann. Med. Phys., Tome IV, No. 4, October-November-December 1961.</li> <li>Bamett, C. H., and J. R. Napier, <i>The axis of rotation at the ankle joint in man</i>, J. Anat., 86:1-9, 1952.</li> <li>Basler, A., <i>Bestimmung des auf die einzelnen Schlen-bezirke wirdenden Teilgewichtes des menschli-chen Korpers</i>, Alderhalden's Handbuch der biologischen Arbeitsmethoden-Abt 5 Teil 5A, Heft 3, 559-574, 1927.</li> <li>Basmajian, J. V., and J. W. Bentzon, <i>An electromyographic study of certain muscles of the leg and foot in the standing position</i>, Surg. Gynec. Obstet., 98:662-666, 1954.</li> <li>Blechschmidt, E., <i>Die Architektur des Fersenpol-sters</i>, Morph. Jahr., 73:1-68, 1934.</li> <li>Bohm, M., <i>Das mechschliche Bein; seine normale Entwicklung und die Entstehung der Wuchsfehler</i>, Enke, Stuttgart. 1935.</li> <li>Braus, H., <i>Anatomie des Menschen, I Band: Bewe-gungsapparat</i>. Springer, Berlin, 1921.</li> <li>Bressler, B., and F. R. Berry, <i>Energy characteristics of normal and prosthetic ankle joints</i>, Prosthetic Devices Research Project, University of California, Berkeley, Series 3, Issue 12, 1950.</li> <li>Carlsoo, S., <i>Influence of frontal and dorsal loads on muscle activity and on the weight distribution in the feet</i>, Acta Orthop. Scand., 34:4:299-309, 1964.</li> <li>Close, J. R., <i>Some applications of the functional anatomy of the ankle joint</i>, J. Bone Joint Surg., 38A:761-781, July 1956.</li> <li>Close, J. R., and V. T. Inman, <i>The action of the ankle joint</i>, Prosthetic Devices Research Project, University of California, Berkeley, Series II, Issue 22, 1952.</li> <li>Close, J. R., and V. T. Inman, <i>The action of the subtalar joint</i>, Prosthetic Devices Research Project, University of California, Berkeley, Series II, Issue 24, 1953.</li> <li>Dempster, W. T., <i>Space requirements of the seated operator</i>, WADC Tech. Rep. 55-159, pp. 83-84, 102-104, 173-178, 1955.</li> <li>Donitz, A., <i>Die Mechanik der Fuszwwzel</i>, Dissertation, Berlin, 1903.</li> <li>Du Vries, H. L., <i>Surgery of the foot</i>, Ed. 2, C. V. Mosby, St. Louis, 1965.</li> <li>Elftman, H., <i>A cinematic study of the distribution of pressure in the human foot</i>, Anat. Rec, 59:481-491, 1934.</li> <li>Elftman, H., and J. Manter, <i>The axis of the human foot</i>, Science, 80:484, 1934.</li> <li>Elftman, H., and J. Manter, <i>The chimpanzee and human feet in bipedal walking</i>, Amer. J. Phys. Anthrop., 20:69-79, 1935.</li> <li>Elftman, H., and J. Manter, <i>The evolution of the human foot with especial reference to the joints</i>, J. Anat., 70:56-67, 1935.</li> <li>Elftman, H., <i>Forces and energy changes in the leg during walking</i>, Amer. J. Physiol., 125:339-356, 1939.</li> <li>Elftman, H., <i>The orientation of the joints of the lower extremity</i>, Bull. Hosp. Joint Dis., 6:139-143, 1945.</li> <li>Elftman,.H., <i>Torsion of the lower extremity</i>, Amer. J. Phys. Anthrop., n. s. 3:255-265, 1945.</li> <li>Elftman, H., <i>The transverse tarsal joint and its control</i>, Clin. Orthop., 15:41-46, 1960.</li> <li>Fick, A., <i>Die Gelenke mit sattelformigen Flachen</i>, Z. rat. Med. V. 9, 1854 (also reprinted in A. Fick, Gesammelte Schriften. V. 1, Wiirzburg, 1903).</li> <li>Fick, R., <i>Uber die'Bewegungen und die Muskelarbeit an den Sprungelenken des Menschen</i>, Sitzungs-berichte der Preuss. Akad. der Wiss. Physik.-mathem., Kl., XXIII:458-495, 1931.</li> <li>Gardner, E., D. J. Gray, and R. O'Rahilly, <i>The prenatal development of the skeleton and joints of the human foot</i>, J. Bone Joint Surg., 41A:847-876, July 1959.</li> <li>Harris, R. I., and T. Beath, <i>Army foot survey</i>, National Research Council of Canada, Ottawa, 1947.</li> <li>Helfet, A. J., <i>A new way of treating flat feet in children</i>, Lancet, 1:262-264, Feb. 11, 1956. Henke, W., Die Bewegung des Fuszes am Sprung-bein, Z. rat. Med., 7:225-234, 1859.</li> <li>Hicks, J. H., <i>The mechanics of the foot, I. The joints</i>, J. Anat., 87:345-357, 1953.</li> <li>Hicks, J. H., <i>The mechanics of the foot, II. The plantar aponeurosis and the arch</i>, J. Anat., 88:25-30, 1954.</li> <li>Hicks, J. H., <i>The mechanics of the foot, III. The foot as a support</i>, Acta Anat., 25:34-45,1955.</li> <li>Hicks, J. H., <i>The mechanics of the foot, IV. The action of muscles on the foot in standing</i>, Acta Anat., 27:180-192, 1956.</li> <li>Hohmann, G., <i>Fuss und bein; ihre Erkrangungen und deren Behandlung</i>, Bergmann, Miinchen, 3 Aufl., 1939.</li> <li>Hutter, G. G., and W. Scott, <i>Tibial torsion</i>, J. Bone Joint Surg., 31A:511-518, July 1949.</li> <li>Jones, F. Wood, <i>Structure and function as seen in the foot</i>, Bailliere, Tindall and Cox, London, 1946.</li> <li>Jones, R. L., <i>The human foot, An experimental study of its mechanics, and the role of its muscles and ligaments in the support of the arch</i>, Amer. J. Anat., 68:1-39, 1941.</li> <li>Jones, R. L., <i>The functional significance of the declination of the axis of the subtalar joint</i>, Anat. Rec, 93:151-159, 1945.</li> <li>Karpovich, P. V., and L. B. Wilklow, <i>A goniometric study of the human foot in standing and walking</i>, U.S. Armed Forces Med. J., 10:885-903, 1959.</li> <li>Keith, A., <i>The history of the human foot and its bearing on orthopaedic practice</i>, J. Bone Joint Surg., HA:10-32, January 1929.</li> <li>Kolb, H.,<i> Morphologische und funktionelle Analyse des m. tibialis anterior</i>, Z. Anat. Entwicklungs-gesch., 106:770-781, 1937.</li> <li>Lanz, T., and W. Wachsmuth, <i>Praktische Anatomie, I Band, 4 Teil; Bein und Statik</i>, Springer, Berlin, 1935.</li> <li>Lease, G. O'D., and F. G. Evans, <i>Strength of human metatarsal bones under repetitive loading</i>, J. Appl. Physiol., 14:1:49-51, 1959.</li> <li>Levens, A. S., V. T. Inman, and J. A. Blosser, <i>Transverse rotation of the segments of the lower extremity in locomotion</i>, J. Bone Joint Surg., 30A:859-872, October 1948.</li> <li>MacConaill, M. A., <i>The postural mechanism of the human foot</i>, Proc. Roy. Irish Acad., 50B:265-278, 1945.</li> <li>Mann, R., and V. T. Inman, <i>Phasic activity of intrinsic muscles of the foot</i>, J. Bone Joint Surg., 46A: 469-481, April 1964.</li> <li>Mann, R., and V. T. Inman, <i>Structure and function</i>, in Du Vries' <i>Surgery of the foot</i>, Ed. 2, C. V. Mosb'y, St. Louis, 1965, pp. 1-44.</li> <li>Manter, J. T., <i>Movements of the subtalar and transverse tarsal joints</i>, Anat. Rec, 80:397-410, 1941.</li> <li>Manter, J. T., <i>Distribution of compression forces in joints of the human foot</i>, Anat. Rec, 96:313-322, 1946.</li> <li>Marsk, A., <i>Studies on weight-distribution upon the lower extremities in individuals working on a standing position</i>, Acta Orthop. Scand., Suppl. 31, 1958.</li> <li>Meyer, H., <i>Statik und mechanik des menschlichen fusses</i>, Jena, 1886.</li> <li>Morton, D. J., <i>The human foot</i>, Columbia University Press, New York, 1935.</li> <li>Paul, J. P., <i>Forces transmitted by joints in the human body</i>, Paper No. 8, Proc Instr. Mech. Engrs., 181:3:8-15, 1966-67. (Joints of the foot are included in the discussion.)</li> <li>Pfitzner, W., <i>Beitrdge sur Kenntnis des menschlichen Extremitdtenskelettes, VII. Die variationen in Aufbau des Fuszskelettes</i>, Morph. Arb., 6:24-528, 1896.</li> <li>Rose, G. K., <i>Correction of the pronated foot</i>, 1, J. Bone Joint Surg.,. 40B:674-683, November 1958.</li> <li>Rose, G. K., <i>Correction of the pronated foot</i>, 2, J. Bone Joint Surg., 44B:642-647, August 1962.</li> <li>Rydell, N. W., <i>Forces acting on the femoral head prosthesis</i>, Acta Orthop. Scand., Suppl. 88, 1966. (Forces acting on feet during locomotion measured by means of an electronic walkway.)</li> <li>Scherb, R., <i>Kinetisch-diagnostische Analyse von Gehstorungen</i>, Technich und resultate der myo-kinesigraphie, Beilageheft Z. Orthop. Bd. 82, 1952.</li> <li>Schwartz, R. P., and A. L. Heath, <i>Foot function correlated with anatomic, clinical, and laboratory data</i>, New York J. Med., 41:447-451, 1941.</li> <li>Skinner, B. M., <i>Notes on the relative lengths of first and second toes of the human foot</i>, J. Anat., 66:123-4, 1932.</li> <li>Smith, J. W., <i>The act of standing</i>, Acta Orthop. Scand., 22:2:159-168, 1953.</li> <li>Smith, J. W., <i>Muscular control of the arches of the foot in standing: an electromyographic assessment</i>, J. Anat, 88:152-163, 1954.</li> <li>Smith, J. W., <i>The forces operating at the human ankle joint during standing</i>, J. Anat., 91:545-564, 1957.</li> <li>Smith, J. W., <i>The relationship of epiphyseal plates to stress in some bones of the lower limb</i>, J. Anat., 96:58-78, 1962.</li> <li>Strasser, H., <i>Lehrbuch der Muskel- and Gelenk-mechanik, III Band, Spezieller Teil Die untere Extremitat, II Fuss und Unterschenkel</i>, 1917, pp. 156-309.</li> <li>Straus, W. L., Jr., <i>The growth of the human foot and its evolutionary significance</i>, Contrib. Embryol. Camegie Inst., 19:93-134, 1927.</li> <li>Straus, W. L., Jr., <i>The foot musculature of the highland gorilla</i>, (Gorilla beringei), Quart. Rev. Biol., 5:261-317, 1930.</li> <li>Thomas, D. P., and R. J. Whitney, <i>Postural movements during normal standing in man</i>, J. Anat., 93:524-539, 1959.</li> <li>Thoren, O., <i>Os calcis fractures</i>, Acta Orthop. Scand., Suppl. 70, 1964.</li> <li>Volkov, T., <i>Les variations squeletique du pied chez les primates et dans les races humaines</i>, Bull. Mem. Soc Anthrop. Sci., 5T4-632, 1903; 5:1:201-331, 1904.</li> <li>Weidenreich, F., <i>Der Menschenfuss</i>, Z. Morph. Anthrop., 22:51-282, 1921.</li> <li>Weidenreich, F., <i>Evolution of the human foot</i>, Amer. J. Phys. Anthrop., 6:1-10, 1923.</li> <li>Wetzenstein, H. A., <i>A new method for assessment of the status and dynamic weight bearing of the foot</i>, Acta Orthop. Scand., 30:2:91-100, 1960.</li> <li>Wetzenstein, H., <i>A new method for assessment of the status and dynamic weight bearing of the foot</i>, 75, 1964.</li> <li>Whitney, R. J., <i>The stability provided by the feet during manoeuvers whilst standing</i>, J. Anat., 96:103, 1962.</li> <li>Wright, D. G., S. M. Desai, and W. H. Henderson, <i>Action of the subtalar and ankle-joint complex during the stance phase of walking</i>, J. Bone Joint Surg., 46A:361-382, March 1964.</li> <li>Wright, D. G., and D. C. Rennels, <i>A study of the elastic properties of plantar fascia</i>, J. Bone Joint Surg., 46A:482-492, April 1964.</li> <li>Wyller, T., <i>The axis of the ankle joint and its importance in subtalar arthrodesis</i>, Acta Orthop. Scand., 32:4:320-328, 1963 </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>Herbert Elftman </b></td></tr><tr><td class="clsTextSmall">Department of Anatomy, Columbia University, New York, N.Y. 10016 The foot is one of the most dynamic structures in the human body. The lively interplay of forces which makes its function possible is easily forgotten and it is too often treated like the graven image of a static structure. The success of modern therapeutic measures in solving other problems has owed much to close cooperation between Nature working from within and assistive devices from without. The forces within the foot can be powerful allies in such a partnership.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_01_049/spring69-45.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_01_049/spring69-46.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_01_049/spring69-47.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_01_049/spring69-48.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_01_049/spring69-49.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_01_049/spring69-50.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_01_049/spring69-51.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_01_049/spring69-52.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 Dynamic Structure of the Human Foot Creator An entity primarily responsible for making the resource Herbert Elftman * https://staging.drfop.org/files/original/e38c9d5be738df236a12e73aa11a7478.pdf 63744e2c2435c2b8aa6be87baa775d5b https://staging.drfop.org/files/original/56b68415d28babc42822184b94ea133f.jpg c1d1ab1268f7d844c5e4adb9f18570b1 https://staging.drfop.org/files/original/468c9f40dadb34370263e2258781e772.jpg 066f09438b83937ce9374ec73d152011 https://staging.drfop.org/files/original/f6b7d160b8278d855a477b3e2ea5c2cb.jpg f93f5d0c017f506a7192b341323b7b69 https://staging.drfop.org/files/original/bf1c26f96bb42345b531ec1166264189.jpg 9fd52199760b1396b088edc497712c32 https://staging.drfop.org/files/original/96c04506d1db97cbfd92fea9a88f48b2.jpg cd55c79d19ab9841de50523ab1e0419a https://staging.drfop.org/files/original/01a220eb783cc84d9ce7dad16b20bdf9.jpg bd31c2caa285cf8fd77da049a48cf137 https://staging.drfop.org/files/original/49d84cfc8f81b98ee25f6ed516a68603.jpg 348aae2a8ee726a6780827ea3caa5d52 https://staging.drfop.org/files/original/f04bf788ae7667d4ba0783d1f063dbeb.jpg fddd1ca9fcc7c38b79f776f973540e84 https://staging.drfop.org/files/original/d15fb9bfe71401e0c9e78eee923227ae.jpg de5d7ef764071728608ace84183afd4a https://staging.drfop.org/files/original/73879f8eef1bcebd75a39d4efb07bbe5.jpg 0c17a23c627102a5b74bfa203bc0affd https://staging.drfop.org/files/original/faf957c4e45f636ead6709d159155cbb.jpg 6a41e41b6042f89654f9aa13b55cff12 https://staging.drfop.org/files/original/e7adf4c708c388d05f78818bc47b73bc.jpg 0224ffefe34ab3baefa64141bd79eaef DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_01_037.pdf Year 1969 Volume 13 Issue 1 Page Number(s) 37 - 48 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_01_037.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_01_037.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>The Mechanical Properties of Bone</h2> <h5>F. Gaynor Evans. Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Bone is the material with which the orthopaedic surgeon deals. Consequently, some knowledge of its mechanical properties is of importance for an understanding of the mechanism and management of fractures, as well as the design of prosthetic or orthotic appliances and protective gear, <i>e.g., </i>crash helmets. The behavior of a body under a load or force is a function not only of the form and structure of the body, but also of the mechanical properties of the material composing the body. For example, a steel beam will support a higher load before breaking and will behave differently under loading than will an oak beam of exactly the same shape and dimensions because of differences in the mechanical properties and structure of steel and of wood.</p> <p>The mechanical properties of bone are determined by the same methods used in studying similar properties of metals, woods, and other structural materials. These methods are based on certain fundamental principles of mechanics, a knowledge of which is essential for understanding the terminology employed.</p> <p><i>Mechanics, </i>the science dealing with the effect of forces upon the form or the motion of bodies, has two subdivisions- statics and dynamics. <i>Statics </i>is the study of bodies at rest or in equilibrium as a result of the forces acting upon them. <i>Dynamics </i>is the study of moving bodies. The mechanical properties of materials are usually studied under static conditions, <i>i.e., </i>under a slowly applied force or load, because the behavior of the test specimen can be more easily analyzed when the load is slowly applied.</p> <p>A <i>force </i>is anything which tends to change the state of a body with respect to its motion or the relative position of the molecules composing the body. More simply stated, a force is a push or a pull. There are three primary kinds of forces: (1) <i>compressive </i>or pushing together forces, (2) <i>tensile </i>or pulling apart forces, and (3) <i>shearing, </i>or forces which make one part of the body slide with respect to an adjacent part (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Types of pure force-stress and strain. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a force is applied to a body, it produces stress and strain within the body. <i>Stress </i>(<b>Fig. 1</b>) is the ratio between the force and the area upon which it acts, <i>i.e., </i>force per unit area. Stress is generally computed in terms of pounds per square inch (psi) or kilograms per square millimeter (ksm). Recently, some investigators of the strength characteristics of bone and other biological materials have been recording stress values in terms of kiloponds, dynes, or newtons per unit area, instead of pounds or kilograms because pounds and kilograms are units of mass as well as units of force. There will be no misunderstanding, however, if one specifies that stress values are in terms of <i>pounds force or kilograms force per unit area. </i>Stress is often used synono-mously with strength, but the term has little value unless the kind of strength, <i>i.e., </i>tensile, compressive, etc., is indicated. All strength values in the following discussion are in terms of <i>pounds force per square inch.</i></p> <p><i>Strain </i>is a change in the linear dimensions of a body as the result of the application of a force (<b>Fig. 1</b>). Since there are no standard units of measurement for strain, it can be recorded as percentage, inches/inch, centimeters/centimeter, etc. Strain can be seen if it is sufficiently large, <i>e.g., </i>as in stretching of a rubber band, but stress, which is only the ratio between force and area, is always invisible. The kind of stress and strain in a body is the same as the kind of force producing it.</p> <p>When stress is plotted against strain, a <i>stress-strain curve </i>is obtained (<b>Fig. 2</b>). From a tangent drawn to the straightest part of the stress-strain curve the <i>modulus of elasticity </i>of the material, or the ratio between unit stress and unit strain, can be computed. The modulus of elasticity is a measure of the <i>stiffness </i>of a material, not its elasticity as one might assume from the name. <i>Elasticity </i>is the property of a material that allows it to return to its original dimensions after the removal of a force or load. The <i>energy </i>the specimen absorbs to failure can be determined by measuring the area below the stress-strain curve.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Stress-strain curves for a dry- and a wet-tested specimen of compact bone from the posterior quadrant of the proximal third of the femoral shaft of a 70-year-old white man who died from pulmonary tuberculosis. The stress values are in pounds force per square inch <a></a>. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The method of choice in determining the tensile or compressive strength of a material is to make a test specimen of a standardized size and shape and test it under a pure tensile or a pure compressive force. Under these conditions the cross-sectional area of the specimen is known, or can be easily computed, and only one force—tension or compression—is involved. Furthermore, the force is uniformly distributed over the cross-sectional area of the specimen. Consequently, the ultimate tensile or compressive strength of the material can be easily calculated from the formula <i>S </i>= <i>P/A, </i>in which S is stress, P is force or load, and A is the cross-sectional area of the specimen (<b>Fig. 1</b>).</p> <p>If the specimen is tested like a simple beam (i.e., supported at the ends and loaded midway between the supports) and bending occurs, tensile, compressive, and shearing forces are all involved. Tensile forces develop on the convex side of the bent specimen while compressive forces occur on the opposite (concave) side (<b>Fig. 3</b>). Both types of forces are maximum at the surface and decrease inwardly to zero at the neutral plane or axis. There are also shearing forces which, like the tensile and compressive forces, are not uniformly distributed over the cross section of the specimen. Under bending conditions, the force responsible for failure as well as its magnitude is more difficult to determine. The bending forces in the neck of the femur, as a result of the load applied to the head of the bone (<b>Fig. 4</b>), have been determined by Zarek <a></a> , an engineer who is currently working in biomechanics. For further discussion of forces in bending, see Harris' <i>Strength of Materials</i>. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Distribution of tensile and compressive forces in a body tested like a simple beam <a></a>. L = length or span between supports; N. A. = neutral axis or plane; P = force or load. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Stress distribution in the neck of the femur.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The speed at which a force is applied to a specimen influences the values obtained for some of its mechanical properties. Mc-Elhaney and Byars <a></a> found that the ultimate compressive strength and the modulus of elasticity of fresh and embalmed femoral cortical bone from cattle and man increased with higher strain rates of loading while the energy-absorbing capacity and the strain at failure decreased. The effect of high strain rates of loading on specimens of beef bone, cut and tested in different directions, has recently been investigated by Bird et al. <a></a></p> <p>Embalming also affects the mechanical properties of bone, at least those of compact bone. Thus, the mean ultimate tensile strength (in the long axis of the specimen and of the intact bone) is greater at the 0.01 significance level in embalmed wet- and dry-tested tibial specimens than in similarly tested unembalmed specimens <a></a>. Furthermore, embalmed, wet-tested tibial specimens have a higher mean tensile strain, a greater mean single shearing strength (perpendicular to the long axis of the specimen) and are harder (Rockwell No.) than similarly tested embalmed specimens <a></a>. However, the latter type of specimens has a higher mean modulus of elasticity. An analysis of variance showed that the increase in the hardness of the embalmed specimens was significant at the 0.01 level. As far as I am aware, there are no similar studies concerning the effect of embalming on the mechanical properties of spongy bone.</p> <p>Two types or forms of bones are found in the foot-irregularly shaped bones (the tarsals) and miniature long bones (the metatarsals and the phalanges). The tarsal bones are essentially shells of compact bones filled with spongy bone, fat, marrow substance, blood, etc. The actual amount of osseous material in bones, such as the tarsals and the bodies of vertebrae, is not very great. According to Policard and Roche <a></a> the talus and the calcaneus are about 80 per cent nonosseous tissue. The percentage of bone in the bodies of 92 human lumbar vertebrae studied by Bromley <i>et al. </i><a></a> varied from a maximum of approximately 24 per cent to a minimum of 15.5 per cent in males and from 21 per cent to 12 per cent in females at 5 and 70 years of age, respectively. As far as I am aware, there are no studies on the mechanical properties of spongy bone from the foot. Therefore, examination of such properties will be based on data obtained from the human femur.</p> <p>Two types of specimens were used-a rectangular bar (the standard specimen) 0.79 cm. x 0.79 cm. x 2.5 cm. and a cube 0.79 cm. on a side. The specimens were obtained from the head, neck, greater trochanter, and condyles of the femur with the long axis of the standard specimens oriented in different directions.</p> <p>The specimens were tested under direct compression in a Riehle 5000-lb. capacity testing machine, equipped with an automatic stress-strain recorder and calibrated to an accuracy of ±0.5 per cent. The low range scale of the machine (0-200 lbs.) was used with the load registered on the dial of the machine in units of 0.5 lbs. The specimens were loaded at a speed of 0.45 in. per min.</p> <p>All specimens were tested wet to more nearly approximate the condition in the living foot. Drying of compact bone increases its ultimate tensile strength (in the long axis of the specimen), its modulus of elasticity, and its hardness (Rockwell No.) but decreases its single shearing strength (perpendicular to the long axis of the specimen) and its tensile strain.<a></a> Similar studies have not, to my knowledge, been made on spongy bone.</p> <p>The ultimate compressive stress (strength) and strain, the modulus of elasticity, and the energy absorbed to failure were computed from stress-strain curves for wet-tested specimens. The density of air-dried specimens was determined with a strontium 90 densitometer developed by Evans, Coolbaugh, and Lebow <i><a></a>. </i>Dry specimens were used to avoid the effects of moisture that might be trapped within the interstices of the specimens. A total of 69 rectangular (standard) specimens and of 15 cubic specimens from 1 adult, white female, 3 adult, Negro males, and 6 adult, white males were tested. All specimens were kept in saline solution until tested. A minimum of 20 load-deformation readings were taken for each specimen during the test period.</p> <p>The results of the study showed that the mean compressive stress (strength) of the cubic specimens was greater than that of the rectangular (standard) specimens from the same region (<b>Fig. 5</b>). This phenomenon is characteristic of practically all materials. In cubic specimens high frictional forces developed between the ends of the specimen and the testing machine to resist the tendency of the specimen to be squeezed out of the machine. Furthermore, the upper part of the cube tends to be impacted into the lower part. Both of these factors contribute to higher values for compressive stress and modulus of elasticity in cubic than in specimens which are longer than wide. Because of these factors, it is felt that the values obtained from the rectangular (standard) specimens more accurately represent the true mechanical properties of spongy bone.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Mean and range of variation in some mechanical properties of spongy bone from different regions of the femur. Compressive stress values in pounds force per square inch. Gt. troch. = greater trochanter; Lat. = lateral; Med. = medial; Cond. = condyle. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the living body, most of the bones are subjected to bending action as a result of gravity, muscular activity during movement, and blows. Consequently, the bones are subjected to a combination of tension, compression, and shearing rather than to a single pure force. The question then arises as to why the strength of bone is usually determined by testing the specimens under a pure force. The answer to this question, on mechanical grounds, has already been given. There are, however, other valid reasons for testing the strength of bone under pure tension or compression.</p> <p>Experimental studies with strain sensitive lacquers on bones within the living body as well as outside of it demonstrate that certain types of linear fractures of the skull, the pelvis, and the long bones all arise from failure of the bone from tensile stresses and strains produced in it by bending <a></a>. The determination of the tensile strength of bone under pure tension thus has direct application to the mechanics of fractures of those types. Clinical experience also indicates that tensile forces are important in the production of many types of fractures.</p> <p>Compression fractures are quite common in the bodies of the vertebrae, especially those in the lumbar region, and in the calcaneus, the most frequently fractured of the tarsal bones <i><a></a> . </i>Compression fractures of the talus also occur. There is, consequently, a sound practical reason for investigating the compressive strength of the tarsal bones, especially the calcaneus and the talus although, to my knowledge, it has not been done. The rationale for determining the strength of spongy bone from the femoral head and condyles under direct compression is that these regions of the bone are normally subjected to compression forces in the erect posture <i><a></a> . </i>Specimens from other regions were similarly tested for comparative purposes.</p> <p>When the results of the tests were compared according to the region of the bone from which the specimens were obtained, without regard to the direction of loading, several differences were found. The rectangular (standard) specimens from the neck had the highest and those from the greater trochanter the lowest mean compressive stress. Among the cubic specimens the highest and the lowest mean compressive stresses were found in specimens from the head and the medial condyle, respectively.</p> <p>Regional variation was also found in the modulus of elasticity (stiffness) of the specimens (<b>Fig. 5</b>). The mean stiffness of the rectangular specimens exceeded that of the cubic specimens from the same region except for the specimens from the head. The rectangular specimens from the neck and the medial condyle, respectively, had the highest and the lowest mean modulus. The maximum and the minimum stiffness means of the cubic specimens were found in those from the head and the medial condyle, respectively.</p> <p>Comparison of the mean compressive strain, mean energy absorbed to failure, and mean density of the rectangular and cubic specimens from different parts of the femur also reveals interesting differences (<b>Fig. 6</b>). The cubic specimens showed somewhat more variation in the mean compressive strain than did the rectangular ones, the strain being greatest in the specimens from the head and least in those from the medial condyle. Little difference was found in the mean compressive strain of the rectangular specimens, those from the head having a slightly greater strain than those from the condyles. The cubic and the rectangular specimens from the head had the highest while those from the medial condyle had the lowest mean energy absorbed to failure. However, the former specimens showed more regional difference than did the latter. The mean density for both types of specimens was greatest in those from the head and least in the ones from the lateral condyle.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Mean and range of variation of some mechanical properties of spongy bone from various regions of the femur. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A statistical analysis of the above data from the rectangular (standard) specimens revealed the following significant differences between the means. The mean compressive stress of the strongest specimens (from the neck) was greater, at the 0.02 significance level, than that of the weakest specimens (from the greater trochanter). The difference between the mean compressive strain of the specimens from the head, which had the highest, and that of specimens from the medial condyle, which had the lowest, was significant at the 0.01 level.</p> <p>The mean energy absorbed by the specimens from the head was significantly greater, at the 0.02 level, than that absorbed by specimens from the medial condyle. The differences between the means for the other mechanical properties of the rectangular specimens were not statistically significant. The number of cubic specimens tested was not sufficiently large for statistical analysis.</p> <p>Comparison of the maximum compressive stress and modulus of elasticity (<b>Fig. 7</b>) of the rectangular and cubic specimens according to the direction of loading showed that spongy bone is an anisotropic material, i.e., a material that is not equally strong in all directions. The rectangular specimens loaded in the direction of the long axis of the neck of the femur showed the highest, while those loaded in the anterior-posterior direction showed the lowest mean compressive stress. Among the cubic specimens, the highest mean compressive stress was found in specimens loaded in a lateral-medial direction and the lowest in specimens loaded in a superior-inferior direction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Mean and range of variation in some mechanical properties of femoral spongy bone according to the direction of loading. Stress values in pounds force per square inch. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The rectangular specimens loaded in a lateral-medial direction had the highest mean modulus of elasticity and those loaded in the anterior-posterior direction the lowest. The cubic specimens loaded in a lateral-medial direction had the highest mean modulus of elasticity while the lowest was found in the specimens loaded in a superior-inferior direction.</p> <p>Considerable variation was also found in the energy absorbed to failure, the compressive strain at failure, and the density of the specimens when evaluated with respect to different directions of loading (<b>Fig. 8</b>). The rectangular specimens loaded in a lateral-medial direction had the highest mean energy-absorbing capacity whereas those located in an anterior-posterior direction had the lowest. The highest mean energy-absorbing capacity among the cubic specimens was found in those loaded in a lateral-medial direction and the lowest in the specimens loaded in a superior-inferior direction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Mean and range of variation in some mechanical properties of femoral spongy bone according to the direction of loading. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The rectangular specimens loaded in a lateral-medial direction had the highest average compressive strain and those loaded in the direction of the long axis of the neck had the least. The compressive strain of the cubic specimens loaded in a lateral-medial direction far exceeded that of all other specimens. The lowest compressive strain among cubic specimens was found in those loaded in the superior-inferior direction.</p> <p>Surprising differences were found in the density of specimens cut in different directions. The density of rectangular and cubic specimens cut in the lateral-medial direction was the same but greater than that of any other specimens. The rectangular specimens cut in the superior-inferior and in the anterior-posterior direction were the least dense. Cubic specimens were the least dense when cut in the superior-inferior direction. These differences in density of the specimens suggest directional variation in the orientation and abundance of trabeculae in various parts of the femur.</p> <p>A statistical analysis of the means for the various mechanical properties with respect to the direction of loading revealed the following significant differences. The variation between the energy absorbed by rectangular specimens, loaded in the lateral-medial direction, was significantly greater at the 0.01 level than that of the specimens subjected to anterior-posterior and to superior-inferior loading. The difference between the maximum compressive strain (found in lateral-medial loading) and the minimum strain (found in specimens loaded in the direction of the long axis of the neck) was significant at approximately the 0.04 level. No other significant differences were found between the means for the other mechanical properties when analyzed with respect to the direction in which the specimens were cut and loaded.</p> <p>Although spongy bone is much weaker than compact bone (<b>Fig. 9</b>), its foam-like structure makes it a good energy-absorbing material, as demonstrated experimentally more than a century ago by Dr. Physick <a></a> and more recently suggested by Evans, Pedersen, and Lissner <i><a></a> . </i>The presence of fat, marrow substance, and blood in the interstices of spongy bone in the living condition enhances its energy-absorbing capacity by making it act like a quasi-hydrostatic system. The capacity of bone to absorb energy is one of its important mechanical properties as far as fracture mechanics is concerned because, as pointed out by Lissner and Evans, <a></a> all physical injuries arise from the absorption of energy. Most fractures are produced by impacts or blows and thus involve energy absorption.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Mean and range of variation in strength of various bones according to type (compact or spongy) and. direction of loading <a></a>. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Another mechanical property of bone to be considered is its fatigue life. This is especially important in relation to march, stress, or fatigue fractures which are most common in the metatarsal bones although they have also been reported in other bones. These fractures are thought to be the result of repetitive loading such as occurs during marching, hence the name "march" fracture.</p> <p>The only investigation known to me on the fatigue life of intact bones is one we made several years ago <i><a></a> . </i>In this study the strength of intact human metatarsal bones was determined by loading them to failure in a Sonntag Flexure Fatigue machine equipped with an automatic counter (which recorded the number of cycles to failure) and shutoff. The chief advantage in using this type of fatigue machine is that it has an inertia force-compensator spring which absorbs or eliminates all unknown inertia forces. Consequently, the force in the specimen being tested, regardless of its rigidity, is equal to the known force produced by the oscillator assembly.</p> <p>Forty-one bones were tested with a force of 15 lbs. (the maximum that could be applied with our machine), 3 bones with 12 lbs., and 8 bones with 10 lbs. Only the second through fifth metatarsals were tested because the first one was too large for the fatigue machine. The influence of moisture upon the fatigue life of the specimens was investigated in 10 bones by allowing water to drip on them during a test. The bones were not degreased and all were tested at room temperature. None of the bones exhibited any known pathologic condition. In order to hold the bone in the fatigue machine during a test, the ends were embedded in Selectron 5026 plastic. The number of repetitions to failure was automatically recorded and the machine shut off as soon as the specimen broke. A cycle means the bone is bent once up and once down.</p> <p>Comparison of the results obtained for the wet- and the dry-tested specimens showed that drying tended to decrease the fatigue life of the bones (<b>Table 1</b>). The probable explanation is that drying increased the modulus of elasticity of the bone and hence the specimens were stiffer. The number of repetitions to failure, with a 15-lb. force, varied from 1,000 to 10,297,000 for the dry specimens and from 150,000 to 13,908,000 for the wet specimens. Metatarsals 2 and 3 showed the greatest fatigue life when tested wet. No consistent relations were found between the fatigue life of the bones and their size or age of the individuals from whom they were obtained. The type of fracture produced experimentally (<b>Fig. 10</b>) was similar to some reported <a></a> in the clinic literature (<b>Fig. 11</b>).</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. 10. Experimentally produced fatigue fracture of an intact human metatarsal bone. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. A clinical fatigue fracture of a metatarsal bone.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is interesting to speculate how long an individual must walk before the metatarsals would be subjected to the same number of repetitions at which failure occurred in our experiments. If it were assumed that an individual walked at the army pace of 120 steps per min., walking 50 min., resting 10 min., one would have to walk continuously for almost a month before the second metatarsal would be subjected to the number of repetitions at which the failure occurred in the present study. During each cycle of loading, the bone was bent up and down in a vertical plane. The fracture was probably a tensile failure initiated on the side which, at the instance of failure, was the convex or tensile side.</p> <p><b>References:</b></p> <ol> <li>Bird, F., H. Becker, J. Healer, and M. Messer, <i>Experimental determination of the mechanical properties of bone</i>, Aerospace Med., 39:1:44-48, 1968.</li> <li>Bromley, R. G., N. L. Docku, J. S. Arnold, and W. S. S. Jee, <i>Quantitative histological study of human lumbar vertebrae</i>, J. Geront., 21: 537-543, October 1966.</li> <li>Evans, F. G., <i>Stress and strain in bones, their relation to fractures and osteogenesis</i>, Charles C Thomas, Springfield, Ill., 1957.</li> <li>Evans, F. G., <i>Significant differences in the tensile strength of adult human compact bone</i>, in H. J. J. Blackwood, Proceedings of the first European bone and tooth symposium, pp. 319-331, Pergamon Press, Oxford, 1964.</li> <li>Evans, F. G., <i>Relazioni tra alcune proprieta meccaniche e struttura istologica dell'osso compatto umano</i>, Arch. Putti, in press.</li> <li>Evans, F. G., <i>Relation of the physical properties of bone to fractures</i>, The American Academy of Orthopaedic Surgeons Instructional Course Lectures, 18:110-121, 1961.</li> <li>Evans, F. G., and M. Lebow, <i>Regional differences in some of the physical properties of the human femur</i>, J. Appl. Physiol., 3:9:563-572, March 1951.</li> <li>Evans, F. G., and M. Lebow, <i>The strength of human compact bone as revealed by engineering technics</i>, Amer. J. Surg., 83:3:326-331, 1952.</li> <li>Evans, F. G., C. C. Coolbaugh, and M. Lebow, <i>An apparatus for determining bone density by means of radioactive strontium (Sr90)</i>, Science, 114:2955:182-185, 1951.</li> <li>Evans, F. G., H. E. Pedersen, and H. R. Lissner, <i>The role of tensile stress in the mechanism of femoral fractures</i>, J. Bone Joint Surg., 33A: 485-501, 1951.</li> <li>Harris, C. O., <i>Strength of materials</i>, American Technical Society, Chicago, 1963.</li> <li>Key, J. A., and H. E. Conwell, <i>The management of fractures, dislocations, and sprains</i>, C. V. Mosby, St. Louis. 1951.</li> <li>Koch, J. C, <i>The laws of bone architecture</i>, Amer. J. Anat., 21:177-298, March 1917.</li> <li>Kraus, G. R., and J. R. Thompson, <i>March fracture: An analysis of 200 cases</i>, J. Roent. Radium Therapy, 52:281-290, 1944.</li> <li>Lease, G. O'D., and F. G. Evans, <i>Strength of human metatarsal bones under repetitive loading</i>, J. Appl. Physiol., 14:1:49-51, 1959.</li> <li>Lissner, H. R., and F. G. Evans, <i>Engineering aspects of fractures</i>, Clin. Orthop., 8:310-322, 1956.</li> <li>McElhaney, J. H., and E. F. Byars, <i>Dynamic response of biological materials</i>, Amer. Soc. Mech. Eng., 65-WA/HUF-9, December 1965.</li> <li>Policard, A., and J. Roche, <i>La formation de la substance osseuse</i>. Essai de coordination des donnees histologiques et biochimiques. Ann. Physiol. Physicochim. Biol., 13:645-703, 1937.</li> <li>Wistar, C, <i>A system of anatomy</i>, Ed. 4, Carey, Lea and Carey, Philadelphia, 1827.</li> <li>Zarek, J. M., <i>Biomechanics: Its application to surgery</i>, Chap. 6 in L. Gillis, Modem trends in surgical materials, Butterworth and Co. Ltd., London, 1958, pp. 106-123.</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>14.</b> </td><td class="clsTextSmall">Kraus, G. R., and J. R. Thompson, March fracture: An analysis of 200 cases, J. Roent. Radium Therapy, 52:281-290, 1944.</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">Kraus, G. R., and J. R. Thompson, March fracture: An analysis of 200 cases, J. Roent. Radium Therapy, 52:281-290, 1944.</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">Lease, G. O'D., and F. G. Evans, Strength of human metatarsal bones under repetitive loading, J. Appl. Physiol., 14:1:49-51, 1959.</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">Evans, F. G., Relation of the physical properties of bone to fractures, The American Academy of Orthopaedic Surgeons Instructional Course Lectures, 18:110-121, 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">Lissner, H. R., and F. G. Evans, Engineering aspects of fractures, Clin. Orthop., 8:310-322, 1956.</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>10.</b> </td><td class="clsTextSmall">Evans, F. G., H. E. Pedersen, and H. R. Lissner, The role of tensile stress in the mechanism of femoral fractures, J. Bone Joint Surg., 33A: 485-501, 1951.</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">Wistar, C, A system of anatomy, Ed. 4, Carey, Lea and Carey, Philadelphia, 1827.</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">Koch, J. C, The laws of bone architecture, Amer. J. Anat., 21:177-298, March 1917.</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">Key, J. A., and H. E. Conwell, The management of fractures, dislocations, and sprains, C. V. Mosby, St. Louis. 1951.</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">Evans, F. G., Stress and strain in bones, their relation to fractures and osteogenesis, Charles C Thomas, Springfield, Ill., 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Evans, F. G., C. C. Coolbaugh, and M. Lebow, An apparatus for determining bone density by means of radioactive strontium (Sr90), Science, 114:2955:182-185, 1951.</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>7.</b> </td><td class="clsTextSmall">Evans, F. G., and M. Lebow, Regional differences in some of the physical properties of the human femur, J. Appl. Physiol., 3:9:563-572, March 1951.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Evans, F. G., and M. Lebow, The strength of human compact bone as revealed by engineering technics, Amer. J. Surg., 83:3:326-331, 1952.</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">Bromley, R. G., N. L. Docku, J. S. Arnold, and W. S. S. Jee, Quantitative histological study of human lumbar vertebrae, J. Geront., 21: 537-543, October 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>18.</b> </td><td class="clsTextSmall">Policard, A., and J. Roche, La formation de la substance osseuse. Essai de coordination des donnees histologiques et biochimiques. Ann. Physiol. Physicochim. Biol., 13:645-703, 1937.</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">Evans, F. G., Relazioni tra alcune proprieta meccaniche e struttura istologica dell'osso compatto umano, Arch. Putti, in press.</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">Evans, F. G., Significant differences in the tensile strength of adult human compact bone, in H. J. J. Blackwood, Proceedings of the first European bone and tooth symposium, pp. 319-331, Pergamon Press, Oxford, 1964.</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">Bird, F., H. Becker, J. Healer, and M. Messer, Experimental determination of the mechanical properties of bone, Aerospace Med., 39:1:44-48, 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">McElhaney, J. H., and E. F. Byars, Dynamic response of biological materials, Amer. Soc. Mech. Eng., 65-WA/HUF-9, December 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>20.</b> </td><td class="clsTextSmall">Zarek, J. M., Biomechanics: Its application to surgery, Chap. 6 in L. Gillis, Modem trends in surgical materials, Butterworth and Co. Ltd., London, 1958, pp. 106-123.</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">Evans, F. G., Relation of the physical properties of bone to fractures, The American Academy of Orthopaedic Surgeons Instructional Course Lectures, 18:110-121, 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>11.</b> </td><td class="clsTextSmall">Harris, C. O., Strength of materials, American Technical Society, Chicago, 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>20.</b> </td><td class="clsTextSmall">Zarek, J. M., Biomechanics: Its application to surgery, Chap. 6 in L. Gillis, Modem trends in surgical materials, Butterworth and Co. Ltd., London, 1958, pp. 106-123.</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">Evans, F. G., and M. Lebow, Regional differences in some of the physical properties of the human femur, J. Appl. Physiol., 3:9:563-572, March 1951.</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>F. Gaynor Evans. Ph.D. </b></td></tr><tr><td class="clsTextSmall">Department of Anatomy and Highway Safety Research Institute, The University of Michigan, Ann Arbor, Mich. 48104.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_01_037/spring69-33.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_01_037/spring69-34.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_01_037/spring69-35.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_01_037/spring69-36.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_01_037/spring69-37.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_01_037/spring69-38.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_01_037/spring69-39.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_01_037/spring69-40.jpg Figure 9 http://www.oandplibrary.org/al/images/1969_01_037/spring69-41.jpg Figure 10 http://www.oandplibrary.org/al/images/1969_01_037/spring69-42.jpg Figure 11 http://www.oandplibrary.org/al/images/1969_01_037/spring69-43.jpg Figure 12 http://www.oandplibrary.org/al/images/1969_01_037/spring69-44.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Mechanical Properties of Bone Creator An entity primarily responsible for making the resource F. Gaynor Evans. Ph.D. * 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/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. * https://staging.drfop.org/files/original/4699d64d3df5994ef8f7e1b85cd99959.pdf b3917f4e00ca2ab8d8c25b3f49862b6e https://staging.drfop.org/files/original/e5ce76adfd45dd6f57b618d54dde10ad.jpg 73269599a0739d162dabc155d43ed468 https://staging.drfop.org/files/original/743b5e834a6bd64136a8729f21c07d13.jpg 94ba2e4204849d17989659f400598a78 https://staging.drfop.org/files/original/36ae3ca908bc73b7f24e244440dda104.jpg f928a27eaaee312841c942cf30496ae1 https://staging.drfop.org/files/original/b65a0390d93c0160d55cc411ff05f1d9.jpg a2f12631b5934dca4d2cffbe177994eb https://staging.drfop.org/files/original/a366ac4453ec47ff2c58896dcaaeed9f.jpg 4d4b69bb9323ba6d1e82d72ee69e7b11 https://staging.drfop.org/files/original/404e9dfeeaf0ddf28ee6cc9724a164be.jpg b7cf2d1829b06c77f60ad53a56ea1532 https://staging.drfop.org/files/original/1b6b21650828332a841575640ebd49c2.jpg b97764b21b3f5e2eb36440de368b7a9e https://staging.drfop.org/files/original/69921ae973886707c7f19d0b0ad8d958.jpg 11567fa8743e3ca28c329197914c2b13 https://staging.drfop.org/files/original/cb3f332ee038c22ea975988c0684ce58.jpg 069149801aa269a87db508949da51d8f https://staging.drfop.org/files/original/924b2334c44029327c1b7924cb3fe7ac.jpg ffebb08a2dd20782db4a706e97eb0c18 https://staging.drfop.org/files/original/667fb5c153d80c36866d27fd5fd55700.jpg 6682288306bc4940fe68f83b9b600f51 https://staging.drfop.org/files/original/f078c25d734e44df7cc68fc2991aaa1e.jpg a46a3f90736de24584111c8e3b4dd414 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_01_027.pdf Year 1969 Volume 13 Issue 1 Page Number(s) 27 - 36 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_01_027.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_01_027.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>Causes of Death in a Series of 4738 Finnish War Amputees</h2> <h5>Georg Bakalim <a style="text-decoration:none;">*</a><br /></h5> <p>The loss of a limb and its replacement by a prosthesis create conditions deviating from the normal. Walking is always more difficult. Loon <a></a> found that the energy consumption of amputees increases with the level of amputation. In the case of an above-knee amputation the effort of walking is greater than in a be-low-knee amputation and, in cases of hemipelvectomy and disarticulation of the hip, energy requirements are still greater. In the same investigation, it was found that walking with crutches, without a prosthesis, requires more energy than walking with a prosthesis. In addition, it appeared that in the presence of disturbances in the stump that affect walking, the consumption of energy increases. A poorly fitted prosthesis has the same effect. During walking, the center of gravity should shift smoothly, not in a jerky way that makes it more difficult to maintain balance. Almost all amputees experience excessive sweating not only of the stump but in general. The tightly fitted socket and the thigh corset used in connection with the old, conventional type of below-knee prosthesis are contributory causes of sweating.</p> <p>Owing to the loss of the weight and accompanying movements of the amputated limb, upper-extremity amputees find it more difficult to keep their balance in walking after amputation. Similarly, the strain on the remaining upper limb in lifting and carrying is greater than before. The increased consumption of energy taxes the circulation and the heart. In this connection, no further attention will be paid to the secondary changes in the weight-bearing structures, particularly the joints and spine, that result from the altered static conditions due to the loss of a limb <a></a>.</p> <p>The health of amputees has been the subject of many previous studies, <i>e.g., </i>those of Rausche, <a></a> Schneider, <a></a> Schulze, <a></a> and Bodechtel <a></a>. Meyer-ingh, Stefani, and Cimbal <a></a> reported a higher rate of hypertension in obese amputees than in amputees of average weight. In an electrocardiographic investigation of 1033 amputees, performed by the same authors, no differences were observed as compared with a normal series. Likewise, in a series of 1128 amputees obesity was not more frequent than in a corresponding group of the general population. <a></a> Loos <a></a> reported similar findings in a series of 647 cases. Solonen, Rinne, Viikeri, and Karvinen <a></a> observed no noteworthy increase in cardiac and vascular diseases in amputees.</p> <p>The purpose of this study was to find out whether death from degenerative cardiac and vascular diseases is more common among amputees than in the general population. At the same time tuberculosis, cancer, accidents, suicide, and miscellaneous causes of death were surveyed from the same standpoint.</p> <h3>Material</h3> <p>The series consists of 4782 war amputees. Data was collected from the files of the State Insurance Department. Finger, hand, toe, and foot amputations have been omitted since these cause no major problems. Before the end of 1944, <i>i.e., </i>during the war, 44 amputees died. These cases are also considered in this study. The age distribution in this group was the same as in the remaining 4738 cases which have been followed up from 1945 till the end of 1965. The causes of death were obtained from the death certificates. During the last 10 years a steadily increasing number of cases have been examined postmortem. In case of a casualty, or when the cause of death is unknown, autopsy is invariably performed. As a rule, the autopsy records contain more than one diagnosis, but in this study only the main diagnoses have been utilized. Although many of the second diagnoses might have been of interest, taking them into account would have implied considerable technical problems and would have rendered the statistical treatment more difficult. Since 1945, 643 subjects have died. During the period 1940-1965 the total mortality was thus 687/4782 (14.4 per cent). The number of mortalities during each year is shown in <b>Fig. 1</b>. A steady rise is seen from 1960 onward. This increased mortality is not surprising, considering that more than 20 years have elapsed since the war and the mean age of the war veterans is about 50. However, this curve alone permits no conclusions to be drawn. In order to form an opinion concerning the mortality of the war amputees, the figures have to be compared to the death rates for the corresponding age groups of the general population.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Annual mortality of war amputees in 1940-1965. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Age And Occupation</h4> <p>For the main causes of death the distribution of the dead war amputees by 5-year age groups is given in <b>Table 1</b>. Mostly, the age groups 40-50 years show the highest mortality. However, for conclusions to be drawn concerning the health of the group under review, comparable data for a "normal" group is required. The occupations of the dead, differentiated mainly on the basis of training, are given in <b>Table 2</b>. In this connection the main interest attaches to the proportion of heavy laborers.</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 /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Farmers (177) and unskilled workers (230) constitute the largest groups. Heavy labor is represented by 72.6 per cent, light occupations by 27.4 per cent. The handicraftsmen number 74 (10.8 per cent). There are as many as 31 shoemakers, which is accounted for by the fact that training for this occupation was offered after the war.</p> <h4>Level Of Amputation</h4> <p>The level of amputation appears in <b>Table 3</b>. Finger, hand, toe, and foot amputations were not included in this series because the trouble caused by them is considered to be so slight that it cannot lead to vascular disease. Two amputees in the present series had Chopart stumps, one had a Pirogoff stump, and in six cases disarticulation of the wrist had been performed. The ratio of above-knee to be-low-knee amputations is 1:2.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Method of Comparison</h3> <p>The age distribution of the series followed up, exclusive of those who died before 1945, and the percentage figures for the corresponding age groups of the general Finnish male population are shown in <b>Table 4</b>. As may be seen in the table, the age distribution of the amputees differs widely from the age distribution of the general Finnish male population as obtained from the Statistical Yearbook of Finland. <a></a> For this reason, the death rates for the general Finnish male population could not be used as such for comparison with the mortality rate of amputees. It was necessary therefore to construct an equivalent, theoretical population with an age distribution corresponding to that of the amputees. The data required was obtained in part directly from the Statistical Yearbook, and in part by calculation based on the death rates for men and women and the sex ratio, or for the earlier years, on the total mortality and the age distribution of the dead, as indicated in the Statistical Yearbook. In the comparisons, it was deemed most appropriate to consider only the period from 1945 till the end of 1964. The amputees who died before 1945 numbered 44, and 71 died in 1965. When these 115 cases were subtracted from the total number of dead in the present series (687), 572 cases remained for the comparative analysis of mortality.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Mortality</h4> <p>As mentioned above, the total mortality for the period under review was 687/ 4782 (14.4 per cent). The causes of death are listed in detail in <b>Table 5</b>. The distribution according to the cause of death has been given in summary form in <b>Table 1</b>. Degenerative vascular diseases of the central nervous system and degenerative cardiac and vascular diseases have the same etiology but each forms a separate entity, and the Statistical Yearbook of Finland provides figures for comparison precisely on this basis. In addition, death rates were available for pulmonary tuberculosis, malignant diseases, accidents, and suicide, other causes falling into a miscellaneous group consisting of cases for which no comparative figures were found in the Statistical Yearbook. Many cases of poisoning and drowning were recorded under accidents. Alcohol abuse was a major etiological factor. It was sometimes difficult to decide whether the cause of death was an accident or suicide.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Comparison of Mortality of the Amputees and the General Population</h3> <p>In what follows, the total mortality is analyzed first and then the mortality in the various groups listed above is analyzed, except for the miscellaneous group for which no comparable data was available.</p> <h4>Total Mortality</h4> <p>On comparing the total number of deaths during the period January 1, 1945, to December 31, 1964, <i>i.e., </i>572, to the mortality of the general Finnish male population, the age distribution was taken into account in two different ways. In both methods, consideration was given to the fact that during the period under review the subjects passed into age groups with a lower expectation of life.</p> <p><i>Method I</i></p> <p>For each 5-year age group of amputees in <b>Table 4</b> (age distribution at the beginning of 1945), the expected losses for the 5-year periods 1945-1949, etc., until the beginning of 1965, were calculated on the basis of the expectations of life indicated in the Statistical Yearbook of Finland, that figure being used which pertains to the mean age of the age group during the period in question. To exemplify, for those who were aged 20-24 years at the beginning of 1945, the expectation of life at 25 years was considered as the relevant figure for the period 1945-1949, since the youngest in the group had survived for 20-24 years and the oldest for 24-29 years. Correspondingly, the expectation of life at 30 years was applied to the period 1950-1955, etc. The 5-year losses were calculated on the basis of the total number of survivors. In <b>Fig. 2</b>, the cumulative curve for the calculated losses from the level of 1945 is compared to the cumulative curve for the actual losses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Cumulative death rates-calculated for 5-year periods compared to cumulative expected death rates. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The recorded death rates for the <i>5-year age groups </i>are slightly lower than the expected figures, but the difference is statistically insignificant. The same obtains to the death rates as expressed by <i>5-year periods </i>(<b>Table 6</b>). The differences between the recorded and the expected figures are of the order of 10 per cent. The greatest differences relate to the periods 1950-1954 and 1955-1959, while for the periods 1945-1949 and 1960-1964, the recorded figures fall below the expected ones by about 2 per cent only.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Method II</i></p> <p>In the Statistical Yearbook of Finland, the number of survivors among 100,000 men of the same age is indicated. On the basis of these figures, the numbers of expected survivors in all age classes represented in this series at the beginning of 1945 were calculated for the end of the age periods 20-24 years, 25-29 years, etc., and the expected death rates in the various age groups were expressed as percentages. The expected total mortality by the end of 1964, <i>i.e., </i>549, is in very good agreement with the actual figure of 572. All the 687 deaths considered, the percentile distribution between the age groups corresponds fairly well to the expected distribution (<b>Table 7</b>, <b>Fig. 3</b>).</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. Death rates for the different age groups compared to the expected death rates. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the causes of death are disregarded, it may be stated that the mortality in the present series corresponds very closely to the mortality in the corresponding general population. This obtains to the figures for the various 5-year periods and the total mortality as well as to the figures for the age groups. There seems to be a tendency toward a lower mortality for amputees than in the general population, and, with regard to the age at death, it appears that among the amputees there may be a trend toward a lower age, though only by one or two years at the most.</p> <h4>Degenerative Egenerative Vascular Diseases of the Central Nervous System</h4> <p>The mortality in degenerative vascular diseases of the central nervous system was 64/687 (9.3 per cent). Traumatic cerebral hemorrhages of course do not belong to this group. Comparable data relating to the general population was obtained from the Statistical Yearbook of Finland, and expected figures were calculated for the period 1945-1964 in the same way with respect to the total mortality. The expected number of deaths in this group of disease was 37.4. The actual number (64) was 71.2 per cent higher. In the age groups 25-44 years the actual number of deaths was 130.9 per cent higher than the expected number; in the age groups 45-64 years it was 49.6 per cent higher; and in the age groups 65-74 it was 42.6 per cent higher (<b>Table 8</b>). No consistent trend is discernible with regard to the age at death.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Degenerative Cardiac And Vascular Diseases</h4> <p>This group includes cardiac infarction, pulmonary infarction, peripheral embolism, myodegeneration, cardiac insufficiency, and arteriosclerosis. The mortality in this group was 219/687 (31.9 per cent). The expected number of deaths in the general population was 134.3. The actual mortality was 63.1 per cent higher. As regards the different age groups, the actual mortality was 193.2 per cent higher than the expected in the group aged 25-44 years at death, 38.9 per cent higher in the group aged 45-64 years, and 28.6 per cent higher in the group aged 65-74 years (<b>Table 8</b>). One hundred and four amputees (47.5 per cent) died at an age of 45-54 years, 51 (23.3 per cent) at an age of 35-44 years, and 44 (20.1 per cent) at 55-64 years. The remaining 20 deaths (9.1 per cent) were evenly distributed between the age groups 25-34 and 65-84 years (<b>Table 1</b>).</p> <h4>Pulmonary Tuberculosis</h4> <p>The mortality in pulmonary tuberculosis was 70/687 (10.2 per cent). The actual mortality was found to be 24.9 per cent lower than the expected mortality (93.2 cases). In the group under 24 years of age the mortality was 172.7 per cent higher than the expected, while in the age groups 25-44 and 45-64 the actual mortality was 10.5 and 70.9 per cent lower, respectively, than the expected (<b>Table 8</b>).</p> <h4>Malignant Diseases</h4> <p>The mortality in malignant disease was 96/687 (14.0 per cent). The mortality was 19.6 per cent lower than the expected. In the age group 45-64 years the mortality was 21.1 per cent lower, and in the age group 65-74 it was also 21.1 per cent lower than the expected mortality. The frequency of malignant disease in different organs appears in <b>Table 5</b>. In none of the present cases was the disease a result of the amputation (<b>Table 8</b>).</p> <h4>Accidents</h4> <p>Accidents were the cause of death in 72/687 cases (10.5 per cent). The actual figures were in all age groups lower than the expected. In the age group under 24, the recorded number of deaths was 78.3 per cent lower than the expected mortality; in the group 25-44 years it was 36.2 per cent lower; in the group 45-64 years it was 24.1 per cent lower. The actual total mortality was 34.2 per cent lower than the expected. This group includes 17 (2.5 per cent) traffic accidents, but these could not be separately analyzed, because traffic accidents are not treated as a separate group in the Statistical Yearbook (<b>Table 8</b>).</p> <p>It thus appears that the mortality from accidents was markedly lower among the amputees than in the general population. It might have been expected that amputees would be more accident-prone both at work and in the traffic, owing to their poorer mobility. The small proportion of traffic accidents among the total number of cases is also striking. Obviously, the amputees move about less than the general population, work at less dangerous places, and are, perhaps, employed to a lesser extent owing to their reduced working capacity.</p> <h4>Suicides</h4> <p>Since about 80 per cent of the suicides are committed by men, it seemed reasonable to use this age distribution as a basis when the expected mortality was calculated in the same way as for the other causes of death. The actual figures for the periods 1955-1959 and 1960-1964 are 68.1 and 36.0 per cent higher than the expected figures. The total number of suicides (63) for the period 1945-1964 is 37.3 per cent greater than the expected number. The greatest difference is noted for the period 1945-1949, the recorded frequency of suicides being 3.6 times higher (260.0 per cent) than the expected (<b>Table 8</b>). By contrast, the figure for 1950-1954 is 73.4 per cent lower than the expected mortality. If these two 5-year groups are added together the difference by which the actual frequency of suicides exceeds the expected has changed to a decrease (-13.8 per cent).</p> <p>It appears that among amputees under 25 years of age, suicides were 300.0 per cent higher, and in the age group 25-44 years 53.8 per cent higher than was to be expected on the basis of the statistics for the general population. By contrast, the number of suicides committed by amputees aged 65-74 years was within 0.2 per cent of the expected figure. The total actual number of suicides exceeds the expected figure by a difference of 37.3 per cent (<b>Table 8</b>).</p> <p>In addition, the rate of suicides among the dead amputees with the same occupation has been calculated. In this respect there is no major difference between heavy labor and other occupations. Technicians have the lowest rate of suicide, those with unknown occupations the highest. With regard to the former, it may be pointed out that their occupation is highly suitable for amputees, while the latter group includes subjects without regular employment, who lived in poor social conditions.</p> <p>The possible relationship between the rate of suicides and the level and site of the amputation is analyzed in <b>Table 9</b>. Among lower-limb amputees the frequency of suicide was twice the frequency among upper-limb amputees. However, when the whole series is taken into account, the difference is not very great, the number of lower-limb amputees being double the number of upper-limb amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The methods of suicide appear in <b>Table 5</b>. Alcohol abuse was known to have played a part in 11 cases, and 6 subjects had used barbiturates in addition. This group of 63 consists of only sure cases of suicide. In the group of accidents, at least a slight suspicion of suicide was present in many cases.</p> <h3>Summary and Discussion</h3> <p>In a series of 4782 war amputees, the total mortality was 687 (14.4 per cent). The period covered by the present study is from 1945 till the end of 1965. In 1960, the mortality of the war amputees began to rise abruptly, and was one of the causes for undertaking this study. This mortality was compared to the mortality in the general Finnish male population. A theoretical, equivalent male population was constructed on the basis of data obtained from the Statistical Yearbook of Finland.</p> <p>When the causes of death were not differentiated, the mortality of the amputees was found to be in good agreement with the mortality of the general population. This obtains to both the whole series and the different 5-year periods. There was even a tendency towards slightly lower figures for the amputees.</p> <p>On the other hand, when the causes of death were differentiated, certain features of interest emerged. The recorded death rates were higher than the expected figures with regard to degenerative diseases of the central nervous system ( + 71.2 per cent), degenerative cardiac and vascular diseases ( + 63.1 per cent), and suicide (+37.3 per cent). These were the causes of death in half the cases. One-fourth of the deaths were due to pulmonary tuberculosis or malignant disease. In both these groups the actual death rate was lower than the expected ( - 24.9 per cent and - 19.6 per cent). In the age group under 25, the mortality in pulmonary tuberculosis was 2.7 times higher than in the corresponding group of the general population, but in all other age groups it was lower than the expected death rate. The number of deaths due to accidents (72) fell below the expected mortality by 34.2 per cent. Obviously, amputees move about considerably less than the general population, and they are less exposed to accidents owing to their limited working capacity.</p> <p>In order to give a general survey of the findings, the main causes of death are listed in <b>Table 8</b>. In addition to the number of deaths, the mortality in each group is expressed as a percentage. Likewise, the expected mortality is given both in absolute figures and as percentages, and the differences between the actual and expected figures are indicated in percentages. In this connection, it has been assumed that the total expected mortality is the same as the actual mortality, as was also suggested by the analysis of the total mortality carried out at the beginning of this study. The amputees seem to be more afflicted with fatal degenerative diseases of the central nervous system and fatal degenerative cardiac and vascular diseases, and suicides seem to be more common among them, as compared with the general population. On the other hand, the mortality from pulmonary tuberculosis, accidents, and a large group of miscellaneous diseases <i>(e.g., </i>various diseases of the lungs and abdominal disorders), was lower among the amputees than in the general population.</p> <p>It may be assumed that the higher frequency of suicides among the amputees is due in part to psychological causes connected with the loss of a limb. Also, a postwar depression may have become more pronounced with the lapse of time. Economic problems and poor social conditions may be regarded as contributory causes.</p> <p>In the care of amputees, the factors of importance are: a satisfactory prosthesis, good condition of the stump, rehabilitation, suitable employment, and judiciously administered subvention. The question arises as to whether all that could have been done for the war amputees was done. Perhaps something had been neglected that could have prolonged the lives in some cases.</p> <p><b>References:</b></p> <ol> <li>Bodechtel, G., <i>Klinik des veget</i>. Nervensystems, Verh. Deutsch. Ges. Inn. Med., 57: 1948.</li> <li>Loon, H. E., <i>Biological and biomechanical principles in amputation surgery</i>, Prosthetics international, Copenhagen, 1960.</li> <li>Loos, H. M., <i>Klinische und statistiche Ergebnesse des Blutdruckuerhaltens bei Amputierten</i>, Medizinische, 29:1050, 1957.</li> <li>Meyeringh, H., and H. Stefani, <i>Besteht nach einer Amputation des Oberschenkels eine Neigung zur Adipositas und zur Hyperextension</i>? Deutsch. Med. Wschr., 81:10, 1956.</li> <li>Meyeringh, H., H. Stefani, and G. Cimbal, <i>Herz und Amputation: Eine klinische EKG Studie</i>, Deutsch. Med. Wschr., 85:9, 1960.</li> <li>Rausche, C, <i>Uber den Zusammenhang zwischen Amputation und arteriellem Hochdruck</i>, Med. Klin., 35:1418, 1939.</li> <li>Schneider, K. W., according to G. Schletter, in A. W. Fischer, R. Herget, and G. Molineus, <i>Das artzliche Gutachten im Versicherungs-wesen</i>, Johann Ambrosius Barth, Munchen, 1955.</li> <li>Schulze, K., according to G. Schletter, in A. W. Fischer, R. Herget, and G. Molineus, <i>Das drtzliche Gutachten im Versicherungswesen</i>, Johann Ambrosius Barth, Munchen, 1955.</li> <li>Solonen, K. A., H. J. Rinne, M. Viikeri, and E. Karvinen, <i>Late sequelae of amputation: The health of Finnish war veterans</i>. Ann. Chir. Gynaec. Fenn., Supplementum 138, 1965.</li> <li>Statistical Yearbook of Finland, 1945-1965, Central statistical office.</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>10.</b> </td><td class="clsTextSmall">Statistical Yearbook of Finland, 1945-1965, Central statistical office.</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">Solonen, K. A., H. J. Rinne, M. Viikeri, and E. Karvinen, Late sequelae of amputation: The health of Finnish war veterans. Ann. Chir. Gynaec. Fenn., Supplementum 138, 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>3.</b> </td><td class="clsTextSmall">Loos, H. M., Klinische und statistiche Ergebnesse des Blutdruckuerhaltens bei Amputierten, Medizinische, 29:1050, 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Meyeringh, H., H. Stefani, and G. Cimbal, Herz und Amputation: Eine klinische EKG Studie, Deutsch. Med. Wschr., 85:9, 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>5.</b> </td><td class="clsTextSmall">Meyeringh, H., H. Stefani, and G. Cimbal, Herz und Amputation: Eine klinische EKG Studie, Deutsch. Med. Wschr., 85:9, 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>1.</b> </td><td class="clsTextSmall">Bodechtel, G., Klinik des veget. Nervensystems, Verh. Deutsch. Ges. Inn. Med., 57: 1948.</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">Schulze, K., according to G. Schletter, in A. W. Fischer, R. Herget, and G. Molineus, Das drtzliche Gutachten im Versicherungswesen, Johann Ambrosius Barth, Munchen, 1955.</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">Schneider, K. W., according to G. Schletter, in A. W. Fischer, R. Herget, and G. Molineus, Das artzliche Gutachten im Versicherungs-wesen, Johann Ambrosius Barth, Munchen, 1955.</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">Rausche, C, Uber den Zusammenhang zwischen Amputation und arteriellem Hochdruck, Med. Klin., 35:1418, 1939.</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">Solonen, K. A., H. J. Rinne, M. Viikeri, and E. Karvinen, Late sequelae of amputation: The health of Finnish war veterans. Ann. Chir. Gynaec. Fenn., Supplementum 138, 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>2.</b> </td><td class="clsTextSmall">Loon, H. E., Biological and biomechanical principles in amputation surgery, Prosthetics international, Copenhagen, 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>Georg Bakalim </b></td></tr><tr><td class="clsTextSmall">State Supervisor of Prosthetic Services, Ministry of Social Affairs, Helsinki, Finland.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_01_027/spring69-21.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_01_027/spring69-22.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_01_027/spring69-23.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_01_027/spring69-24.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_01_027/spring69-25.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_01_027/spring69-26.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_01_027/spring69-27.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_01_027/spring69-28.jpg Figure 9 http://www.oandplibrary.org/al/images/1969_01_027/spring69-29.jpg Figure 10 http://www.oandplibrary.org/al/images/1969_01_027/spring69-30.jpg Figure 11 http://www.oandplibrary.org/al/images/1969_01_027/spring69-31.jpg Figure 12 http://www.oandplibrary.org/al/images/1969_01_027/spring69-32.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 Causes of Death in a Series of 4738 Finnish War Amputees Creator An entity primarily responsible for making the resource Georg Bakalim * https://staging.drfop.org/files/original/10c1e9153313406ba4f5bb6316536cb0.pdf f021c880f280590c0b2349861906bbcb https://staging.drfop.org/files/original/dc11864cea6523c87bf2d8df4550c001.jpg 13279d0e9cb832a37dc538a352203e0b https://staging.drfop.org/files/original/2002e46ffabbd7a8026db85c3669de1f.jpg 74ffcd886b527321c2f9d37afc60ab20 https://staging.drfop.org/files/original/9dc4487b2acddd05e4f0f442510b35b9.jpg d5f724d51a1e6ba2b8a1d03c305f1774 https://staging.drfop.org/files/original/3a68d5d8a5f6b3952661c4bbd46eefa7.jpg 89904eeb58e41489800af4cb2a49a63e https://staging.drfop.org/files/original/77c9d3c2d4a941dc2c53cdf6f0a49971.jpg fc10f1203fdabd37b416196d917e1a9b https://staging.drfop.org/files/original/1ba9f329202448af3fa4efbfd9070888.jpg 2f146206c850edfddfda674098294ccb https://staging.drfop.org/files/original/35727e9c9abf2b58afcb30a82a68b630.jpg 6e3ea0d5ebea2f60d1d2cf5edb70215a https://staging.drfop.org/files/original/7880f6b348c16563637e568b84221d13.jpg 1b1a6610e78623175fbdc6336c343ba5 https://staging.drfop.org/files/original/bda95fea38a30663bb14a54fdd0bf252.jpg 003b6c53652ab72a46888a097359d477 https://staging.drfop.org/files/original/1c9248ec6e5c79bd34a6b0e521ddc916.jpg d08a866941e3cec5031a61f6feb966fa https://staging.drfop.org/files/original/c604af9b9225d4ffc11d1b6d9f2b0fdf.jpg db1f4c9447ff9977f7a3c7a7cbc0d8ac https://staging.drfop.org/files/original/d289c21c42aa9f609743bcb0fe52e10a.jpg 5cee6ff75cd02de689a5b21010742089 https://staging.drfop.org/files/original/ee73aa307cf4e9cc566ca1852eb9efa2.jpg 386ce91b1d4443ce1250cd660c0715ab https://staging.drfop.org/files/original/4a3d7f3112ca91a59eaf1ff5a9a5a204.jpg ee3ea0c538854c55e5170f52570aba84 https://staging.drfop.org/files/original/b830cc45412e5424f35cc65c231b8d5b.jpg 0fcd7e975fb49b493c0e6d7c0191bc84 https://staging.drfop.org/files/original/b2e854fc9a5e33325ed8ec746dda8ae0.jpg 2f339c44ea64b52504a784b6443b4a77 https://staging.drfop.org/files/original/6de37e945a0e41d8484dc77c16bc3cd6.jpg 04bdad71e4b68a0386a544b9b4121882 https://staging.drfop.org/files/original/febbd73f2648976234d696c9b757b7ae.jpg d7658aff6e0000e75444773e217cde8e https://staging.drfop.org/files/original/d5b7a908de158673aff7c895d77eba42.jpg fe328b7b8ee047f1d66414ae1226bf7e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_02_013.pdf Year 1969 Volume 13 Issue 2 Page Number(s) 13 - 30 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_013.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_02_013.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>The NYU Transparent Socket Fabrication Procedure</h2> <h5>Thomas Grille <a style="text-decoration:none;">*</a><br />Ronald Lipskin <a style="text-decoration:none;">*</a><br />Richard Hanak <br /></h5> <p>It has been recognized for a long time that a transparent socket that could be made to fit the stump would be a useful tool in studying the relationship between the amputation stump and the socket of a prosthesis. Early attempts by a number of investigators to devise sockets of acrylics such as Plexiglas and Lucite were abandoned because of the difficulty encountered in controlling the contours and because of the inordinate amount of time required for fabrication of a single socket.</p> <p>In 1966, the New York University Prosthetics and Orthotics group undertook a comprehensive study to develop a practical method of fabricating a transparent socket using newer materials and fabrication techniques.</p> <p>The criteria for the selection of the transparent material to be utilized for the socket were that it be water-clear with good transparency, have adequate strength and fracture resistance, and be non-toxic. The method of fabrication was to be reasonably simple and was not to require an excessive amount of actual working time or sophisticated equipment; the materials and equipment were to be readily available.</p> <p>Two basic approaches were explored: vacuum forming and casting.<a style="text-decoration:none;">*</a> Transparent polycarbonate sheet material was used in the attempts to make a socket using the vacuum forming method. Below-knee sockets were made by this method, but it was necessary to form the socket in two parts and to bond them together, a procedure which was time-consuming and which required extreme care if accuracy was to be obtained.</p> <p>Both epoxy and polyester resins were tried for casting transparent sockets. Satisfactory results could be obtained with epoxy resins, but excellent results were obtained consistently with polyester casting resins when RTV silicone rubber was used on the outer surface of a male plaster slush mold and the casting surfaces were covered with polyvinyl chloride film. This article describes the procedures, in a step-by-step fashion, for fabrication of a transparent socket using polyester casting resins.</p> <h4>Silicone Male Mold</h4> <p>A conventional hard socket is supported on a wood attachment block during the fabrication of the silicone rubber male mold. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>1. Using approximately five layers of plaster bandage, the proximal trim line of the conventional socket is built up to the level that existed prior to trimming (about 1 in. above the proximal end of the socket with the interior surface made reasonably flat). After the plaster bandage has hardened, any rough interior areas are sanded smooth, and any plaster that interferes with the interior contour is removed.</p> <p>2. To facilitate separation of the silicone shell from the hard socket, the interior surface of the hard socket is sprayed with Dow Corning Silastic RTV Mold Release. <b>Fig. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>3. In order to retain the liquid silicone rubber in the hard socket, masking tape is used to form a V2-in.-wide rim around the proximal edge of the plaster-bandage buildup.</p> <p>4. Dow Corning Silastic D RTV Silicone Rubber is mixed with 5% by weight of Silastic D RTV thinner. One-half to one lb of silicone is used for BK sockets and 1-1/2 to 2 lb are used for AK sockets, depending upon socket size.</p> <p>5. Stannous octoate catalyst is added in a ratio of 100 drops or 2.2 gm to 1 lb of silicone rubber. This provides a 10-min working and a 1-hr curing time, which is the optimum for this procedure. The working time can be changed by varying the amount of catalyst. (Although this catalyst recommendation differs from the product-use instructions, its use is suggested because it has been found to be more convenient.) If stannous octoate is not available, a proportion of one part of standard catalyst to five parts of silicone rubber is used. <b>Fig. 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>6. The mixture is poured into the hard socket, then the socket is rotated by hand so that the entire inner surface is covered. After this has been accomplished, the socket is rotated only in one direction to insure an even distribution of the mixture to a uniform thickness of approximately % in. The rotation (in one direction) is continued until the mixture is set (10-15 min); the mixture is then allowed to cure at room temperature for 45 min. <b>Fig. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A uniform wall thickness of approximately 1/8 in. is important in order to provide adequate shock absorption during break-out and to avoid the formation of an undersized socket. <b>Fig. 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>7. The silicone-rubber shell is pulled away from the medial wall, and a slit is made down the medial side of the socket. The slit will simplify the removal of the completed male mold by permitting the hard socket to be spread open. The slit is started 1/2 in. below the proximal brim and ended 2 in. short of the distal edge. (A wooden tongue blade and a clamp can be used to keep the silicone shell away from the medial wall while cutting the socket.) <b>Fig. 6</b> - <b>Fig. 7</b></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 /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>8. The male mold will be fabricated with a hollow core in order to simplify breaking it out of the transparent socket. With the silicone shell in the hard socket, a plaster slush mold is poured to a 3/4-in. thickness, except at the distal end, where the thickness should be approximately 1-1/2 in. The plaster is allowed to set. <b>Fig. 8</b> - <b>Fig. 9</b></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 /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>9. A pipe drilled with a few vacuum holes is inserted as a mandrel into the slush mold, and secured at its distal end with additional plaster. The middle section of the mold is filled with paper, and plaster is added at the proximal end of the mold to secure the mandrel. The plaster is allowed to set. <b>Fig. 10</b> - <b>Fig. 11</b></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 /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>10. To separate the completed male mold from the hard socket, the plaster-bandage buildup is removed, the socket is opened along the slit, and the socket is slipped off. <b>Fig. 12</b> - <b>Fig. 13</b></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 /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>11. To permit the application of vacuum to the undercut areas, 1/8-in. holes are punched through the silicone shell and 1/8-in. holes are drilled through the underlying plaster. The holes must be cut through to the void space in the male mold. <b>Fig. 14</b> - <b>Fig. 15</b></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 /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Female Mold</h4> <p>12. An alignment pin is used to insure correct alignment of the distal ends of the male and female molds during casting of the transparent socket. A hole 1/2 in. in diameter is punched in the silicone shell, and one 1/2 in. in diameter and 3/4 in. deep is drilled into the distal aspect of the male mold. An alignment pin, cut 1/2<i> </i>in. in diameter by 3 in. long of nonferrous metal rod. is inserted into the distal hole. <b>Fig. 16</b> - <b>Fig. 17</b></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 /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>13. In order to provide a 1/4-in. wall thickness for the transparent socket, a 1/4-in. Dacron felt sleeve, a 1/8-in. Dacron felt sleeve, and a cotton stockinette sleeve are prepared, all to fit over the male mold. Compression eventually will reduce the thickness of the sleeves to the desired 1/4 in. Holes 1/2 in. in diameter are cut in the ends of the sleeves to permit clearance of the alignment pin. The two felt sleeves are pulled over the male mold and trimmed even with the proximal edge of the mold. <b>Fig. 18</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>AK Sockets Only</i></p> <p>To reinforce the proximal-lateral wall, a 5-in. x 7-in. strip of 1/8-in. felt is attached to the outer sleeve with Barge cement (<i>a</i>).</p> <p>Because of limited space between the male and female molds for AK sockets, a means for pouring the polyester resin into the completed female mold must be provided by creating a lip, or inlet, at its proximal anterior brim (<i>b</i>). A triangular piece of 1/4-in. felt is rolled to form a funnel and fastened with Barge cement to the anterior brim of the outer sleeve so that the top of the funnel is even with the top surface of the mold. (The funnel is not needed in the below-knee socket fabrication, because in that case there is adequate space between the male and female molds.)</p> <p>14. To facilitate alignment of the male and female molds, and to insure a uniform wall thickness of the transparent socket, the felt is cut away in the region above the posterior socket trim line as illustrated. The female mold will be contoured so that a proximal surface of this mold will contact the corresponding surface of the male mold. <b>Fig. 19</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>BK Sockets Only</i></p> <p>The felt layers are cut out in the region above the popliteal trim line. The cutout should not cross the popliteal trim line. <b>Fig. 20</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>AK Sockets Only</i></p> <p>The Dacron layers are trimmed in the flat areas above the posterior and medial brims, leaving approximately 1 in. of uncut material above the socket trim lines. <b>Fig. 21</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>15. The stockinette sleeve is now pulled over the felt on the male mold and tied to the mandrel. <b>Fig. 22</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>16. To provide for the transparent socket pedestal, a piece of 1/32-in.-thick plastic sheet is wrapped around the distal end of the male mold, over the sleeve, beginning at the point where the male mold starts to slope in and extending to the distal end of the alignment pin. The vertical seam and horizontal juncture line are sealed with tape. <b>Fig. 23</b> - <b>Fig. 24</b></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 /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>17. Plaster is poured into the cylindrical cavity formed by the plastic sheet, leaving 1/2<i> </i>in. of the alignment pin exposed above the plaster level. The plaster is allowed to set, and the plastic sheet is removed. <b>Fig. 25</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>18. An inflated balloon is inverted over the lay-up and pushed downward as the air is slowly released. The distal end of the balloon is tied off around the alignment pin, and the proximal end around the mandrel. The balloon is then covered with a coat of silicone spray. <b>Fig. 26</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>19. To fabricate the female mold, 4-in. plaster bandage is wrapped around the balloon-covered male mold, starting at the distal end and overlapping each previous wrap by approximately 3 in. until a 4- to 6-layer thickness is achieved. Care is taken to avoid using excessive tension while applying the plaster bandage so as to prevent compression of the felt and reduction of the wall thickness of the transparent socket. In addition, the undercuts (<i>e.g., </i>the patellar region in BK sockets) are minimized or reduced by bridging the bandage in that area. <b>Fig. 27</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To provide a good receptacle for the exposed length of the alignment pin, it is covered with additional plaster, and the plaster is allowed to set. <b>Fig. 28</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>20. The balloon and stockinette are trimmed off to expose the proximal end of the mold. <b>Fig. 29</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>21. Using a combination square or a strip of metal bent to 90 deg as a guide, orientation lines are drawn on the proximal ends of the molds to provide references for their realignment. Two lines on each of the four sides are sufficient. <b>Fig. 30</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>22. The molds are separated, and the felt and stockinette lay-up is removed from the inside of the female mold.</p> <p>23. The plaster pedestal is broken out of the female mold, and the balloon and the alignment pin are removed without breaking the pin's receptacle.</p> <p>24. At this point, a slit is made in the female mold to simplify its removal from the transparent socket after casting. Starting 1 in. below the proximal rim on the medial side, a cut is made vertically along three-quarters of the socket length. The cut is covered with two vertical layers of plaster bandage on the exterior surface. The interior surface is smoothed where necessary. <b>Fig. 31</b> - <b>Fig. 32</b></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 /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>25. To complete the mold, 1/16-in.-dia vacuum holes are drilled in the undercut area of the female mold to insure the correct surface contour on the transparent socket. <b>Fig. 33</b> - <b>Fig. 34</b></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 /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Alignment Of The Molds And Casting</h4> <p>26. The outer surface of the female mold is covered with a 1/4-in. felt sleeve. A PVA bag is pulled over this sleeve, and both covers are trimmed even with the proximal edge. A vacuum tube is attached to the distal end of the PVA bag and secured with plastic tape.</p> <p>27. A heavy coating of Vaseline petroleum jelly is applied to the inside surface of the female mold. <b>Fig. 35</b> - <b>Fig. 36</b></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 /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>28. The end of a second PVA bag is fastened to the alignment pin with a rubber band and then both are inserted (glossy side in) into the alignment pin receptacle in the female mold. The interior PVA bag is lapped over the exterior PVA bag and sealed with pressure-sensitive tape. At least 4-in. overlaps must be provided because this PVA bag will later be fastened to the male mold mandrel. <b>Fig. 37</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>29. Vacuum is applied and the wrinkles are smoothed out on the interior PVA bag. This lining provides the smooth exterior surface of the transparent socket. <b>Fig. 38</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>30. A PVA sheet (glossy side out) is pulled over the male mold and fastened to the mandrel with plastic tape. The sheet is reinforced around the alignment pin with plastic tape, and a 1/2-in. hole is cut through the tape and the PVA bag for the alignment pin. Vacuum is applied and the wrinkles in the PVA sheet are smoothed out. <b>Fig. 39</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>AK Sockets Only</i></p> <p>The valve body may be placed before or after casting. If placement is done before casting, the valve body is filled with beeswax and glued with Barge cement to the PVA sheet on the male mold in the appropriate location. The valve body must be so located that it will not subsequently contact the wall of the female mold during the casting procedure. <b>Fig. 40</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>31. The female mold is placed in a bench vise or other supporting device, with the proximal end up and proximal edges horizontal. The male mold is oriented in the female mold by means of the alignment pin and placed all the way down on the pin. <b>Fig. 41</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>BK Sockets Only</i></p> <p>The posterior surfaces of the molds are butted in the region superior to the popliteal trim lines, and the orientation marks are aligned. The molds are taped together securely to maintain the alignment.</p> <p><i>AK Sockets Only</i></p> <p>The surfaces superior to the posterior and medial brims are butted and the orientation marks aligned. The molds are secured with tape. <b>Fig. 42</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>32. One to 1-1/2 qt of polyester casting resin for below-knee or 2 to 3 qt for above-knee sockets (depending on the size) are combined with the catalyst, with constant stirring. The manufacturer's instructions are followed regarding the amount of catalyst required to obtain a "slow setting time." Ideally, the resin should have a 1/2-hr gel time, which is adequate time for pouring. The resin is poured slowly and continuously while the female mold is simultaneously tapped to prevent any air bubbles being entrapped in the casting. <b>Fig. 43</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>33. After the resin has set to a soft gel (about 30 min), the tape around the PVA bags is removed, and the outer PVA bag and Dacron sleeve are removed. The male mold PVA bag is punctured around the pipe, and the female mold PVA bag is pulled secure and tied to the mandrel. <b>Fig. 44</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>34. After the resin has set to a firm gel (about 1 hr after pouring), the plaster strips are peeled off the slit in the female mold. The female mold is then removed by spreading the slit open, with care being taken not to tear the PVA bag on the transparent socket. The resin is allowed to cure for an additional hour at room temperature. <b>Fig. 45</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>35. The vacuum equipment is removed. The transparent socket (on the male mold) is heated in the oven at 165 deg F for 4 hours. The oven is turned off, and the socket is left until the oven cools to 125 deg F. This heat-treating helps to eliminate any internal stresses that may have developed during the curing phase. <b>Fig. 46</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Finishing The Socket</h4> <p>36. The PVA bags are cut along the proximal edge of the male mold. To protect the transparent socket surfaces from scarring, the PVA bags are left in place. The plaster slush mold is carefully chiseled away, and the mandrel and silicone shell are removed. <b>Fig. 47</b> - <b>Fig. 48</b></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 /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>37. The socket is cut down to the proximal trim lines, using a band saw and electric sander. The rough edges are smoothed by hand-rubbing with fine-grade sandpaper. The transparency can be restored to these edges by applying a surface coating of resin to the area, covering with a PVA sheet, and allowing to cure.</p> <p>38. Any flashing on the interior surface around the alignment pin is removed, and the bottom of the hole is sealed with tape. The hole is filled with resin and allowed to cure.</p> <p><i>AK Sockets Only</i></p> <p>If the valve body was placed before the casting, a hole saw of the same size as the valve body diameter is now used to bore through to the valve body. To improve the boring angle, the distal corner of the socket pedestal is sawed and ground down. <b>Fig. 49</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the valve body has not yet been placed, the anteromedial corner of the socket pedestal is sawed and ground off to provide a flat surface. Then, using a hole saw of the same size as the valve body diameter, a hole is bored through the socket wall. The valve body is carefully secured in place with either polyester resin or epoxy cement so that the inner surface of the valve body is flush with the inner surface of the socket. <b>Fig. 50</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>39. Before the socket is attached to an adjustable leg, the pedestal base is sanded flat and to the proper alignment angulation, using a disk sander. <b>Fig. 51</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>BK Sockets Only</i></p> <p>Suspension-strap retainers are attached to the below-knee socket with #8-32 flat-head machine screws. The holes may be countersunk by using an inside countersink tool. <b>Fig. 52</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>40. The socket attachment plate is fastened to the transparent socket by drilling and tapping eight holes in the pedestal base and securing with flat-head machine screws. <b>Fig. 53</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>41. The PVA bags are removed, and the completed transparent socket is polished with silicone spray and a soft cloth. (This spray is also a good lubricant to facilitate donning the socket.) <b>Fig. 54</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Completed above-knee socket mounted on an adjustable leg. <b>Fig. 55</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Completed below-knee socket.</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>Footnote</b></td></tr><tr><td class="clsTextSmall">R. Lipskin and T. Grille, The Development of the NYU Transparent Socket Fabrication Technique, November 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>Ronald Lipskin </b></td></tr><tr><td class="clsTextSmall">Present address: Prosthetics Center, Bioengi-neering Research Service, 252 Seventh Ave., New York, N. Y. 10001.</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>Thomas Grille </b></td></tr><tr><td class="clsTextSmall">Now with Key Mfg. Co., Brooklyn, N. Y. 11207.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-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 The NYU Transparent Socket Fabrication Procedure Creator An entity primarily responsible for making the resource Thomas Grille * Ronald Lipskin * Richard Hanak  https://staging.drfop.org/files/original/211972ac2450f7c379e75a6afbeee2dc.pdf ae8db5d5134f237d958bbd2b68be6d08 https://staging.drfop.org/files/original/520946adfb02dd1afbd9b4c67af73f08.jpg 61cd9ff898171a3445f27886c90a2493 https://staging.drfop.org/files/original/9170dd45d7ca4e14488f584a811dd23e.jpg fe5833e8ce6bc7bdf61f5f73baf816e3 https://staging.drfop.org/files/original/3b0777a43f09e4e4ee2114768fb56d30.jpg d22944087f7c13edf9ac4ccc260893d8 https://staging.drfop.org/files/original/fe459c0ecfb645ab7220642b51f9c593.jpg f2423f9a630bfe7e433bda250a03a58c https://staging.drfop.org/files/original/7cfdf4864b7be4044c17cc555926b0e2.jpg 05467aefe472260562820f5c91fb6f4c https://staging.drfop.org/files/original/54b46adc00046b649185688bcfa06ed8.jpg d9288be7f7a62533a8e62cb9e56ac3e8 https://staging.drfop.org/files/original/e21b7388fdb6d845283dd747b9618c11.jpg dfe82d1c37e1a9669c31bcfda7e97869 https://staging.drfop.org/files/original/c228c40b5262dd433fd295410cdae1e4.jpg 6f2c4233f38372d631252e490f83e18f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_01_013.pdf Year 1969 Volume 13 Issue 1 Page Number(s) 13 - 26 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_01_013.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_01_013.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>Clinical Evaluation of the Engen Plastic Hand Orthosis</h2> <h5>Hector W. Kay, M Ed. <a style="text-decoration:none;">*</a><br /></h5> <p>A primary function of the hand is prehension, the ability to grasp an object. While the hand can perform numerous types of grasp, of major importance is the type involving flexion of the index and middle fingers towards or against the opposing thumb to provide what is sometimes referred to as "three-jaw-chuck" prehension.</p> <p>Temporary or permanent paralysis can impair or completely inhibit the function of hand, wrist, or entire upper extremity, and the ability to oppose the thumb to the flexing fingers may be lost. In these instances, various types of orthotic systems have been designed to achieve the goals of prevention or correction of deformities, or restoration of function, or both. A key feature of these systems is the stabilization of the thumb in opposition to the fingers.</p> <p>Pioneering efforts in the area of hand-splinting were undertaken at the Georgia Warm Springs Foundation where many types of assistive devices were developed to meet the needs of a large patient population having residuals of poliomyelitis. Although the number of polio patients has decreased in recent years, rehabilitative medicine has expanded to include patients with many other types of neuromuscular and skeletal disorders. A systematic method of hand splinting to meet the needs of these patients has continued to be of paramount importance. On-going efforts in this regard have been maintained not only at GWSF but also at Rancho Los Amigos Hospital and other institutions. <a></a></p> <p>As part of Research Project VRA RD-1564, Thorkild J. Engen, Project Director, Baylor University College of Medicine, Houston, Texas, in 1959 initiated the development of a plastic hand orthosis having the basic configuration shown in <b>Fig. 1</b>. <a></a> Based on the premise that preservation of hand posture is best maintained by support, rather than suspension, the device is designed to hold the thumb in the opposed position and simultaneously support the metacarpal arch. The aim has been to develop a standardized item shaped to conform to the natural contours of the hand which could then be adapted to meet individual needs. The Engen orthosis is made in four sizes: large, medium-large, medium, and small; and for both right and left hands. Because the orthosis is fabricated of polyester resins, it can be remolded upon application of heat.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Basic Engen plastic hand orthosis being prepared for individual application. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the early stages of redevelopment, the Engen orthoses were fabricated of epoxy resins with and without fiberglass reinforcement. Ultimately these models were discarded because of breakage problems. The plastic shells originally submitted to New York University for a laboratory evaluation program were made of fiberglass and polyester resins. <a></a> The current shell is a polyester resin and nylon laminate prepared by means of a vacuum-molding technique. With the new materials, the fitting technique is essentially unchanged; the orthosis is molded and modified by the orthotist as necessary to provide a custom fit.</p> <p>In the course of development, attachments were devised or adapted to provide wrist support and to provide prehension.</p> <p>Three versions or adaptations of the Engen plastic hand orthosis were selected as the subject of the field evaluation: the short opponens orthosis, the long oppo-nens orthosis, and the reciprocal wrist-extension, finger-flexion unit. Additional modifications of the basic concept involving the use of external power were specifically not included in the study.</p> <h3>Short Opponens Orthosis</h3> <p>The so-called short opponens orthosis is the simplest application or adaptation of the Engen equipment. <a></a> It consists essentially of the basic hand shell with a retaining strap (<b>Fig. 2</b>). The prime purpose of this device is to maintain the thumb in apposition to the index and long fingers and to support the metacarpal arch. The functional goal is the achievement of "three-jaw-chuck" prehension as distinct from "lateral" grasp. Patients said to benefit from this orthosis are those with neuromuscular disorders resulting in various degrees of muscle imbalance of the intrinsic and opponens muscle groups. Such patients would typically have spinal cord injuries at the C-7, C-8, and T-l levels, peripheral neuropathy (ulnar and median nerves), or hemiplegia.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Two views of the short opponens orthosis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Long Opponens Orthosis</h3> <p>This adaptation <a></a> consists essentially of the basic plastic hand shell with an attached extension arm which is stabilized on the forearm by appropriate straps (<b>Fig. 3</b>). Like the short opponens orthosis, this device is designed to prevent deformity and achieve "three-jaw-chuck" prehension if the necessary residual muscle movements are present and can be controlled. Patients with spinal lesions at the C-5, C-6 levels, peripheral neuropathy involving the median or ulnar nerves, or both, and the radial nerve, or hemiplegia, are said to be suitable candidates for this device.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Two views of the long opponens orthosis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Reciprocal Wrist-Extension Finger-Flexion Orthosis</h3> <p>This adaptation, which is the most complex of those studied, is designed to provide prehension when voluntary wrist-extension power is available (<b>Fig. 4</b>). Quadriplegic patients who retained innervation to the wrist-extensor muscles are said to be appropriate subjects for this type of functional orthosis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Two views of the reciprocal orthosis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Procedures</h3> <h4>Participating Clinics and Personnel</h4> <p>As an initial step in the activation of the proposed field study, the Committee on Prosthetics Research and Development, through its staff and Subcommittee on Evaluation, selected five treatment centers known to be active and interested in the application of hand splints. These clinics were approached and each agreed to participate in the study. The institutions and personnel involved were:</p> <ol> <li>Duke University Medical Center, Durham, N. C. (Frank W. Clippinger, Jr., M.D.; Bert R. Titus; Felton Elliott).</li><li>Georgia Warm Springs Foundation, Warm Springs, Ga. (Edward Haak, M.D.; H. G. Bowden).</li><li>Highland View Hospital, <a style="text-decoration:none;">*</a> Cleveland, Ohio (Al-vin A. Freehafer, M.D.; Arthur Guilford, Jr., G. A. Guilford and Sons).</li><li>Ohio State University, Columbus, Ohio (Marvin H. Spiegel, M.D.; Lawrence Czap; Charles W. Rosenquist, Columbus Orthopaedic Appliance Co.).</li><li>Veterans Administration Hospital, Hines, Ill. (James F. Kurtz, M.D.; Vladimir T. Liberson, M.D.; Walter J. Piotrowicz, CO.).</li></ol> <h4>Instruction In Fabrication Procedures</h4> <p>The study of the Engen devices was initiated by an instructional course in the three applications to be evaluated. This course was conducted by the developer and his staff at the Texas Institute for Rehabilitation and Research, Houston, Tex., from Dec. 5 to 8, 1966 (orthotists, four days; physicians, one day). Instructional material and fitting check lists were prepared by the developer, <a></a> and used as the basis for the course. A special training session for Mr. Sigars was conducted December 4-6, 1967, after he joined the Rancho Los Amigos Hospital team.</p> <h4>The Study Plan</h4> <p>Concurrent with the recruitment and training of participating clinic personnel, the CPRD staff, in collaboration with the developer, and under the guidance of its Subcommittee on Evaluation, prepared the schedule and data-recording forms for the study. <a></a></p> <p>Essentially, each clinic was requested to seek patients appropriate for applications of the Engen devices. Data related to the fittings would be recorded on the forms developed by the Committee on Prosthetics Research and Development. Each patient fitted was to be followed for a period of 12 months unless treatment was terminated prior to that time. The CPRD staff was to provide liaison with the field clinics as necessary during the course of the study.</p> <h3>Results</h3> <h4>Technique Transferability</h4> <p>With a new fabrication or fitting technique which is said to yield excellent results in the hands of the developer, an important consideration is whether or not the skill and "know-how" involved in the applications can be successfully transferred to others.</p> <p>In the present study the means of achieving this transfer were: (1) Written instructional material prepared by the developer; (2) A course of instruction which included practice in the fabrication of devices; and (3) Follow-up visits made by the developer to each participating facility. Problems encountered locally were analyzed and supplementary instruction given.</p> <p>It was the consensus of the evaluation team as well as that of the participants that the fabrication techniques for the three EPHO adaptations under study were successfully transmitted by these procedures. Moreover, while the orthotists participating in the evaluation were selected and highly skilled, indications were that less skilled technicians could be satisfactorily taught by the same methods.</p> <h4>Patient Fittings</h4> <p><i>The Sample</i></p> <p>During the period of the evaluation program, 22 patients were fitted with the Engen Plastic Hand Orthosis. Distribution in terms of the three adaptations under study were: short opponens orthosis, 7; long opponens orthosis, 3; and reciprocal units, 12.</p> <p>Moreover, data was available on an additional 48 patients distributed as follows: short opponens orthosis, 11; long opponens orthosis, 7; and wrist-driven reciprocal units, 30. These patients were fitted at Hines VA Hospital following the closure of the official phase of the study. Some findings of interest from these additional fittings are included.</p> <p>In the total of 70 fittings reported, 18 were with short opponens, 10 with long opponens, and 42 with reciprocal units, roughly a 2:1:4 ratio. Whether this ratio could be extrapolated to the general population is not known.</p> <p>Typical conditions for which the three versions of the EPHO<a style="text-decoration:none;">*</a> were applied were: (1) short opponens orthosis: rheumatoid arthritis of the hands (<b>Fig. 5</b>); quadriplegia (to prevent deformities and support the hand in a position of function pending fitting of reciprocal units); contraction deformity of the wrist; (2) long opponens orthosis: quadriplegia (as a stabilizing device pending reduction of contractures and fitting with a reciprocal unit) (<b>Fig. 6</b>); or as a base for the addition of self-help devices (<b>Fig. 7</b>); reciprocal units: quadriplegia (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Left, palmar and dorsal views of patient's arthritic hands. Above, left hand fitted Engen short opponens orthosis and Thomas outrigger splint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Patient fitted with Engen long opponens orthosis as stabilizing device. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Patient fitted with Engen long opponens orthosis with attachment for self-help devices. Note atrophy of thenar cleft. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Patient fitted with reciprocal unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Outcomes</i></p> <p>Results of the fittings in the five participating clinics were variable, success or failure being related primarily to three factors:</p> <ol> <li>Proper selection of patients. In several of the clinics patients were selected under somewhat experimental circumstances, that is, either the motivation of the patients was less than optimal or the anticipated benefit to be derived from the Engen device was marginal. In these instances, the fittings typically proved to be failures.</li><li>Objectivity in the evaluation of outcomes. Two of the clinics participating in the study had devices of their own design which were "competitive" with the Engen items. Personnel of these clinics were of the opinion that the Engen devices provided no features superior to their own devices other than perhaps the telescoping rod on the reciprocal unit application.</li><li>Meticulous care in application and follow-up. Although the Engen Plastic Hand Orthosis is essentially a prefabricated shelf item, it must be carefully tailored to the needs of the individual patient. This tailoring may involve: (a) some reshaping of the plastic shell to accommodate atrophy or size discrepancy in the patient's hand; (b) the addition of accessory finger pieces and other equipment to the basic Engen shell.</li></ol> <p>Moreover, since the condition of the patient's hand changes with time and with the use of the Engen splint, follow-up to maintain fit of the device is essential. This follow-up is obviously best accomplished when the patient is being treated on an in-patient basis, in-house orthotic facilities are available, and there is close cooperation between the disciplines involved in the care of the patient.</p> <p>Where the foregoing conditions were satisfactorily met, excellent success was achieved in the fittings of the Engen devices. Selected cases which illustrate the applications and outcomes of the three EPHO modifications under study are presented below.</p> <h3>Case Presentations</h3> <h4>Short Opponens Orthosis</h4> <p><i>Case No. 1</i></p> <p>A. M. was a 40-year-old male with a diagnosis of quadriplegia resulting from a physiologically incomplete lesion of the spinal cord at the C-5 level. A short op-ponens orthosis was prescribed for his right, dominant hand with a view to aiding in the restoration of function, and the prevention and correction of deformities. It was hoped that eventually Mr. M. would be a candidate for a right reciprocal unit. The patient was described as having a motivational level of fair and a tolerance to pain that was average.</p> <p>Mr. M. was fitted with a medium-sized orthosis. The suitability of the preformed size and shape was rated as good and the ease of customizing and the clarity and completeness of the instructions for doing so were also rated as good. No special modifications of the shell were necessary for this patient.</p> <p>A. M. was reevaluated at 1, 3, 6, 9, and 12 months following the initial fitting. The efficacy of the splint in achieving the objectives of the fitting was rated as good in all respects. The patient's performance in such activities as turning pages in a book and writing was rated as fair. The performance in feeding and using a toothbrush was cited as being poor. The patient's reactions to the orthosis were good with respect to fit, comfort, and cosmesis, and fair as regards function. During the course of his treatment the patient was given physical and occupational therapy and special instruction in the use of the Engen device. He was also given medication for spasticity which did not involve the hands.</p> <p>The evaluation of the device with regard to this patient remained remarkably consistent throughout the entire 12 months of the test period except that the patient's own reactions to the functional assistance provided by the device declined from fair to poor from the third month on.</p> <p>The outcome in this instance was considered to be excellent, but two other patients, D. R. and J. A., whose initial conditions were remarkably similar, withdrew from the study one and four months, respectively, after the initial fitting. In these two instances the restoration of function achieved with the orthosis was minimal and this factor, combined with low levels of motivation, resulted in the withdrawals.</p> <p><i>Case No. 2</i></p> <p>Patient N. E. was a 60-year-old male with a diagnosis of rheumatoid arthritis of some eight years' duration. He was prescribed an EPHO short opponens orthosis for his right, dominant hand, the objectives being assistance in the restoration of function and the prevention and correction of deformities. His tolerance to pain was described as average, and his skin condition as thin, and his motivational level was said to be good.</p> <p>N. E. was fitted with the large-sized EPHO shell. With regard to the fitting, the suitability of the preform size and shape was rated as good, as were the ease of customizing and the clarity and completeness of instructions. No special modification was necessary initially, but some five weeks later a Thomas outrigger suspension was applied to prevent further subluxation of the metacarpophalangeal (MCP) joints (<b>Fig. 5</b>). Mr. E. was reevaluated at 1, 3, 6, 9, and 12 months following fitting and then left the clinic area taking the provided splint with him.</p> <p>Initially the achievement of objectives involving the prevention and correction of deformities was rated as good, but the restoration of function as poor. Mr. E.'s performance in typical activities of daily living were all rated as poor. The patient's reactions to the device were good with respect to fit, comfort, and cosmesis, but poor as regards function.</p> <p>As Mr. E. continued to wear the experimental device his ratings in all performance activities were raised to fair, and finally to good in such activities as page-turning, writing, and feeding. The patient's rating of the functionality of the device gradually improved until finally it was reported as good.</p> <p>In this fitting the outcomes appeared to be positive from the beginning with respect to the prevention and correction of deformities with gradually increasing benefit in the area of function.</p> <h4>Long Opponens Orthosis</h4> <p><i>Case No. 3</i></p> <p>Patient J. K. was a 21-year-old male. His primary diagnosis was quadriplegia with a spinal-cord injury at the C-5, C-6 levels which was incurred some nine months prior to his inclusion in the evaluation program. He was fitted with an EPHO long opponens orthosis, medium-size, to the right hand which was less impaired than the left. His hands were atrophied, especially in the thenar-cleft area, and he had a slight lateral palmar drift on the (right) hand fitted. The patient's motivational level was said to be good and his pain tolerance average. The objectives of the fitting were restoration of function, and prevention and correction of deformities in the hope that he might eventually be fitted with a reciprocal orthosis.</p> <p>The application of the device proceeded without difficulty except that the device was somewhat too large for the patient's atrophied thenar-cleft area. The splint tended to displace itself into this area. Three weeks after the initial fitting a reduction in the cock-up angulation was recommended by the developer, together with the addition of a T-bar to abduct the thumb and a dorsal strap for better retention.</p> <p>The patient preferred the EPHO splint to his previously worn Royalite device and requested that the EPHO be modified to include the self-aid attachments worn on the earlier splint. The device was subsequently reinforced with a Monel metal piece and has held up well since that time. The patient's flexed lateral palmar drift was held in proper position by the orthosis.</p> <p>At the one-month follow-up of this patient the ratings of outcomes were generally poor to fair with only the patient's reaction to the cosmesis of the device being designated as good. However, steady improvement occurred throughout the follow-up period, and by 9 months after initial fitting the device was rated as good in all characteristics specified in the evaluation program. Thus, in this instance, the outcomes of fitting the Engen plastic hand orthosis must be considered as excellent.</p> <p><i>Case No. 4</i></p> <p>On another patient, F. G., with a somewhat similar disability, the results of the fitting were considerably less positive. This patient was a 40-year-old male with complete transverse severance of the spinal cord at the C-6, C-7 levels. The injury to this patient had occurred some six and a half years prior to the present study and he had had a surgical transfer of the brachioradialis tendon to the wrist extensors on his left hand several years previously. The hand tended to go into marked radial deviation on voluntary extension of the wrist. He could raise his elbows and shoulders bilaterally. He had muscle spasms.</p> <p>F. G. was fitted with a medium-sized long opponens orthosis and it was immediately noticeable that the splint would not hold the patient's marked radial deviation. At the developer's suggestion the cock-up angle of the splint was reduced to prevent creeping and a plastic clip added on the proximal medial side. A lateral Velcro strap was added to pull the ulnar side of the wrist toward the radial side, and an elastic sling was added to correct the flexion of the interphalan-geal (IP) joint of the thumb. The patient was to be considered for a reciprocal orthosis if his contractures could be reduced. The patient's motivational level was rated as poor with respect to any type of splinting.</p> <p>The outcomes of this fitting initially were also mixed and failed to show appreciable improvement, particularly with regard to function, over a 6-month follow-up period. The patient was then taken off the program at his own request.</p> <h4>Reciprocal Wrist-Extension Finger-Flexion Orthosis</h4> <p><i>Case No. 5</i></p> <p>Patient V. C. was a 42-year-old male who had sustained a spinal-cord injury at age 26. His primary diagnosis was "dislocation and compression of the spinal cord at the C-5, C-6 levels with complete paralysis." With no prior experience with orthotic devices, he was fitted with a reciprocal unit on his right, dominant hand. His motivational level was rated as good, but his pain tolerance was given as low. The objectives of the fitting were restoration of function and prevention and correction of deformities.</p> <p>The fitting utilized a large reciprocal orthosis and finger pieces but a medium-sized forearm piece. The component sizes were considered to be good for this patient. However, the shape of the plastic shell did not provide good support for the arch of the hand or conform well to the thenar-cleft area. A thumb sling and a middle-finger IP stabilizer were added. A later review of this case indicated that the MCP and the wrist joints were incorrectly placed. With these conditions the patient had no desire to try and use the splint and did not wish to keep it. Replacement of the malpositioned joints effected a marked improvement in the function of the device and the patient's acceptance of it. This high level of performance and acceptance was maintained throughout the remainder of the patient's 12-month participation in the study. In this case, obviously the difference between success and failure hinged on the proper joint positioning, emphasizing the importance of this aspect of the fitting. This type of experience was repeated with a number of other patients in the evaluation.</p> <p><i>Case No. 6</i></p> <p>Patient W. M. was a 47-year-old male who sustained a spinal-cord injury approximately one year prior to being fitted with the Engen orthosis. His diagnosis was given as "compression of cord, level C-5, C-6 incomplete, C-7 complete." Mr. M.'s motivational level was said to be good, but his pain tolerance was given as low. He was fitted with a reciprocal orthosis on his right, dominant hand, the objectives being restoration of function, and prevention and correction of deformities.</p> <p>The initial application of the device seemed to proceed satisfactorily, the component parts being a large plastic shell, a larger finger unit, and a large forearm piece. The sizes and shapes of the various components seemed to be appropriate. Three days later a "knuckle bender" was added because of tightness of the MCP joints and a modified Oppenheimer splint was fitted to increase the limited range of wrist extension and thumb abduction.</p> <p>A later review of this case indicated that the joint hinges had been incorrectly positioned and this deficiency was corrected. Again a dramatic improvement in the achievement of fitting objectives, functional level and patient acceptance, was evident, although this subject's function was not as good as that of the previous patient. This case again illustrates the importance of joint positioning and indicates the use of the Engen basic equipment as a module to which other accessories might be added.</p> <h3>Summary and Recommendations</h3> <p>In the present study it would appear evident that orthotists with prior experience and skill in the fabrication of hand splints can be taught to apply the EPHO variations successfully. In this connection the instructional manual and fitting checkout sheets developed in conjunction with the field study provided an excellent basis for the transfer of techniques from developer to field orthotists. However, this written material is not regarded as an adequate substitute for direct person-to-person instruction. Moreover, a follow-up visit to each of the clinics following initial fittings helps to insure that the techniques taught are being properly applied and assists in the solution of specific local problems.</p> <p>The outcomes of the field fittings of the Engen equipment were mixed, positive results being related primarily to three factors: (1) proper selection of patients, including consideration of motivational factors; (2) meticulous care in application and follow-up of the devices; and (3) objectivity in evaluating outcomes. Where these considerations were observed, the successful outcomes achieved support the developer's claims for the device.</p> <p>Fitting results for each subject in the study showed no significant changes after 6 months' wear of the Engen device. Hence, consideration might be given to reducing the follow-up period in similar future studies from 12 to 6 months.</p> <h4>The Devices</h4> <p><i>Prescription Criteria</i></p> <p>The criteria for prescription of the Engen adaptations as set forth above were re-affirmed by the results of the field study. The following additional comments also emerged:</p> <ol> <li>Short Opponens Orthosis <ul><li>a. has been found useful as a stabilizing splint in several instances of postsurgical management;</li> <li>b. has been used in providing patients with various self-help devices as attachments to the basic shell;</li> <li>c. with special modifications has been used in rheumatoid arthritic cases to help prevent ulnar and radial finger drift and align the fingers in proper position for finger prehension;</li> <li>d. has been used as the stabilizing splint pending evaluation for application of a reciprocal unit.</li></ul></li><li>Long Opponens Splint with Extension Arm Support <ul><li>a. has also been utilized for the same applications as the short opponens orthosis above.</li></ul></li></ol> <h4>Specific Findings</h4> <p>Specific findings relating to the design and applications of the EPHO devices were:</p> <ol> <li>Although the Engen Plastic Hand Orthosis is ostensibly a prefabricated shelf item, it must be carefully tailored to the needs of the individual patient. This tailoring may involve: <ul> <li>a. some reshaping of the plastic hand shell to accommodate atrophy or size discrepancy in the patient's hand;</li> <li>b. the addition of accessory finger pieces and other equipment to the basic Engen shell.</li></ul></li><li>In the installation of the EPHO reciprocal orthosis, great care must be exercised in the location of the joint axes.</li><li>Since the condition of the patient's hand changes with use of the Engen splint, follow-up to maintain fit of the device is essential. This follow-up is best accomplished when the patient is being treated on an in-patient basis, in-house orthotic facilities are available, and there is close cooperation between the disciplines involved in patient care.</li><li>The telescopic rod feature of the reciprocal unit was frequently cited as a most significant new characteristic of this type of orthosis.</li><li>Although definitely related to the level of experience gained in the application of the EPHO devices, saving of the orthotist's time was a significant feature of the system.</li><li>Some deficiencies in the design and materials of the EPHO were noted: <ul> <li>a. The range of three sizes provided initially were considered inadequate but the addition of the fourth (medium-large) size virtually eliminated this problem.</li> <li>b. A very common problem was that of fitting the hand shell to atrophied thenar-cleft musculature. The likelihood that this problem would be encountered and measures for adapting the shell to meet it should be emphasized in the instructional material.</li> <li>c. Some problems were encountered with stripping and bending of the telescopic rods.</li> <li>d. Some tendency for the shells to revert to their original shape after heating and modification was reported. However, in general, the physical properties of the splints were considered adequate to last an indefinite period with proper care and maintenance.</li></ul></li></ol> <p>In conclusion, the field evaluation of the EPHO adaptations clearly revealed that the devices are useful additions to the armamentarium of orthotic items available for the treatment of patients with disabilities of the hand. It is recommended that the outcomes of this study be forwarded to the prosthetics-orthotics schools with a view to the possible inclusion of instruction in this system as part of the orthotics curriculum.</p> <p><b>References:</b></p> <ol> <li>Anderson, Miles H, <i>Upper extremities orthotics</i>, Charles C Thomas, Springfield, Ill., 1965.</li> <li>Bisgrove, J. G., <i>A new functional dynamic wrist extension-finger flexion hand splint, a preliminary report</i>, J. Assoc. Phys. Ment. Rehab., 8:5:162-163, September-October 1954.</li> <li>Engen, Thorkild J., <i>A plastic hand orthosis</i>, Orthop. Pros. Appl. J., 13:2, September 1959.</li> <li>Engen, Thorkild J., <i>A "modification" of a reciprocal wrist extension-finger flexion orthosis</i>, Or-thop. Pros. Appl. J., 14:1, March 1960.</li> <li>Engen, Thorkild J., <i>Instructional manual for a reciprocal wrist extension-finger flexion orthosis</i>, Baylor University, Houston, Tex., 1: April 1968.</li> <li>Engen, Thorkild J., <i>Fabrication instructions, long opponens orthosis,</i> unpublished.</li> <li>Engen, Thorkild J., <i>Fabrication instructions, short opponens orthosis</i>, unpublished.</li> <li>Kay, Hector W., and A. Bennett Wilson, Jr., <i>Clinical evaluation of prosthetic and orthotic devices and techniques</i>, Committee on Prosthetics Research and Development, National Academy of Sciences, Washington, D.C., 1969.</li> <li>Vorchheimer, Heidi, <i> Summary of fittings - Engen hand orthoses</i>, Prosthetic and Orthotic Studies, New York University, June 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>Footnote</b></td></tr><tr><td class="clsTextSmall"> Utilizing the basic Engen items as modules to which accessory equipment was added if indicated by the needs of the patient.</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">Kay, Hector W., and A. Bennett Wilson, Jr., Clinical evaluation of prosthetic and orthotic devices and techniques, Committee on Prosthetics Research and Development, National Academy of Sciences, Washington, D.C., 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>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Engen, Thorkild J., Instructional manual for a reciprocal wrist extension-finger flexion orthosis, Baylor University, Houston, Tex., 1: April 1968.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Engen, Thorkild J., Fabrication instructions, long opponens orthosis, unpublished.</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Engen, Thorkild J., Fabrication instructions, short opponens orthosis, unpublished.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Kay, Hector W., and A. Bennett Wilson, Jr., Clinical evaluation of prosthetic and orthotic devices and techniques, Committee on Prosthetics Research and Development, National Academy of Sciences, Washington, D.C., 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">Unfortunately, the Highland View Hospital team had to withdraw prior to the commencement of the study. It was replaced by a team from Rancho Los Amigos Hospital consisting of E. Shannon Stauffer, M.D., and Dale Fries, orthotist. In the course of the study, Mr. Fries transferred to another position and was replaced by Mr. Charles Sigars.</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">Engen, Thorkild J., A plastic hand orthosis, Orthop. Pros. Appl. J., 13:2, September 1959.</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">Engen, Thorkild J., A plastic hand orthosis, Orthop. Pros. Appl. J., 13:2, September 1959.</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">Vorchheimer, Heidi, Summary of fittings - Engen hand orthoses, Prosthetic and Orthotic Studies, New York University, June 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>3.</b> </td><td class="clsTextSmall">Engen, Thorkild J., A plastic hand orthosis, Orthop. Pros. Appl. J., 13:2, September 1959.</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>1.</b> </td><td class="clsTextSmall">Anderson, Miles H, Upper extremities orthotics, Charles C Thomas, Springfield, Ill., 1965.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bisgrove, J. G., A new functional dynamic wrist extension-finger flexion hand splint, a preliminary report, J. Assoc. Phys. Ment. Rehab., 8:5:162-163, September-October 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>Hector W. Kay, M Ed. </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development, 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/1969_01_013/spring69-13.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_01_013/spring69-14.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_01_013/spring69-15.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_01_013/spring69-16.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_01_013/spring69_17.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_01_013/spring69_18.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_01_013/spring69-19.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_01_013/spring69-20.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 Clinical Evaluation of the Engen Plastic Hand Orthosis Creator An entity primarily responsible for making the resource Hector W. Kay, M Ed. * https://staging.drfop.org/files/original/563b7e3d5e654828605f04deb909797d.pdf bdd8ac1d4ea751b6467591119d581c32 https://staging.drfop.org/files/original/06192bdad0f19b8b8f1a62b6de034970.jpg b1d165ad8953da55d9ae82c37eb333fa https://staging.drfop.org/files/original/11faed39014403a6dc246e19447a1e04.jpg e053bf6273abb66dfc3e4b534d6f0ef2 https://staging.drfop.org/files/original/ab3f22ae3bf0b961414fc0148beb8ad2.jpg c8cc8b308e2f932c66508ebcb3918fe5 https://staging.drfop.org/files/original/a98488decd50e21af69363b9e67475e2.jpg 8ae2865195228b7aca7c75f753e4584b https://staging.drfop.org/files/original/3104c38e2e1fdde67ea076415c929bf7.jpg ce62f98c13cdfb73a43c7b2f673348df https://staging.drfop.org/files/original/1bfb3db8f0a4653731d81faa29559635.jpg bc64124b91d9ba11eef6f8356c5d0319 https://staging.drfop.org/files/original/1a846b2a0fe0a6fddc0540823690ccff.jpg d1f0c1cb1a48e93b1be62020126a530d https://staging.drfop.org/files/original/54f4c041c313324c6dd89aba4c7335e8.jpg 1a38657457516471793399d4f2ade79f https://staging.drfop.org/files/original/c5555a3c031f1ad854aeee2c5fbd1376.jpg 836517a1021bc3d397aab93236925ba2 https://staging.drfop.org/files/original/ddd6cf419da77ba7ed5f5f1bcf7c62b3.jpg adca9e2f32b00a97ee7de032d4c3efc4 https://staging.drfop.org/files/original/8a780fa990993d128a1889acb02fe387.jpg a021a16bcf45de281a02a47e05ebe5a8 https://staging.drfop.org/files/original/1657876e7ff4af53ca8144dee7ddb077.jpg 9dd2ddab021621e602392a91ed65eae6 https://staging.drfop.org/files/original/7da95365c1b01ff987fb41f4868ee168.jpg e09de561d7cb9a7fe09ddbb9766aafe6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_02_001.pdf Year 1969 Volume 13 Issue 2 Page Number(s) 1 - 12 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_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_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>Recent Advances in Below-Knee Prosthetics</h2> <h5>A. Bennett Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>The concept of constructing a below-knee prosthesis with side joints and a thigh lacer was set forth by the Dutch surgeon Verduin in 1696 (<b>Fig. 1</b>) and followed universally until the advent of the patellar-tendon-bearing prosthesis in the late 1950's. <a></a> Although other innovations such as contact over the distal end of the stump, suction suspension, and "muley" sockets were introduced from time to time, they were never widely used, possibly because principles governing their use were not set forth in a systematic manner.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Verduin leg (1696). From MacDonald, J., Amer.J. Surg., 1905. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In 1957, the predecessor of CPRD, the Advisory Committee on Artificial Limbs, encouraged the University of California at Berkeley to study the problems of the below-knee amputee and to improve the then current management practices. As a result, some of the leading prosthetists in this country were invited to Berkeley later in 1957 for the express purpose of examining in detail the prosthetics practices for BK amputees and rationales for those practices. <a></a> An analysis of the findings of that conference led to the development of the patellar-tendon-bearing prosthesis, known now as the PTB prosthesis.</p> <p>The original version of the PTB prosthesis was a plastic laminate socket which was formed over a modified plaster-of-Paris model of the stump, and which contained a soft inner liner that contacted the entire surface of the stump. <a></a> The major weight was borne by the medial flares of the tibia and the patellar tendon. No knee joints or thigh corsets were used, suspension being effected by a fabric strap around the thigh just above the femoral condyles (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Cutaway view of the original patellar-tendon-bearing (PTB) prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The PTB concept was offered in formal education programs in this country and gradually gained acceptance, so that by 1961 slightly more than half of the below-knee prostheses provided in the United States were of that type. <a></a> The concept also has been accepted widely in other countries, and the PTB now is generally considered to be the standard prosthesis for below-knee amputations.</p> <p>In recent years, research groups and individual prosthetists have introduced improvements to the basic concept. <a></a> This article describes the advanced practices in the management of the below-knee amputee that have been developed since the introduction of the PTB prosthesis.</p> <h3>The Hard Socket</h3> <p>The original PTB socket design called for a lining of leather or Naugahyde backed by sponge rubber. Perspiration caused problems in many instances, however, because Naugahyde does not "breathe" and leather deteriorates rapidly in the presence of sweat. This problem prompted some prosthetists to eliminate the liner, and the "hard" PTB socket has become increasingly popular.</p> <h3>The PTS Socket</h3> <p>The suspension strap for the PTB prosthesis, as designed originally, was usually satisfactory, but there were enough dissatisfied amputees to prompt a number of prosthetists to seek improved suspension methods. In addition to developing different strap designs (<b>Fig. 3</b>) <a></a>, several groups experimented with new configurations for the proximal border of the socket. The research team at Nancy, France, introduced the "prothese tibiale a emboitage supracondylien," popularly known as the PTS, in which the proximal border extends above the patella and the femoral condyles (<b>Fig. 4</b>), <a></a> thus holding the socket on the stump. This concept was introduced into the United States by Nitschke and Marschall <a></a> and the PTS prosthesis is being used at an increasing rate in the United States. The technique may be used with or without a liner. Hamontree <a></a>, in reporting his experiences with 94 cases, noted that, although he believed that the majority of the patients could have been satisfied with the original version of the PTB, a certain percentage could have been successfully fitted only with the PTS version.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Left, continuous-strap suspension arranged in a figure eight with Velcro for adjustment; right, anterior view of two inverted V-straps looped through a ring and attached inside a hard socket close to the brim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. A right, below-knee stump and the amputee wearing a PTS-socket prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Wedge Suspension Socket</h3> <p>Another attempt to improve upon the strap type of suspension resulted in the KBM (Kondylen Bettung Munster) prosthesis <a></a>, in which a small wedge is inserted between the proximal area of the socket and the area of the stump along the medial condyles of the femur (<b>Fig. 5</b>). Developed at the University of Munster, this concept was introduced into the United States by Fillauer <a></a> and is now known as the supracondylar-wedge suspension system. The wedge system may be used with or without a socket liner, but generally no liner is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The supracondylar-wedge suspension method. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Air-Cushion Socket</h3> <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, Wilson and his associates <a></a> designed and developed the "air-cushion socket" (<b>Fig. 6</b>), which reduces the magnitude of the vertical components of weight-bearing forces at other points on the stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Cutaway view of the air-cushion socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The air-cushion PTB consists of an elastic inner sleeve (stockinet impregnated with silicone rubber) suspended from the level of the tibial tubercle in a rigid outer shell that is closed distally. Stump support is provided by the tension of the sleeve itself and by the compression of the air in the chamber between the inner sleeve and outer cap.</p> <p>Trials in the United States, Denmark, and Yugoslavia <a></a> have shown that the air-cushion version of the PTB is particularly useful for patients with very sensitive stumps. In fact, there appear to be few, if any, contraindications to the use of the air-cushion socket, the only disadvantages being that slightly more time is required to fabricate the socket and that few modifications can be made after it has been fabricated.</p> <h3>Porous Socket</h3> <p>In seeking ways to alleviate the problems caused by perspiration, the U. S. Army Medical Biomechanical Research Laboratory developed a porous plastic laminate. <a></a> Conventional epoxy resins and filler materials are used in the fabrication, but special care must be taken in controlling the proportions of the ingredients and in curing. The first porous laminates developed by AMBRL were satisfactory for upper-extremity sockets, but they were not strong enough for routine use in lower-extremity sockets. Subsequently, the technicians developed a fabrication technique using epoxy resins that overcame the major shortcomings of the earlier laminates. <a></a> New York University, after studying 20 children and young adults, reported that the porous-laminate socket appeared to be a "significant and worthwhile addition" to below-knee prosthetics specifically and to limb prosthetics generally. <a></a> There were fewer problems with perspiration, and skin eruptions were ameliorated. In addition, the prostheses with porous-laminate sockets weighed less. When perspiration was a major problem, the two disadvantages cited-slightly increased fabrication time and greater difficulty in maintaining socket cleanliness-were far outweighed by the advantages.</p> <p>Because most of the innovations to the original PTB design are not mutually exclusive, it was possible to develop a chart showing the combinations of features that can be used to devise a below-knee prosthesis that best meets the needs of the individual patient (<b>Fig. 7</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 /> <h3>Casting Methods</h3> <p>The method for obtaining a model of the stump for fabrication of the PTB socket, as described in the original manuals, consisted of wrapping the stump with plaster-of-Paris bandages, shaping the wrap with the fingers, and subsequently modifying the male mold produced from the female cast, or wrap. Any number of attempts have been made to devise a procedure that would require less skill. One such method that has been accepted by many prosthetists is the sling-casting, or suspension-casting, technique developed by Hampton <a></a> (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Ring and sock for suspension casting of the below-knee stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the suspension-casting technique, the stump is wrapped while it is held in a vertical position that simulates weight-bearing during standing. Felt patches to provide relief for sensitive areas of the stump can be applied directly to the stump, and a minimum amount of modification is necessary, although the need for modification is not eliminated entirely.</p> <p>Research workers and clinicians have been searching for years for a material that will enable the prosthetist to form a socket directly over the stump, thereby eliminating the need for plaster wraps and male molds. Experience with a synthetic rubber, Polysar<a style="text-decoration:none;">*</a> X-414, has shown that this material definitely has a place in the fabrication of sockets. <a></a> Temporary, or provisional, below-knee prostheses consisting of a synthetic-balata socket and pylon-type components are proving to be useful. Because it becomes pliable at temperatures easily tolerated by the skin, synthetic balata can be applied directly over the stump. Extruded tubing of various diameters with walls 1/4-in. thick is available. A piece of tubing slightly smaller in diameter than the stump is heated in water to about 160 deg F, then forced over the stump, which has been padded in appropriate areas (<b>Fig. 9</b>). To give proper shape to the socket, a length of pressure-sensitive tape, 1 in. wide, is wrapped over the outside, and final forming is carried out manually. To provide total contact, the distal end is filled with "foam-in-place" silicone. The socket is easily mounted on a pylon unit for use as a temporary prosthesis, or a more permanent one if desired. The prosthesis can be given a natural appearance by applying and shaping semirigid blocks of Koroseal "Spongex"<a style="text-decoration:none;">*</a> (<b>Fig. 10</b>). Contours of the socket can be changed at any time by heating the area with a heat gun and reshaping it manually.<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Top, application of socket tube to the stump; bottom, trimming of socket brim prior to final molding. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Foam blocks for fitting over pylon and socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Time of Fitting</h3> <p>During the past decade, the advantages of fitting a prosthesis as soon after amputation as possible have been demonstrated repeatedly. Goldner and his associates <a></a> demonstrated that "early" fitting-that is, providing the patient with a temporary prosthesis as soon as the wound has healed rather than waiting for a maximum amount of shrinkage to take place-could drastically reduce time and costs of rehabilitation. Even more dramatic results have been obtained by fitting artificial limbs immediately after surgery, especially with below-knee amputees <a></a> (<b>Fig. 11</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. 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." Inset: A below-knee amputee fitted with the immediate postsurgical prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The technique of immediate postsurgical fitting was originated in France by Berlemont, was carried further by Weiss in Poland, and, after a considerable experimentation period in the United States, is now being taught routinely in the prosthetics education programs in this country. <a></a> The technique consists of applying a rigid dressing over the stump and attaching an adjustable pylon and foot. Standing and ambulation is begun as soon as the patient's condition permits. For young, otherwise healthy patients, some ambulation can begin on the day following amputation.</p> <p>Usually the rigid dressing is left in place until the wound has healed and the sutures can be removed-about 10-14 days postoperatively. A second rigid dressing is provided for another 10- to 14-day period, at which time a "permanent," or definitive, limb can be provided. The advantages of immediate postsurgical fitting include reduction of edema, less pain, shorter periods of hospitalization and therapy, and fewer contractures. The technique has become standard practice in many centers with trained teams. <a></a></p> <h3>Hardware</h3> <p>To make early fitting and immediate postsurgical fitting easier, a number of adjustable pylons have been developed. Those currently available are shown in <b>Fig. 12</b>. Some of their characteristics are given in <b>Table 1</b>. These units are strong enough and light enough for extended usage with or without some sort of cosmetic cover. A number of approaches to cosmetic treatment such as the use of Spongex, mentioned above, have been offered, but none have been accepted widely by prosthetists. Work on this problem is continuing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Below-knee pylon-type prostheses that can be used for fitting immediately after surgery. A, Hosmer Postoperative Pylon; B, Northwestern Pylon (Hosmer); C, Veterans Administration Prosthetics Center (VAPC) "Standard" Pylon; D, Canadian "Instant" Prosthesis (Hosmer); E, United States Manufacturing Co. Pylon; F, Finnie-Jig (Arthur Finnieston Co.). Metal straps for attachment to a plaster-of-Paris socket are available, but not shown. Courtesy of Veterans Administration Prosthetics 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 /> <h3>Education and Research Needs</h3> <p>At the December 1968 "Symposium on Below-Knee Prosthetics", <a></a> sponsored by the Committee on Prosthetics Research and Development, a number of suggestions for improving prosthetics education and practice were offered.</p> <ol> <li>The body of knowledge about BK prosthetics that has been developed in recent years should be made available to practicing prosthetists and other clinicians.</li><li>All institutions offering prosthetics-education courses should include the information presented at the symposium in their curricula.</li><li>Opportunities for continuing education, such as postgraduate-type courses for clinic teams in the latest prosthetics techniques, should be provided.</li><li>Additional manuals and other instructional materials should be prepared. In addition, a central group that would be responsible for the orderly preparation and dissemination of technical information is needed.</li><li>Current research efforts in BK prosthetics should be continued, but with emphasis placed on the development of a truly refined theory of fitting.</li></ol> <p>Because most of the recent improvements to the design of the below-knee socket, especially in suspension techniques, have been accomplished by practicing prosthetists, there is little need for the research centers to devote their time to developing additional improvements. On the other hand, there is very little knowledge about the basic principles underlying optimum fitting of prostheses. Therefore, the research centers should be encouraged to obtain basic information about the effects of pressure and shear forces on tissues, and to more clearly indicate the biomechanical forces required in the various phases of walking. Following that work, methods by which those principles could be put into practice should be developed, including the use of hydrostatic sockets and other methods that might provide automatic adjustment.</p> <p>As a result of these suggestions, a pilot course in advanced below-knee prosthetics practices was held at Northwestern University (see "News and Notes") on August 4-13, 1969, for prosthetist instructors from the University of California at Los Angeles, New York University, and Northwestern University. The University Council on Prosthetics Education is now developing a curriculum for short-term postgraduate courses in below-knee prosthetics. The advanced techniques will also be offered in regular courses in below-knee prosthetics.</p> <p><b>References:</b></p> <ol> <li>The American Academy of Orthopaedic Surgeons, Inc.,<i> Historical development of artificial limbs</i>, Chap. 1 in <i>Orthopaedic appliances atlas</i>, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>Burgess, Ernest M., <i>The below-knee amputation</i>, Inter-Clinic Inform. Bull., 8:4:1-22, January 1969.</li> <li>Burgess, Ernest M., and Joseph H. Zettl, <i>Amputations below the knee</i>, Artif. Limbs, 13:1:1-12, Spring 1969.</li> <li>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>Caldwell, Jack L., <i>Inverted V-strap suspension for PTB prosthesis</i>, Artif. Limbs, 9:1:23-26, Spring 1965.</li> <li>Committee on Prosthetics Research and Development, <i>Below-knee prosthetics</i>, A report of a symposium, National Academy of Sciences, Washington, D. C, December 1968.</li> <li>Committee on Prosthetics Research and Development, <i>Immediate postsurgical fitting of prostheses</i>, A report of a workshop, National Academy of Sciences, Washington, D. C, May 1968.</li> <li>Compere, Clinton L., <i>Early fitting of prostheses following amputation</i>, Surg. Clin. N. Amer., 48:1:215-226, February 1968.</li> <li>Dolan, Clyde M. E., <i>The Army Medical Biomechanical Research Laboratory porous laminate patellar-tendon-bearing prosthesis</i>, Artif. Limbs, 12:1:25-34, Spring 1968.</li> <li>Fillauer, Carlton, <i>Supracondylar wedge suspension of the P T.B. prosthesis</i>, Orth. and Pros., 22:2:39-44, June 1968.</li> <li>Goldner, J. Leonard, Frank W. Clippinger, and Bert R. Titus, <i>Use of temporary plaster or plastic pylons preparatory to fitting a permanent above knee or below knee prosthesis</i>, Final Report of Project RD-1363-M, Duke University Medical Center, Durham, N. C, circa 1967.</li> <li>Hamontree, Sam E., Howard J. Tyo, and Snowdon Smith, <i>Twenty months experience with the "PTS"</i>, Orth. and Pros., 22:1:33-39, March 1968.</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>Hill, James T., Henry Mouhot, and Robert E. Plumb, <i>Manual for preparation of a porous PTB socket with soft distal end</i>, Tech. Rep. 6804, U. S. Army Medical Biomechanical Research Laboratory, Washington, D. C, May 1968.</li> <li>Kuhn, G. G., S. Burger, R. Schettler, and G. Fajal, <i>Kondylen Bettung Munster am Unter-schenkel Stumpf</i>, "KBM-Prothese," Atlas d'Appareillage Prothetique et Orthopedique, No. 14, 1966.</li> <li>Litt, Bertram D., and LeRoy Wm. Nattress, Jr., <i>Prosthetic services USA-1961</i>, American Orthotics and Prosthetics Association, Washington, D. C, October 1961.</li> <li>Lower-Extremity Amputee Research Project, Minutes of symposium on BK prosthetics, University of California, Berkeley, April 1957.</li> <li>Marschall, Kurt, and Robert Nitschke, <i>Principles of the patellar tendon supra-condylar prosthesis</i>, Orthop. Pros. Appl. J., 21:1:33-38, March 1967.</li> <li>Marschall, Kurt, and Robert Nitschke, <i>The P.T.S. prosthesis (Complete enclosure of patella and femoral condyles in below knee fittings)</i>, Orthop. Pros. Appl. J., 20:2:123-126, June 1966.</li> <li>Pierquin, L., G. Fajal, and J. M. Paquin, <i>Prothese tibiale a emboitage supracondylien</i>, Atlas d'Appareillage Prothetique et Orthopedique, No. 1, January 1964.</li> <li>Plumb, Robert E., and Fred Leonard, <i>Patella-tendon-bearing below-knee porous socket with soft Silastic distal end</i>, Tech. Rep. 6311, U S. Army Medical Biomechanical Research Laboratory, Washington, D. C, June 1963.</li> <li>Radcliffe, C. W., and J. Foort, <i>The patellar-tendon-bearing below-knee prosthesis</i>, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1961.</li> <li>The Staff of the Prosthetics Research Group, Biomechanics Laboratory-University of California, <i>Manual of below knee prosthetics</i>, The Regents of the University of California, November 1959.</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> <li>Wilson, L. A., E. Lyquist, and C. W. Radcliffe, <i>Air-cushion socket for patellar-tendon-bearing below-knee prosthesis</i>, Tech. Rep. 55, Department of Medicine and Surgery, Veterans Administration, Washington, D. C, May 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Below-knee prosthetics, A report of a symposium, National Academy of Sciences, Washington, D. C, December 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Immediate postsurgical fitting of prostheses, A report of a workshop, National Academy of Sciences, Washington, D. C, May 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Immediate postsurgical fitting of prostheses, A report of a workshop, National Academy of Sciences, Washington, D. C, May 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>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Burgess, Ernest M., The below-knee amputation, Inter-Clinic Inform. Bull., 8:4:1-22, January 1969.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Burgess, Ernest M., and Joseph H. Zettl, Amputations below the knee, Artif. Limbs, 13:1:1-12, Spring 1969.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">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><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Compere, Clinton L., Early fitting of prostheses following amputation, Surg. Clin. N. Amer., 48:1:215-226, February 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Goldner, J. Leonard, Frank W. Clippinger, and Bert R. Titus, Use of temporary plaster or plastic pylons preparatory to fitting a permanent above knee or below knee prosthesis, Final Report of Project RD-1363-M, Duke University Medical Center, Durham, N. C, circa 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Sockets of this material should not be left near radiators or in an abnormally warm environment, such as the interior of a closed automobile parked in sunlight on a warm day, because synthetic balata becomes pliable at temperatures as low as 120 deg F.</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">B. F. Goodrich Co.</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>24.</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 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>13.</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>9.</b> </td><td class="clsTextSmall">Dolan, Clyde M. E., The Army Medical Biomechanical Research Laboratory porous laminate patellar-tendon-bearing prosthesis, Artif. Limbs, 12:1:25-34, 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Plumb, Robert E., and Fred Leonard, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, Tech. Rep. 6311, U S. Army Medical Biomechanical Research Laboratory, Washington, D. C, June 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>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Dolan, Clyde M. E., The Army Medical Biomechanical Research Laboratory porous laminate patellar-tendon-bearing prosthesis, Artif. Limbs, 12:1:25-34, Spring 1968.</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Hill, James T., Henry Mouhot, and Robert E. Plumb, Manual for preparation of a porous PTB socket with soft distal end, Tech. Rep. 6804, U. S. Army Medical Biomechanical Research Laboratory, Washington, D. C, May 1968.</td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Plumb, Robert E., and Fred Leonard, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, Tech. Rep. 6311, U S. Army Medical Biomechanical Research Laboratory, Washington, D. C, June 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">Committee on Prosthetics Research and Development, Below-knee prosthetics, A report of a symposium, National Academy of Sciences, Washington, D. C, December 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Wilson, L. A., E. Lyquist, and C. W. Radcliffe, Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, Tech. Rep. 55, Department of Medicine and Surgery, Veterans Administration, Washington, D. C, May 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Fillauer, Carlton, Supracondylar wedge suspension of the P T.B. prosthesis, Orth. and Pros., 22:2:39-44, June 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Kuhn, G. G., S. Burger, R. Schettler, and G. Fajal, Kondylen Bettung Munster am Unter-schenkel Stumpf, 'KBM-Prothese,' Atlas d'Appareillage Prothetique et Orthopedique, No. 14, 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>12.</b> </td><td class="clsTextSmall">Hamontree, Sam E., Howard J. Tyo, and Snowdon Smith, Twenty months experience with the 'PTS', Orth. and Pros., 22:1:33-39, March 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>References</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Marschall, Kurt, and Robert Nitschke, Principles of the patellar tendon supra-condylar prosthesis, Orthop. Pros. Appl. J., 21:1:33-38, March 1967.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Marschall, Kurt, and Robert Nitschke, The P.T.S. prosthesis (Complete enclosure of patella and femoral condyles in below knee fittings), Orthop. Pros. Appl. J., 20:2:123-126, June 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>20.</b> </td><td class="clsTextSmall">Pierquin, L., G. Fajal, and J. M. Paquin, Prothese tibiale a emboitage supracondylien, Atlas d'Appareillage Prothetique et Orthopedique, No. 1, January 1964.</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">Caldwell, Jack L., Inverted V-strap suspension for PTB prosthesis, Artif. Limbs, 9:1:23-26, 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>6.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Below-knee prosthetics, A report of a symposium, National Academy of Sciences, Washington, D. C, December 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Litt, Bertram D., and LeRoy Wm. Nattress, Jr., Prosthetic services USA-1961, American Orthotics and Prosthetics Association, Washington, D. C, October 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>References</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and J. Foort, The patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1961.</td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">The Staff of the Prosthetics Research Group, Biomechanics Laboratory-University of California, Manual of below knee prosthetics, The Regents of the University of California, November 1959.</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">Lower-Extremity Amputee Research Project, Minutes of symposium on BK prosthetics, University of California, Berkeley, April 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">The American Academy of Orthopaedic Surgeons, Inc., Historical development of artificial limbs, Chap. 1 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>A. Bennett Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, 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/1969_02_001/69autumn-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-13.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Recent Advances in Below-Knee Prosthetics Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/b4f40bca2c90d2cb7aaabe73acdc9755.pdf 93f307630ba83bd52f500cbae4929830 https://staging.drfop.org/files/original/6ade0b441b483cc9f3804c0eb907cef2.jpg 510989eb599f892c8b2e8c055704eb08 https://staging.drfop.org/files/original/f992d6f159add6551a5927ffdad104a4.jpg 2b3059782381c1b405945cc1df2a65e4 https://staging.drfop.org/files/original/97cfb5d939b20b09ce8eef3379376ff5.jpg 3159b4335f45fb7d187f4e230713fe30 https://staging.drfop.org/files/original/e71107f0f952e070fd0f18a250c50c5e.jpg 3187980e5eb0db54e1fd157d75985aef https://staging.drfop.org/files/original/9f5149248ae20c875ebc879851fc505d.jpg 7975ed4b11b397c330fbd73d34711061 https://staging.drfop.org/files/original/95f314b39e2ef9df0a3d3e113c78841d.jpg 20023369bfd507d6c8b1eaf7c139ccad https://staging.drfop.org/files/original/1e75d8d603b0a37b68c5d88f571954d8.jpg 06838a7e96d784457010a04ffb0d4939 https://staging.drfop.org/files/original/47657fbbbf25bb2870775a5111f1ae16.jpg c6bf99f27ce81525ce4a3c18d6a22984 https://staging.drfop.org/files/original/e2a1a8f0badea8e1360e71eacea7e5ae.jpg 1f9b134869c49e1a7594c8a28780e58c https://staging.drfop.org/files/original/62d143747db0eb1a6cec876a190f8120.jpg 85a7f0afcba88084e4cdc1a630c7606a https://staging.drfop.org/files/original/78e31cec1089a104b5192b24ccb1c522.jpg b7a478f3d3152aeafe4cbc46b503926f https://staging.drfop.org/files/original/a78e4e9e46e8d715eca8b5ddc28d10d1.jpg 63281a59efb08f181a317a6aae358edd DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_01_001.pdf Year 1969 Volume 13 Issue 1 Page Number(s) 1 - 12 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_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_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>Amputations Below the Knee</h2> <h5>Ernest M. Burgess. M.D. <a style="text-decoration:none;">*</a><br />Joseph H. Zettl, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>The elective amputation must be considered plastic and reconstructive in nature. The need to create a dynamic and sensory motor end-organ should be foremost in the surgeon's mind in planning an amputation, and is emphasized here once more. The below-knee stump no longer hangs suspended in an open-end socket. The variable degrees of pressure and weight-bearing over the entire stump surface afforded by the total-contact patellar-tendon-bearing prosthesis enhance the surgeon's opportunity to fashion a functional terminal end-organ. Stump strength created by surgical muscle stabilization; pliable, sensitive, but nontender skin and scar; adequate soft tissue coverage of bone ends and other pressure-sensitive areas; high ligation and division of nerves to remove neuromata from pressure zones; meticulous rounding and tailoring of bone surfaces; all contribute to an ideal organ for substitute limb application. The atrophic, wasted, bony, below-knee stump so commonly encountered in years past is no longer acceptable. Stump-muscle stabilization, <i>i.e., </i>the attachment of sectioned muscles under appropriate tension to bone (myodesis) and to opposing muscles (myoplasty), is a prime requisite for dynamic stump activity. Muscle stabilization is especially needed in the through-knee and the above-knee amputee. Our experience also justifies its routine use in below-knee amputation. Muscle-to-bone suture does add operative handling of tissues and encircling sutures carry the potential of local muscle constriction. For these reasons myodesis is not recommended for use in the below-knee amputation for vascular disease. The new technique developed by the Prosthetics Research Study utilizes the long posterior myofascial flap sewn anteriorly to anterolateral deep fascia and tibial periosteum and provides a reasonable degree of muscle fixation without risk of strangulation. Muscle-to-bone suture is reserved for the nonischemic patient.</p> <h3>Nonischemic Patients</h3> <p>The optimum level for a below-knee amputation in the presence of adequate blood supply is at the junction of the middle and lower third of the leg. However, the level of amputation will often be determined by the causal pathology, including infection, the degree of scarring of the tissues, and related factors. The surgeon should save all effective length down to optimum level, consistent with providing a comfortable, nontender stump.</p> <p>A cylindrical stump shape is desired. The surgeon should think in terms of producing a "foot-like" organ at the below-knee level. The total-contact socket is the "shoe on the foot." Just as plastic surgical techniques are required in operating on the hand and foot, the same techniques of gentleness in skin and other tissue handling are applicable to amputation surgery. When viewed in this light, the amputation becomes a surgical challenge instead of a distressing surgical exercise. Immediate postsurgical prosthetic fitting not only supports and augments the dynamic approach to rehabilitation, it offers certain physical advantages, <i>i.e., </i>immobilization, appropriate continuous pressure relationships, and comfort. These benefits further justify its incorporation into the over-all management of the below-knee amputee.</p> <h4>Amputation Technique For The Nonishemic Patient</h4> <p>The patient is prepared for surgery in the usual manner. A pneumatic tourniquet is used. Short, broad fishmouth skin flaps are outlined to provide a mediolateral closure. In the nonischemic patient the flaps are fashioned approximately equal in length. It is advisable to cut the flaps long, then trim them at the time of closure to provide correct skin tension without puckering or undue tension. Skin and fascia are reflected together.</p> <p>Scarring, infection, deformity, or other unusual circumstances may necessitate modification of the skin closure. Flaps can be outlined to permit closure in any plane or direction provided the resulting scar is nonadherent, nontender, and able to withstand properly and comfortably wearing of a total-contact socket. Anterior location of the scar, condemned in the past, actually is well tolerated even in elderly patients. The application of principles of plastic surgery in skin management must prevail.</p> <p>In the average adult the tibia is transected 2 1/2 to 3 in. above the distal level of the skin incision. The fibula is divided 3/8 to 1/2<i> </i>in. higher. A reciprocating power saw facilitates clean bone section. The tibial periosteum is elevated about 3/4 in. above the cut end of the tibia and the an-teromedial angle beveled to provide a larger radius on the anteromedial aspect. Careful <i>rounding </i>of the edges with a sharp, fine-tooth file is now done. Bone surfaces must be smooth so as to eliminate the possibility of high unit pressures.</p> <p>When the muscles are to be reattached to bone, a procedure recommended where it is physiologically feasible, 4 to 6 holes not more than 7/64 in. in diameter are drilled through the lateral and posterior periphery of the tibia about 3/8 in. proximal to the distal end. Muscles are sectioned long, the gastrocnemius-soleus is left as a myofascial flap sufficiently long to bring it around the end of the tibia to the anterior surface, and nerves and blood vessels are ligated and divided, the former well above amputation level, the latter at the level of tibial section. The nerves are ligated high, as indicated, but are not pulled down so forcibly that traction-avulsion injury results proximal to ligation.</p> <p>Muscles are now sutured to the bone through the drill holes with medium braided polyester suture and tying the knots within the medullary cavity of the tibia. The loop sutures pass through the body of the major muscle groups and through deep fascia. They should be attached under moderate tension, slightly greater than rest length and therefore capable of providing maximum function. Muscle groups are now sectioned just beyond the end of the tibia except for the gastrocnemius-soleus flap which is left long, beveled, and brought over the end of the tibia as a thinned myofascial flap and sutured to anterior deep fascia and anterior periosteum. Good muscle stability and stump contour are provided by this technique. The moderately bulbous stump will rapidly contour to an ideal cylindrical shape in the rigid postsurgical dressing.</p> <p>The skin flaps are trimmed and closed with interrupted fine polyester sutures in such a manner that no tension is present, yet a firm stump without redundant tissue is provided (<b>Fig. 1</b>). Drainage of the stump is optional. We prefer a through-and-through Penrose drain; however, suction drainage is convenient and some wounds will not require any drainage.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Below-knee stump of nonischemic patient immediately after closure. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Rigid Dressing</h4> <p>The wound is covered with a saline-dampened nonadherent silk or nylon dressing and a small amount of fluffed gauze (2 to 3) is placed over the distal stump end. A sterile three-ply Orion Lycra stump sock is rolled carefully over the stump to avoid damage to the suture lines. The superior portion of the stump sock is held firmly suspended anteriorly and in a proximal direction by an assistant. A simple adjustable shoulder-suspension harness which is interchangeable for right and left can be substituted to achieve the same result.</p> <p>Relief pads of felt or polyurethane are glued to appropriate locations on the stump sock to provide relief for bony prominences. Prefabricated pads are available in a standard size, right and left, but must be trimmed, skived, and beveled in appropriate areas to suit individual requirements. The pads are designed and located to provide relief of pressures over the patella, the tibial tubercle including the tibial crest, and the distal-anterior (bevel) aspect of the tibia. Dow Corning medical adhesive is used to secure the felt relief pads in place while the polyurethane relief pads are provided with an adhesive backing. A sterile reticulated polyurethane distal pad of the proper size is selected and applied to the distal stump end over the tibial relief pads (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Application of distal polyurethane pad. Other relief pads are already in place. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For the initial part of the rigid dressing, elastic plaster bandage is used because, when pulled within limits of its elasticity, this bandage provides safe and beneficial compression to the stump while conforming well to its contours, providing a smooth, effective, rigid dressing.</p> <p>Before the wrap is started, the tibial relief and distal relief pads are secured in place with one-and-three-quarter turns of elastic plaster bandage (<b>Fig. 3</b>). Firm tension is applied to the distal portion of the stump from a posterior-to-anterior direction, while the plaster bandage is pulled almost to the limit of its elasticity. By supporting the posterior skin flap, tension on the suture line is reduced and the soft tissues are immobilized. The wrap is then started on the distal end and carried prox-imally to a level slightly past mid-thigh while tension is maintained in the bandage. A minimum of two layers is required. Circumferential wrapping is carried out from the lateral to the medial aspect, when viewed from the front, in order to avoid anterior displacement of the gastrocnemius (<b>Fig. 4</b>). Tension in the wrap decreases progressively as the application proceeds proximally to the level of the knee joint where it is simply rolled on up to slightly past mid-thigh. It is important to apply the dressing with firm tension to the distal portion of the stump and to avoid proximal constriction to blood flow. The knee is held in 5 to 15 deg. of flexion controlled by longitudinal tension applied to the stump sock from the proximal end. Owing to the inherent structural weakness of elastic plaster bandage, the initial wrap must be reinforced with conventional plaster bandage and splints. Two splints are applied over the distal portion of the rigid dressing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Beginning the rigid dressing by securing the tibial relief and distal relief pads in place with elastic plaster bandage. </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 the first layers of the rigid dressing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A minimum of two layers of conventional plaster bandage is applied starting at the distal third and wrapping proximally with even, overlapping circular wraps (<b>Fig. 5</b>). At the proximal border of the cast a suspension strap is incorporated anteriorly. For an obese patient with excessive soft tissue over the thigh, a second suspension strap is applied posterolaterally. With the plaster of Paris still wet, the cast is gently compressed with the base of each hand just proximal to the femoral condyles to provide an effective built-in suspension mechanism.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Completed rigid dressing. Note alignment reference line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the plaster has hardened sufficiently, the contoured waistbelt is applied to the patient and connected to the strap or straps of the rigid dressing. The prosthetic unit is located and attached to the cast with a roll of conventional plaster bandage (<b>Fig. 6</b>). The pylon is sized and cut to correspond to the length of the sound extremity. A window is cut out of the plaster over the patella to insure complete relief in this area (<b>Fig. 7</b>). The prosthetic unit is then disconnected from the cast socket before the patient is taken to the recovery room.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Attachment of upper portion of prosthetic unit to the rigid dressing. Note alignment reference line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Window in rigid dressing to provide complete relief over patella, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Postsurgical Care</h4> <p>As a rule, a minimum amount of pain is experienced by patients that have been provided with a rigid dressing. It is unusual for drugs stronger than mild opiates and sedatives to be required for relief. A slight degree of weight-bearing on the stump will usually tend to reduce any discomfort that might be present.</p> <p>The patient should be encouraged to stand up and bear some weight on the prosthesis as soon after the first 24-hour period postoperatively as is practicable.</p> <p>The time and extent of ambulation must be determined by the responsible surgeon. Walking training should be carried out only under the direction of a physical therapist or other qualified personnel. Activity should be increased daily as the patient's condition permits. Parallel bars, walkerettes, crutches, and canes are used as aids in ambulation. Two bathroom scales may be used to determine the degree of weight-bearing that is taken on the amputated side. These measurements provide a good guide to the clinic team concerning the progress being made by the patient. The patient should never be allowed to ambulate without supervision. Furthermore, ambulation should not be permitted without the prosthesis because in this case the effect of gravity tends to pull the socket away from the stump, thereby reducing the pressure between stump and socket.</p> <p>On the second postoperative day (48 hours after surgery) the drain is removed. If there does not appear to be any reason for removing the cast, such as elevated body temperature, extreme discomfort, or excessive looseness of fit, the cast is kept in place up to 14 days. If for any reason the cast is removed, whether intentionally or unintentionally, it is mandatory that, if a new cast is indicated, it be applied immediately. During the first two postoperative weeks edema will form rapidly upon removal of the cast and, unless a new cast is reapplied within a very short period, the patient will have to be treated in the conventional manner. The old cast should never be reapplied because of the trauma that is apt to result. When the socket is removed purposely, a cast cutter is used. Often the sutures can be taken out at the time of removal of the first cast, 10 to 14 days after surgery. Sometimes it is necessary to wait until removal of the second cast, 15 to 20 days postoperatively.</p> <p>In many instances the stump will be sufficiently mature and stable for use of a definitive prosthesis at the time the second cast is removed. When this is so, a cast of the stump is taken and appropriate measurements are recorded so that fabrication of a permanent prosthesis can proceed immediately. When the definitive prosthesis is delivered, a light plaster socket mobilizing the knee joint is provided for use when the definitive prosthesis is removed. Use of a plaster socket has proven to be superior to elastic bandages to prevent edema. If delays are anticipated in providing the patient with a definitive prosthesis, the prosthetic unit, pylon, and foot are applied to the short cast to continue ambulation activities.</p> <h3>The Ischemic Patient</h3> <p>Throughout the United States and Canada an estimated 80 per cent of all major, elective, civilian amputations result from ischemia. All but a relatively few involve the lower extremity. Significant advances in surgical and postsurgical management coupled with the use of improved prostheses now allow amputation below the knee in the great majority of these patients.</p> <p>It is difficult to overestimate the importance of the knee in amputee rehabilitation, especially in the older, classical ischemic patient. Debility, impaired vision, poor balance, neuropathy, compromised circulation and joint function in the remaining lower limb, and chronic systemic illness, all emphasize the critical need to save the knee. The older bilateral leg amputee, especially, needs his knees to approach the rehabilitation goal that permits a reasonable degree of ambulation and self-sufficiency. In a consecutive series of 128 unselected major lower-extremity amputations for peripheral vascular disease (1964 through 1968), we have been able to obtain primary healing at below-knee level in 86 per cent. Once healed, the stumps remain healed. With adequate prosthetic care, secondary breakdown will seldom occur. These patients were among the approximately 300 cases requiring amputation of the lower extremity that were used in studying and developing the techniques of fitting prostheses immediately after surgery. As a result of these experiences, separate surgical techniques have been developed for the ischemic patient and for the nonischemic patient.</p> <h4>Level Of Amputation</h4> <p>The great achievements in surgical reconstruction of the peripheral vascular system represent a leading chapter in medical progress during the past two decades. Continuing basic and clinical research throughout the world supports the hope that an even higher percentage of limb salvage can be expected in the years ahead. However, despite the practical effectiveness of modern vascular reconstructive surgery, statistics indicate that amputations for ischemia are increasing both relatively and absolutely in relation to population throughout the western world.</p> <p>When acute or chronic compromise of arterial blood supply reaches a level insufficient to support tissue viability and when reconstructive surgery and nonsurgical supportive measures fail, amputation will be required.</p> <p>Patients requiring amputation are entitled to comparable medical and surgical consideration, comparable team effort, and the same high-level rehabilitation management attending similar patients whose ischemic limbs are treated by vascular reconstruction. Too often, ablative surgery does not command this high estate.</p> <p>Decision to amputate may be simple and evident. Gross necrosis of tissue with demarcation, uncontrollable infection, pain, irreversible neuropathy, alone or in combination, and with results of specific tests to assay circulation, will establish the need to amputate. When all available information poses a serious question as to the possibility of limb salvage by reconstructive surgery rather than amputation, it has been common practice to attempt such surgery, even though extensive. Before questionable extensive reconstructive arterial surgery is carried out, the surgeon should consider critically the overriding probability of its failure with mandatory subsequent amputation. Will the proposed surgery compromise the level of amputation? Will amputee rehabilitation be additionally complicated by further deterioration of general health incident to the extensive surgical attempt at limb salvage? On a number of occasions, below-knee amputations have been performed in ischemic patients who were being considered for possible vascular surgical treatment but in whom, after review of all available information, such surgery might well have damaged the existing blood supply to a degree that an above-knee amputation would then have been required. It is important that the responsible surgeon understand the great rehabilitation value of the knee and weigh all facts relevant to the rehabilitation potential.</p> <p>There is no single test or combination of tests now available that will demonstrate specifically the lowest effective amputation level. Successful below-knee amputations have been obtained repeatedly in patients whose arteriograms indicated complete occlusion of the superficial femoral artery.</p> <p>A careful physical examination is the first requisite in determination of the level of amputation. Appearance of the soft tissues, temperature of the skin, the presence or absence of edema after elevation, growth of hair, level of sensation and acuity, together with palpation of pulses, are all important and cannot be supplanted by laboratory data. Arteriography, plethysmography, thermography, and a number of other objective techniques are useful. These include skin mapping with interar-terial fluorescein, the use of radioactive Xenon #133, and transcutaneous ultrasonic Doppler recordings. Each adds to the available information and assists in level determination. Old established guidelines for determining amputation level are not valid when weighed against recent experience.</p> <p>Unless it is <i>clearly evident </i>that a through-knee or above-knee amputation will be required, the surgeon should prepare the leg for both below-knee and above-knee amputation. Incisions through the skin and muscle preparatory to belowknee surgery can then be carried out quickly.</p> <p>Bleeding and tissue viability can be observed directly and the final decision can now be made as to the level of amputation. Only a few minutes are added to the operative time should one elect the above-knee or through-knee level.</p> <h4>Amputation Technique For The Ischemic Patient</h4> <p>No tourniquet is used. The leg is draped free with the patient supine. Open and infected areas are walled off and shielded by sterile adherent plastic drapes prior to skin preparation. The level of amputation is 3-1/2 to 5 in. below the knee, <i>i.e., </i>a short below-knee stump (<b>Fig. 8</b>). It has been recognized for many years that skin over the posterior leg has better blood supply than that anterior and anterolateral, and a long posterior and a short anterior skin flap are now used routinely. A long anterior flap, or even equal anterior and posterior flaps, should be avoided. The anterior scar resulting from use of a long posterior flap poses no problem in fitting the prosthesis. The modern total-contact below-knee prosthetic socket can accept a stump with scar placement in any position, provided it is nonadherent, well-healed, and nontender, and it is now standard policy in the Prosthetics Research Study to place the scar wherever it will heal most advantageously.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Left, stump of 33-year-old patient on 26th day after amputation because of infection owing to nonunion of the tibia. Right, permanent prosthesis provided same patient on 26th day postoperative. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The anterior skin flap is fashioned approximately at the level of anticipated tibial section. The posterior flap must then be 5 to 6 in. longer to provide proper skin coverage without undue tension (<b>Fig. 9</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Outline of skin flaps for below-knee amputation on typical ischemic patient. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After outlining the skin flaps, dissection is carried down through the deep fascia to the tibia. The periosteum is incised and stripped proximally 1 in. The anterolateral muscles are divided down to the intermuscular septum; blood vessels and nerves are ligated appropriately and severed; and then the tibia and fibula are sectioned, preferably with a power saw. The fibula is cut no more than 3/8 to 1/2 in. above the level of the tibia. Soft tissues are dissected from the posterior aspect of the tibia and fibula down to the level of the posterior transverse division of skin. The leg is then separated and removed. The tibia is very carefully rounded with a short bevel over its anterior and medial aspects. It is important that no rough bone areas or ridges remain. A long bevel is specifically avoided. Nerves are pulled down and sectioned high with a sharp knife. They are not injected, crushed, or cauterized. The major nerves are ligated with a fine suture just above the site of division before the division is made. Encircling suture controls oozing from the blood supply that accompanies the nerve, and it also appears to localize neuroma formation and to lessen overgrowth and adherence to adjacent structures. The posterior muscle mass consisting of the gastrocnemius-soleus and deep flexor group is now beveled and tailored to permit the entire muscle flap to come forward and be sewn anteriorly to the deep fascia of the anterolateral muscle group and to the reflected periosteum over the anterior tibia. Contouring and trimming of the gastrocnemius medially and laterally gives a smooth musculofascial flap stabilized over the end of the bones. The skin is then brought up and closed without subcutaneous suture (<b>Fig. 10</b>). Medial and lateral "dog ears" are contoured moderately. They should not be taken back sufficiently to disturb skin circulation. The immediate postsurgical socket rapidly shapes the stump including moderate skin irregularity at the medial and lateral angles. The wound is drained deep to the muscle flap, <i>i.e., </i>to bone. Through-and-through drain or suction drainage may be used. An immediate postsurgical rigid dressing and prosthesis are then applied.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Below-knee stump of typical ischemic patient showing position of suture line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Postsurgical Care</h4> <p>Drains are removed 48 hours after surgery. If the patient's general condition permits, ambulation with guarded weight-bearing is begun 24 to 48 hours following surgery. The advantages of upright activity with limited stance and gait are obvious. However, only touch-down weight-bearing not exceeding 25 lb. is allowed until the initial cast is changed. Personnel in charge of the patient should be instructed carefully as to their responsibility in preventing the patient from bearing excessive weight or from falling.</p> <p>The postsurgical management with an immediate prosthesis has resulted in much less pain than previously encountered. Postoperative pain is generally of a diffuse aching type. Complaint of localized pain almost always indicates abnormal pressure and requires inspection of the stump and change of the socket. Unless complications develop, <i>i.e., </i>evidence of infection, excessive loosening of the socket, or severe pain, the initial rigid dressing should be left intact until the time of anticipated suture removal, usually two to two-and-one-half weeks following surgery. The cast is then removed, with the patient under sedation but not anesthesia, the wound is inspected, sutures are removed if indicated, and a new temporary prosthesis is applied. By this time the patient is usually ready for unsupported crutch ambulation and discharge from the hospital. A temporary prosthesis is worn continuously until a definitive limb is provided. Ordinarily the final limb can be fabricated, fitted, and worn four to five weeks following below-knee amputation. Typical ischemic patients are shown in <b>Fig. 11</b> and <b>Fig. 12</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. A 69-year-old, white male had multiple difficulties consisting of arteriosclerosis obliterans with complete right superficial femoral occlusion, diabetes mellitus, arteriosclerotic heart disease with mitral insufficiency, and coronary occlusion. No reconstructive vascular surgery was considered to be feasible. The preoperative condition of his foot is indicated on the left. Good stump healing was achieved by the 25th postoperative day, center. The definitive prosthesis was applied on the 28th postoperative day, right. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. A 73-year-old, white female with severe chronic peripheral vascular disease without diabetes. Two attempts at femoral popliteal bypass graft had been made in the three weeks prior to "breakdown" of the graft operative sites. Progressive gangrene of the foot had ensued with demarcation just above the ankle level. Figure in upper left shows the appearance of the leg prior to amputation. A short below-knee level of amputation was selected and a long posterior musculocutaneous flap developed, upper right. The appearance of the below-knee stump at 19 and 29 days following surgery is indicated in the lower figures. The definitive prosthesis was fitted on the 32nd postoperative day. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Necrosis of skin flaps can result from either inadequate blood supply or undue pressure. If the level of amputation is so low that the blood supply is insufficient to support a below-knee amputation, it will be evident at the initial cast change. The decision then to amputate at a higher level should be made promptly. Re-amputation rate in the PRS series to through-knee or above-knee over the four-year period has been 9.4 per cent. As experience and techniques have improved, the re-amputation rate for below-knee cases with ischemia has continued to decrease. The surgeon, of course, likes to avoid all re-amputations. However, salvage of the knee is of such paramount importance that an occasional re-amputation may be required if we are to save all knee joints possible in view of our inadequate means for determining the best level for amputation.</p> <h3>Summary and Conclusions</h3> <p>Below-knee amputation is statistically by far the most important major amputation used today. The vast majority of major lower-extremity amputations performed for ischemia will heal primarily and remain healed at below-knee level. The below-knee amputation for ischemia is short in length, the posterior skin and myofascial flaps are fashioned long, and the technique is precise. The resulting stump is cylindrical in shape, well-padded, comfortable, and easily fitted with modern below-knee prostheses of the total-contact type. An immediate postsurgical prosthesis is an integral part of the over-all below-knee amputee management in both the ischemic and nonischemic patient. Restoration of function and rehabilitation of the below-knee amputee, both unilateral and bilateral, have improved in almost spectacular fashion when the guidelines and management which have been outlined are followed.</p> <p><b>References:</b></p> <ol> <li>Baddeley, R. M., and J. C. Fulford, <i>The use of arteriography in conservative amputations forlesions of the feet in diabetes mellitus</i>, Brit. J. Surg., 51:633-658, September 1964.</li> <li>Berlemont, M., <i>Notre experience de I'appareillageprecoce des amputes des membres inferieursaux Etablissements Helio-Marinsde Berck</i>, Ann. Med. Phys., Tome IV, No.4, October-November-December 1961.</li> <li>Berlemont, M., <i>L'appareillage des amputes des membres inferieurs sur la table d'operations,paper given at the International Congress of Physical Medicine</i>, Paris, 1964.</li> <li>Bickel, William H., <i>Amputations below the knee in occlusive arterial disease</i>, Surg. Clin. N. Amer., Mayo Clinic Number, August 1943.</li> <li>Bickel, William H., and R. K. Ghormley, <i>Amputations below the knee in occlusive arterial disease</i>, Proc. Mayo Clinic, 18:361, 1943.</li> <li>Block, M. S., and F. W. Whitehouse, <i>Below knee amputation in patients with diabetes mellitus</i>, Arch. Surg., 87:682-689, October 1963.</li> <li>Bradham, R. R., and R. D. Smoak, <i>Amputations of the lower extremity used for arteriosclerosis obliterans</i>, Arch. Surg., 90:60-64, January 1965.</li> <li>Burgess, Ernest M., <i>The below-knee amputation</i>, Inter-Clinic Inform. Bull., 8:4, January 1969.</li> <li>Burgess, E. M., and R. L. Romano, <i>The management of lower extremity amputees using immediate postsurgical prostheses</i>, Clin. Orthop., 57:137-146, 1968.</li> <li>Burgess, E. M., and R. L. Romano, <i>New day for leg amputees</i>, Rehab. Rec, July-August 1965.</li> <li>Burgess, E. M., and J. H. Zettl, <i>Immediate postsurgical prosthetics</i>, Orthop. Pros. Appl. J., June 1967.</li> <li>Burgess, Ernest M., Joseph E. Traub, and A.Bennett Wilson, Jr., <i>Immediate postsurgical prosthetics in the management of lower extremity amputees</i>, Prosthetic and Sensory AidsService, U.S. Veterans Administration, 1967.</li> <li>Compere, Clinton L., <i>Early fitting of prosthesis following amputation</i>, Surg. Clin. N. Amer., 48:1:215-226, 1968.</li> <li>Dederich, Rolf, <i>Die muskelplastische Stumpfkorrektur</i>, Zentralbl. Chir., 81:29:1194-1206, 1956.</li> <li>Dederich, Rolf, <i>Plastic treatment of the muscles and bone in amputation surgery</i>, J. Bone Joint Surg.,45B:l:60-66, February 1963.</li> <li>Eraklis, A., and W. Brownell, <i>Below knee amputations in patients with severe arterial insufficiency</i>, New Eng. J. Med., 269:938-942, October 1963.</li> <li>Ertl, Johann, <i>Uber Amputationsstumpfe</i>, Chirurg, 20:218-224, May 1949.</li> <li>Glattly, Harold W., <i>A preliminary report on the amputee census</i>, Artif. Limbs, 7:1:5-10, Spring 1963.</li> <li>Golbranson, F. L., Charles Asbelle, and Donald Strand, <i>Immediate postsurgical fitting and early ambulation</i>, Clin. Orthop., 56:119-131, 1968.</li> <li>Guthrie, G. J., <i>A treatise on gun-shot wounds</i>, Ed. 2, Burgess and Hill, London, 1820.</li> <li>Harris, P. D., S. I. Schwartz, and J. A. DeWeese, <i>Midcalf amputation for peripheral vascular disease</i>, Arch. Surg., 82:381-383, March 1961.</li> <li>Hey, William, <i>Practical observations in surgery</i>, Ed. 3, Cadell and Davies, London, 1814.</li> <li>Hoar, C. S., Jr., and J. Torres, <i>Evaluation of below-the-knee amputation in the treatment of diabetic gangrene</i>, New Eng. J. Med., 266: 440-443, March 1962.</li> <li>Jansen, Knud, <i>Amputation, a manual of principles and methods</i>, World Veterans Federation, Paris, 1965.</li> <li>Kelly, P. J., and J. M. Janes, <i>Criteria for determining the proper level of amputation in occlusive vascular disease: A review of 232 amputations</i>, J. Bone Joint Surg., 39A:833-891, July 1957.</li> <li>Kendrick, R. R., <i>Below knee amputation in arteriosclerotic gangrene</i>, Brit. J. Surg., 44:13-17, July 1956.</li> <li>Loon, Henry E., <i>Below-knee amputation surgery</i>, Artif. Limbs, 6:1:86-99, June 1962.</li> <li>Loon, Henry E., <i>Biological and biomechanical principles in amputation surgery</i>, Prosthetics International, Committee on Prostheses, Braces, and Technical Aids, International Society for the Welfare of Cripples,Copenhagen, 1960.</li> <li>Mondry, F., <i>Der Muskelkraftige Ober-und Unterschenkelstumpf</i>, Chirurg, 23:517-519, November 1952.</li> <li>Murphy, Eugene F., and A. Bennett Wilson, Jr., <i>Anatomical and physiological considerations in below-knee prosthetics</i>, Artif. Limbs, 6:2:4-15, 1962.</li> <li>Pedersen, Herbert E., <i>Lower extremity amputations for gangrene</i>, The American Academy of Orthopaedic Surgeons Instructional Course Lectures, 15:262, 1958.</li> <li>Pedersen, H. E., R. L. LaMont, and R. H. Ramsey, <i>Below-knee amputation for gangrene</i>, Southern Med. J., July 1964. Reprinted in Orthop. Pros. Appl. J., 18:281- 287, December 1964.</li> <li>Radcliffe, C. W., and James Foort, <i>The patellar tendon-bearing below-knee prosthesis</i>, Biomechanics Laboratory, University of California. Berkeley and San Francisco, 1961.</li> <li>Robb, H. J., L. F. Jacobsen, and B. Jordan, <i>Midcalf amputation in the ischemic extremity: Use of lateral and medial flap</i>, Arch. Surg., 91:506-508, September 1965.</li> <li>Rosenberg, N., <i>Midleg amputation in patients with necrotic leg muscles</i>, Arch. Surg., 81:614-617, October 1960.</li> <li>Silbert, Samuel, <i>Mid-leg amputations for gangrene in the diabetic</i>, Ann. Surg., 127:503, 1948.</li> <li>Slocum, D. B., <i>An atlas of amputations</i>, C. V. Mosby, St. Louis, 1959.</li> <li>Smith, B. C,<i> Amputation through lower third of leg for diabetic and arteriosclerotic gangrene</i>, Arch. Surg., 27:267, 1933.</li> <li>Tillgren, C., <i>Obliterative arterial disease of the lower limbs: A study of the course of the disease</i>, Acta Med. Scand., 178:103-119, July 1965.</li> <li><i>Manual of below-knee prosthetics</i>, University of California, San Francisco, Biomechanics Laboratory, November 1959.</li> <li>Weiss, Marian, personal communication and demonstration, Konstancin Rehabilitation Hospital, Poland, 1964.</li> <li>Weiss, Marian,<i> Neurological implications of fitting artificial limbs immediately after amputation surgery</i>. Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</li> <li>Weiss, Marian, <i>Myoplasty—immediate fitting—ambulation, paper presented at the Sessions of the World Commission on Research in Rehabilitation</i>, Tenth World Congress of the International Society, Wiesbaden, Germany, September, 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>Joseph H. Zettl, C.P. </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetics Research Study, Seattle, Wash.</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>Ernest M. Burgess. M.D. </b></td></tr><tr><td class="clsTextSmall">Principal Investigator, Prosthetics Research Study, Seattle, Wash., and Director of Amputations and Congenital Defects Service, Children's Orthopedic Hospital, Seattle, Wash. This study was conducted under Contract V5261P-438 with the Veterans Administration.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_01_001/spring69-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_01_001/spring69-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_01_001/spring69-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_01_001/spring69-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_01_001/spring69-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_01_001/spring69-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_01_001/spring69-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_01_001/spring69-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1969_01_001/spring69-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1969_01_001/spring69-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1969_01_001/spring69-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1969_01_001/spring69-12.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 Amputations Below the Knee Creator An entity primarily responsible for making the resource Ernest M. Burgess. M.D. * Joseph H. Zettl, C.P. * https://staging.drfop.org/files/original/9278e2810ea9f78e2de4c8bba8abbd72.pdf a774a49fa86c90712363d0801131e532 https://staging.drfop.org/files/original/08588a42be997361ba8f0142b7823983.jpg bee92071ff1c11bb2d2ceb61ca93b3df https://staging.drfop.org/files/original/9c17baf3b9691a8d9a37cdce7212e703.jpg feecd87d738ea94d1b39cc924df85985 https://staging.drfop.org/files/original/3d034d5f3443f358031dab6eba679d06.jpg 1f5e08192e9e7ef11a3299d1f9749209 https://staging.drfop.org/files/original/451f37e9c36d349733b74e0af0e323d3.jpg 232044070b13d5921ba696566e6e560e https://staging.drfop.org/files/original/efaaeec0404c6bfdb706ef31a7cc8773.jpg 31daf4bc27bde9e0a78a2d1ffc3a261f https://staging.drfop.org/files/original/11ccde34591e33f4bf94ae477a409147.jpg 32fd97e2284084e280a5a3c40bc68e12 https://staging.drfop.org/files/original/b9380eca06f68f68dc024f24e35ce0fa.jpg bf40832a2704e549a6292d2e59bc98bb https://staging.drfop.org/files/original/c7b17c455f05352581a7c7a67769c333.jpg 7c8cbab28c7a54a0495778bcbf11af86 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_02_036.pdf Year 1968 Volume 12 Issue 2 Page Number(s) 36 - 41 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/1968_02_036.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_02_036.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>Toronto Orthosis for Legg-Perthes Disease</h2> <h5>W. P. Bobechko, M.D., F.R.C.S.(C.) <a style="text-decoration:none;">*</a><br />C. A. McLaurin, B.A.Sc, P.Eng <a style="text-decoration:none;">*</a><br />W. M. Motloch <a style="text-decoration:none;">*</a><br /></h5> <p>The treatment of Legg-Perthes disease has been given considerable attention at the Hospital for Sick Children in Toronto during the last few years. It is now known that certain types of Legg-Perthes disease have a good prognosis regardless of the type of treatment used, whereas other types tend to have a poor prognosis. Proper prescription of treatment must, therefore, recognize this difference in prognosis.</p> <p>Attempts have been made to assess the outcome of the disease on the basis of age at onset and the degree of involvement of the ossific nucleus of the femoral head.</p> <p>In children who develop Legg-Perthes disease prior to the age of five years, the prognosis tends to be better than in a child who develops the condition at an older age. This difference is probably related to the total mass of bone that has to be re-ossified, since it has been noted that in a smaller femoral head the time for re-ossification is often shorter, being in the vicinity of 12 to 18 months compared to several years for an older child.</p> <p>The degree of involvement also plays a most important part, and attempts have been made here to differentiate between cases where the entire femoral head is involved, with avascular necrosis of the entire ossific nucleus, and those where merely a portion is involved. The partial-head-type of Legg-Perthes disease carries a much better prognosis and is less liable to deformity, since a part of the femoral head remains uninvolved.</p> <p>If there is any tendency towards the formation of a metaphyseal cyst, the possibility of a poor long-term result is increased.</p> <p>The stage at which the patient is first seen is of the utmost importance. If the child is seen early in the course of the disease, before joint deformity has occurred, proper management, if instituted quickly, can often result in a congruous joint. If, however, there is already considerable flattening and subluxation when the child is first seen, then the result, of course, cannot be as good. If the entire process of reossification has already occurred by the time the child is first seen, the golden opportunity has passed, and at this stage only secondary reconstructive procedures can be carried out, with even less satisfactory results.</p> <p>Certain selected cases are suitable for innominate osteotomy, in which the femoral head is covered and seated just as if the hip were held in abduction and internal rotation. At present, innominate osteotomy is restricted to the child who carries an unusually bad prognosis; that is, a child over the age of six years with total involvement of the femoral head. In addition, an arthrogram must be made to be certain that a significant joint deformity is not already present. If a deformity is present, innominate osteotomy is contraindicated. In addition, prior to the use of an innominate osteotomy, full joint movement must be obtained, which sometimes will require traction or soft tissue release of contracted structures, such as the psoas tendon.</p> <p>In the very young child with only a part of the head of the femur involved, often no treatment is indicated, provided that no soft tissue contractures have occurred. If soft tissue contractures are present, then soft tissue release may suffice, with or without a short period of traction.</p> <p>This leaves a small group of children for whom bracing may be used to advantage. These children would typically be in the under-six age group, with partial or total head involvement and with free joint movement, before deformity has set in.</p> <p>In the past, ischial weight-bearing braces have been used in the treatment of Legg-Perthes disease with little regard for the various forms and severity of the disease process. Cineradiography has revealed that as the patient walks with an ischial-bearing brace the involved hip tends to move medially and laterally, a condition which may contribute to subluxation and further flattening in the form of a coxa plana; therefore, use of such braces has been discontinued at the Hospital for Sick Children.</p> <p>In 1957, Dr. William Craig<a style="text-decoration:none;">*</a> of Los Angeles first reported <a></a> the use of the abduction and internal rotation method of treatment of Legg-Perthes disease, a procedure which has been modified by Dr. Gordon Petrie<a style="text-decoration:none;">*</a> of Montreal. <a></a> When a child was allowed to bear weight on the legs in the abducted cast, it was found that a remodeled femoral head would, in fact, develop in a spherical fashion in its round and uninvolved acetabulum. This method has proved satisfactory in many instances, but there are certain disadvantages. Because the child's legs must be kept in abduction for a period of several years, cast changes must be made at 8-to 12-week intervals. Considerable stiffness develops about the knees and ankles and, in some instances, there has been a suggestion of flattening of the femoral condyles because of the continuous pressure that is applied to the knee as it is held in one position over a prolonged period of time. In addition, prolonged plaster immobilization encourages the development of osteoporosis, atrophy of muscle, pressure sores, and other problems.</p> <p>To eliminate some of the problems encountered with the use of abduction casts, a new type of articulated experimental brace has been designed. Known as the "Toronto Legg-Perthes Brace," it provides for 90-deg. abduction and slight internal rotation, yet allows hip and knee movements so that the child may ambulate and sit (<b>Fig. 1</b> and <b>Fig. 2</b>). With the brace, the child is encouraged to walk as much as possible, for it is the weight-bearing movement with the hips centered in a safe position that encourages successful remodeling of the femoral head during growth. The brace is removed easily, but the child, of course, must not be allowed to walk without the brace. It is emphasized that at present (1968) this brace has been used on an experimental basis for the past 18 months, and we do not yet have any indications as to whether any problems will develop, such as those that were produced by ischial weight-bearing braces which, in fact, produced a coxa plana and probably did more harm than good. Cineradiography on one patient has indicated that the femoral head does stay within the acetabulum during loading and unloading of the joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Front and rear views of the Toronto brace for Legg-Perthes disease. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The Toronto brace for Legg-Perthes disease in use. <i>Left, </i>Three-quarter view in the standing position; <i>Right, </i>side view in the sitting position. Note that the thighs are maintained in the abducted position at all times. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Sixteen patients are presently using the Toronto brace and, in our present state of knowledge, this new type of brace appears to fulfill all the criteria set forth.</p> <h3>Biomechanics</h3> <p>The Toronto brace holds the legs in 90-deg. abduction with respect to each other, with the feet rotated internally. The body weight, when the patient stands erect, is distributed axially through each leg to each foot. The shoes are fastened to blocks of wood with the plantar surface at an angle of 45 deg. to the floor. The foot blocks are tied together by rods which are rigidly attached to the blocks but articulated at the sagittal plane. The force diagram is shown in <b>Fig. 3</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Resolution of forces being applied to patient using the Toronto brace for Legg-Perthes disease. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Each tie rod is connected by a ball joint to a rigid frame that supports the two thigh cuffs. The thigh cuffs take no load when the patient stands with knees extended, yet the hips are held in abduction as the knees are flexed. The geometry permits each knee to flex independently of the other (<b>Fig. 4</b>) and, because ball joints are used, accurate alignment is not necessary. The ball joints also allow dorsi-plantar flexion of the foot block (<b>Fig. 5</b>). Because the plantar surface of the shoe and foot is at 45 deg. to the floor, plantar flexion of the foot itself is accompanied by toe-in and dorsiflexion of the foot is accompanied by toe-out. Otherwise, toe-in and toe-out are securely held to the appropriate angle (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Schematic view from the front of the Toronto brace for Legg-Perthes disease to show the geometry of the system. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Location of the shoe with respect to the foot block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Schematic view from the top of the Toronto brace, showing angular position of the sole of the shoe. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Fitting and Fabrication</h3> <p>The first step in fitting and fabrication of the Toronto orthosis is to make a tracing of the patient's legs and pelvis when he is supine with each leg abducted 45 deg. from the center line of the body. (If this cannot be accomplished, traction or soft tissue release is indicated before fitting can proceed.) The shoes are put on the patient's feet so that the edge of the sole is traced rather than the edge of the foot itself, because the shoes are a part of the total structure. The following information should be indicated on the tracing (<b>Fig. 7</b>):</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Typical tracing needed for fabrication of the Toronto brace for Legg-Perthes disease. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The position of the thigh cuffs, which should be 1 in. above the patella and 2 in. below the groin.</li><li>The position of the shoe, when the sole of the shoe is placed at a 90-deg. angle to the long axis of the leg.</li><li>The position of the knee axis.</li><li> Measurements of the lower (LC) and upper (UC) circumferences of the thigh cuffs.</li></ol> <p>The frame, joint block, tie rods, foot blocks, and thigh cuffs are outlined on the tracing to facilitate fabrication.</p> <h3>Frame</h3> <p>The frame, which supports the thigh cuffs and joint block, is made from 1 in. X 1/4<i> </i>in. 24ST-4 aluminum bar, bent cold into a more or less diamond shape to conform to the tracing, and attached to the upper sides. The joint block is attached to the lower apex.</p> <h3>Joint Block</h3> <p>The purpose of the joint block is to provide a firm mounting for the ball joints to which the tie rods are attached. The block is assembled from five sections cut from 3 in. X 3 in. X 1/2 in. 65 ST (or equivalent) aluminum angle. Two automotive-type tie rods and joints are used for the ball joints,<a style="text-decoration:none;">*</a> which are located in the block so that they are in line with the knee axis. The threaded shank of the socket is bent to a 45-deg. angle before being brazed to the tie rod (<b>Fig. 8</b>). The tapered shank (Morse taper no. 1) on the ball of the joint is fitted to a hole in the joint block when the Chevy II part is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Method of bending threaded shank of the ball joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Tie Rods</h3> <p>The tie rods which connect the joint block with the foot blocks are made from chrome molybdenum tubing, 3/4 in. O.D. X .056 in. wall thickness. Tubing of this strength is required to resist damage that may be encountered with curbs, steps, etc. One end of the tie rod is brazed to a foot-block plate and the other end to the threaded shank of the joint.</p> <h3>Foot Blocks</h3> <p>The foot blocks are used to secure the shoes to the rods and support the shoes at the correct angle. Each foot block consists of a metal plate and a triangular block of wood. The metal plate is brazed to the distal end of the tie rod, and the wooden block is fastened to the plate with epoxy resin and wood screws. The shoes are fastened to the sloping surface of the wood block with rubber cement and wood screws. Note that the shoes are aligned on the block with approximately 15 deg. to 20 deg. internal rotation, as shown in <b>Fig. 6</b>. The bottom surface of the blocks should be covered with a tough soling material. A section of automobile tire is very serviceable, but tends to mark floors. It can be fastened on with rubber cement and wood screws. Frequent replacement is usually necessary.</p> <h3>Thigh Cuffs</h3> <p>The thigh cuffs should fit from 2 in. below the groin to 1 in. above the proximal border of the patella. The distal posterior edge should be flared to minimize discomfort in the popliteal area when the knees are flexed. The cuffs should be made to fit (not too tightly) over the trousers. They should be made from a semi-flexible material with a lateral opening so that the brace can be put on and taken off readily. Velcro straps provide a convenient method of adjustment. Cuffs made at the Centre were formed from a thermoplastic material from Smith and Nephew called "San Splint." A similar material, "Orthoplast," is marketed by Johnson and Johnson. The thigh cuffs and Velcro straps have required frequent replacement in active patients.</p> <h3>Gait Training</h3> <p>Usually about three days of intensive training by a physiotherapist are required for the child to learn to walk in the brace. Two crutches are used. They are usually held in front of the body, although the occasional child keeps one crutch behind. Stairs and curbs can be negotiated with little difficulty, and some patients learn to walk without crutches for short distances.</p> <p>The braces are removed for bathing, swimming, and sleeping, but the child must never be allowed to stand, kneel, crawl, or walk without the brace.</p> <p><b>References:</b></p> <ol> <li>Craig, William, Personal communication, 1967.</li> <li>Petrie, Gordon, Personal communication, 1968.</li> <li>Salter, Robert B., <i>Innominate osteotomy in the treatment of congenital dislocation and subluxation of the hip</i>, J. Bone Joint Surg. (Brit.), 43B:3:5l8-539, August 1961.</li> <li>Salter, Robert B., Personal communication, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Joints from a 1965 Chevy II have been used satisfactorily.</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">Petrie, Gordon, Personal communication, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Dr. James A. Petrie, Orthopaedic Surgeon, Royal Victoria Hospital, Montreal, P.Q., Canada.</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">Craig, William, Personal communication, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Dr. William Craig, 328 W. 23rd St., Los Angeles, Calif. 90007.</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>W. M. Motloch </b></td></tr><tr><td class="clsTextSmall">Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Road, Toronto 17, Canada.</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>C. A. McLaurin, B.A.Sc, P.Eng </b></td></tr><tr><td class="clsTextSmall">Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Road, Toronto 17, Canada.</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>W. P. Bobechko, M.D., F.R.C.S.(C.) </b></td></tr><tr><td class="clsTextSmall">Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Road, Toronto 17, Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-08.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 Toronto Orthosis for Legg-Perthes Disease Creator An entity primarily responsible for making the resource W. P. Bobechko, M.D., F.R.C.S.(C.) * C. A. McLaurin, B.A.Sc, P.Eng * W. M. Motloch * https://staging.drfop.org/files/original/3dc12ac74d007b30cd9ac2192ac0215c.pdf 5d7beccc83e107ade0d0749486469958 https://staging.drfop.org/files/original/a0a401a9b25d17513105126cb0e22659.jpg 0fcc33c1d8a6f3816a522919abb35777 https://staging.drfop.org/files/original/44c99f5d58723ecaa4e79eaf87cf3981.jpg 892fb6ec39817908bb4edc85e61acf13 https://staging.drfop.org/files/original/3ef2a0fe19537ad158c472f2949df71b.jpg 55a4929f1a78ab78e33373d5ea6ce3f9 https://staging.drfop.org/files/original/3612577ff647fd7ecd02f0df52948026.jpg 08f3fa9b0f6f0385168f6e324ceda5a0 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_02_028.pdf Year 1968 Volume 12 Issue 2 Page Number(s) 28 - 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/1968_02_028.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_02_028.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>Some Considerations in Management of the Above-Knee Geriatric Amputee</h2> <h5>Newton C. McCollough, III, M.D. <a style="text-decoration:none;">*</a><br />Augusto Sarmiento. M.D. <a style="text-decoration:none;">*</a><br />Edward M. Williams, M.D. <a style="text-decoration:none;">*</a><br />William F. Sinclair, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>The gradual increase in the life span of people in the developed countries of the world has resulted in a tremendous increase in the number of amputees in the older age, or "geriatric," group. A survey by Glattly in 1962 <a></a> showed that approximately 52 per cent of all amputees fitted with prostheses for the first time were over 50 years of age. Of these patients, 82 per cent had had amputations as a result of disease, 2 per cent because of tumor, and 16 per cent because of trauma. Most of these, of course, were lower-extremity cases.</p> <p>As short a time as 10 years ago, only a relatively few geriatric amputees were provided with limbs, and not much attention was given to the special problems of older patients. However, it has now been demonstrated that, with expert care, older amputees can be fitted with functional prostheses and that the results obtained are well worth the extra efforts required. The below-knee case obviously presents fewer problems as a rule than does the above-knee case, but though surgeons are now saving more and more knee joints there will always be a certain number of above-knee cases that require attention.</p> <p>Just as in the case of younger amputees, geriatric patients should be fitted as soon as possible. The longer the patient goes without a prosthesis, the greater the possibility for the development of contractures, edema, and other undesirable conditions. If the patient is not provided with a prosthesis immediately after the amputation, he should be fitted with a preparatory prosthesis as soon as he is seen by the clinic team.</p> <p>When treating the geriatric amputee, the clinic team must keep in mind constantly that the patient's potential is far from that of an otherwise healthy person, and certain compromises must be made if optimum results are to be achieved. The primary factors to be considered are condition of the skin, muscle tone and strength, coordination and balance, and energy potential.</p> <h3>Anatomical and Physiological Factors</h3> <p>Skin loses its turgor and becomes more fragile as age increases, and although it does not necessarily become more sensitive to the touch it does become more subject to abrasion and breakdown. This is true especially for the below-knee amputee but also demands special consideration when fitting and training the above-knee patient, and every effort is made to limit relative motion and pressure between the socket and stump.</p> <p>The older a person becomes the more likely he is to collect a fair number of scars, some of which may become supersensitive. The patient who has had an amputation secondary to vascular occlusion may well have scars present in the femoral triangle or abdominal scars from previous sympathectomies (<b>Fig. 1</b>). Particular care must be given to socket fit and suspension in order to avoid undue pressure and abrasion of these scarred areas. The presence of abdominal or inguinal hernias must likewise be taken into consideration and appropriate relief given if necessary.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Sensitive scars in the inguinal area secondary to vascular reconstruction may require modifications in the quadrilateral socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Subcutaneous atrophy occurs in the elderly patient and may present difficulties with socket fitting. The loss of fatty tissue padding often gives rise to complaints of extreme discomfort in areas subjected to high pressure, such as the ischial tuberosity and the laterodistal end of the femur. It may also complicate socket fitting, because flabby tissues tend to roll and therefore provide less stability. Muscles also tend to atrophy with age and, in addition to becoming weaker, have correspondingly less tone and less bulk, as any surgeon knows who has operated through the muscles of an elderly patient. Loss of muscle tone and bulk further decreases the soft tissue padding over bony prominences and may contribute to socket discomfort. Loss of definition of muscle groups leads to loss of stump contour and hence less stability between socket and stump. The decrease in muscular strength which accompanies atrophy results in less strength for actuating the prosthesis; hence, the weight of the artificial limb becomes an extremely important factor.</p> <p>Coordination and balance definitely are affected by the process of aging and rapidly become impaired when any degree of cerebral arteriosclerosis is present. Studies have shown that vestibular function decreases steadily after 50 years of age and, in addition, there is a general slowing of reflex motor action to proprioceptive stimuli which is irreversible. <a></a> The prosthesis, therefore, must be modified frequently to provide increased stability.</p> <p>The energy expenditure in the elderly above-knee amputee has been studied only recently, and is highly significant in the management of this class of patient. Miiller and Hettinger showed that energy expenditure was 25 per cent greater in above-knee amputees than in normal people. <a></a> Bard and Ralston gave a figure of 20 per cent greater energy expenditure in the above-knee amputee over the normal person. <a></a> Later, Ralston studied 17 above-knee amputees, all over 50 years of age, and found that the average energy expenditure was 55 per cent greater than for a normal elderly person. <a></a> He further demonstrated that a normal subject walking at a comfortable speed consumed 580 cc. of oxygen per min., whereas the same subject at maximum walking speed consumed 715 cc. of oxygen per min. This figure coincided almost exactly with the figure of 700 cc. of oxygen per min. consumed by above-knee amputees walking at a slow speed. The average pulse rate in these elderly amputees walking at slow speed was 110 per min. From these studies it is obvious that energy expenditure is greatly increased when an elderly person must use an artificial limb instead of his own.</p> <p>The use of crutches without a prosthesis has been used in the past as a criterion for prescribing prostheses for the elderly. However, this not only demands more energy from the patient than the prosthesis itself, but also demands more balance and coordination, and therefore the use of this criterion has been discontinued. Many patients who are not able to use crutches without a prosthesis can achieve some functional activity with a prosthesis. Use of a temporary, or preparatory, prosthesis (<b>Fig. 2</b>) offers the best index to future function. <a></a> This is to be distinguished from a pylon, which has no articulated knee joint and no prosthetic foot. The temporary, or preparatory, prosthesis has a completely formed, quadrilateral, total-contact socket on an adjustable knee with a positive knee lock, an aluminum shank, and an articulated SACH (solid-ankle, cushion-heel) foot.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. A typical temporary above-knee prosthesis for determining the feasibility of a permanent prosthesis for the elderly amputee. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Socket Design</h3> <p>Hall has reviewed the principles which led to the development of the quadrilateral socket as we know it today: <a></a></p> <ol> <li>Actively functioning muscles should have relief.</li><li>Stabilization forces should be applied where no functioning muscles exist.</li><li>Functioning muscles should be placed at slightly greater than rest length for maximum power.</li><li>Properly applied pressure is well tolerated by neurovascular structures.</li><li>Force is best tolerated if it is distributed over the largest available area.</li></ol> <p>For these reasons, the quadrilateral socket is relieved anterolaterally for the functioning rectus muscles and postero-laterally for the functioning gluteus maxi-mus muscle; it is flattened along the lateral wall to provide the greatest surface area for the forces of abduction and along the posterior wall to provide a similar large area for the forces of extension, and is molded snugly into Scarpa's triangle to keep the ischial tuberosity displaced posteriorly on the ischial seat.</p> <p>Although it may seem like fitting a round peg into a square hole, the quadrilateral socket has provided the most satisfactory union between stump and prosthesis ever achieved for the above-knee amputee, because its shape permits proper function of the muscles which move the stump. At the same time, the forces generated by this muscular activity are distributed over relatively large areas.</p> <p>This is in contradistinction to the "plug-fit" socket which was used formerly and which did not take properly into consideration muscle action and the forces generated. The plug-fit socket, seemingly more compatible because it provides a round hole for a round peg, allows the ischium to slide inside the socket brim and the weight to be borne chiefly on the gluteal muscle mass and adductor region. Because the weight is borne chiefly by the soft tissues and because the socket is of a conical shape, there is a wedging effect of the stump in the socket and the distal tissues are pulled tightly over the end of the femur, frequently causing pain or stump breakdown. Stability about the long axis is poor because of its round cross section. In addition, the forces of abduction are distributed over relatively small areas as the femur is pushed out against the lateral wall.</p> <p>The use of the plug-fit socket has been largely abandoned today, but some of its features are useful at times for the geriatric amputee, particularly when pressure is to be avoided over Scarpa's triangle because of a femoral bypass graft or because of inadequate circulation. In some geriatric patients there is justification for modifying the quadrilateral shape in the direction of a rounded or plug-fit shape, retaining, however, certain characteristics of the quadrilateral socket.</p> <p>The quadrilateral socket is not made to a rigid pattern but is modified from a typical pattern in various ways to accommodate individual stumps. If the rectus femoris is unusually large, it may be accommodated by further relief. The same is true for the hamstring and gluteal groups. If the gluteal muscles are underdeveloped or atrophied, less relief can be given. In the elderly, because of tissue atrophy, ischial weight bearing is often uncomfortable and the posterior wall may be modified to distribute the load over the gluteal group. If it is necessary to have the Scarpa's-triangle area free from pressure, this can be accomplished by relief in this area, allowing the ischium to slide into the socket over a properly contoured posterior brim.</p> <p>We must also reconcile ourselves to the fact that, as much as we delight in rehabilitating the geriatric amputee to an ambulatory status, he will, nevertheless, spend much of his time sitting, and certain socket modifications must be made to provide comfort during prolonged periods of sitting. The thickness of the posterior wall may be decreased so that pressure neuropathy of the sciatic nerve does not develop, and the anterior brim may be lowered so that excessive pressure does not develop in the region of the femoral neurovascular bundle or the anterior superior iliac spine.</p> <p>There appear to be no contraindications to the fitting of total-contact sockets to the elderly above-knee amputee. With total contact, not only are the tissues supported evenly and edema and skin breakdown prevented, but a greater proprioceptive and kinesthetic sense is developed, a condition of even more importance to the geriatric amputee than it is to his younger counterpart. Total contact, however, is not as important with pelvic suspension as it is with suction suspension, and it is difficult to maintain, particularly when stump socks are used.</p> <h3>Suspension</h3> <p>There is uniform agreement that suction provides the best suspension available. Suction suspension, however, has a limited use in the geriatric amputee because of the exertion required in donning the prosthesis and the fact that many elderly patients have a limited ability to bend forward.</p> <p>The pelvic band is in wide use, but it has disadvantages. It is apt to create excessive pressure about the lower abdomen when the patient is sitting. It must be well padded to prevent the development of excessive pressure over the iliac crest and over any scarred areas on the abdomen. The location at the hip joint is critical.</p> <p>The preferred method of suspension in the elderly above-knee amputee is the Silesian bandage or one of its modifications. When used with the quadrilateral total-contact socket, it provides comfortable suspension and gives good stability. It may be modified to include a shoulder strap, or may be modified further to incorporate an elastic webbing band from the posterior portion of the belt to the posterior wall of the socket to act as a hip-extensor aid. <a></a></p> <p>The inability of most elderly above-knee amputees to don a suction socket properly has led to the development of a split-socket type of appliance at the University of Miami Prosthetic Laboratory (<b>Fig. 3</b>). In this type of prosthesis the intimate fit of the suction-type socket is obtained, yet it is donned easily by the geriatric amputee. [A complete description of the split-socket type of appliance will be published in the Spring 1969 issue of <i>Artificial Limbs.</i>-Ed.]</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The double-wall above-knee suction socket with anterior opening developed by the University of Miami Prosthetic Laboratory for easy application in the older amputee. The flexible inner socket is jointed to the outer by a lateral Velcro strap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Alignment</h3> <p>The above-knee socket, in general, is adducted at least 5-10 deg. to restore the normal position of the femur and place the abductor muscles at their optimum functional length. Adduction of the socket also has the effect of narrowing the base of gait, an important factor in energy conservation. <a></a> If the abductor muscles are not placed in their optimum position of function, if the socket is abducted too far, or if the prosthetic foot is located too far laterally, the center of gravity of the body must shift over the supporting leg in order to gain sufficient stability during walking. Conversely, if the adduction of the socket is sufficient to hold the femur in a normal position of adduction and to keep the abductor muscles at their optimum length, these muscles will act to stabilize the pelvis with a minimum amount of contraction while dissipating the force of stabilization by femoral pressure against the lateral wall of the socket. This ideal cannot always be achieved in the elderly patient and the socket sometimes has to be aligned in the neutral or slightly abducted position in order to gain the required stability, at the expense of increased energy consumption.</p> <p>Aligning the socket in some degree of flexion increases the power of hip extension and voluntary knee stability. In general, the above-knee socket should be aligned in some degree of flexion, usually by 5 deg. in excess of the maximum amount of hip extension that can be obtained by the amputee while standing on his good leg without producing excessive lordosis. The amount of flexion will vary from 5 to 35 deg., depending on the length of the stump and the amount of hip-flexion contracture present. Alignment of the socket in flexion is limited by the length of the stump, and in the longer stump is minimal. As socket flexion is increased, the knee bolt must be moved somewhat more posteriorly in order to retain the same alignment stability at the knee. <a></a></p> <p>Although adduction of the socket is quite efficient because there is very little excursion of the femur outward toward the lateral wall of the socket in walking, flexion is not nearly so efficient because the large posterior muscle mass allows considerable backward shift of the femur in the soft tissues prior to its exerting significant pressure on the posterior wall. This has been documented by the senior author in a cineradiography movie of above-knee stumps in sockets (<b>Fig. 4</b>). Because of this backward excursion of the femur in the soft tissues as the thigh is extended, it is felt that the femur should be set in the maximum amount of flexion consistent with cosmesis to give greater voluntary control of extension to the knee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Frames from a cineradiography film of an above-knee stump in the socket. <i>Left, </i>The femur displaces posteriorly in the soft tissues a considerable distance before effective force can be transmitted to the posterior socket wall to stabilize the knee. <i>Right, </i>The limb is at heel strike prior to hip-extensor thrust. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the elderly patient with less voluntary control and deficiencies of balance and coordination, even a long stump may require the alignment characteristics of the medium or short stump.</p> <h3>Stability of the Knee Joint</h3> <p>Knee stability is usually achieved by a combination of voluntary control by the hip extensors and alignment of the knee axis so that it is posterior to the weight-bearing line (so-called alignment stability), or by a lock or brake. Voluntary control of knee extension is usually diminished in the geriatric amputee because of muscular weakness and poor coordination, and often an increased amount of alignment stability is necessary. This alignment stability, in combination with a single-axis constant-friction knee, the most standard type, is generally sufficient. However, there may be instances in which additional stability during weight bearing is necessary, and this can be provided by the use of a unit, such as the Bock Safety Knee, which gives a braking action during weight bearing. The chief disadvantage of this type of unit is the added weight of the mechanism.</p> <p>For the elderly amputee with extreme instability and insecurity, such as a bilateral amputee, or one in whom there is a severe flexion contracture, some type of positive knee lock is usually necessary. The knee is locked in extension throughout all phases of gait, producing obvious gait deviation, but as someone once said, "an abnormal gait is better than no gait at all," which would otherwise be the case.</p> <p>Hydraulic knee units can be used successfully by the elderly above-knee amputee, and offer many advantages when the amputee has sufficient muscle power to handle these necessarily heavier limbs. The chief advantage of the hydraulic unit in geriatric patients is that it allows more anterior placement of the knee joint without sacrificing stability, and less energy is consumed in hip flexion to initiate the swing phase of gait. The other primary advantage of the hydraulic knee unit, that of permitting rapid walking by faster and more reliable knee extension, is frequently lost on geriatric amputees as they usually walk with a slow, purposeful gait.</p> <p>Until recently it has been a most difficult task to provide the knee-disarticula-tion and long above-knee stumps with adequate swing-phase control. DuPaCo recently introduced a set up so that the DuPaCo "Hermes" unit can be used with these long stumps.</p> <p>Stability at heel strike is extremely important to prevent buckling of the knee or jack-knifing, which may occur in the elderly above-knee amputee with insufficient hip-extensor power. The less resistance to plantar flexion, the more stability there is at heel contact and shortly thereafter. Locating the foot anteriorly with respect to the knee also increases stability during the period just after heel contact.</p> <p>The SACH foot is generally satisfactory for use by geriatric amputees, although in cases where weight is a real consideration a wooden foot with an aluminum ankle joint can be lighter than the SACH feet available commercially. For the elderly amputee the heel should be relatively soft in order to act as a shock absorber and enhance stability of the knee at heel contact. A single-axis wooden foot in which the softness of the plantar bumper can be varied can give greater stability than even the softest SACH heel available. However, excessive stability results in unnecessary expenditure of energy.</p> <p>The foot must occasionally be outset more than usual to enhance lateral stability in the elderly. This again is another example of obtaining stability at the expense of increased energy consumption, for outset of the foot requires a greater lateral shift of the center of gravity in walking.</p> <h3>Ambulation</h3> <p>While it is desirable to return all elderly above-knee amputees to an ambulatory status, it is often not practicable. Nearly all bilateral above-knee amputees over 50 years of age will find the wheelchair an easier and more practical means of locomotion than the use of prostheses. One must carefully evaluate the patient in terms of strength, endurance, balance, and coordination prior to prescribing a prosthesis. The patient and his family or, more likely, the government will be saved unnecessary expenditure by proper selection of patients for fitting. Often, one must accommodate the patient's own desire to find out for himself whether or not he should be relegated to the wheelchair permanently. In the true geriatric amputee, once ambulation has been achieved it is best to continue the use of some type of external support, depending upon the patient. Usually a cane or single crutch on the opposite side will be sufficient support for the elderly amputee. In some extreme cases a walker may be used, which admittedly makes for poor gait pattern, but this is preferable to no gait at all. The use of external support not only gives increased mechanical stability but also provides the amputee with additional proprioceptive feedback from the terrain on which he is walking, thus leading to better balance. In determining the functional capacity of the bilateral amputee in the older age group, the use of "stubbies" is strongly recommended and the patient should graduate to nonarticulated pylons with increasing height, to a preparatory prosthesis, and, finally, to a permanent prosthesis. Needless to say, the bilateral above-knee patient must always use external support when walking, and a wheelchair should be considered the primary mode of locomotion.</p> <h3>Summary</h3> <p>In order to provide optimum function in the elderly above-knee amputee, one must consider thoroughly certain anatomical and physiological characteristics of the patient which may indicate the necessity for modifications of the standard prosthesis. The characteristics are individual and vary greatly from one elderly amputee to another, but include skin condition, condition of the subcutaneous tissue, muscle strength and tone, coordination, and general factors relating to energy consumption. Modifications based on these factors may then be made in the prosthesis to ensure optimum functional performance. These modifications may include changes in socket shape and alignment, changes in the suspensory apparatus, provisions for increased stability at the knee, and provisions in the ankle to ensure over-all stability. In every instance an attempt should be made to provide the amputee with a minimum prosthetic weight. The future level at which the amputee will function can best be anticipated by the initial use of a temporary, or preparatory, prosthesis.</p> <p><b>References:</b></p> <ol> <li>Anderson, M. H., John J. Bray, and C. A. Hennessy, <i>Prosthetic principles-above knee amputations</i>, Charles C Thomas, Springfield, El., 1960.</li> <li>Bard, Gregory, and H. J. Ralston, <i>Measurementof energy expenditure during ambulation, with special reference to evaluation of assistive devices</i>, Arch. Phys. Med., 40, October 1959.</li> <li>Birren, J. E., <i>Age changes in speed of simple responses and perception and their significance for complex behavior</i>, Old age in the modern world, E. and S. Livingstone, London, 1955, pp. 235-247.</li> <li>Glattly, Harold W., <i>A preliminary report on theamputee census</i>, Artif. Limbs, 7:1:5-10, Spring 1963.</li> <li>Hall, Cameron B., <i>Prosthetic socket shape as related to anatomy in lower extremity amputees</i>, Clin. Orthop., 37:32-46, November-December 1964.</li> <li>Muller, E. A., and T. Hettinger, <i>Arbeitsphysiologische Untersuchungen verschiedener Ober-shenkel-Kunstbeine</i>, Ztschr. f. Orthop., 81: 525, 1952.</li> <li>Radcliffe, Charles W., <i>Functional considerationsin the fitting of above-knee prostheses</i>, Artif. Limbs, 2:1:35-60, January 1955.</li> <li>Radcliffe, Charles W., Norman C. Johnson, and James Foort, <i>Some experience with prosthetic problems of above-knee amputee</i>, Artif. Limbs, 4:1:41-75, Spring 1957.</li> <li>Ralston, H. J., <i>Some observations on energy expenditure and work tolerance of the geriatric subject during locomotion</i>, in <i>The geriatric amputee</i>, NAS Publication 919, 1961.</li> <li>Staros, Anthony, <i>The temporary prosthesis for the above-knee amputee</i>, in <i>The geriatric amputee</i>, NAS Publication 919, 1961.</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>7.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Functional considerationsin the fitting of above-knee prostheses, Artif. Limbs, 2:1:35-60, January 1955.</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">Anderson, M. H., John J. Bray, and C. A. Hennessy, Prosthetic principles-above knee amputations, Charles C Thomas, Springfield, El., 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>8.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Norman C. Johnson, and James Foort, Some experience with prosthetic problems of above-knee amputee, Artif. Limbs, 4:1:41-75, Spring 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Hall, Cameron B., Prosthetic socket shape as related to anatomy in lower extremity amputees, Clin. Orthop., 37:32-46, November-December 1964.</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>10.</b> </td><td class="clsTextSmall">Staros, Anthony, The temporary prosthesis for the above-knee amputee, in The geriatric amputee, NAS Publication 919, 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>9.</b> </td><td class="clsTextSmall">Ralston, H. J., Some observations on energy expenditure and work tolerance of the geriatric subject during locomotion, in The geriatric amputee, NAS Publication 919, 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>2.</b> </td><td class="clsTextSmall">Bard, Gregory, and H. J. Ralston, Measurementof energy expenditure during ambulation, with special reference to evaluation of assistive devices, Arch. Phys. Med., 40, October 1959.</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">Muller, E. A., and T. Hettinger, Arbeitsphysiologische Untersuchungen verschiedener Ober-shenkel-Kunstbeine, Ztschr. f. Orthop., 81: 525, 1952.</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">Birren, J. E., Age changes in speed of simple responses and perception and their significance for complex behavior, Old age in the modern world, E. and S. Livingstone, London, 1955, pp. 235-247.</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">Glattly, Harold W., A preliminary report on theamputee census, Artif. Limbs, 7:1:5-10, 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>William F. Sinclair, C.P. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</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>Edward M. Williams, M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</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>Augusto Sarmiento. M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</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">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_02_028/1968_02_028-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_02_028/1968_02_028-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_02_028/1968_02_028-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_02_028/1968_02_028-04.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 Some Considerations in Management of the Above-Knee Geriatric Amputee Creator An entity primarily responsible for making the resource Newton C. McCollough, III, M.D. * Augusto Sarmiento. M.D. * Edward M. Williams, M.D. * William F. Sinclair, C.P. * https://staging.drfop.org/files/original/d824e24cf044272c06c6c6eef12d0ea7.pdf c91b6f3dbdcb7034212884899f66193b DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_02_00i.pdf Year 1968 Volume 12 Issue 2 Page Number(s) i - iii 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/1968_02_00i.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_02_00i.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>The Problem of the Geriatric Amputee</h2> <h5>Herbert E. Pedersen, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>It has been demonstrated that 70 to 90 per cent of all peacetime amputations result from gangrene in the lower extremities of elderly patients. Hansson<a></a> reported that in Sweden the amputation rate in males over 60 years of age rose from 34 per 100,000 population in 1947 to 129 per 100,000 in 1962. He predicted that those rates would continue to rise. Our experience in the United States seems to parallel that in Sweden, and therefore interest in the specific problems of the "geriatric" amputee is now high.</p> <p>During the period of increasing incidence, the mortality rate following amputation for gangrene has declined sharply, from 45 per cent to approximately 5 per cent for all amputations. Furthermore, studies show that, following amputation, patients live long enough to justify every effort at their rehabilitation, and that when they effectively use a prosthesis they live longer and the remaining extremity survives longer.</p> <p>For some time it has been recognized that the lower the level of a successful amputation the greater the chance that the patient will effectively use a suitable prosthesis. The most important factor in the ability of the geriatric amputee to use effectively a satisfactory prosthesis is the presence of the knee joint. In the absence of other complications, the patient who was able to walk before the onset of his disease should be able to walk with any type of satisfactory prosthesis after amputation below the knee once the stump is well healed.</p> <p>It is apparent that the current problem of the geriatric amputee is not primarily one of prosthetic components, prosthesis design, fitting and alignment, or gait training. The current problem of the geriatric amputee is preservation of the knee joint.</p> <p>For at least 20 years literature has been available which discusses the specific indications for amputation levels of the lower extremity and details the surgical techniques necessary to ensure successful amputations at low levels in the ischemic extremity. The principles set forth in that literature became very important to surgeons who were particularly interested in amputations. Recently, as the result of the work of Burgess et al. on immediate postsurgical fitting and the concomitant upsurge of interest in amputations, many more surgeons have come to recognize the importance of these principles. The research project headed by Burgess and sponsored by the Prosthetic and Sensory Aids Service of the Veterans Administration, aside from its other important contributions, has done more to stimulate interest in amputations than any other single peacetime venture.</p> <p>Despite the renewed interest in amputations, it is still true, unfortunately, that most amputations for gangrene are performed by surgeons who are much more interested in other problems. Far too many feel that the nature of the disease makes amputation above the knee inevitable, or that the mortality and morbidity associated with unsuccessful attempts at amputation at low levels preclude such efforts. The techniques for successful management of delayed healing are poorly understood. In many areas it is still not recognized that the problem in diabetes, leading to progressive lower-extremity tissue necrosis, is frequently uncontrolled infection, rather than ischemia.</p> <p>This all suggests that in terms of man-hours, dollars, and total available facilities, great improvement in the rehabilitation of the geriatric amputee can come from a more efficient educational program which will lead to a higher incidence of successful amputations at low levels.</p> <p>It has been suggested that to reach the surgeons who perform most of the amputations for gangrene there is need for a document which is generally accepted and widely distributed, and which will be read by those surgeons. In 1961 the Committee on Prosthetics Research and Development, recognizing the need for improvement in the rehabilitation of the geriatric amputee, sponsored a conference for the purpose of stimulating research in that area. The report of the conference, <i>The Geriatric Amputee </i>(NAS Publication 919), was well received, and, in addition to serving its original purpose as a reference for research personnel, has been used extensively in education and training of medical and paramedical personnel. New knowledge has made obsolete much that is contained in <i>The Geriatric Amputee</i>, and CPRD has recommended to the Committee on Prosthetic-Orthotic Education that the necessary steps be taken to provide an authoritative document that will be useful to all who are engaged or expect to be engaged in the rehabilitation of the geriatric amputee. To this end, CPOE is calling upon a number of individuals from various disciplines with vast experience to assist in the preparation of such a document.</p> <p>Surgeons need not wait, however, until publication of this volume to begin to take positive action to improve the lot of future geriatric amputees. They should review the literature and take every action possible to retain the knee joint in the geriatric case when amputation is indicated.</p> <p><b>References:</b></p> <ol> <li>Hansson, Jan, <i>The leg amputee</i>, Acta Orthop. Scand. (Suppl.), <b>69</b>:1-104, 1964.</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>1.</b> </td><td class="clsTextSmall">Hansson, Jan, The leg amputee, Acta Orthop. Scand. (Suppl.), 69:1-104, 1964.</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>Herbert E. Pedersen, M.D. </b></td></tr><tr><td class="clsTextSmall">Chairman, Committee on Prosthetic-Orthotic Education, National Research Council, 2101 Constitution Ave., N.W., Washington, D. C. 20418; Chairman, Department of Orthopaedic Surgery, Wayne State University Medical School, Detroit, Mich. 48207</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> 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 Problem of the Geriatric Amputee Creator An entity primarily responsible for making the resource Herbert E. Pedersen, M.D. * https://staging.drfop.org/files/original/900c406bee3adcda50bf8b6267359ead.pdf df82042fb3ac474e9dedb922d4912194 https://staging.drfop.org/files/original/fe114a930bf052972f072f3dceff189a.jpg baf11ca27502acca8baaf54e3ca55687 https://staging.drfop.org/files/original/2bea6a4071dcb885ee29cf80b031c21d.jpg 495cb08e3d3b7f57cf3c08c8ab99bd81 https://staging.drfop.org/files/original/6ce3fbdbe8f4750a79fc8b18340555b4.jpg 863124825991da3ae0b5ba0c515a41e1 https://staging.drfop.org/files/original/022c06bc2eadf40c0f1e04c53578a7a1.jpg b890e5d134886cf5f9630c735ed31b4d https://staging.drfop.org/files/original/488da4aeb82fd8a32ad0e2ca277a641f.jpg bce900c1fcc880b0989b617b2ee94ea5 https://staging.drfop.org/files/original/3bf5f22ba09b4acc4594ca080bb9a838.jpg 95b37754f135d90549bda9247fbc0e23 https://staging.drfop.org/files/original/3d8f97204bb2bb16ed9d02d6d9f40501.jpg 03284aa41c6c0b02c4a6f995614ac73b https://staging.drfop.org/files/original/d634c2d774e6dd2826a9839c7f153913.jpg d5757b210e0771bb37226bdf6cc6bbe1 https://staging.drfop.org/files/original/362e4848532095e03dc40255afdfc1f2.jpg 42bc04ccce92bc21e883090f6981081a https://staging.drfop.org/files/original/bd7d7e55042feb7315cc9b240e582e1a.jpg 5cebe71dc1c91759df3936df3c824f98 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_01_025.pdf Year 1968 Volume 12 Issue 1 Page Number(s) 25 - 34 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/1968_01_025.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_01_025.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>The Army Medical Biomechanical Research Laboratory Porous Laminate Patellar-Tendon-Bearing Prosthesis</h2> <h5>Clyde M. E. Dolan, M.S. <a style="text-decoration:none;">*</a><br /></h5> <p>In warm or humid climates, the problem of heat and perspiration within a nonporous plastic laminate prosthesis covering a substantial area of the body is particularly troublesome. The accumulation of sweat in a patellar-tendon-bearing (PTB) socket or a shoulder cap, combined with the inability of the laminate to permit evaporation or diffusion of water vapor, frequently causes mild to severe discomfort and even skin lesions sufficiently severe to require that the use of the prosthesis be suspended. Moreover, when a rubber (Kemblo) and leather liner is used, the sweat may cause it to deteriorate.</p> <p>Initial efforts of the U.S. Army Medical Biomechanical Research Laboratory (AMBRL) to produce porous plastic laminates for prosthetic applications were well received when applied to upper-extremity devices; <a></a> but, when the same technique was applied to PTB prostheses, the strength and durability of the material proved to be inadequate <a></a> In addition, problems of low porosity, nonreproducibility, and increased fabrication time were cited as serious deficiencies in the technique. <a></a></p> <p>In 1966, AMBRL reported on the development of an epoxy porous laminate which when fabricated according to the instruction manual <a></a> offered the following claimed advantages over prior techniques utilizing polyester resins:</p> <ol> <li>The new laminates were two and one-half times stronger under laboratory test conditions.</li><li>The new technique produced laminates which were twice as porous as prior versions.</li><li>The fabrication procedure was simpler, required only one curing temperature, and could be reproduced more reliably.</li></ol> <h3>Description of the Technique</h3> <h4>Stump-Casting Procedures</h4> <p>The stump-casting and cast-modification procedures are essentially the same as those taught in the various prosthetics educational programs. However, the positive stump model is prepared for a suction lamination. This technique, which involves the use of a vacuum pump to make the PVA bag conform to the socket contours, is familiar to many pros-thetists but is not a routine procedure in the fabrication of a PTB socket with soft insert.</p> <h4>Fabrications Procdedures</h4> <p>The procedures for fabricating a porous epoxy laminate PTB socket with a soft distal end differ from those used in the polyester lamination system as follows: the utilization of Silastic Elastomer 385 and Foam Elastomer 386 to form the soft distal end, and the procedure of impregnating the Banlon and nylon stockinette with a predetermined quantity of resin mixture consisting of epoxy EPON, Versamid, pigment, and methylene chloride.</p> <p>Preimpregnation of the stockinette and evaporation of the solvent prior to layup result in a stronger, more porous socket.</p> <h3>Finishing Procedures</h3> <p>Standard finishing procedures are not used because they would reduce the porosity of the socket. A procedure in which indexing pins are used to align the porous shank with the socket is detailed in the 1963 AMBRL instruction manual <a></a> and is incorporated in the NYU revision of the 1966 AMBRL manual. <a></a></p> <p>The one variation from the AMBRL procedure that was introduced in the finishing process by NYU was the use of polyurethane as a buildup material over the socket instead of A.C. polyethylene wax (steps 51 and 52 in the 1966 AMBRL manual). Polyurethane foam was believed to offer the prosthetist a faster method for accomplishing the external buildup over the socket. The foam also permits the use of power equipment for shaping, which the wax does not.</p> <h3>Preliminary Evaluation</h3> <p>A preliminary evaluation completed at NYU in March 1967 <a></a> critically considered the epoxy porous laminate procedure in the following respects on the basis of four fittings on below-knee amputees: the fabrication process, amputee reactions, durability, and laboratory tests. The fittings were carried out in the New York metropolitan area during a period of very hot, humid weather in the summer of 1966, which afforded ideal conditions for investigation of amputee reactions to socket porosity.</p> <p>In summary, the conclusions of the preliminary evaluation were:</p> <p>That the May 1966 AMBRL instruction manual was generally clear and easy to follow. However, the finishing procedures lacked the completeness of those set forth in the June 1963 AMBRL manual. A revision of the former was prepared, incorporating details of this part of the technique. The procedures were consistent with accepted prosthetics practice, and no unusual equipment was necessary.</p> <p>That the actual time required for fabrication was approximately one and a quarter hours longer than that required for fabrication of the conventional PTB prosthesis. The bench time can be reduced somewhat if the suction hose is inserted into the oven, eliminating the necessity of setting up the undercut areas of the stump model prior to placement of the socket in the oven for curing.</p> <p>That the coloring and the finish of the experimental prostheses were uniform, and the porosity was highly acceptable. Since no socket liner is used in this procedure, but rather a soft distal end, the amputee's tolerance to a "hard" socket was incidentally investigated. None of the amputee subjects in this preliminary evaluation noted any adverse reaction to the lack of a soft insert. All reported a significant reduction in discomfort associated with perspiration during the period of wear, remarking that the stump socks were much less saturated at the end of the day.</p> <p>That the experimental prostheses were significantly lighter in weight, with an average reduction of 32 per cent. The prostheses showed no signs of breakdown or clogging of the pores over a six- to 12-month period of wear, and showed excellent retention of original conformation. All are still being worn satisfactorily after 18 months.</p> <p>On the basis of this preliminary evaluation, the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development recommended that a field study be initiated to evaluate the porous laminate technique on a broad sample of juvenile subjects.</p> <h3>Scope and Objectives of the Field Study</h3> <p>Six clinics (Atlanta, Birmingham, Durham, Memphis, New Orleans, and Orlando), all located in hot, humid climates in the southern and southeastern sections of the United States, were invited to send a prosthetist representative to a three-day course in the fabrication of the AMBRL porous laminate PTB prosthesis, conducted at New York University in May 1967. Each clinic agreed to fit five subjects during the summer of 1967 with porous PTB prostheses fabricated by or directly under the supervision of the prosthetist attending the course.</p> <p>The field study was designed to evaluate the AMBRL porous laminate used in the following respects:</p> <ol> <li>Fabrication procedures.</li><li>Subjective reactions (comfort and cosmesis).</li><li>Medical considerations (stump hygiene and skin condition).</li><li>Durability and adjustments.</li></ol> <h3>The Sample</h3> <p>The sample consisted of 20 subjects-11 males and nine females between four and 20 years of age. Five were from Atlanta, three from Birmingham, three from Durham, two from Memphis, and seven from New Orleans. There were seven right and ten left below-knee amputees, two bilateral amputees (one right below-knee and left Syme's; one bilateral below-knee), and one unspecified. Eleven of the amputations were congenital, ten acquired, and one unspecified. All subjects were experienced prosthesis wearers, the prior prosthesis having been worn for seven months to three years.</p> <p>The types of prostheses worn by these subjects prior to the study are listed as follows:</p> <table> <tbody><tr> <td> <p><b>PTB sockets</b></p> </td> </tr> <tr> <td> <p>With side joints and lacer, without liner</p> </td> <td> <p>   3</p> </td> </tr> <tr> <td> <p>With supracondylar cuff, with liner</p> </td> <td> <p>   8</p> </td> </tr> <tr> <td> <p>With supracondylar cuff, without liner</p> </td> <td> <p>   6</p> </td> </tr> <tr> <td> <p>Syme's prosthesis</p> </td> <td> <p>   2</p> </td> </tr> <tr> <td> <p>Other or unspecified</p> </td> <td> <p>   3</p> </td> </tr> <tr> <td> <p> </p> </td> <td> <p> </p> </td> </tr> <tr> <td> <p><b>TOTAL: </b></p> </td> <td> <p><b>  22</b></p> </td> </tr></tbody></table> <h3>Methodology</h3> <p>At least, five clinic visits by each amputee subject were required for the appropriate evaluations. An outline of the procedures follows.</p> <h4>First Visit (Screening and Prescription)</h4> <p>At the first visit, clinic personnel discussed the purpose of the study with patient and parents, indicating the type of data that would be requested. A porous laminate PTB prosthesis was to be prescribed at this time. For purposes of uniformity, all experimental limbs were to use supracondylar suspension. General biographical information was recorded, as well as subjective comments concerning the previously worn prosthesis.</p> <h4>Second Visit (Delivery)</h4> <p>The porous laminate prosthesis was delivered at the second visit, and initial reactions of the subject and the clinic team were recorded. The prosthetist's report was initiated and retained by the prosthetist for submission at the termination of the study, as a means of recording fabrication and maintenance problems.</p> <h4>Third Visit (One Month Postdelivery)</h4> <p>The child's stump was examined to ascertain if any dermatological changes had occurred which might be attributable to the porous socket. Subjective reactions to the experimental prosthesis and reactions of the subject to the prosthesis as compared with the previously worn prosthesis were recorded.</p> <p>At this time the experimental prosthesis was rendered nonporous by the application of Saran Wrap, duplicating the procedure used in the preliminary evaluation at NYU. The prosthesis was then worn under these conditions for a two-week period of hot weather.</p> <h4>Fourth Visit (After Wear with Saran Wrap)</h4> <p>The stump was examined for dermatological changes. Any differences reported by the subjects as a result of eliminating socket porosity were assessed. The Saran Wrap was then removed.</p> <h4>Fifth Visit (After Six Weeks' Wear of the Porous Prosthesis without Saran Wrap)</h4> <p>Subjective and comparative reaction were once more elicited. The prosthetist's report was submitted.</p> <h3>Field Study Results</h3> <p>During the NYU course of instruction in this technique, one prosthetist was adversely affected by the epoxy resin. The difficulty had been noted occasionally in earlier studies. The developer has recognized the potential hazard, and appropriate handling precautions must be carefully observed. <a style="text-decoration:none;">*</a></p> <p>The epoxy resins (EPON 815) and curing agents (T-l) and, to a lesser extent, Versamid 140, are primary skin irritants. When in contact with the skin for a sufficient period of time, these materials are capable of producing a contact dermatitis in most individuals. In a relatively few hypersensitive workers, they can produce an allergic type of dermatitis in a relatively short period of time.</p> <p>Intermittent skin contact with these materials will not usually cause a dermatitis among normal workers; however, because of the occasional hypersensitive individual who cannot always be identified in advance, the precautionary measures suggested above should be used at all times.</p> <p>In addition to the foregoing precautions, good general ventilation is highly recommended.</p> <p>The first case of dermatitis usually indicates that proper handling procedures are not being observed, although in a very hypersensitive individual this is not necessarily true. The dermatitis should be treated promptly, and the source of contact should be ascertained and eliminated. The rash may be alleviated in most instances by soaking with warm Burow's Solution for 15-30 min., three or four times daily. Rashes that do not respond to treatment should be seen by a physician</p> <p><i>Based upon Handling Precautions for the Resin-Solvent System Used for Preparing Porous Laminates, an intramural memorandum issued by AMBRL in May 1967.</i></p> <h4>Fabrication Procedures</h4> <p>Telephone contacts with the participating prosthetics facilities during the course of the field study indicated that, with one exception, the fabrication procedures posed no serious problems. One facility was unable to duplicate the procedures because of difficulties with equipment. (Adequate temperature control is mandatory for successful preparation; this facility's oven temperature could not be reliably maintained for precuring the layup material.) Prosthetists' fabrication reports were received from five of the participating clinics.</p> <p>All reports indicated that two or three additional hours were required to fabricate a porous PTB prosthesis. Phases of the process cited as time-consuming were the weighing, processing, and curing; breakouts and reassembly; finishing; and the preparation of the soft distal end.</p> <p>No criticisms were made of the instructions contained in the manual. The process, however, was evidently more demanding than the conventional technique. Close attention to accuracy and detail is essential for successful preparation of the porous laminate.</p> <p>The increased fabrication time and effort, the need for some special materials, and the necessity for adequately ventilated work areas may result in some cost increases. One clinic expressed concern about the attitude of the local state agency in this respect, and one prosthetist suggested that the increased cost be borne in mind when the prescription is written.</p> <h4>Reactions of Subjects and Clinic Personnel</h4> <p>The experimental limbs were generally considered superior to the previously worn prostheses in several respects. Initial reactions to the porous prostheses, elicited immediately after delivery, are shown in <b>Table 1</b> and <b>Table 2</b>. After a one-month period of wear, corresponding reactions of the subjects and the clinics were recorded; these results appear in <b>Table 3</b> and <b>Table 4</b>.</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 /> </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 /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Examination of <b>Table 2</b> and <b>Table 4</b> (comparative reactions) indicates few changes from the positive first impression as wear increased, with a trend toward more emphatic positive comments.</p> <p>One month after delivery, the patient, his parents, and the clinic were asked their preference between the previously worn prosthesis and the experimental prosthesis. The results are shown in <b>Table 5</b>. In addition, the clinics were asked if they would prescribe a porous laminate prosthesis for other patients. Three clinics said "Yes," one said "No," and one said "Probably."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After four weeks of wear, the prostheses were covered with Saran Wrap to eliminate the porosity of the sockets while leaving the prostheses intact. No change was made in fit, weight, alignment, or other factors that might affect reactions. The subjects were asked to wear the experimental limbs under these conditions for a two-week period of hot weather. Seventeen subjects reported data for this test period. The majority indicated that perceived heat within the socket increased and that perspiration became a problem (introducing dermatological problems and discomfort). <b>Table 6</b> lists the reactions of the subjects regarding the test period utilizing the Saran Wrap.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Comparison of <b>Table 6</b> with <b>Table 2</b> shows a significant change in the perception of heat within the socket. Of those subjects offering opinions, 90 per cent considered the experimental prosthesis very satisfactory or satisfactory prior to the application of Saran Wrap, and 10 per cent considered it unsatisfactory. With the Saran Wrap, only 27 per cent reported the prosthesis satisfactory, and 73 per cent considered it unsatisfactory or very unsatisfactory-certainly a very dramatic reversal of reactions on the part of the wearers.</p> <p>Since no changes were introduced in fit, weight, or alignment, it was not expected that perception of socket comfort would change significantly under the test conditions, except to the extent that comfort might be affected by heat in the socket. Prior to the test period 95 per cent reported satisfactory reactions to comfort, while 5 per cent considered the prosthesis unsatisfactory; with the use of Saran Wrap, 83 per cent considered the experimental limb satisfactory and 17 per cent unsatisfactory.</p> <p>An uninterrupted six-week wear period followed the study of the effects of the Saran Wrap covering. At this time, subjects and clinic teams were asked to submit a non-comparative assessment of the experimental prosthesis and a separate questionnaire comparing the experimental prosthesis to the one worn before the field study. The results appear in <b>Table 7</b> and <b>Table 8</b>. These data were received regarding 17 experimental prostheses.</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 /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After a three-month period of wear, subjects and clinics were asked to indicate preferences as to the type of prosthesis to be worn in the future (<b>Table 9</b>). When clinics were asked if they would recommend the porous laminate prosthesis for other patients, three said "Yes," one said "No," and one said "Possibly."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Medical Considerations</h4> <p>A definite decrease in stump hygiene difficulties was specifically reported for two subjects in the study, leading to a recommendation by one clinic that the porous laminate be considered in cases presenting dermato-logical problems. There were no instances of deterioration of stump condition that could be related to the porous laminate, although socket adjustments were required in some cases.</p> <h4>Durability and Adjustments</h4> <p>Two clinic chiefs and their prosthetists expressed doubt that the porous laminate prosthesis would be sufficiently durable for patients who give their prostheses extremely heavy use. No such problems were encountered in an 18-month follow-up of the adult patients participating in the original NYU study of the epoxy porous prosthesis. The developer implies that adequate strength can be provided with this technique, even for heavy subjects, although only limited supporting data for this contention are available.</p> <p>One prosthesis fitted with side joints and thigh corset, which compromised the requested supracondylar suspension, showed repeated breakdown. If side joints are to be provided, the porosity of a substantial socket area must be sacrificed in order to provide adequate strength. Consequently, porous lamination may not offer as significant an advantage for these patients. In view of this problem, reservation of the porous laminate procedure for the PTB-type of fitting without side joints may be indicated. This point merits further investigation.</p> <p>One prosthesis was reported to have de-laminated between the insert and the outer wall. However, it appears that this complaint referred to a failure of the bond between socket and shell and not to delamination <i>per se. </i>Two other prostheses showed marked wear during the period of study, although no functional problems were encountered.</p> <p>Adjustments are more difficult to perform on the porous laminate socket, since it is impossible to fill in an area without sacrificing porosity. It is also more difficult to relieve an area. Because the finished laminate is so much thinner than conventional products, reducing the area may render it too weak for normal use.</p> <h4>Discussion</h4> <p>The high level of acceptance of the experimental prosthesis is supported by repeated references to three principal factors.</p> <p>"Increased comfort" is a broad term which encompasses, both directly and indirectly, the decreased weight of the porous limbs compared to the previously worn prostheses, decreased perspiration (with concomitant dermatological improvement) and reduction of heat within the socket, and the added comfort of the soft distal end.</p> <h4>Weight</h4> <p>To confirm the subjective impression of lighter weight, the weights of previously worn prostheses and experimental prostheses were compared. <b>Table 10</b> indicates the percentage of weight reduction for the 14 prostheses where such data were available. It can be seen that the average reduction is approximately 25 per cent.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Perspiration and Heat</h4> <p>Approximately one-third of the reasons cited for the preference of the porous laminate for future use related to the diminution of perspiration and the perception of the experimental limb as cooler. The results of the two-week test period (experimental socket covered with Saran Wrap) dramatically illustrate the importance of socket porosity in this regard.</p> <h4>Soft Distal End</h4> <p>In their preliminary testing, both the developer and New York University found no serious problems occasioned by the change from an insert to a hard socket with soft distal end. The observation was borne out in the field study during which the incidental investigation of the soft distal end elicited several positive comments (one clinic, although recommending a standard laminate in the future fitting of a patient to provide greater durability, would recommend that the new prosthesis incorporate the soft distal end procedure).</p> <h4>Amputee and Clinic Reactions</h4> <p>Patients and their parents were almost unanimous in their acceptance of the porous prosthesis (nearly 95 per cent of the patients and their parents preferred the experimental technique), whereas the clinics exhibited much less enthusiasm. At the close of the study, only two of the five clinics would definitely prefer the porous laminate for future use. It is important to note that the two clinics which recommended the porous laminate for future use accounted for the fitting of 11 of the 17 subjects who completed this phase of the study. Reluctance to prescribe the porous laminate resulted in extremely limited samples from the three clinics who preferred the standard technique.</p> <p>Two of the clinics rejecting the porous laminate for the future use of the patients fitted in the study might, however, recommend the porous prosthesis for <i>other </i>patients. Therefore, only one clinic categorically rejected the experimental prosthesis.</p> <p>Several suggestions may be advanced to help resolve this apparent discrepancy of opinion. During the study, as early as one month postdelivery, four reports were received which indicated dissatisfaction with the appearance of the experimental limbs. The poor appearance was specifically related to difficulties in keeping the comparatively rough surface clean. It was noted that the porous prostheses tended to appear dirty after only a short period of use, with one experimental prosthesis being rejected for this reason. Interrogation cf adult patients involved in the preliminary laboratory study showed that the prostheses are in fact difficult to clean and that they gather varying amounts of dirt, but none of the patients spontaneously complained of this problem. It might be expected that children would be less sensitive to this problem than adults.</p> <p>A further explanation for the clinics' less emphatic endorsement may lie in the increased cost factors (due to two to three hours' increase in fabrication time and materials), the need for some specialized equipment, and the occasional allergenic reactions of shop personnel to the uncured resin-solvent system. Therefore, the prosthetists' reluctance to utilize the technique may have been transmitted to the clinics.</p> <h3>Summary</h3> <p>The AMBRL porous laminate technique as applied to the PTB prosthesis was evaluated over a three-month period on 20 children at five juvenile amputee clinics in the southern section of the country. Essential aspects investigated were the fabrication process, subjective reactions, medical considerations, adjustments, and durability.</p> <p>The data indicated that porous laminate PTB prostheses were generally well accepted by patients and parents but less so by clinic personnel. The developer's claims of reduced perspiration, added comfort, decreased der-matological problems, and lighter weight were generally corroborated; weight reduction was the most consistently reported advantage.</p> <p>Increased fabrication time and some increase in the complexity of the fabrication process were cited as problems. Cosmetic characteristics elicited both favorable and unfavorable remarks; the propensity of the porous laminate to collect and trap dirt particles caused some dissatisfaction, while the textured appearance of the porous laminate was preferred in some instances.</p> <p>Concern was expressed regarding the durability of the porous laminate, particularly when applied to a prosthesis which was subjected to arduous use, although the experimental evidence was apparently insufficient for such concern.</p> <p>Based upon patients' and parents' preference for the experimental limbs, including instances of improvement in stump condition, it appears that the porous laminate PTB is a significant and worthwhile addition to prosthetics technology. Other applications of the porous laminate may also be recommended, particularly for those patients with substantial body areas enclcsed within a socket, with severe perspiration problems, or where a lightweight prosthesis is indicated. Shoulder caps, transthoracic sockets, above- and below-elbow sockets, or hip-disarticulation and hemipelvectomy applications may be considered. Informal observations of several upper-extremity fittings have again indicated that the porous laminate offers distinct advantages in terms of decreased perspiration and weight.</p> <p><b>References:</b></p> <ol> <li>Dolan, Clyde M. E., <i>The AMBRL porous laminatepatellar-tendon-bearing prosthesis</i>, New York University, Prosthetics and Orthotics, Post-Graduate Medical School, March 1968.</li> <li>Hill, James T.,<i>A manual for the preparation of above and below elbow porous prostheses</i>, TechnicalReport 6204, Army Prosthetics Research Laboratory, Washington, D.C., January 1962.</li> <li>Hill, James T., and Fred Leonard, <i>Porous plasticlaminates for upper-extremity prostheses</i>, Artif. Limbs, Spring 1963, pp. 17-30.</li> <li>Plumb, Robert E., and Fred Leonard,<i> Patella-tendon-bearing below-knee porous socket with soft Silastic distal end</i>, Technical Report 6311, Army Medical Biomechanical Research Laboratory, Washington, D.C., June 1963.</li> <li>Plumb, Robert E., and John J. Urban, <i>Patella-tendon-bearing below-knee porous socket with soft Silastic distal end</i>, MR-62-62, Army Prosthetics Research Laboratory, Washington, D.C., November 1962.</li> <li>Plumb, Robert E., James T. Hill, and HenryMouhot, <i>Instruction manual for preparing a porous epoxy PTB socket with soft distal end</i>,Technical Report 6609, Army Medical Biomechanical Research Laboratory, Washington, D.C., May 1966.</li> <li>Plumb, Robert E., James T. Hill, and HenryMouhot,<i> Instruction manual for preparing a porous epoxy PTB socket with soft distal end</i>, Technical Report 6609, Army Medical Biomechanical Research Laboratory, Washington, D.C., May 1966 (as amended by New York University).</li> <li>New York University, Prosthetic and OrthoticStudies, School of Engineering and Science, <i>Preliminary evaluation of AMBRL porous laminate patellar tendon-bearing prosthesis</i>, May 1965.</li> <li>New York University, Prosthetic and OrthoticStudies, Post-Graduate Medical School,<i>Preliminary evaluation: AMBRL porous laminate PTB prosthesis</i>, March 1967.</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">Disposable gloves should be worn when handling all resins and solvents. Face shield or goggles are advisable when pouring or mixing the resins.</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">New York University, Prosthetic and OrthoticStudies, Post-Graduate Medical School,Preliminary evaluation: AMBRL porous laminate PTB prosthesis, March 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>7.</b> </td><td class="clsTextSmall">Plumb, Robert E., James T. Hill, and HenryMouhot, Instruction manual for preparing a porous epoxy PTB socket with soft distal end, Technical Report 6609, Army Medical Biomechanical Research Laboratory, Washington, D.C., May 1966 (as amended by New York University).</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">Plumb, Robert E., and Fred Leonard, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, Technical Report 6311, Army Medical Biomechanical Research Laboratory, Washington, D.C., June 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">Plumb, Robert E., James T. Hill, and HenryMouhot, Instruction manual for preparing a porous epoxy PTB socket with soft distal end,Technical Report 6609, Army Medical Biomechanical Research Laboratory, Washington, D.C., May 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">New York University, Prosthetic and OrthoticStudies, School of Engineering and Science, Preliminary evaluation of AMBRL porous laminate patellar tendon-bearing prosthesis, May 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>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Plumb, Robert E., and Fred Leonard, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, Technical Report 6311, Army Medical Biomechanical Research Laboratory, Washington, D.C., June 1963.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Plumb, Robert E., and John J. Urban, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, MR-62-62, Army Prosthetics Research Laboratory, Washington, D.C., November 1962.</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">Hill, James T.,A manual for the preparation of above and below elbow porous prostheses, TechnicalReport 6204, Army Prosthetics Research Laboratory, Washington, D.C., January 1962.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Hill, James T., and Fred Leonard, Porous plasticlaminates for upper-extremity prostheses, Artif. Limbs, Spring 1963, pp. 17-30.</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>Clyde M. E. Dolan, M.S. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Scientist, Prosthetic and Orthotic Studies, NYU Post-Graduate Medical School, 317 East 34th St., New York, NY. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 2 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-01.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-02.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-03.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-04.jpg Figure 6 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-05.jpg Figure 7 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-06.jpg Figure 8 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-07.jpg Figure 9 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-08.jpg Figure 10 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-09.jpg Figure 11 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-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 The Army Medical Biomechanical Research Laboratory Porous Laminate Patellar-Tendon-Bearing Prosthesis Creator An entity primarily responsible for making the resource Clyde M. E. Dolan, M.S. *