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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Full Text PDF Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_01_010.pdf Text Any textual data included in the document <h2>Partial Foot and Syme Amputations: An Overview</h2> <h5>John H. Bowker, M.D. <a style="text-decoration: none;">* </a></h5> <h3>Historical Aspects</h3> Until the middle of this century, partial foot and Syme amputations were done almost exclusively as a sequel to trauma. The presumption was that the normal vascular supply of the remaining foot would usually lead to healing. Both dry gangrene due to peripheral vascular disease and wet gangrene, related to infection superimposed on dysvascularity, were commonly treated by above-knee amputation or below-knee amputation, the choice often being dictated by local surgical prejudice.<a></a> The rationale was to amputate at the level where one could anticipate primary healing. This had considerable validity in the pre-antibiotic era, when failure of primary healing might mean death of the patient from secondary infection. However, in the United States at the present time, a growing number of partial foot amputations are being done for patients with arterial and/or capillary blood vessel disease, the majority of whom have diabetes mellitus. This major turnaround in attitude on the part of progressive surgeons is due to a number of technological breakthroughs of the past two decades. These may be characterized as follows: <ol> <li> A proliferation of antibiotics to cover most aerobic and anaerobic bacterial infections, largely eliminating the specter of death following failure of an initial procedure. </li> <li> Development of techniques to measure limb blood flow, both in small distal arteries by means of the Doppler effect and at the tissue level, by determination of transcutaneous oxygen perfusion and other methods.<a></a> </li> <li> The evolution of the operating microscope, which has led to the development of evermore distal arterial bypass procedures, including ankle to foot jump grafts.<a></a> These often allow healing of distal amputations which would not have healed prior to bypass. </li> <li> Development of new plastics with a variety of production-controllable characteristics in liquid, sheet, and foam versions. This has led directly to the design of more physiologic and cosmetic partial foot prostheses. </li> <li> Studies of energy consumption during gait which demonstrate the physiologic advantages of distal amputations such as the Syme.<a></a> </li> </ol> With the risk to the patient minimized and the probability of better function, the surgeon should now be willing to risk the occasional failure, that is, the need for a secondary procedure, in order to better assist the vast majority of his or her patients. <h3>Advantages of Partial Foot and Syme Amputations</h3> The partial foot amputee continues to bear weight on the residual foot in a manner which approximates the normal in regard to proprioceptive feedback, as opposed to the below-knee level in which an entirely new feedback pattern must be interpreted. The great majority of adult onset diabetics with peripheral neuropathy also retain sensation in the arch and heel areas. The heel-lever is intact and variable portion of the toe-lever remains. This will range from full-length, as in the case of a ray (toe and metatarsal) amputation, to virtually none in the case of a Chopart (midtarsal) amputation. The ease of restoration of a normal gait pattern is largely dependent on the length of toe-lever remaining. Whenever possible, therefore, toe-lever length should be preserved by election of a longitudinal (ray) amputation rather than a transverse level (transmetatarsal, tarsometatarsal (Lis-franc) or midtarsal). A further advantage is, in an emergency, the partial foot amputee is not dependent on a prosthesis. There are also two distinct psychological advantages of partial foot amputations. The less drastic alteration of body image as compared to the below-knee level may decrease the sense of loss as well as produce a smaller disruption of an active life-style. The less conspicuous and more cosmetically acceptable prostheses available today, even for the more radical partial foot amputations, may also help reduce the impact of the psychological loss. There has been disagreement about whether the Syme amputation qualifies as a partial foot amputation because all the bony elements of the foot have been removed. The preservation of the heel pad, a major soft tissue component of the foot, in the Syme amputation is what confers full weight-bearing capability and distal proprioceptive benefits on the residual limb. The notion that the heel pad is not an important element of the foot is easily dispelled by observing the difficulty in effectively reambu-lating a person who has lost the heel pad in an otherwise intact foot. Studies of gait parameters including oxygen consumption, cadence and velocity have shown the advantages of the Syme over the below-knee level.<a></a> The benefits noted are not diminished by the need for a more extensive prosthesis than is necessary for less radical partial foot amputations. <h3>Etiology</h3> Trauma continues to result in a significant number of these amputations. In wartime, booby-traps and land-mind explosions are frequent, while in peacetime, accidents with motor vehicles, especially motorcycles and lawn mowers seem to be the most frequent causes. In northern latitudes, frostbite remains a common etiology. However, the majority of partial foot and Syme amputations in our institution are an indirect result of inadequate protective sensation to the feet, secondary to peripheral neuropathy. This loss of normal sensation is commonly associated with diabetes mellitus, alcoholism, Hansen's disease (leprosy), or myelomeningocele (spina bifida). The difficulty starts with injury to the foot, either acutely as a laceration, puncture or burn or, more commonly, from pressure or shear forces associated with ill-fitting shoes, and/or chronic overuse of the foot. In response to these forces, areas of skin over bony prominences develop calluses which then break down to form ulcers. These are most common under the metatarsal heads or on the toes. Infection ensues, progressing from cellulitis to abscess formation to septic arthritis and osteomyelitis, resulting in amputation. Circulatory factors also play a role, especially in diabetic patients. Small vessel disease results in restricted passage of oxygen and antibiotics, across the capillary basement membrane, to damaged and infected tissues. Atherosclerotic changes in the arterial tree can produce major blockage of blood flow correctible only by arterial reconstruction or by-pass. Smoking can play major roles both in the onset and aggravation of atherosclerotic arterial disease and in delaying or preventing wound healing after injury or surgery. In persons with neuropathy, compliance with a careful routine of foot care is mandatory if major problems are to be prevented. It is easy to deny that a problem exists when no warning pain is felt. Depression over the long-term possibility of limb loss may so depress many diabetic patients that they are immobilized, unable to protect themselves and to prevent what they most fear, amputation. Psychological counseling, individual or group, can aid in breaking patterns of denial and in dealing with the subsequent depression. Ultimately, the patient must accept the responsibility for foot care if amputation is to be avoided.<a></a> <h3>Surgical Considerations</h3> Partial Foot Amputations The surgeon should attempt to preserve as much length and width of the foot as possible commensurate with: <ol> <li> Healing potential of the soft tissues as determined by circulatory evaluation; </li> <li> Eradication of the local disease process, i.e., removal of all necrotic and infected tissues; </li> <li> Closure of the wound with local skin flaps over all surfaces subject to major weight-bearing or shear forces (Split thickness skin grafts may be used elsewhere, such as the dorsal surface and arch of the foot.); and </li> <li> Good function. A lesser toe should not be left as the only remaining toe because of its increased susceptibility to injury. A second ray amputation is preferable to a second toe amputation alone because of the loss of lateral support to the great toe, which may result in a secondary bunion deformity. This constitutes a new bony pressure point likely to result in another ulcer. </li> </ol> With amputation at or proximal to the tarsometatarsal (Lisfranc) joint, care must be taken to balance the motor (muscle) function of the foot to prevent contractural deformity. At or above this level, release of dorsiflexor and evertor tendons without their reattachment leads to a severe equinovarus deformity due to the unopposed action of the triceps surae (gastrosoleus). Even with reattachment of the muscles at the more proximal level, their effective force is lessened due to shortening of the toe-lever. To overcome this advantage of the triceps surae, it is recommended that a fractional percutaneous heel cord lengthening of the Hoke-Hatt type be done as part of the initial surgery.<a></a> Even short transmetatarsal amputations may benefit from this procedure. <h3>Syme Amputation</h3> Full end weight-bearing on the heel pad with normally-channelled proprioceptive feedback is what distinguishes the Syme amputation from below-knee amputation. The three keys to success in Syme amputation are selection of the proper candidate, meticulous surgery to preserve the Syme's unique characteristics and maintenance of the weight-bearing heel pad in a centralized position. Since the heel pad is dependent on the posterior tibial artery for its blood supply, preoperative evaluation of the heel pad blood supply by Doppler or other means is recommended in order to reduce the chance of failure to 20% or less. Meticulous surgical technique is required throughout to avoid damage to the posterior tibial artery and to the vertically oriented, fat filled chambers of the heel pad, which provide the cushioning, allowing comfortable and long-lasting end-bearing.<a></a> Painful incisional neuromas are avoided by finding and cutting short all sensory nerves in both wound edges. Excessive laxity of the heel pad, which will cause difficulty in fitting, is avoided by several means. First, accurately planned incisions will avoid tissue redundancy. At closure, any excess skin should be trimmed, but closure under tension must be avoided. Second, suturing the deep fascial tissues of the heel pad to the anterior fascia or to the anterior tibial cortex will hold it firmly in place. Third, a light-weight carefully padded plaster cast (two 4" rolls) will prevent pad shift during the first four to five weeks of healing, when a snug walking cast can be applied. This is changed every two weeks until shrinkage has slowed. From this point on, centralization of the heel pad is a function of a carefully fit and maintained prosthesis. <h3>Basic Problems to be Solved</h3> Despite the obvious physical and psychological benefits of partial foot and Syme amputations, these procedures have not enjoyed wide popularity. In my opinion, this is largely due to a failure of dissemination of information regarding these advantages to the two groups most involved: amputation surgeons and pros-thetists/orthotists. On the one hand, amputation surgeons must be able to recognize potential candidates for conservative procedures and be willing to try them. On the other hand, the prosthetist or orthotist to whom he refers his patients must be able and willing to accept the challenge of fitting these sometimes difficult cases, e.g., producing a prosthesis which adequately meets the suspension needs of a Chopart amputation residual limb. Parenthetically, both the techniques and materials used put this area of expertise somewhere between prosthetics and orthotics, hence the name "prosthoses" for the devices constructed. Further refinement of present designs, especially in regard to cosmesis, and development of new concepts to produce better suspended and lighter prostheses are needed. Studies of gait patterns using these devices will assist in this effort and will help select the most physiologically effective designs. Elimination of shear forces, a function of both suspension and fit, will eliminate most of the criticism of these devices common in the past. <h3>Summary</h3> At the present time, partial foot and Syme amputations are considered viable alternatives to the below-knee level. This is true not only in trauma cases, but in diabetic patients with arterial and/or capillary blood vessel disease. Technological advances which have produced this change over the past two decades include: improved broad-spectrum antibiotics; effective devices for measurement of arterial blood flow and tissue oxygenation; development of arterial by-pass procedures, including the ankle and foot; and more physiologic and cosmetic partial foot and Syme prosthetic designs made possible by development of new plastics in a variety of physical forms. The end weight-bearing and proprioceptive benefits of these amputations lead to low excess energy demands on the amputee as compared to higher amputation levels. A major psychologic benefit is the relatively small alteration of body image. The etiology of these amputations and the surgical details to be observed and pitfalls to be avoided are discussed in some detail. Better dissemination of information to amputation surgeons and pros-thetists/orthotists regarding the benefits of these amputations is recommended. There is a need for the refinement of present designs as well as development of new concepts to produce better suspended, lighter and more cosmetic prostheses. References: <ol> <li>Burgess, E.M. and F.A. Matsen, III, "Determining Amputation Levels in Peripheral Vascular Disease," J. Bone and Joint Surgery, 63A:1981, pp. 1493-1497.</li> <li>DiCowden, M.A., personal communication.</li> <li>Glattly, H.W., "A Statistical Study of Twelve Thousand New Amputees," Southern Medical Journal, 57:No-vember, 1964, pp. 1373-1378.</li> <li>Hatt, R.N. and T.A. Lamphier, "A Simplified Procedure for Lengthening the Achilles Tendon," New England J. Med., 236:1947, pp. 166-169.</li> <li>Harris, R.I., "Syme's Amputation: The Technical Details Essential for Success," J. Bone and Joint Surgery, 38B:1956, p. 614.</li> <li>Taylor, L.M., Jr., E.S. Phinney, and J.M. Porter, "Present Status of Reversal Vein Bypass for Lower Extremity Revascularization," J. Vascular Surgery, 3:1986, pp. 288-297.</li> <li>Waters, R.L., J. Perry, D. Antonelli, and H. Hislop, "Energy Cost of Amputees: The Influence of Level of Amputation," J. Bone and Joint Surgery, 52A:1976, pp. 42-46.</li> </ol> *John H. Bowker, M.D., is Professor and Associate Chairman of the Department of Orthopaedics and Rehabilitation at the University of Miami School of Medicine, and Medical Director of the University of Miami/Jackson Memorial Rehabilitation Center, 1611 N.W. 12th Avenue, Miami, Florida 33136. Page Number(s) 10 - 13 Year 1988 Volume 12 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Partial Foot and Syme Amputations: An Overview Creator An entity primarily responsible for making the resource John H. Bowker, M.D. * https://staging.drfop.org/files/original/475312ad901e4ae50427aca982b96391.pdf 16c5a7f900bf5cd9f0075d663907a89c https://staging.drfop.org/files/original/f946e814ca104b1ab87b53b87b6b3c43.jpg 4eebe01c35bb30eaec673139c764c259 https://staging.drfop.org/files/original/49517f0922e98539ac3edf1a8ffdee4d.jpg d7ecf857cfc2c67c1e8a164c675ffae8 https://staging.drfop.org/files/original/e1a3036e9d2bcea88e93e31c9321ee05.jpg 8f41bfd2fd79a1fcf5b6b869231034da https://staging.drfop.org/files/original/da9fc3922ff615899e8cd528ace5c3d8.jpg c10cfb063259e8b5b8c497db3b3825ca https://staging.drfop.org/files/original/5c28655b2bac581bd2b3251173ef77d4.jpg 13d4fbf3a65ed2ac03d8aae664728070 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_01_014.pdf Text Any textual data included in the document <h2>Partial Foot Prostheses/Orthoses</h2> <h5>Melvin L. Stills, CO. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> Prostheses and orthoses prescribed for partial foot amputations vary in design and principle. Authors have described the need or the lack of need of toe lever arms, extensions above or below the ankle, and hard and soft sockets. Almost every design violates a principle thought to be a requirement of the other designers of partial foot prostheses/orthoses. The purpose of this paper is to describe some of the designs now being advocated and to give the rationale for their use. <h3>Above the Ankle</h3> Many authors and designers believe that the proper management of a mid-transverse metatarsal amputation, or more proximal, must include an extension above the ankle. Many of these designs take the form of an ankle-foot orthosis (<a href="/files/original/f946e814ca104b1ab87b53b87b6b3c43.jpg">Fig. 1</a>). This orthosis may be fabricated from thermoplastic materials (polypropylene), thermoset plastics (polyester or acrylic) which may be incorporated with graphite or other space age materials to reduce weight and increase strength (<a href="/files/original/49517f0922e98539ac3edf1a8ffdee4d.jpg">Fig. 2</a>), or may be incorporated into conventional metal and leather types of orthoses. Those devices fabricated from thermoplastics and thermoset materials are generally formed over a positive model of the amputated extremity. The portion of the device contacting the foot is designed to achieve total contact and is generally lined with a soft interface material to increase comfort and/or provide better distribution of forces. The normal profile of the foot may be restored during the initial fabrication process or added later as a buildup of foam. This foot buildup acts as an extension of the foot lever arm, or in some instances may only act as a shoe filler. If an attempt is made to extend the foot lever arm, it may be necessary to complete shoe modifications which would include a full length spring steel shank cushion heel and walker sole. It is considered that this combination of prosthesis, orthosis, and shoe will provide a smooth transition from foot flat to heel off and permit an effective push off. <a href="/files/original/f946e814ca104b1ab87b53b87b6b3c43.jpg">Figure 1</a>. Polypropylene ankle-foot orthosis with foam toe filler. <a href="/files/original/49517f0922e98539ac3edf1a8ffdee4d.jpg">Figure 2.</a> Graphite reinforced laminated posterior prosthetic shell for transtarsal amputation. Tarso-metatarsal amputations may require a solid ankle device. This device employs similar methods of construction with the addition of an anterior section extending from the level equal to the height of the posterior section and distally to the dorsum of the remaining foot. This addition acts to lock the foot and lower leg into the posterior section and eliminates ankle motion. The shortened foot is difficult to retain in the posterior section, and the addition of the anterior shell provides better purchase and retention. The proximal region of the anterior section may take the form of a patellar tendon bearing socket, or extend to midcalf, or in some designs extend only to the area just above the ankle. Variations of all three commonly exist, and the amount of ankle control will be determined by the design selected. If a design is selected which limits ankle motion, most authors agree that shoe modifications are required to achieve normal gait. A cushion heel applied to the shoe will permit smooth transition from heel strike to foot flat. Prosthetists who routinely employ these designs have reported good results with successful ambulation. <h3>Below the Ankle (Slipper Type)</h3> A number of designs exist that do not extend above the ankle joint. They appear to be divided into the following categories: (1) rigid, (2) semi-rigid, (3) semi-flexible, and (4) flexible. All of these systems are fabricated on a positive model of the residual limb. The positive model is modified to increase loading of good tissue and to relieve or decrease pressures on sensitive areas prior to the forming of the definitive socket. The rigid and semi-rigid systems are based on a laminated or thermoform socket. Limited flexibility is built into these systems, using flexible resins in fabricating the semi-rigid shells. A foam lining is generally employed to act as an interface between the rigid walls of the socket and the skin of the residual limb. The profile of the foot is restored with a buildup added to the socket. Complications may be encountered in using the rigid/semi-rigid designs when motion occurs inside the socket. Breakdown on the distal plantar surface of the residual limb is not uncommon, and this complication has led to the development of the semi-flexible and flexible designs. Semi-flexible designs utilize a combination of material, generally having a base of urethane elastomer. One such system which is semi-flexible in nature and utilizes a laminated rigid University of California-Berkley shoe insert as its base. The insert is bonded to a modified monoelastic cushion heel foot and the entire system is laminated together with a urethane elastomer.<a></a> The resultant system does not interfere with normal ankle motion, and authors report good acceptance (<a href="/files/original/e1a3036e9d2bcea88e93e31c9321ee05.jpg">Fig. 3</a>). <a href="/files/original/e1a3036e9d2bcea88e93e31c9321ee05.jpg">Figure 3.</a> UCBL thermaformed shoe insert with Lynadure forefoot. Another semi-flexible design uses solely a urethane elastomer for fabrication of the socket and foot. This design is referred to as a slipper-type elastomer prosthesis (STEP). The STEP design is somewhat complex in its design and fabrication. Permanent tooling is developed for each individual patient and may be retained by the patient for possible fabrication of replacement devices at a later date. This tooling consists of a permanent polyester resin positive model of the residual limb and a negative mold of the finished prosthetic foot. This device is fabricated using semi-flexible urethane elastomer.<a></a> If a pressure point is noted on the residual limb, modifications are made to the prosthesis by removing material from the exterior surface of the prosthesis in order to reduce rigidity in that area and to insure a smooth socket interface. Good results have been reported from the use of this prosthesis. <h3>Flexible Foot Prostheses</h3> A flexible cosmetic prosthetic foot (<a href="/files/original/da9fc3922ff615899e8cd528ace5c3d8.jpg">Fig. 4</a>) has been developed which utilizes only reinforced silicone materials. A negative weight bearing alginate impression is made of the residual limb and contralateral foot. An exact detailed dental stone positive model of the residual limb is made from this impression. A wax check socket is fabricated on this model and checked for comfort and fit on the patient. Modifications are made to relieve sensitive areas and to load appropriate surfaces. Appropriate loading is based on the prosthetist's impression of soft tissue density and how much pressure the patient can tolerate. A mirror image model of the sound foot is sculpted from wax and checked for sizing against the patient. A negative model of the sculpted foot is then made using a lost wax method. The resulting negative model of the foot may then be used in conjunction with the rectified model of the residual limb to produce the prosthesis. The material employed is a pure reinforced silicone that is precolored to match the patient's skin tones. At the fitting, the detailed colored matching is achieved using the sound side as a model for cosmetic restoration. To date, approximately 100 patients have been fit with this flexible silicone cosmetic prosthetic foot, and patient acceptance has been almost 100 percent. The developer<a></a> initially intended the prosthesis solely as a cosmetic device (<a href="/files/original/5c28655b2bac581bd2b3251173ef77d4.jpg">Fig. 5</a>). However, patients reported they had increased comfort and functional levels with the reinforced silicone prosthesis. <a href="/files/original/da9fc3922ff615899e8cd528ace5c3d8.jpg">Figure 4</a>. Reinforced silicone slipper type prosthetic foot. See Figure 2 for earlier fitting. <a href="/files/original/5c28655b2bac581bd2b3251173ef77d4.jpg">Figure 5.</a> Cosmetic functional silicone foot prosthesis. Requests for cosmetic restoration by males are almost equal in number to those requested by females. The psychological effect of cosmetic restoration has not yet been evaluated; however, it is probable that this has some influence on the functional acceptability of the prosthesis by the patient. Many of the patients fitted with a flexible silicone cosmetic prosthetic foot have previously been fit with partial foot prostheses of the types previously described. Mechanical comparisons of function of these designs would be valuable, but to my knowledge, have not yet been done. <h3>Summary</h3> A balanced foot is almost a necessity for successful fitting of any of the prosthetic systems. Trauma related amputations apparently do well with the slipper-type prosthesis, and the developer of the silicone system reports successful fitting in diabetic patients as well. The need for the prostheses to extend above the ankle appears to be limited to those patients with very short amputations, but successful fittings have been demonstrated with the slipper-type, sometimes using an ankle strap for suspension. There is no definitive statement that I can make recommending any one system over another. It appears that many partial foot amputees are being successfully managed with prostheses that do not extend above the ankle. It also appears that a higher rate of success is occurring when semi-flexible and flexible prostheses are being fit. It is believed by many that partial foot amputation can offer significant functional improvement over Symes level amputations and the use of this surgical technique needs to be reevaluated in light of the new technologies and materials available today for providing the partial foot amputee with a functional prosthesis. <h3>Acknowledgements</h3> A number of talented individuals have contributed to the information and materials presented in this paper, and in order to avoid inadvertently omitting someone's name, I wish to thank them all as a group for their assistance. <h3>Bibliography</h3> Childs, Charles and Timothy Staats, "The Slipper Type Partial Foot Prosthesis," Advanced Below Knee Prosthetic Seminar, UCLA Prosthetic and Orthotic Education Program, Fabrication Manual, 1983 Edition. Condie, David and Melvin Stills, "Biomechanics and Prosthetic/Orthotic Solutions—Partial Foot Amputations," Presented and to be Published as Proceeding "Dundee 85". Fillauer, Karl, "A Prosthesis for Foot Amputation Near the Tarsal-Metatarsal Junction," Orthotics and Prosthetics, Vol. 30, No. 3, September, 1976, pp. 9-11. <a href="http://www.acpoc.org/library/1978_01_011.asp">Hayhurst, Donald J., "Prosthetic Management of Partial Foot Amputee," Inter-Clinic Information Bulletin, Vol. XVII, No. 1, January-February, 1978, pp. 11-15.</a> Lunsford, Thomas, "Partial Foot Amputations—Prosthetic and Orthotic Management," Atlas of Limb Prosthetics, American Academy of Orthopedic Surgery, The C.V. Mosby Company, 1981, pp. 322-325. Wilson, Michael T., "Clinical Application of RTV Elastomers," Orthotics and Prosthetics, Vol. 33, No. 4, December 1979, pp. 23-29. References: <ol> <li>Lynadure, Medical Center Prosthetics, Inc., Houston, Texas.</li> <li>Calthane 1900, Cascade Orthopedic Supply, Inc., Chester, California.</li> <li>Mr. H. Buckner, C.O.T., Life-Like Laboratory, Dallas, Texas.</li> </ol> *Melvin L. Stills, CO. Melvin L. Stills, CO., is with the University of Texas Health Science Center, Division of Orthopedics, 5323 Harry Hines Blvd., Dallas, Texas 75235. Page Number(s) 14 - 18 Year 1988 Volume 12 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1988_01_014/1988_01_014-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_01_014/1988_01_014-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_01_014/1988_01_014-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_01_014/1988_01_014-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_01_014/1988_01_014-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Partial Foot Prostheses/Orthoses Creator An entity primarily responsible for making the resource Melvin L. Stills, CO. * https://staging.drfop.org/files/original/c056d5b5a2d5292f7ea7a2216c435354.pdf 14428dbbc64bb672eab6dba111374692 https://staging.drfop.org/files/original/039849a9bbceb9fb919ccc08ac599212.jpg 23bca0088192426d9167c9c7d9e9d44c https://staging.drfop.org/files/original/f197722dfcff2c0aac358b6fcc12d2eb.jpg 161a1c77318b8073974e27d61d273bc9 https://staging.drfop.org/files/original/1749053d5b5f32553d0c1fe1f894c64e.jpg 3380cde244b9b2f336392b04665d1732 https://staging.drfop.org/files/original/e0887c118d00cc471ff8de5bf88811f3.jpg d25c837f996f02af2fc5e6e1f15a76c5 https://staging.drfop.org/files/original/fb3a271a31f4d3f1d7d07493673581d3.jpg cc66ef1f8e51ec73b5b2f73b2cfb26a5 https://staging.drfop.org/files/original/a0cdfd4316a17eb6233a90ae1f54727d.jpg df6536c12852883e6140ab2bd6a2eb74 https://staging.drfop.org/files/original/37a2a6c5c5b3fa090ca1aa5f15a1c855.jpg e2c8a5972b78da0ae35e57c29ead0c0a https://staging.drfop.org/files/original/2d1dd36d6e47d7c89ef2024f8633baa2.jpg 5ff571b0dd18d2ce9ae71785e9716822 https://staging.drfop.org/files/original/d5ce24b019b33092116f6dab2dcb1ad8.jpg fa9b285cc6d96d43260008b1e6983207 https://staging.drfop.org/files/original/c4ef31384fca87b5d234cd3857247810.jpg 8f8fe63d422f492829cf8f7221eac5c9 https://staging.drfop.org/files/original/a16361aca619486a85231e5bf4f67da1.jpg bddcc94158c1706f18aaa77bf8cb0a7a Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_01_019.pdf Text Any textual data included in the document <h2>A Partial Foot Prosthesis for the Transmetatarsal Level</h2> <h5>Jack N. Collins, C.P.O. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> Traditionally prosthetists and orthotists have faced the problem of partial foot amputations with the skills, materials, and observations gained from past experiences or from others in the field. The author is not aware of any extensive research in prosthetics for partial foot amputations. Attempts to provide a suitable prosthesis have ranged from a simple toe filler with arch support, to an ankle immobilizer at P.T.B, level, and lace-on fillers of many descriptions. In the author's observation, any prosthesis that goes above the ankle results in the buildup of unwanted forces. The late Charles Childs, C.P.O.,<a></a> made the greatest breakthrough in partial foot prostheses. I attended his seminar in late 1978 and was very impressed with the entire approach demonstrated, especially the cosmesis and fit at shoe level height. Unfortunately, after a few weeks wear, the rubber material used in the fabrication of the prosthesis did not retain its shape and support against the extreme forces exerted in walking. The forces developed on the short lever arm, the foot, in walking are greater than at any other level of amputation. These forces applied in walking and running are not confined to the plantar surface of the residual foot, but are transmitted in part to the entire surface of the prosthesis. In turn, some of these forces are applied to whatever footwear is worn. Thus, the footwear applies a resistant force to the prosthetic appliance, quite often to the detriment of the appliance and the residual foot. It must be stated at this point that the prosthesis about to be described has not been evaluated with foot amputations at the Lisfranc or Chopart level, but only on transmetatarsal level. And from our limited experience, developed over the past 7 to 8 years, a mid-trans-metatarsal amputation presents fewer problems in toe-off than amputations at a greater or lesser length. With this in mind, the evaluation, casting, and fabrication techniques used will be described. <h3>Evaluation, Casting and Fabrication</h3> Evaluation is made in routine manner, for amputation level, range of motion at ankle, contractures, cut bone covering, abrasions, callosities and sensitive areas. With patient seated in a chair, invaginate a casting balloon over the residual foot with a short piece of plastic tubing on the dorsum of the foot. Mark with indelible pencil all boney prominences, callosities and sensitive areas (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-01.jpg">Fig. 1</a>). Very carefully roll on a 4" roll of plaster in a manner to cover the entire foot to the inferior edge of the lateral malleoli and with a thickness sufficient to retain its shape on removal. While the plaster is still soft, have the patient place his foot on the floor, with the knee at 90°, foot in neutral position (not in valgus), and with the weight of the leg on the plaster. Make marks with indelible pencil on the cast at 90° across the plastic tube. With a cast saw cut down the tube to remove the cast. If care is taken in applying the plaster, you will have a very smooth and detailed cast on removal (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-02.jpg">Fig. 2</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-01.jpg">Figure 1. Foot ready for casting with casting balloon and plastic tubing in place.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-02.jpg">Figure 2. Cast removed</a> Close the cast carefully with plaster wrap, apply the release agent, and pour the cast with mandrel in place about 45° to vertical. This makes it easier to apply P.V.A. and stockinette. Remove the plaster wrap from the model. Very little modification should be necessary. Add about 1/8" plaster buildup over the boney prominence at the distal end and over any callosities or other sensitive areas. It is not necessary to modify as in the U.C.B.L. Shoe Insert casting method. Using a Scarpas knife, remove about 3/16" to 1/4" plaster from the plantar surface 1/2" proximal to the metatarsal ends, the width of the metatarsals, and taper in the direction of the heel about 1" to 1 1/2" depending on the size of the foot. The anterior edge of cut should have a 5/16" radius (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-03.jpg">Fig. 3</a>). Dry or seal the model. <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-03.jpg">Figure 3. Modified positive model</a> Pull on one layer of nylon stockinette to allow for the patient's sock. Pull the P.V.A. over cast for vacuum. Tailor a piece of 1 oz. Dacron felt to cover the plantar surface. The felt should extend over the anterior distal end, laterally to cover the base of the 5th metatarsal, and medially to cover the scaphoid prominences. Sew one end each of four lengths of nylon stockinette and pull on the model with the Dacron felt in place. On heavier more active patients, one layer of woven glass reinforcement is added between the felt and stockinette. When pulling on the stockinette, take care not to pull out the stretch of the stockinette. The stretch needs to be retained in the silicone laminated areas to allow donning. Take two 4" P.V.A. sleeves and cut 12" long pieces from the small end of each to make feeder tubes. Apply a 6" moist P.V.A. sleeve to the model so as to give a smooth surface all over. Do not tie off the ends, but do dry with a heat gun. Use a tongue depressor to push the small end of one of the feeder tubes under the P.V.A sleeve at the heel of the model. The tube should be about 3/8" from the plantar surface of the heel. In the same manner, position the remaining feeder tube under the P.V.A. sleeve over the dorsum of the model. The tube should be about 3/8" from the proximal edge. Roll a 1" wide by 6" long piece of 1/16" thick polyethylene into a funnel and place in the open end of one of the tubes (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-04.jpg">Fig. 4</a>). Mix 80 grams of Dow Corning 382 silicone with 2 or 3 drops of appropriate color and catalyze as directed by Dow Corning, pour into the funnel and very carefully squeeze into the stockinette. On the dorsum of the foot, laminate the section the shoe lace will cover, or a little more area. Squeeze with your finger tips to get a thorough and even penetration working the Silastic, laterally, and distally down to, but not onto the plantar surface. Working with the fingers gives better penetration without spreading the resin to unwanted areas. After this has cured, repeat in the same manner posteriorally. The posterior portion should extend distally down the back of the heel to the sole and anteriorally along the proximal trimline for a width of 1" distal of the trimline so that it meets the posterior border of the anterior lamination medially and laterally (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-05.jpg">Fig. 5</a>). When the posterior portion has cured and both feeder tubes have been removed, tie off the pipe end of the 6" P.V.A. sleeve and pour in 150 grams of 4110 Laminae that has been catalyzed and pigmented. Saturate the remaining lamination and maintain it under a vacuum until cured. While the polyester is still warm, trim to the shoe top level and remove the prosthesis from model (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-06.jpg">Fig. 6A</a> and <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-07.jpg">Fig. 6B</a>). The prosthesis is now ready for fitting. <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-04.jpg">Figure 4. Completed layup with P.V.A. sleeve and feeder tubes in place</a> <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-05.jpg">Figure 5. Initial phase of lamination. Dorsum and proximal border of socket have been laminated with Dow Corning 382 Silastic.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-06.jpg">Figure 6A. Socket completed and removed from model, medial view</a> <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-07.jpg">Figure 6B. Lateral view</a> In weight bearing, check for comfort, undue pressure, and position of the foot. More than likely it is in some valgus, as any foot amputated proximal to the head of the first metatarsal loses its medial support. With small wooden wedges, you can determine the amount of posting needed under the distal end of the first metatarsal to hold the foot in a neutral position. When this has been done, mix a small amount of thickened polyester and add it to the distal plantar surface of the first metatarsal area to establish the desired position. When comfort and fit have been achieved, the prosthesis is ready to be completed. Obtain a shoe from the patient for foot sizing. Take a plaster wrap of the distal portion of an appropriately sized S.A.C.H. foot. When the plaster on the S.A.C.H. foot has cured, remove it from the foot, and inspect the inside for smoothness. Fill any voids and smooth nicely. Dry the plaster and paint the inside with ambroid or celluloid. Spray the inside of the toe cast with silicone release agent. Rivet with two #12 copper rivets, all" long by 1 1/2" wide .0035 thick blued steel spring, that has been shaped to the contour of the inside surface of the shoe sole, to the plantar surface of the socket. Shear off the distal portion of the spring so it ends about 1" from the toe. Drill a hole for a #12 copper rivet and rivet on a small "U" shaped piece of leather to act as an anchor for the silicone toe piece (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-08.jpg">Fig. 7</a>). Drill 1/2" hole in the distal plantar surface of the toe cast. Wipe the anterior surface of the prosthesis with acetone. It must be clean. Fit the plaster shell over the spring and anterior portion of the prosthesis as far proximal as necessary to obtain proper foot length. Be sure the spring or leather anchor does not come in contact with the inside of the plaster mold. When properly positioned, solidly tape the plaster wrap to the prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-09.jpg">Fig. 8</a> and <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-10.jpg">Fig. 9</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-08.jpg">Figure 7. Socket with toe spring and leather anchor rivetted in place</a> <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-09.jpg">Figure 8. Socket and plaster toe mold</a> <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-10.jpg">Figure 9. Toe mold taped in place</a> Mix 65 grams of Dow Corning #382, 5 grams Dow Corning Q74290 Prosthetic Foam, and 2 or 3 drops of appropriate pigment. Catalyze and pour slowly into the 1/2" hole in the toe. Stand the assembly on the back of the heel, toe up, and support it in this position until foamed and cured. When the foam has cured, carefully use a thin instrument to pry the silicone toe gently loose from the plaster. It should come off with little effort. Depending on the smoothness of your plaster toe mold, the release agent used, and the foam mixture, the prosthesis should be very presentable (<a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-11.jpg">Fig. 10</a>). If it is rough and has air holes, sand it smooth and paint on a coat of Pigmented Dow Corning #382. <a href="http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-11.jpg">Figure 10. The completed prosthesis</a> <h3>Summary</h3> The rigid control of the residual foot, yet flexible entry and toe off, together with good patient acceptance, cosmesis, and wearibility makes this type prosthesis our choice in the prosthetic management of transmetatarsal amputations. We call this the C.O.S.I. Partial Foot Prosthesis (Collins Orthopedic Service, Inc.). <h3>Addendum</h3> It is the author's opinion that Lisfranc and Chopart level amputations could be approached in a similar manner by extending the distal support and point of toe off to a more normal position. However, this opinion is not based on personal experience with using the C.O.S.I. Partial Foot Prosthesis to fit these level amputations. This would require some thought and quite a bit more effort in the lamination procedure. References: <ol> <li>Childs, Charles, Pacific Orthotic and Prosthetic Services, 111 East First Street, Medford, Oregon 97535.</li> </ol> *Jack N. Collins, C.P.O. Jack N. Collins, C.P.O., is with Collins Orthopedic Service, Inc. 2875 Joyce Street, Fayetteville, Arkansas 72703. Page Number(s) 19 - 23 Year 1988 Volume 12 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 FIGURE 6A http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-06.jpg FIGURE 6B http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-07.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-08.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-09.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-10.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1988_01_019/1988_01_019-11.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Partial Foot Prosthesis for the Transmetatarsal Level Creator An entity primarily responsible for making the resource Jack N. Collins, C.P.O. * https://staging.drfop.org/files/original/acdfaaea21f1bfb4bdf97517f56845da.pdf 8af470c4b6b701d48e3966ab0ccc3937 https://staging.drfop.org/files/original/da4a595957bc641bc12ab26505f5bc08.jpg 23df8755ba0d58ec9874f7994d9987b6 https://staging.drfop.org/files/original/3e1236ea8c0c6360fc9d94a682044776.jpg f6f4a8994e2b10e235ee989b410d0094 https://staging.drfop.org/files/original/f25284165068c830330ede2c991e2476.jpg d4825a44e2c821c04b64c148b394c7e3 https://staging.drfop.org/files/original/5d0bc90db35789e97ef273601770ac77.jpg ccef6e0b55533d001c84558310b107be https://staging.drfop.org/files/original/3ed8dd3d9835175e80b43108f1e0ea71.jpg 0aa14032fb6af7d768b416963fbcd6fb https://staging.drfop.org/files/original/c3873a676dcabeca9b3d3fe41c175283.jpg d8935b1a857dc9988df89329d750a061 https://staging.drfop.org/files/original/2a8d7cea53b9c3f88d25c8d7ad9afca6.jpg 3e5e6cdd2e67572178aba7a53ebb8bf8 https://staging.drfop.org/files/original/c9b975f98002c412af3fafaa613f23c2.jpg 36bcdc363071c806bbb269950ca61d95 https://staging.drfop.org/files/original/c1b80cf0553630bc898178fc4a134a50.jpg 479573d0757401271d9c5e2d2db19e0b Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_01_024.pdf Text Any textual data included in the document <h2>Imler Partial Foot Prosthesis I.P.F.P.: "Chicago Boot"</h2> <h5>Clarence D. Imler, CP. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> Surgeons are now performing a greater number of distal amputations, including those of the distal forefoot. Among these are the Lis-France, Chopart, Boyd, and other difficult to fit deformities. The Imler Partial Foot Prosthesis fulfills the need for a light weight, structurally strong prosthesis, that provides ankle support, has an anterior lever arm, acts as a shoe filler, and is cosmetically acceptable. The essential element of the prosthesis is the interface, consisting of a vacuum formed copolymer1 U.C.B, type insert with a toe filler of soft foam. This interface is inserted into a laminated, flexible rubber-epoxy-resin (Lyna-dure) cosmetic sleeve that encompasses the foot and interface. This sleeve extends proximally to above the malleolus and has an anterior opening. The interface is removable, and enables the prosthetist to make adjustments (i.e., alignment and/or relief). Closure is obtained by eyelets and lacer for greater suspension, or Velcro® for cosmesis. <h3>Casting Procedure</h3> A negative impression may be obtained using any conventional method. A midfoot amputation should be placed on a casting board or covered with a plastic bag and inserted into a patient's shoe to simulate heel height. Very little weight should be applied to avoid spreading of the foot. With a Chopart amputation, where the calcaneous is plantar flexed or rotated posteriorly, a casting board is not used. The casting in all cases is similar to the procedure used when casting for a U.C.B, shoe insert. <h3>Modification of the Positive Model</h3> Modification includes a standard 3mm anterior relief. A 1mm relief for the malleoli is added, along with relief for any bony prominence or scar tissue as needed. Remove 2mm of plaster both medially and laterally, proximal to the calcaneous to enhance the support effect of the U.C.B, type heel cup. There is no relief needed for the anterior tibia, and in some cases plaster is removed for a tighter fit (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-1.jpg">Fig. 1</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-1.jpg">Figure 1. A modified positive model.</a> <h3>Interface with Toe Filler</h3> Over the modified positive model, thermo-mold a section of 5mm Pelite™, for an anterior end pad. Trim and bevel the edges to achieve a smooth transition (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-2.jpg">Fig. 2</a>). A sheet of 3/16" Colyene is vacuum formed over the cast and end pad, with an anterior seam (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-3.jpg">Fig. 3</a>). The interface may also be laminated with either acrylic or polyester resin. The posterior trim line is proximal to the calcaneous. The medial and lateral trimlines are both distal to the malleoli, and the anterior trimline is at mid-height level. Care should be taken not to cut into the Pelite™ pad as it extends above the trimline (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-4.jpg">Fig. 4</a>). The anterior toe section can be constructed by various means. Pelite™ of 5mm firm density should be added until a flat surface distally is attained (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-5.jpg">Fig. 5</a>). The anterior toe section is constructed of 12mm firm density Pelite™, bonded together lengthwise. This toe section is bonded to the heel cup and shaped to size. Other materials or foams may be used but they must be firm enough to hold their shape during lamination (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-6.jpg">Fig. 6</a>). The finished heel cup interface with toe filler is replaced on the cast and inserted into the patient's shoe. At this point, a final determination is made of the alignment, and whether additional material must be added or removed to fit the shoe to leave room for the outer lamination (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-6.jpg">Fig. 6</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-2.jpg">Figure 2. The positive model with distal cap in place.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-3.jpg">Figure 3. A vacuum-formed heel cup.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-4.jpg">Figure 4. A heel cup with distal end cap.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-5.jpg">Figure 5. A heel cup with distal end built up and flattened.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-6.jpg">Figure 6. Toe extension.</a> Adjustments are made at this juncture. The heel cup and toe filler can be divided and the heel cup rotated, relative to the toe filler, to produce eversion, inversion, plantar/dorsi-flexion, toe-in, or toe-out. Due to the flexibility of the outer sleeve, these changes may be accommodated without the need for a new lamination. A 1.5mm thick strip of polyethylene is thermo-formed over the anterior surface. This will act as a separating agent, forming the tongue and overlap. This is cut to a width of approximately 2.6cm The length extends from the proximal edge of the cast, to 5mm past the proximal edge of the Pelite™ toe filler. The edges are beveled for a smooth transition. The layup for the outer sleeve lamination consists of a nylon hose covered by a PVA bag, which is capped off and put under full vacuum. Two layers of Comfort® stretch nylon stockinette and one layer of IPOS stretch nylon are applied. The strip of polyethylene wrapped in two layers of Dynalon3 is sandwiched between this and two additional layers of Comfort® stretch nylon and two layers of IPOS stretch nylon. A second PVA bag is applied with vacuum, and the rubber epoxy resin (Lynadure) is introduced (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-7.jpg">Fig. 7</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-7.jpg">Figure 7. Lynadure lamination.</a> Before final trimming, determine if closure is to be achieved by eyelets and lace or Velcro®. If eyelets are used, make a center cut through to the polyethylene strip, with inverted "T" slits to the edges of the strip. Remove the polyethylene strip and cut the inner tongue along the medial and distal edges only. To obtain a Velcro® closure, first cut along the medial and distal edge of the polyethylene strip, remove the strip, and cut the inner tongue along the lateral and distal border. Before cutting the laminate, be sure the material has fully cured; if the material has not completely cured, it may pull apart. The I.P.F.P. weighs approximately 250 grams, depending on the shoe size. It is extremely lightweight, but very durable. A leg length discrepancy may be accommodated for in the prosthesis by adding a Pelite™ pad of the proper height, either before or after the interface is vacuum formed. The prosthesis is thinly constructed to be used by the patient with regular shoes. There is no need for split-sized, or extra depth inlay shoes, in most cases. <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-8.jpg">Fig. 8</a> shows the finished prosthesis in a patient's shoe. <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-8.jpg">Figure 8. The prosthesis in the patient's shoe.</a> Fabrication has changed very little since initial development. The Lynadure lamination layup has been strengthened with additional layers of stockinette and Dynalon. A few pros-thetists have requested that the co-polymer heel cup be extended anteriorly to the toes as an A.F.O. for greater push off. Another adaptation is the anterior section of a SACH foot with toes laminated into the Lynadure sleeve with the toes exposed, for cos-mesis when wearing open toe shoes or sandals (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-9.jpg">Fig. 9</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-9.jpg">Figure 9. The finished prosthesis.</a> This may not be the answer to every partial foot amputation, but is an alternative to be considered when fitting a patient with a particularly difficult situation. <h3>Resources and Materials</h3> Co-Polymer, Colyene: Orthotic Prosthetic Enterprises, 1316 Sherman Avenue, Evanston, Illinois 60202. Lynadure: Medical Center Prosthetics, 6955 Almeda Road, Houston, Texas 77021. Dynalon: Hosmer Dorrance Corporation, 561 Division Street, Campbell, California 95008. *Clarence D. Imler, CP. Clarence D. Imler, CP., is with Oakbrook Orthopedic Services, Ltd., 1 South 132 Summit Avenue, Suite 102, Oakbrook Terrace, Illinois 60181. <div style="width: 400px;"></div> Page Number(s) 24 - 28 Year 1988 Volume 12 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-7.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-8.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-9.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Imler Partial Foot Prosthesis I.P.F.P.: "Chicago Boot" Creator An entity primarily responsible for making the resource Clarence D. Imler, CP. * https://staging.drfop.org/files/original/d386a411367e3ccde8de539fc4a1242f.pdf 4ed3a9095b43b4bd7f3819c9eb8dfa7a https://staging.drfop.org/files/original/7a5e8868268876fcf1e3856884e6c69c.jpg fd74970347d887a411311884e1262354 https://staging.drfop.org/files/original/caec0103bc664a9d5e8457d1901a9e15.jpg 6b145520feb78ecf54f8c9a9684c4a26 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_01_029.pdf Text Any textual data included in the document <h2>The Total Contact Partial Foot Prosthesis</h2> <h5>Richard LaTorre, CO. <a style="text-decoration: none;">*</a></h5> The purpose of this paper is to present a prosthetic fitting procedure for a "Partial Foot" level amputation. The "Transmetatarsal," "Lisfranc," "Chopart," and "Pirogoff" type amputations are all treated with this procedure with some modification, mainly in length of forefoot. The partial foot as a category presents more anxiety among physicians and prosthetists and clinics, than is generally realized. For the avascular patient, a "toe filler" is not adequate, no matter how cosmetic it appears. Classically, patients who are diabetics and have been given toe filler type prostheses tend to develop eversion, a tightening of the Achilles tendon, and are usually doomed to perforating ulcers on the distal plantar anterior or distal anterior portion of the residual foot. The solution presented here is an ultra-lightweight prosthesis, one that removes stress (caused by torque on the leg), protects the extremity from shock at heel strike and toe off, controls plantar and dorsi-flexion, controls eversion, controls edema, and still is cosmetically acceptable. This style prosthesis has been in use since March, 1974. By 1977, 62 prostheses of this type had been successfully delivered. The largest group of patients was between 45 and 65 years of age and almost equally divided between males and females. The next largest group was geriatrics (over 65) and only four patients were in the 20 to 45 age group. Only one patient went on to further amputation. As a result of wearing this type of prosthesis, the residual limb is usually warm, free of ulcers, callosities, and edema. When compared to the contra-indicated extremity, it appears to be generally healthier and most patients state "it feels better than my other leg." By 1984, this type of prosthesis was being fabricated at the rate of one every three weeks. At present, the average is one every two weeks. "Lower Profile" partial foot prostheses are also fitted, but only after the patient has successfully worn this two piece design for at least six months. This insures, if trouble starts with a Low Profile prosthesis, there is no "down time" for the patient; they simply go back to "old faithful." Incidentally, we have also developed three different styles of the Low Profile partial foot prosthesis (that we have not described in the literature), but have never been able to develop a series of four or more successes for each design. <h3>Evaluation and Casting</h3> Prior to casting, a prosthetic evaluation is made to determine joint limitations, noting mainly inversion/eversion and degree of plantar flexion/dorsi-flexion. Old scars are noted, as is the condition of skin over bony prominences and any possible weeping of draining areas. The patient's weight, height, and occupation are included in the evaluation before casting. Determination of material, usually polypropylene, thickness of material selected, and length of the prosthesis to be fitted is made at this time. The negative cast is usually taken with the patient in the sitting position. Any scab or draining area is covered with Saran Wrap® or its equal. Stockinette is then applied to the extremity from the toe to the supracondylar area. With indelible pencil the malleoli, anterior crest of the tibia, head of the fibula, old scars, and any extremely sensitive-to-touch areas, as well as those that may cause future problems, are marked. Casting is a two step procedure. The residual foot should be barely touching the floor and the foot to tibia relationship should be 90°. Splints of plaster of Paris are laid on the anterior tibia from a point approximately 2 cm. distal of the level of the tibial tuberosity distally to the point of floor contact. If it has been decided to weight-relieve the ankle complex, the well known P.T.B, casting procedure is used at this point. The extremity is now wrapped with Coban bandage. Coban is a plastic seersucker type material that acts as a waterproof Ace bandage and will not adhere to plaster. This technique enables the practitioner to make a thin-walled cast that is easier to remove from the tender extremity. The "Coban Technique" gives an eggshell hard cast, because it compresses the plaster, thus enabling the user to use less plaster and still obtain a firm satisfactory cast. As soon as the extremity is wrapped, it is replaced in the original position, (i.e. foot to tibia relationship of 90°). After the cast has sufficiently hardened, the bandage is removed and rerolled for future use. The already cured plaster and stockinette are now coated with K-Y Jelly. Plaster strips 4" x 12" are applied vertically to the posterior and lateral aspects of the extremity, overlapping the anterior cured cast from 3/4" to 2". The extremity is wrapped once again with the Coban bandage and returned to the sitting position. The Coban bandage is removed and reference lines are horizontally laddered across the cast overlapping areas when the posterior section has hardened. The exterior cast is carefully removed, the stockinette is cut away posteriorly, and the anterior "shell" carefully removed. Both sections are quickly re-oriented to each other and sealed together. In the laboratory, the negative cast is rinsed with a solution of soap or detergent, the surplus is poured out, the cast is placed in a sandbox, and the positive model is poured with bulk plaster. A pipe is placed in the cast and held in place until the plaster has set. <h3>Fabrication</h3> When the model is hard, the negative cast is stripped away. The model is held in a bench vise, sanded smooth, and plaster is added to problem areas noted at the time of casting. The amount added is 6-7 mm. at both malleoli, fibular head, and along the tibial crest. A 3mm. buildup over any scar or weeping area is sufficient. At this point, the model is covered with a layer of stockinette. An appropriately cut section of sheet polypropylene is placed in an oven at 400°F for ten minutes. The material is draped over the anterior portion of the model. The material will have the consistency of taffy when removed from the oven. If any wrinkles appear, the plastic must be discarded and a new piece cut and molded. Sometimes several trials are necessary until satisfactory results are achieved. When cooled, the anterior portion is removed from the model, trimmed, and all edges smoothed to the touch. The plantar trimline is just anterior of the os-calcis. The medial and lateral trim lines are on the midlines viewed in the sagittal plane. The original technique has been modified so as to provide a more posterior plantar trim line that now encompasses the os-calcis. This reassembles an inverted "T" shape. The model, minus the anterior molded shell, is further prepared by tacking a leather inner-sole that fits the patient's shoe (or opposite foot pattern inverted) to the plantar surface of the model. One inch nails are driven into the anterior portion of the positive model to provide an anchor for the plaster to be added next. The cast with the innersole attached is placed on a casting board. This is usually done with the aid of a vertical alignment jig, but can be accomplished manually without a jig if great care is exercised. This aligns the model to simulate the normal contour of the shoe relative to ball and heel. Bulk plaster is now applied to the innersole and built up onto the anterior foot portion. When firm, the plaster is trimmed to the edges of the innersole. The model is placed back in the vise horizontally and rotated so the posterior surface faces the fabricator. Appropriate size plastic is laid out and cut, and the molding process is repeated. Once cooled, the posterior shell is removed from the model. The forefoot is trimmed away laterally so all that remains, from midfoot running distally, is an innersole-like projection (i.e., it resembles a molded polypropylene solid ankle-ankle-foot orthosis). The anterior buildup of plaster is now removed from the original model. The polypropylene anterior shell snaps back on the model and the posterior shell goes over it. A Velcro® closure is attached to the proximal portion and a filler is cemented onto the innersole portion to simulate the forefoot and fill the shoe. The material used is plastazote bonded with barge cement. This version was used until 1983 when a woodsman who complained that "the toes lose their spring" was encountered. This was found not to be a problem with other patients. To satisfy this patient, roughly ten modifications of the forefoot section were tried. Unsuccessful were thicker polypropylene, metal reinforcement (spring steel), "double soling" the forefoot, and many other less involved changes. All met with patient displeasure. Success came with the fabrication of a forefoot "box section." To fabricate one, bulk plaster is poured into a shoe box top to provide a mold. Polypropylene is molded over this. The molded plastic is cut into quarters and the four corner pieces are arranged in such a manner that the corners fit together forming a three dimensional cross shape. Place them onto the anterior "sole" of the prosthesis. Trim to fit the edges of the sole. Rivet the two anterior (left and right) sections to each other and then to the toe section of the prosthesis. Next, rivet the remaining two pieces together and place this section against the anterior shell. Trim and fit it until a 5/8" gap is formed between it and the "anterior box" section. Rivet the remaining loose box section to the sole (<a href="http://www.oandplibrary.org/cpo/images/1988_01_029/1988_01_029-1.jpg">Fig. 1</a>). The 5/8" gap between the two "box" sections is filled with foam rubber (<a href="http://www.oandplibrary.org/cpo/images/1988_01_029/1988_01_029-2.jpg">Fig. 2</a>). The durometer selected depends on how firm a toe break is desired. This design has provided the more agressive patient with a toe action that simulates the push-off activity of the contralateral foot. <a href="http://www.oandplibrary.org/cpo/images/1988_01_029/1988_01_029-1.jpg">Figure 1. Box sections rivetted in place. Anterior shell shown in the back ground.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_01_029/1988_01_029-2.jpg">Figure 2. Foam rubber bumper laying beside forefoot section. Anterior shell in place.</a> <h3>Fitting</h3> The prosthesis is now ready for fitting. Shoes used have usually been of the double depth type with removable innersole. This type is preferred because it gives extra depth inside the shoe for the affected extremity and allows room for, and needed balancing of, the remaining foot. Most often the patient has been fit with the extra depth shoes and they later purchase ordinary footwear and manage without incident. It is felt that the total contact principle that has been so beneficial to other amputees has been adopted successfully in the design of this prosthesis. By encapsulating the extremity, edamatous problems have been prevented and circulation boosted, or so the patients have reported. The skin texture is soft and warm by comparison to the contraindicated limb. In fact, many patients have remarked that the extremity had always felt cold but now the other leg feels cold by comparison. This prosthesis prevents the problem of distal end friction that can result in further amputation. It is not possible for a shoe to cause friction to any part of the residual limb. One patient, who is a farm machinery repairman, has also found that it prevents the problem of bruising of the shin he encountered in his occupation. This style prosthesis, for all its length and function, weighs little more than the toe-filler type prostheses and is certainly lighter than other versions. It is relatively more expensive than most toe-fillers, but considerably less expensive than other types of prostheses, such as a conventional Chopart. On heel strike, the material "puckers" slightly, cushioning the impact. On foot flat, as well as at toe-off, the action of the foresection simulates the norm. In many patients, better gait on the affected extremity than on the contra-indicated limb has been observed. The gaits of all patients fitted have improved dramatically and some are undetectable to the eyes of even trained personnel. <h3>Conclusion</h3> Experience to date is that the above described prosthesis provides superior gait, less cost, less weight, and better patient acceptance than other types of Chopart prostheses. The material will torque with the extremity and does cause friction to tissue of poor quality. This material was originally presented in 1974 and not submitted for publication because it was thought that it would be outdated within a year or two. Evidently, this was a wrong assumption. With an ever increasing number of surgeons doing more distal amputations, there have been more and more requests for this information. <h3>Acknowledgments</h3> We thank Siegfried Paul, C.P.O., for awakening us to thermoplastics, Thorkild Engen, CO., for introducing us to polypropylene, and Dr. Richard Jacobs for being all that a great physician should be. *Richard LaTorre, CO. Richard LaTorre, CO., is President of LaTorre Orthopedic Laboratory, 846 State Street, Schenectady, New York 12307. <div style="width: 400px;"></div> Page Number(s) 29 - 32 Year 1988 Volume 12 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1988_01_029/1988_01_029-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_01_029/1988_01_029-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_01_038.pdf Text Any textual data included in the document <h2>The Rancho Syme Prosthesis with the Regnell Foot</h2> <h5>Michael J. Quigley, C.P.O. <a style="text-decoration: none;">*</a> Sam E. Hamontree, CP. <a style="text-decoration: none;">*</a> Joe Antorietto </h5> The Syme amputation has been with us since 1842, when James Symes developed it for three reasons, "(1) the risk to life will be smaller, (2) a more comfortable stump will be afforded, (3) the limb will be more seemly and useful for ambulation."<a></a> Since then, the major improvement in the surgical technique has been the introduction of the two stage Syme amputation,<a></a> which was developed to increase the success rate in dysvascular and infected patients. Wagner further refined the technique at Rancho Los Amigos Hospital, and increased his success rate to 95% by the use of Doppler ultrasound to determine adequate blood flow.<a></a> Wagner also advocates removing the flares of the tibia and fibula during the second stage to narrow the distal end and provide better cos-mesis. The advantages of the Syme level of amputation are many (Fig. 1), but the design of the prosthesis has been a constant challenge for prosthetists (Fig. 2). The Syme level amputee is typically more active, walks at a faster pace, and expends less energy than the below-knee amputee;<a></a> for these reasons the demands on the prosthesis are greater. Breakage of Syme prostheses has been a constant problem, especially with prosthetic designs that have openings (medial opening, posterior opening, etc.). Syme prostheses that have no openings must allow enough room for the bulbous end of the leg to pass through, giving a "stovepipe" appearance to the leg. In addition, the "no opening" designs had other advantages, i.e., the silastic bladder expandable wall design was not durable and tended to delaminate, the full insert type added additional bulk to the prosthesis, and the removable pad design needed constant adjustment. The Rancho expandable wall prosthesis eliminates many of the problems inherent in other designs. This prosthesis was first described in the AAOS Atlas of Limb Prosthetics although fabrication was not detailed at that time. The Rancho expandable wall prosthesis incorporates the following features: <ol> <li> Strength—The "no opening" design laminated to the Regnell foot provides maximum strength and durability. </li> <li> Expandable liner—A durable elastic window sewn in a thin flexible inner liner eliminates problems with silastic or Pe-lite™ inserts, which will tear or add excess bulk. </li> <li> Cosmesis—No buckles or straps are required. No line or seam at ankle joint. Bulk is kept to a minimum with thin wall thickness. </li> <li> Ease of adjustment—Although the expandable inner is bonded in place permanently, it can be left unbonded for the first month of wear to allow for adjustments. </li> <li> Can accommodate large distal ends—Two expandable windows can be made in the flexible liner to allow for large distal ends. </li> </ol> <h3>Negative Impression Procedure and Measurements</h3> The plaster negative impression is taken in the conventional manner. Reliefs are made over the bony prominences by the use of 1/8" padding before the impression is taken. The circumferences of the distal end and the narrowest part of the ankle should be compared. Maximum cosmesis is attained when the malleoli have been trimmed and the largest circumference at the distal end is about 3/4" greater than the smallest ankle circumference. Fabrication After the necessary modifications are made to the positive model, measure the M-L at the distal end, then move the calipers proximally until the model has the same M-L. This will determine the length of the elastic panel (Fig. 3). If the circumference of the distal end is 1 1/4" or greater than the narrowest part of the model, two elastic panels will be necessary. Figures 3A & 3B. Measure distal end with M-L calipers and move proximally until the same M-L is found to determine the length of polyethylene panels and the buildup needed on the inner socket. To allow space for the elastic panel, polyethylene "inserts" (Fig. 4) are cut to the length determined above, and are inserted between two nylon stockinettes for the expandable liner. The polyethylene inserts are laminated into the nylon using a 80% flexible, 20% rigid resin. Figure 4. A: Medial/lateral polyethylene inserts are inserted between the two points made by the calipers. B: Inserts are laminated into expandable bladder using 80% flex and 20% rigid. The PVA bag is left on the lamination and a polyurethene foam buildup is made over the lamination (Fig. 5); this is then measured and shaped down to 1/4" less than the circumference of the distal end. A PVA bag is pulled over the foam and an outer shell of 6 nylon is laminated using rigid (90-10) resin (Fig. 6). After the resin sets, a hole is drilled in the distal end and the outer lamination is forced off the model using compressed air (Fig. 7). The polyurethene foam buildup and PVA bag are then removed from the inner lamination. Figure 5. Foam buildup which results in the void necessary for the expandable bladder to open, allowing the patient to don the prosthesis. Figure 6. Laminated outer shell over the expandable bladder with the foam buildup. Figure 7. Bladder being pulled out of the laminated outer shell. Remove the polyethylene inserts by drilling small holes in the center of each end and slitting the outer nylon with a razor (Fig. 8 and Fig. 9). Most of the laminated nylon covering the outside of the polyethylene sleeve is removed, leaving a 1/4" overlap to hold the stitching for the elastic panel. A single vertical razor slit is made on the inside of the liner to allow expansion. Use the polyethylene sleeves as patterns to cut out one-way stretch elastic. The proper elastic for this procedure, called grip-net, is difficult to find, as it must have a heavy durable weave and comes in a wide roll (8" or greater). Figure 8. Drilling holes at widest proximal and distal points to properly position the slit in the bladder for the elastic panels. Figure 9. Slit the lamination with a razor vertically to connect the drill holes. The polyethylene panels are used to determine the shape and size of the elastic panels that have been trimmed to size and are to be inserted into the bladder. The elastic panels are temporarily taped in place and then sewn in place in a long arm patcher sewing machine (Fig. 10). The liner may have to be folded and/or lubricated with silicone to allow the machine to reach the end of the insert. The prosthesis is now ready for static alignment on the Regnell foot (Fig. 11). Figure 10. The elastic panels are inserted; it helps to tape them in temporarily at the proper width in preparation for sewing in the elastic Figure 11. Outer socket and inner expandable socket with elastic panels sewn in place. The Regnell foot is an external keel design specifically suited for Syme prostheses because the distal end of the socket can be placed very close to the floor: a thin sole and heel cushion take little space under the prosthesis. No ankle bolt is needed, and the finished laminated external keel provides good cosmesis. The toe break is located and designed to allow for more optimum A-P alignment of the socket, resulting in smoother functional rollover and more cosmetic shaping. Static Alignment Static alignment can be set up by either sinking the socket into the keel of the foot, or by cutting off the top of the foot with a bandsaw, leaving only the amount equal to the leg length discrepancy (Fig. 12). The socket is then sunk into the block cut-off of the foot and tack glued to the prosthesis (Fig. 13). The second method allows the prosthetist easier M-L and A-P and toe-out adjustments by simply moving the block on the prosthesis and regluing. Dynamic alignment is achieved in the usual manner. Figure 12. Socket is set into the block, aligned, and glued to the Regnell foot. Figure 13. Lateral view of static aligned prosthesis ready for fitting. Finishing Following dynamic alignment, the socket is shaped to blend into the foot and roughed up. All soft parts of the foot are taped off and the final lamination of 2 nylon is made. The sole of the foot is not removed during lamination (Fig. 14). The lamination is then trimmed away, leaving the sole and toe break free (Fig. 15). Figure 14. Following dynamic alignment with the patient, the socket is shaped to the foot and made ready for finishing of the outer prosthesis. Two nylons are used with rigid laminate with the sole in place and taped off. Figure 15. The finished, laminated prosthesis. Expandable liner must be permanently bonded to the outer socket at same point, but can be left separate initially to allow for adjustments. The expandable liner is inserted into the outer shell. If no adjustments are anticipated, the liner is bonded to the outer shell at the proximal border with sealing resin. <h3>Summary</h3> The Rancho expandable wall Syme prosthesis, when used with a Regnell foot, provides a very practical solution to the problems existing in other Syme prostheses. Many of the durability and cosmesis problems have been eliminated. Whenever possible, prosthetists should encourage physicians to perform more Syme level amputations, and to try to achieve less bulky distal ends when these amputations are performed. <h3>Acknowledgments</h3> The prosthesis described here was developed in response to the needs of Richard Voner, CP., of Orthomedics and William Wagner, M.D., of Rancho Los Amigos Hospital, Downey, CA. The fabrication procedure was developed by Ortho-medics Central Fabrication, which also provided the fabrication photos. Figure 16. Syme patient holding expandle liner. Figure 17. Syme patient pulling on the liner. Note the expansion of the elastic panels; normally this would not be seen as the liner would be bonded to the outer socket. Figure 18. Patient standing on the finished prosthesis. References: <ol> <li>Syme, J. "Amputation at the Ankle Joint," London Edinburgh Monthly J. Medical Science, 2, 1843, p. 93</li> <li>Harris, R.I. "Syme Amputation," J. Bone and Joint Surgery, 38B, 1956, p. 614.</li> <li>Spitther, A.W., J.J. Brennen, and J.W. Payne, "Syme Amputation Performed in Two Stages," J. Bone and Joint Surgery, 55A, 1973, p. 568</li> <li>Wagner W., "The Syme Amputation," AAOS Atlas of Limb Prosthetics.</li> <li>Waters, R.L., J. Perry, D. Antonelli, and H. Hislep, Energy Costs of Walking of Amputees, The Influence of Level of Amputations.</li> <li>Voner, R,, "The Syme Amputate: Prosthetic Management," AAOS Atlas of Limb Prosthetics, pp. 334-340.</li> </ol> *Sam E. Hamontree, CP. Sam E. Hamontree, CP., is Executive Vice President of Orthomedics, 2950 E. Imperial Hwy., Brea, California 92621. *Michael J. Quigley, C.P.O. Michael J. Quigley, C.P.O., is President of Oakbrook Orthopedic Services, Ltd., 1 South 224 Summit Avenue, Oakbrook Terrace, Illinois 60181. Page Number(s) 38 - 40 Year 1988 Volume 12 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Needs Revision- See Trello Figure 6 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-14.jpg Figure 15 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-15.jpg Figure 16 missing Figure 17 missing Figure 18 missing 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 Rancho Syme Prosthesis with the Regnell Foot Creator An entity primarily responsible for making the resource Michael J. Quigley, C.P.O. * Sam E. Hamontree, CP. * Joe Antorietto https://staging.drfop.org/files/original/d30d90150edc24e748bab158375cb723.pdf aa70fbf64b2b0a120d496af8fc3055be https://staging.drfop.org/files/original/225dc1b21aefe0852c68ef5b2e996348.jpg 8ab20befafe25dde5db91d3b298002e9 https://staging.drfop.org/files/original/0b2de6b395b114394842205a02afef18.jpg a63b96cb4a0c54917747fb79a032b485 https://staging.drfop.org/files/original/64306830b9afd89a7374bd95f3a753b8.jpg 9158f03044f9ae6c9d51e47bd761513d https://staging.drfop.org/files/original/3a0c484f58ba18c2b9bf3063e1455320.jpg affb00b0c04bff688f65f72440927ee4 https://staging.drfop.org/files/original/0b4a9ac4b93a10eaf842a3baf263266b.jpg d882b9048a91bfd682ad26c6e302954f Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_01_041.pdf Text Any textual data included in the document <h2>Technical Note: Fabrication of the Syme Prosthesis</h2> <h5>Robert Gilley, CP. <a style="text-decoration: none;">*</a></h5> I first became familiar with this method of fabricating a Syme prosthesis in 1981, when I was transferred to Snell's of Memphis from Nashville. The technique had been in widespread use there and in the Memphis area for sometime, with every evidence of satisfactory service. I am describing the procedure here for it has proven to be not only durable, but a most practical and simple method of fabrication. A Syme socket is set in a foot block (Kingsley catalog, #K1910) slightly behind the anterior-posterior centerpoint (<a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-1.jpg">Fig. 1</a>). Care should be taken to set it in the proper angle of flexion and adduction. <a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-1.jpg">Figure 1. Socket set in block.</a> An ordinary Kingsley Syme SACH foot (Catalog #K07) is taken and sectioned horizontally below the level of the proximal surface of the keel (<a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-2.jpg">Fig. 2</a>). This leaves the distal portion with a flat proximal surface. <a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-2.jpg">Figure 2. Cross sectional diagram of Syme SACH foot, showing cut line.</a> The foot and socket are then positioned together in the proper bench alignment. The height is checked and corrected by removing material from the socket block. Bench alignment is reestablished and the position of the bolt hole is marked on the distal surface of the socket block. The bolt hole is drilled and a recess for the adapter nut is counterbored in the distal end of the socket. This is done with an improvised counterbore made from a 3/8"-16 bolt and adapter nut. The adapter nut is set in place, and thickened resin is used to secure it there and smooth the surface. The foot and socket are assembled and excess material is removed from the socket block (<a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-3.jpg">Fig. 3</a> and <a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-4.jpg">Fig. 4</a>), leaving some to allow for any adjustments in toe-out. The foot bolt should be cut to length. <a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-3.jpg">Figure 3. Foot and socket unassembled.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-4.jpg">Figure 4. Foot and socket assembled.</a> Following completion of dynamic alignment, the prosthesis is laminated and finished in a manner identical with that employed to finish the shin of any below-knee or above-knee prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-5.jpg">Fig. 5</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-5.jpg">Figure 5. The finished prosthesis.</a> To recapitulate, the technique offers the prosthetist an efficient and expeditious method of fabricating a Syme prosthesis with good cosmetic results. It has the added advantage that foot replacement, should it become necessary, is facilitated. *Robert Gilley, CP. Robert Gilley, C.P.O., is Supervisor of Prosthetics Central Fabrication Services for Durr-Fillauer Medical, Inc., Orthopedic Division, 2710 Amnicola Highway, Chattanooga, Tennessee 37406. Page Number(s) 41 - 43 Year 1988 Volume 12 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_01_041/1988_01_041-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Technical Note: Fabrication of the Syme Prosthesis Creator An entity primarily responsible for making the resource Robert Gilley, CP. * https://staging.drfop.org/files/original/892690a8157d28658a834c3528307f12.pdf 46635f9f3a0bd0099000df31390bb18f https://staging.drfop.org/files/original/f83483273e4ca873c2b6c4b749295b36.jpg 1806cb232e00d7f2e1aa8c0d43cf5030 https://staging.drfop.org/files/original/44ad63daa60b63d3e5eb235ee4bed6af.jpg b941ec42fb9f33e4b53d6e8c3131f2e8 https://staging.drfop.org/files/original/538baa25b4c0b8a6e366d350ab8efe22.jpg ca48e869ff98e23bdfbe302f048a00d3 https://staging.drfop.org/files/original/1313f2ed2e7ca5cfacff0dcb7183e6ea.jpg 35d3f849afd43c43e0b9995145ac60cf https://staging.drfop.org/files/original/7a5327ee43eb8d131b9d230581c3ea78.jpg 92bc8538f3959fb74b71e0fc01066b25 https://staging.drfop.org/files/original/168dba5c3df51c517fed3c05cf7259a2.jpg c5c8829fa389af76f59224e172c0874a https://staging.drfop.org/files/original/c4ec5d68676dafe3a670f1224ebea94b.jpg 7bdd0b16e025474332d2b91468b6828c https://staging.drfop.org/files/original/7dd172ac59d2034ee24963329d2b08c4.jpg 1ad409c2443e6aaee7fc0cfbad0b89e0 https://staging.drfop.org/files/original/7fa6c4953b72189fd674a1df2dfc7a94.jpg e6d74833e34b051102932b0497b62db5 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_02_044.pdf Text Any textual data included in the document <h2>Clinical Analysis of Foot Problems</h2> <h5>Karen S. Seale, M.D. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> Orthotists are vital members of the foot care team. Their expertise and special interests in materials and biomechanics add a unique dimension to the management of foot problems. It is hoped that the principles of clinical assessment of foot problems set forth in this article will foster even greater interest in and understanding of the pathophysiology of foot problems. The purposes of this article are threefold: <ol> <li> To familiarize the orthotist with the general concepts of clinical analysis of the foot. </li> <li> To assist the orthotist in designing the most appropriate orthosis based on clinical assessment of the problem. </li> <li> To give examples of clinical analysis of the following common foot problems for which an orthotic treatment may be prescribed: <ol> <li> Heel pain </li> <li> Pes planus </li> <li> Metatarsalgia </li> <li> Ankle instability </li> </ol> </li> </ol> <h3>Discussion</h3> Clinical analysis of the foot consists of obtaining a pertinent history and performing a physical examination of the lower extremity. The medical history is an opportunity to gather as much information as possible by asking the patient to describe the pain, problem, or deformity. Specific information is sought by asking about the type of pain, its duration, onset (whether insidious or abrupt), location of the pain, and activities that help or aggravate the pain (such as rest, walking, or wearing or removing certain shoes). Physical examination involves inspection, palpation, and manipulation. Observe the patient, first with and then without his typical footwear, both standing and walking, with arms hanging freely at the sides. The patient should be observed from the front and from the back. With the patient seated at a height comfortable for the examiner and the shoes removed, palpation and manipulation can be performed. Palpation is not intended to inflict pain, but rather to identify areas of discomfort. For example, applying direct pressure in the center of the heel pad may cause discomfort in a patient with "heel spur" syndrome. In addition to palpation, manipulation is used to assess range of motion of the various joints and to determine the biomechanical relationships of the component parts of the lower extremity. Although a description of a comprehensive foot examination is beyond the scope of this paper, clinical analysis of four common foot problems is included in the next section. <h3>Heel Pain</h3> A very common clinical problem for which shoe modifications may be prescribed is heel pain. Although many causes of heel pain exist, common etiologies include, (1) fat pad atrophy, (2) plantar fascitis or "heel spur" syndrome, and (3) neuritis of the medial calcaneal or lateral plantar nerves. Atrophy of the fat pad is particularly common among older individuals who will complain of localized pain about the heel brought on by walking, especially in hard soled shoes. Varying degrees of fat atrophy of the metatarsal area as well as the heel pad are observed on physical examination and the underlying tubercle of the calcaneous can be readily palpated. The key to successful shoe modification in treating this condition is to increase the padding beneath the heel. The onset of chronic heel pain due to plantar fascitis or "heel spur" syndrome may be either acute or insidious. It is often most severe upon arising in the morning, but improves after a period of "warming up." However, it may worsen if the patient remains on his feet during the day or with intermittent periods of rest and activity. The patient is usually tender to palpation at the origin of the plantar fascia on the plantar tubercle of the calcaneus and about one centimeter distally (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-1.jpg">Fig. 1a</a>). The principles of shoe modification management are soft soles, relief in the center of the heel, and a soft arch support to better distribute the weight and relieve the painful heel area. <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-1.jpg">Figure 1A. Point of tenderness in patient with plantar fascitis.</a> Neurologic causes of heel pain include neuritis and/or compression of the medial calcaneal nerve, the lateral plantar nerve, or the nerve to the abductor digiti quinti, which is a branch of the lateral plantar nerve.<a></a> The pain is usually not well localized as with plantar fascitis, but tends to be diffuse. On physical examination tenderness may be found on the medial aspect of the heel over the origin of the abductor hallucis (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-2.jpg">Fig. 1b</a>). Occasionally, the examiner can elicit pain or tingling along the medial aspect of the heel with light tapping or pressure in this area. For these patients, an orthosis which limits excessive pronation, and thereby decreases the pull of the abductor hallucis across the nerves, is useful. <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-2.jpg">Figure 1B. Point of tenderness in patient with neuritis of medial calcaneal and/or lateral plantar nerve. </a> <h3>Pes Planus</h3> Pes planus, or flat foot, is a descriptive term indicating the loss of height of the medial arch, but is a more complex entity than the name implies. There are many causes of symptomatic flat feet, including posterior tibial tendon rupture, Charcot joint degeneration secondary to neuropathy, rheumatoid arthritis, and generalized ligamentous laxity.<a></a> The specific complaints vary depending on the etiology, but in general, pes planus leads to diffuse aching of the foot and early fatigue. Patients with inflammation or early rupture of the posterior tibial tendon will note pain on the medial aspect of the foot and ankle early on, but as significant deformity develops, pain occurs on the lateral aspect of the hindfoot due to impingement of the fibula against the valgus-tilted calcaneus.<a></a> The rheumatoid patient may have a great deal of diffuse pain, whereas the patient with Charcot joint degeneration secondary to neuropathy may have little or no pain in the presence of very severe deformity. Pes planus is best observed seen while the patient is standing. One notes the decrease in the medial arch height, the increase in forefoot abduction and external rotation as well as the presence of heel valgus (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-3.jpg">Fig. 2a</a>). Observations, made from behind as the patient walks, are (1) the excessive external rotation of the foot relative to the line of progression, and (2) the lack of significant heel inversion motion from foot flat to heel lift. <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-3.jpg">Figure 2A. Note loss of longitudinal arch, with the excessive forefoot abduction and external rotation.</a> Further biomechanical evaluation is performed by sitting in front of the seated patient to observe the relationships of the hindfoot to the leg and of the forefoot to the hindfoot. The subtalar joint motion is assessed by grasping the heel and tilting it laterally (into valgus or eversion) and then medially (into varus or inversion). Not infrequently, the patient with pes planus will demonstrate excessive eversion, greater than the normal excursion of 10°. The foot is then placed in its "neutral position," which is the point at which the calcaneus is centered under the tibia and the talar head is adequately covered by the tarsal navicular. This is done by the examiner's holding the heel in alignment with the long axis of the tibia or in a few degrees of valgus and then adducting the forefoot approximately halfway between maximum forefoot abduction and maximum adduction. The position of the plantar aspect of the forefoot relative to the perpendicular axis of the tibia is noted. There is usually a component of forefoot varus which means the plantar aspect of the foot is facing medially (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg">Fig. 2b</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg">Figure 2B. Forefoot varus-plantar aspect of foot facing medially.</a> The principles of orthotic management of pes planus include correcting the valgus tilt of the calcaneous, providing a medial arch support, and posting of the first ray to control the hyper-pronation. <h3>Metatarsalgia</h3> Metatarsalgia is pain in the forefoot area for which a wide variety of etiologies have been identified. For the purposes of this article, which is aimed at the practicing orthotist dealing with foot problems, the discussion will be limited to the following: <ul> <li> Fat pad atrophy </li> <li> Sesamoiditis </li> <li> Disorders of the lesser metatarsophalangeal joints </li> <li> Interdigital neuroma </li> <li> Rheumatoid arthritis </li> <li> Pes cavus </li> </ul> Fat Pad Atrophy As in heel pad atrophy, the soft tissue padding under the metatarsal heads may become atrophied with age, causing diffuse pain under the metatarsal heads due to the lack of sufficient padding for shock attentuation. The patient may complain of pain especially when walking on a hard floor without shoes. The atrophy is apparent on general inspection; palpation reveals the prominence of the metatarsal heads plantarly. The patient may be tender to palpation directly under the metatarsal heads. Soft soled shoes and soft inner soles with metatarsal pads proximal to the metatarsal heads are beneficial modalities. Sesamoiditis Patients with inflammation of the sesamoids of the first metatarsophalangeal joint will complain of well localized pain on the medial aspect of the foot just proximal to the first metatarsal head upon weight bearing. There may be a history of repeated jumping or running on the balls of the feet or of a crush injury due to a heavy object falling on the foot. The patient may walk by rolling his foot into supination and inversion, thus bearing the majority of the weight on the lateral border of the foot. Palpation directly over the involved sesamoid will cause localized tenderness beneath either the tibial or the fibular sesamoid (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg">Fig. 3a</a>). Look for associated edema and swelling under and around the first metatarsal head. Passive extension of the first metatarsophalangeal joint will aggravate the pain. Placing the patient in low heeled shoes with padding devices which relieve weight bearing under the first metatarsal head are indicated. <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg">Figure 3A. Area of point tenderness of fibular sesamoiditis.</a> Disorders of the Lesser Metatarsal Joints Disorders such as subluxation or dislocation, isolated synovitis, or Freiberg's disease can cause pain limited to a single metatarsophalangeal joint.<a></a> The onset of pain may be insidious and there may or may not be a history of trauma associated with the onset of pain. The patient is usually able to point to the involved area. Pain can be elicited upon palpation of the involved joint and with passive manipulation. Synovial thickening may be appreciated when comparing the thickness of the involved joint to the normal joint of the opposite foot. Interdigital Neuroma The well localized pain associated with an interdigital, or Morton's, neuroma is caused by a thickening of the soft tissues surrounding the common digital nerves on the plantar aspect of the foot and occurs most frequently between the third and fourth metatarsal heads. This entity occurs frequently in women and probably results from the repeated trauma to the metatarsal region caused by the wearing of high heeled shoes. The patient is usually able to point out the area of maximum pain on the plantar aspect of the foot, pain which occasionally radiates to the toes, and which is worse with weight bearing when wearing snug, thin soled shoes. Removing the shoes and massaging the foot usually affords some temporary relief. The physical examination will be normal to inspection, but upon palpation pain can be elicited by squeezing the soft tissues between the involved metatarsal heads. This is done by using the thumb and forefinger of one hand to simultaneously press from dorsal and plantar while compressing all the metatarsal heads medially and laterally with the opposite hand (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-5.jpg">Fig. 3b</a>). Occasionally, the enlarged nerve tissue can actually be felt to roll between the finger and the thumb. <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-5.jpg">Figure 3B. Technique for eliciting tenderness of interdigital neuroma between third and fourth metatarsal heads.</a> Keeping the pressure off the involved area with a metatarsal support proximal to the metatarsal heads and eliminating snug, high heeled shoes can be helpful in decreasing the pain. Rheumatoid Arthritis The typical advanced deformities of rheumatoid arthritis causing metatarsalgia are hallux valgus with lateral deviation and dorsal dislocation of the lesser metatarsophalangeal joints. This results in the distal displacement of the plantar fat pad, thus leaving the metatarsal heads displaced plantarly with insufficient fat pad coverage (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-7.jpg">Fig. 3c</a> and <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-8.jpg">Fig. 3d</a>). Broad, soft soled shoes with an adequate height of the toe box to accommodate the deformities are necessary. Providing a soft, total contact insert with metatarsal padding proximal to the prominent metatarsal heads is helpful in decreasing the weight born by the metatarsal heads and more evenly distributing the weight across the sole of the foot. <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-7.jpg">Figure 3C. Typical forefoot deformities of rheumatoid arthritis-hallux valgus and dorsal dislocation of metatarsalphalangeal joints (plantar view).</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-8.jpg">Figure 3D. Typical forefoot deformities of rheumatoid arthritis-hallux valgus and dorsal dislocation of metatarsalphalangeal joints (lateral view).</a> Pes Cavus A common complaint of the person with pes cavus, or a high arch, foot deformity is metatarsalgia. The elevated arch results in greater weight being borne on the metatarsal heads. The cavus foot is more rigid and, thus, has less shock attentuation capability than the normal, more supple foot. Metatarsalgia can be worsened in the presence of clawing of the toes, which involves hyperextension of the metatarsophalangeal joints, thus making the metatarsal heads even more prominent plantarly. The deformity can best be appreciated on physical exam by watching the patient in a standing position. In addition to the elevated longitudinal arch, heel varus may be noted. Plantar flexion of the first ray may be present and can be seen by viewing the foot anteriorly with the patient seated. Stabilize the calcaneus in alignment with the tibia and note the level of the plantar aspect of the first metatarsal head relative to the others. The patient with metatarsalgia secondary to pes cavus may benefit from a soft arch support to increase the weight bearing surface of the foot and to improve shock attenuation. <h3>Ankle Instability</h3> Ankle instability may be the result of lateral ligamentous laxity, a varus heel, or a varus an-gulated tibia.<a></a> A patient with lateral ligamentous laxity of the ankle may give a history of having initially sustained an ankle sprain secondary to significant ankle trauma followed by recurrent sprains with minimal or no trauma. The wearing of high heeled shoes worsens the tendency of recurrent ankle sprains as this further throws the foot into supination. Ligamentous laxity causing ankle instability can usually be demonstrated by the "lateral talar tilt" test. The ankle is stress tested both in dorsiflexion, to test the calcaneofibular ligament, and in plantarflexion, to test the anterior talofibular ligament. The tibia is held stationary as the examiner applies pressure on the lateral aspect of the hindfoot in a medial direction (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-9.jpg">Fig. 4</a>). The ankle, which lacks adequate ligamentous support, will tilt medially indicating instability. <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-9.jpg">Figure 4. "Lateral talar tilt" test for ankle instability.</a> The presence of heel varus can be appreciated by viewing the patient from behind as he stands with shoes removed. It will be noted that the calcaneous is medial to the longitudinal axis of the tibia. Upon manipulation of subtalar joint motion, there may be decreased eversion of the calcaneous relative to inversion. A person who had a varus angulated tibia, either from a congenital deformity or secondary to a tibia fracture which has united in varus, may also experience ankle instability. With such malalignment, the biomechanical forces pass lateral to the center of the calcaneous. Observing the standing patient from the front, the examiner will note that an imaginary plumb line dropped from the center of the patella will fall lateral to the center of the ankle on the affected side. A lateral heel and sole wedge tilts the hind-foot into slight valgus to help prevent recurrent ankle instability. <h3>Summary</h3> The principles of clinical assessment of four common clinical problems for which orthotic treatments are prescribed have been discussed. The information gained from the medical history and physical examination used in clinical assessment of foot problems can aid the ortho-tist in improving his or her effectiveness as a vital member of the foot care team. References: <ol> <li>Baxter, Donald E., "The Evaluation and Treatment of Forefoot Problems in the Athlete" (Unpublished manuscript).</li> <li>Baxter, Donald E. and C. Mark Thigpen, "Heel Pain-Operative Results," Foot & Ankle, 5:1, 1984, pp. 16-25.</li> <li>Johnson, Kenneth, "Tibialis Posterior Tendon Rupture," Clinical Orthopaedics & Related Research, 166, 1983, pp. 143-150.</li> <li>Mann, Roger A., "Biomechanical Approach to the Treatment of Foot Problems," Foot & Ankle, 2:4, 1982, pp. 205-212.</li> <li>Mann, Roger A., "Metatarsalgia," Postgraduate Medicine, 75:5, 1984, pp. 150-167.</li> <li>Mann, Roger A. Surgery of the Foot, The C.V. Mosby Co., 1986.</li> </ol> *Karen S. Seale, M.D. Karen S. Seale, M.D. is assistant professor in the Department of Orthopedics, University of Arkansas Medical School Center Page Number(s) 44 - 50 Year 1988 Volume 12 Issue 2 Figure 1 FIGURE 1A http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-1.jpg FIGURE 1B http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-2.jpg Figure 2 FIGURE 2A http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-3.jpg FIGURE 2B http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg Figure 3 FIGURE 3A http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-5.jpg FIGURE 3B http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-6.jpg FIGURE 3C http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-7.jpg FIGURE 3D http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-8.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-9.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Analysis of Foot Problems Creator An entity primarily responsible for making the resource Karen S. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_02_051.pdf Text Any textual data included in the document <h2>Orthotic Management of the Arthritic Foot</h2> <h5>C. Michael Schuch, C.P.O. <a style="text-decoration: none;">*</a></h5> With ever increasing public exposure, orthotists are being requested more frequently to confront new challenges caused by physical disability. In the spectrum of orthotic protocols, management of the arthritic foot and ankle is a relatively new challenge. During the past five years, the Department of Orthopaedics and Rehabilitation, the Division of Rheumatology, and the Division of Prosthetics and Orthotics, all of the University of Virginia Medical Center, have comprised an Arthritis Rehabilitation Research and Training Center, providing a regional referral center for arthritis patients. Orthotic services for these patients have concentrated on the foot and the ankle, and this population of patients has been substantial enough to permit the development of a consistently successful protocol of management. The intent of this paper is to review the skeletal anatomy of the ankle and foot, discuss the types of arthritis and their relative pathophysiology and clinical manifestations, and finally to present our protocol for management of the various problems presented by the arthritic foot and ankle. <h3>Review of Ankle-Foot Anatomy</h3> The skeleton of the foot consists of three groups of bones: tarsal bones, metatarsal bones, and phalanges. The tarsal bones are further divided into two groups, the first group consisting of the talus and the calcaneus, together forming the hindfoot. The talus, which is the only bone to articulate with the tibia and the fibula, acts as a rocker by which the foot as a unit can be dorsiflexed and plantarflexed at the hinge of the ankle joint. In stance, the talus receives the entire weight of the lower limb; half this weight is transmitted forward to the bones forming the arch of the foot, and half of the weight is transmitted downward to the heel or calcaneous. The calcaneus, or os calcis, is the bone of the heel. It supports the talus, withstands shock as the heel strikes the ground, and transfers forward the portion of body weight it receives from the talus. The second group of tarsals consists of the five bones anterior to the talus and the calcaneus. The navicular, cuboid, and three cuneiforms increase flexibility of the foot, particularly in its twisting movements. These bones form the longitudinal arch of the foot, and are referred to collectively as the midfoot. The five metatarsal bones lie anterior to and articulate with the second group of tarsal bones described above. Each metatarsal consists of a base, a shaft, and a head, in respective order from proximal to distal. The distal-most bones of the foot are the five phalanges, which extend from the five metatarsals and form the bones of the toes. The metatarsals and the phalanges form the forefoot. The foot has three arches: the medial, lateral, and transverse. The normal medial arch rises through the calcaneous to the head of the talus, and from this high point it descends forward through the navicular, cuneiforms, and first three metatarsal heads. The lateral arch, which is lower than the medial, extends from the calcaneus to its high point at the cuboid, and down through the fourth and fifth metatarsals. The transverse arch rises across the width of the foot between the medial and lateral borders, primarily under the metatarsal shafts. The junctions of these various groups of bones form the joints that allow the functional motions of the ankle and foot to occur. The talocrural (ankle) joint consists of the medial and lateral malleoli and the trochlear surface of the talus. This joint permits the motion of plantar-flexion and dorsiflexion. The subtalar (talocal-caneal) joint is formed by the articulation of the talus and the calcaneus, and permits the heel to share in inversion and eversion. The transverse tarsal (midtarsal) joint is not an anatomic entity, but an important functional grouping of two joints which occur anterior to the talus. These two joints, the talocalcaneonavicular and the calcaneocuboid, permit much of the inversions version of the foot. The other tarsal joints, tarsometatarsal joints, and distal joints aid in flexibility of the foot from heel strike through mid-stance, and help the foot form a rigid lever during toe-off, or the propulsion part of the gait cycle. Each of the joints of the ankle and foot, including the joints between the sesamoids and the first metatarsal are lined with synovium so that when inflammatory conditions that affect the synovium are present, the foot and ankle may show dramatic changes clinically, radio-graphically, and pathologically. <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-1.jpg">Figure 1. View of patient's feet afflicted with rheumatoid arthritis. Note, hallux valgus, claw toes, depressed longitudinal arch, and pronation or eversion at the subtalar joint.</a> <h3>Types and Pathophysiology of Arthritis</h3> While there are a half dozen or more differing types of arthritis,<a></a> we will limit our discussion to the types that have a tendency to involve the foot and ankle. The most commonly seen and most debilitating form of arthritis is rheumatoid arthritis. Rheumatoid Arthritis Rheumatoid arthritis is an inflammatory condition of unknown etiology that primarily affects the synovial lining of joints, tendons, and bursae. Secondarily, it may cause destruction to cartilage, bone, ligaments, and other soft tissue. Most people with rheumatoid arthritis have some degree of foot and/or ankle involvement.<a></a> The joints of the feet are initially involved more often than the joints of the hands.<a></a> Vaino showed that more than 88% of adults and 69% of children with rheumatoid arthritis have involvement of the feet during some phase of the disease.<a></a> Guerra states that the earliest sign of rheumatoid arthritis is congestion of the synovial membranes with edema.<a></a> As the synovial inflammatory tissue and fluid within the joint accumulate, there is swelling of the soft tissue, and decreased range of motion of the joint. The inflamed synovium adjacent to the marginal bare areas causes destruction of bone, resulting in bony erosion at the margins. Because the inflamed synovium, known as the pannus, also proliferates, expansion occurs over the cartilage and destroys the cartilage through enzymatic action, producing symmetrical joint space narrowing. The pannus may also penetrate the unprotected bare bone and cause destruction of the cartilage from the marrow side. The reactive hyperemia, part of the inflammatory process, is implicated in the periarticular osteoporosis and the discontinuity of the subchondral bony plate.<a></a> Joint destruction and deformities occur and become fixed as the weakened support structure of the ankle and foot gives way to the normal mechanical stresses placed upon it; changes in alignment of joints allow muscles, tendons, and ligaments that cross the joints to exert different forces, and stiffness and pain in the joints prevent mobility.<a></a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-2.jpg">Figure 2. Schematic view showing the effects of claw toes with subluxed MTP joints, resulting in metatarsal head prominences on the plantar surfaces of the foot.</a> Clinical manifestations can include all joints of the ankle-foot, collectively or individually. Ankle involvement in rheumatoid arthritis is not as common as involvement of other joints of the foot.<a></a> The clinical picture of ankle involvement is less dramatic than with the other joints, with swelling, stiffness, decreased range of motion, and pain being the indicators. Unlike the ankle, the hindfoot is often affected early in rheumatoid arthritis. The most common deformity of the hindfoot is pes plano-valgus, or more simply, valgus of the hindfoot and flattening of the longitudinal arches.<a></a> The midfoot-tarsal joints develop inflammatory changes that contribute to the pes planovalgus deformity of the hindfoot and midfoot.<a></a> In time, each of the tarsal bones seem to be equally involved, causing loss of pronation-supination and malleability of the foot in general. The forefoot shows marked abnormalities on clinical and radiologic examination. The altered forces created by hindfoot and midfoot deformities act with the inflammatory process, affecting the metatarsal-phalangeal (MTP) joints and proximal interphalangeal (PIP) joints to give the typical findings of hallux valgus, claw toes, subluxation and depression of the metatarsal-phalangeal joints, abduction of the forefoot, and splay foot. Involvement here as in other parts of the foot is symmetric and increases with disease duration.<a></a> Osteoarthritis The next most commonly seen type of arthritis to cause foot problems is osteoarthritis, or degenerative joint disease. This form of arthritis is not a systemic inflammatory disease; rather it is a disease that is secondary to the wear and tear phenomena on joints. Disruption of the cartilagenous matrix occurs as a result of enzymatic action. Large weight-bearing joints of the body are particularly prone to dysfunction. The ankle joint and the first MTP joint seem most susceptible, with weight bearing, trauma, and footwear having all been implicated as causative agents. Radiologic examination reveals asymmetric narrowing of the joint space, the areas of stress demonstrating less interosseous space.<a></a> Other Arthritis Types The arthritis patient population requiring foot orthotic management primarily falls into one of the above two categories of diagnosis. However, occasions will arise necessitating foot and or ankle management for patients with other arthritic diagnoses. The seronegative arthridities are ankylosing spondylitis, Reiter's syndrome and its variants, and psoriatic arthritis. Two additional types of arthritis that may affect the foot and/or ankle are gout and systemic lupus erythematosis. While differing in pathophysiology from rheumatoid arthritis and osteoarthritis enough to warrant separate diagnostic classification, the clinical manifestations of the ankle and foot are similar. <h3>Orthotic Designs and Indications</h3> As in all orthotic management, the scope of the problem dictates the complexity of the orthosis. We have been pleased with the simplicity of the decision making process that has been developed at the University of Virginia. Sophisticated evaluation processes are not necessary; patient communication concerning location of pain and routine physical examination of ankle-foot abnormalities are sufficient. Observation of gait irregularities usually reinforce communication/physical examination findings. Orthotic management conveniently falls into two levels of complexity: foot orthoses (FO's) and ankle-foot orthoses (AFO's). Foot Orthoses The objectives of foot orthoses for arthritic patients include, (1) maintainence and support of existing arches of the foot; (2) re-establishment of fallen arches when flexibility permits; (3) provision of inversion-eversion balance or stability; (4) distribution of weight bearing pressures; and (5) provision of soft tissue supplement. The clinical picture requiring this level of orthotic management can range from mild longitudinal arch depression with callous formation under the metatarsal heads to severe loss of the longitudinal arches, medial drift of the talocalcaneonavicular joint complex, subluxation of MTP joints with depressed and protruding metatarsal heads, hallux valgus, and claw deformities of the phalanges. Traditional foot orthoses for this type of clinical picture have been Plastizote® inserts, molded directly to the patient's foot. However, Plastizote® is not durable; it packs down quickly with wear. The more severe the deformity, the quicker the material loses its integrity and ability to meet the objectives of foot orthoses as described above. Occasionally, arthritic patients have presented or reported being fit with rigid foot orthoses, fabricated of Nyloplex (Rohadur), usually provided by podiatrists. While this material selection and orthotic design are ideal for many cases, we have found it to be highly unsuccessful with arthritic patients to the point that we consider rigid foot orthotics contraindicated for this patient population. Our experience has shown that this type of orthosis lacks the flexibility and soft tissue supplement necessary to promote acceptance by patients with arthritis. The choice of materials and design for arthritic foot orthoses at the University of Virginia has been PVC-Pelite™ foot orthoses, molded over positive models of the patient's foot or feet. <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-3.jpg">Figure 3. View showing left foot impression taken in foam foot impression block. Note "X" identifying metatarsal head prominence.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-4.jpg">Figure 4. Foot impression filled with molding plaster forming a positive model of the patient's foot.</a> Description of Technique Negative impressions of the patient's feet are obtained using any of the commercially available foam impression blocks. This impression is taken with the patient seated, to capture the shape of the existing arches at their maximum height, free of weight-bearing loads. Care should be taken to balance inversion-eversion as the foot is pressed into the foam. Positive models are obtained in the conventional manner by pouring molding plaster into the impression forms. Modification of the positive model is necessary to meet the objectives of foot orthoses for arthritic patients as discussed above. The longitudinal arch is increased mildly, especially posteriorly, as proposed by Carlson, et al., in their technique for modification of the UCB foot orthosis.<a></a> This modification meets the objectives of maintenance and support of existing arches, provision of eversion or valgus stability, and distribution of weight bearing forces. The metatarsal or transverse arch modification is perhaps most important, and the degree of this modification in terms of size and depth parallels the severity of MTP subluxation and metatarsal head depression. It is frequently greater than 1/2" in depth. The shape of this modification should simulate that of prefabricated rubber metatarsal pads, which are commercially available in varying sizes and depths. Proper placement of this modification is critical; when an existing transverse arch can be identified, it should be exaggerated. If there is no identifiable transverse arch, the modification for this arch in the positive model falls under the metatarsal shafts, with the dome or apex of the plaster removal just posterior to the metatarsal heads, and the proximal edges blending gradually into the longitudinal arches. This modification provides support to uplift the depressed metatarsal heads and reduce trauma at the push-off phase of the gait cycle. It also meets the objectives of maintenance and support of existing arches in some cases, re-establishment of fallen arches in other cases, and better distribution of weight-bearing loads. The final modification to the positive model includes adding plaster to the plantar aspect of the PIP joints of the phalanges, which aids in providing a smooth transition from the MTP to the phalangeal area of the foot orthosis. The positive model is now complete and ready for molding of the base material, PVC Pelite™, which is available in 4' square sheets, 1/8" thick. PVC Pelite™ is ideal for foot orthoses because: (1) the PVC laminate (vinyl covering) assists the Pelite™ in maintaining its desired shape after heat molding; (2) the PVC laminate provides strength and durability, decreasing and even eliminating incidences of the Pelite™ packing down, and (3) the PVC laminate consists of closed cells and is waterproof, which makes it easy to clean and discourages the growth of bacteria and fungus. The size of the PVC Pelite™ sheet to be molded over the positive model is determined by closely tracing the positive model onto the PVC Pelite™ and allowing extra material to cover the longitudinal arch and extra material beyond the phalanges. Care should be taken to closely trace the lateral and posterior aspects of the positive model, because excess material here makes molding or vacuum forming more difficult, frequently resulting in bunching or folding of the material and, thus, an unacceptable orthosis. Heating the PVC Pelite™ sheet can take place in an oven, an electric skillet, or with a heat gun. The vinyl covering of PVC Pelite™ should not be subjected to high heat or heated directly since it can delaminate under these conditions and develop bubbles or blisters. When sufficiently pliable and moldable from the heat, the PVC Pelite™ sheet is molded in place over the plantar surface of the positive model using any of the following techniques: <ol> <li> Wrapping the PVC Pelite™ in place around the positive model with an elastic bandage. </li> <li> Vacuum formed in place using a vacuum hose placed inside a small airtight plastic bag. </li> <li> Vacuum formed in place using a commercially available foot orthosis vacuum-forming machine. </li> </ol> <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-5.jpg">Figure 5. Positive models of patient's feet, plantar surface facing up. Note identification of transverse (metatarsal) arch and prominent metatarsal heads.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-6.jpg">Figure 6. Molded PVC-Pelite™ foot orthosis, with longitudinal and metatarsal arch support.</a> Once the PVC Pelite™ is molded in place and cooled sufficiently for the molded shape to be maintained, a sheet of 1/2" thick medium density Pelite™ is cut to fill the transverse and longitudinal arch areas as a single piece. (To save time we have these precut in large numbers to a single large size that can be trimmed to fit a given positive mold.) This piece of 1/2" medium density Pelite™ is heated to a moldable state using oven, skillet, or heat gun, and is then molded or vacuum formed in place as was the PVC Pelite™. When sufficiently cooled, it is glued in place using Polyadhesive and sanded to a feather edge so that it will blend with the PVC Pelite™. Additional modifications to this PVC Pelite™ foot orthosis design may include either of the following: <ol> <li> For increased soft tissue supplement and shock absorption, 1/8" PPT can be glued to the bottom surface of the PVC Pelite™ foot orthosis. </li> <li> For maximum soft tissue supplement in cases of severe metatarsal head protrusion, nylon lined 1/8" PPT may be glued on top of PVC Pelite™ foot orthosis. </li> </ol> Either modification will require greater depth within the patient's shoes. With or without the above modifications, final shaping and fitting are done to the patient and his shoes. An additional point worthy of mention: soft tissue supplement, weight bearing pressure distribution, metatarsal head pain relief, and other plantar surface objectives can be attained with this foot orthosis system regardless of shoe integrity. However, when the objective is control of the inversion-eversion (varus-valgus) balance in the foot, or maintenance, support, or re-establishment of the longitudinal arch, the shoes become an adjunct to the foot orthosis and thus must have a firm heel counter with good integrity along the medial aspect of the longitudinal arch. <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-7.jpg">Figure 7. Rheumatoid arthritis patient wearing right molded, rigid copolymer AFO and left molded, weight-bearing, bivalve, rigid AFO.</a> Ankle Foot Orthoses Although somewhat rare compared to the numbers of patients we have encountered requiring foot orthotic management, there are those arthritics with severe enough involvement to warrant a higher level orthosis. The typical picture requiring AFO management is pain, swelling, and decreased range of motion located in the ankle (talocrural) joint, with frequent moderate to severe pes planus and subtalar (talocalcaneal) erosion. Although rheumatoid arthritis patients dominate this type of patient population, it is not unusual for patients with osteoarthritis to present at this level. Again, severity of involvement dictates the complexity of the orthosis. We have used two types or designs of AFO's in our management of these kinds of problems: rigid, molded plastic AFO's and bivalved, weight bearing, rigid, molded plastic AFO's (also known as PTB AFO's or axial load resist AFO's.) The distinction between the two is quite simple. When pain in the ankle or subtalar joint is due to the forces of walking or movement, i.e. if the normal movements of the ankle-subtalar complex in the course of walking causes or increases pain, yet standing stationary is comfortable and pain-free, the only need is elimination of motion which can be provided by a rigid, molded AFO. When pain is experienced in both standing and ambulation, the goals are to redistribute weight-bearing loads by reducing the amount of weight to be borne through the diseased ankle-foot complex and to eliminate range of motion. These objectives can be met with a bivalved, weight-bearing, rigid, molded AFO. As standard AFO's are commonplace items in any orthotic practice, detailed discussion in this context serves no purpose. However, the need for rigidity should be emphasized. The lower vertical trimlines need to be anterior to the malleoli, and carbon composite inserts can be used if necessary. Our chosen design for bivalved, weight bearing, rigid, molded AFO's is that described by Wilson, Stills, and Pritham<a></a> with the addition of a higher posterior trimline in the popliteal area, similar to that in a below-knee prosthesis. The reduction in the range of knee flexion as a result of this higher posterior trim is a minor sacrifice for a major gain in reduction in pain. We purposely try to avoid the use of the term PTB orthosis because of its erroneous weight-bearing implications. The patella tendon is identified by mild modification of the positive model in this anatomical region, similar to but much less aggressive than in a so called "PTB" prothesis. However, there is little concentrated weight-bearing in this area; the goal of weight-bearing is equal distribution throughout the entire part of the lower leg contained within the orthosis. Perhaps the most accurate prosthetic acronym describing the weight-bearing goals of the bivalved, weight-bearing, rigid, molded AFO, is the "total surface bearing" concept. In the case of an intact lower limb as is encountered in orthotics, modification of the term "to maximum surface bearing" seems appropriate. None of our patients requiring rigid AFO's has required SACH (solid-ankle cushion-heel) and rocker sole shoe modifications. We do recommend the use of shoes with soft soles constructed of Vibram® or crepe. <h3>Shoes for Arthritic Patients</h3> Proper shoes are a vital component of orthotic management of the arthritic foot. As was stated earlier, some foot orthotic objectives can be attained with shoes of poor quality or integrity. However, properly designed and fitted shoes can only enhance the best designed and fabricated foot or ankle-foot orthoses. Our large arthritic patient population at the University of Virginia has allowed us to recommend and fit a wide variety of accommodative shoes. As we gained experience, it became apparent that we could rely on a minimum inventory of shoe types or designs. I refrain from the use of the descriptor "style" because there may be several "styles" available within a shoe design category. The categories of "design" that I refer to could be listed and described as follows: <ol> <li> Thermo adjustable shoes </li> <li> Extra depth shoes </li> <li> Running shoes. </li> </ol> Thermo Adjustable Shoes <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-8.jpg">Figure 8. View of various shoes useful in the management of patients with arthritis affecting the feet and ankles.</a> This shoe type or design is made primarily of Dermaplast®, which is a heat shrinkable Plastizote®. Known as Apex Ambulators®, there are two styles available: #1201, the simplest and most accommodative, and #1273, a more cosmetic version of the first style. Style #1201 is of black Dermaplast™ with a thin outer fabric covering, crepe wedge soles, Velcro® lap closure (eases donning for those arthritics with hand involvement), and removable Plastizote® insole. There is no heel counter reinforcement. The indications for this type of shoe is last resort, severe deformities, especially in the dorsal aspect of the foot, that are difficult or impossible to accommodate in shoes of firmer and less adjustable materials. Examples of such deformities are severe hammer toes, severe hallux valgus, and/or nodules on the dorsum of the feet or toes. This shoe is fitted slightly large and then heated while on the patient's foot (with protection by socks, of course). The application of heat causes the Dermaplast® to shrink and mold to the patient's foot shape, thus accommodating the severe deformity. The shoe upper material of Plastizote® and fabric is very soft and forgiving to such deformities. In all cases, we replace the removable Plastizote® insoles with molded PVC-Pelite™ foot orthoses. The other style of Apex Ambulators® thermo adjustable shoes, #1273, is very similar to that described above. The major difference is the outer covering of the uppers, which in this second style is thin, pliable leather. This shoe is more cosmetically appealing to most patients because the leather uppers allow the choice of four colors, (the catalogue number varies with color variations). It has slightly more integrity than the #1201 style, including a moderately reinforced heel counter. It also has a removable tongue, which is secured in place with Velcro®, a feature that enhances its adjustability. It is available with either lace or Velcro® loop back closure. Accommodation of deformities can be accomplished either by heating and shrinking a loose fit as with the #1201's above or by fitting the shoes to the proper size and then stretching the uppers with shoe stretching tools over areas of deformity. Extra Depth Shoes Extra Depth® shoes are offered by several manufacturers and provide greater depth throughout the entire shoe. This depth is ideal for accommodating molded foot or ankle foot orthoses designed for arthritic foot deformities. Extra depth shoes, like molded AFO's, are a familiar item in any orthotic practice, and therefore do not necessitate detailed discussion. However, there are two important considerations regarding their application to arthritic patients: (1) the shoe style selected should be made of very soft leather, preferably calfskin or deerskin, as these leathers are most easily spot stretched to accommodate deformities, and are the most forgiving to areas of inflammation; (2) adequate width in the forefoot or toebox of the shoe cannot be overemphasized. The extra depth shoes that we recommend for our arthritic patients are manufactured and distributed by Alden Shoe Company and P.W. Minor. The designs and styles vary in leather utilized, closure (lace or Velcro®), and amount of heel counter reinforcement. All have soft crepe soles and uppers that can be modified for deformities with relative ease using shoe stretching tools and equipment. Running Shoes Running or jogging shoes should be familiar to orthotists and patients alike. Their application to patients with arthritic foot problems stem from three of their characteristics: (1) they are acceptable to many patients who do not accept the "lack of style" of other appropriate shoes; (2) most utilize separate, removable insoles, which when removed, allow adequate room for use of molded foot or ankle foot orthoses; and (3) most are very light in weight. Problems we have encountered with running shoes include seams in the dorsal aspect of the toe box, making spot stretching difficult or impossible, and construction of vinyl or other synthetic materials which also make stretching difficult or less successful. <h3>Conclusion and Results</h3> An experience based protocol for orthotic management of the arthritic foot has been described. This experience is based on over 300 arthritic patients who required orthotic management by our service since 1985. Seven patients have been fit with eight bivalve, weight-bearing rigid, molded AFO's (one bilateral). One of these seven patients benefitted from a rigid, molded AFO on his lesser involved lower extremity. The remaining patients have been managed with custom molded PVC Pelite™ foot orthoses. Many of the patients fit with PVC Pelite™ foot orthoses were successfully converted from direct molded Plastizote® shoe inserts. Through routine follow up and chart reviews, we have found less than a three percent rejection rate; more important, we have found more active patients who enjoy a better quality of life. <h3>Appendix</h3> Alden Shoe Company, Taunton Street, P.O. Box 617, Middleborough, Massachusetts 02346. Apex Ambulators, Apex Foot Products, 330 Phillips Avenue, S. Hackensack, New Jersey 07606. PPT, The Langer Biomechanics Group, 21 East Industry Court, Deer Park, New York 11729. PVC Pelite™, Durr-Fillauer Medical, Inc., Orthopedic Division, P.O. Box 5189, Chattanooga, Tennessee 37406. P.W. Minor Extra Depth Shoe Co., 3 Treadeasy Avenue, Batavia, New York 14020. References: <ol> <li>Carlson, J. Martin, and Gene Berglund, "An Effective Orthotic Design for Controlling the Unstable Subtalar Joint," Orthotics and Prosthetics, 33:1, March, 1979, pp. 39-49.</li> <li>Guerra, J. and D. Resnick, "Arthridities Affecting the Foot and Ankle-Pathology and Treatment. The Relationship Between Foot and Ankle Deformity and Disease Duration in Fifty Patients," Foot and Ankle, 2:6, 1982, pp. 325-331.</li> <li>Portwood, Margaret M., "The Foot and Ankle in Rheumatic Disorders," Principles of Physical Medicine and Rehabilitation in the Musculoskeletal Diseases, Grune and Stratton, 1986, Chapter 19, pp. 489-513.</li> <li>Short, C.L., W. Bauer, W.E. Reynolds, In Rheumatic Arthritis, Harvard University Press, Cambridge, 1957, pp. 194-195.</li> <li>Tillman, K., The Rheumatic Foot: Diagnosis, Pathomechanics, and Treatment, Stuttgart, Georg Thieme Publishers, Boston, PSG Publishing Co., 1979, pp. 3-61.</li> <li>Vaino, K., "The Rheumatoid Foot: A Clinical Study With Pathologic and Roentgenological Comments," Ann. Chir. Gynaecol. 45 (Suppl), 1956, pp. 1-107.</li> <li>Wilson, A. Bennett, Jr., David Condie, Charles Pritham, and Melvin Stills, Lower-Limb Orthotics, A Manual, First Edition, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Temple University, Drexel University.</li> </ol> *C. Michael Schuch, C.P.O. C. Michael Schuch, C.P.O., is an Assistant Professor in Orthopaedics and Rehabilitation and Associate Director of Prosthetics, Orthotics, and Rehabilitation Engineering Services at the University of Virginia Medical Center, Box 467, Charlottesville, Virginia 22908. Page Number(s) 51 - 60 Year 1988 Volume 12 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-7.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-8.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Orthotic Management of the Arthritic Foot Creator An entity primarily responsible for making the resource C. Michael Schuch, C.P.O. * https://staging.drfop.org/files/original/d926666429d9f2cdaf83ae21fe646c4f.pdf fc83de5564adb8c10840e56fc70c62ee https://staging.drfop.org/files/original/3b5e2b430dabd8baf145e6318ad9a8ac.jpg 01ae62dacd8de2696172979a524bc346 https://staging.drfop.org/files/original/c3618fa7bba7b72cca5c7f35c50ccebf.jpg 6ffb262220815834326298815ce4703a https://staging.drfop.org/files/original/6e60ab4bfaa6a84d3cd16563dd3a1b00.jpg b7d55619ad69dca45bb140cb75b7ff3d https://staging.drfop.org/files/original/6cef018bad60db66a6ccacad7eaa8947.jpg 5567ec543d1d62d47c68c307b1277865 https://staging.drfop.org/files/original/720bdb4a059cfeabf344aa1141a372ae.jpg 6858cb4c2244e6b253e500666c4e1865 https://staging.drfop.org/files/original/92e2ffc11c03bf7e45ccd8ceb1d94c1a.jpg 9c8423654d6cb14560a481688f433867 https://staging.drfop.org/files/original/7ccbc9292d966c3628e96d4de8252295.jpg 829221dd8b8b0904dfb59d0079def2c8 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_02_061.pdf Text Any textual data included in the document <h2>The Susceptible Insensate Foot</h2> <h5>Mitchell E. Kalter, M.D. <a style="text-decoration: none;">*</a> Richard L. Jacobs, M.D. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> Patients with limbs which are both insensate and functionless often are best treated with amputation to improve hygiene, functional potential with prosthetics, and often cosmesis. There exists, however, a large population of patients whose lower extremities are insensate, but remain functional. Because of continued functional demands, and the loss of important protective mechanisms, breakdown of the delicate articulations occurs resulting in neuropathic arthropathy. While there are a multiplicity of disease states associated with neuropathic arthropathy, there are certain general principles and characteristics inherent in the final common pathway of the Charcot joint. In years past, neuro-syphillis was the major cause. Nowadays, diabetes mellitus is by far the most common cause. This article will explore some of the historical aspects, causes, pathophysiology, clinical manifestations, and principles of treatment as they relate to neuropathic arthropathy of the susceptible insensate foot. <h3>Historical Aspects</h3> Jean Martin Charcot, at La Salpetriere in 1868, first called attention to "ataxic" forms of arthropathy associated with neurological diseases, the most commonly recognized cause being tabes dorsalis.<a></a> Charcot attributed the acute and destructive arthropathy to the loss of certain "neurotrophic influences" ncessary to support the normal joints.<a></a> Charcot's contemporaries, Volkmann and Virchow, disagreed with this "trophic," or what was known as the "French" theory.<a></a> They argued that the arthropathy was due to continued mechanical stress and trauma on an insensitive biological structure.<a></a> These stresses continued in the absence of normal protective reflexes, which inevitably lead to a cycle of injury, inflammation, further injury, and finally instability and joint destruction. The end result, now the "Charcot joint." This basic process was gradually recognized in an ever broadening horizon of disease entities. Myelitis and syringomyelia were recognized as causes in 1875 and 1892 respectively.<a></a> It was not until 1936 that Jordan described neuropathic arthropathy in the diabetic,<a></a> now the most common cause of Charcot joints.<a></a> <h3>Etiologic Factors</h3> The myriad of conditions which can produce Charcot joints is well outlined elsewhere.<a></a> The three most common causes are diabetes mellitus, tabes dorsalis, and syringomyelia.<a></a> The prevalence of neuropathic arthropathy in diabetes is only 0.1% to 0.5%, as compared to tabes dorsalis and syringomyelia which are 5% to 10% and 25%, respectively.<a></a> The almost epidemic numbers of diabetics makes them the largest group seen clinically, however. Various theories have been espoused, such as Charcot's "neurotrophic" theory, Volk-mann's "mechanistic" theory, and "neurovascular" theories.<a></a> Each stresses some aspect of the observations made in the neuropathic ar- thropathy process. Certainly, "trophic" nerves have never been proven.<a></a> Mechanical trauma most certainly has a major role in the process, as is noted by many authors.<a></a> The basic concept of the mechanical theory is the blunting or eliminating of pain and proprioceptive information received from the involved body part. This dampens the afferent input for both conscious and nociflexive response patterns which have evolved to protect the extremity from intolerable mechanical stresses, and thus avoid injury.<a></a> The loss of proprioceptive and fine sensory input leads to ataxic gait patterns which further increase mechanical stresses. The spectrum of sensory deficit can be from an apparently normal sensory examination, to complete anesthesia.<a></a> Patients can experience pain, but it is invariably much less than expected for the degree of trauma and distortion of bone and soft tissues.<a></a> When pain does occur, it is usually secondary to severe posttraumatic inflammation of richly innervated synovial and pericapsular structures.<a></a> Joint proprioception, which normally inhibits hypermo-bility, is diminished, or absent, allowing instability to develop and progress.<a></a> Attempts to explain the rapidity of the process and bony reabsorption, seen especially in the diabetic patient,<a></a> have been made with the "neurovascular" theory.<a></a> This theory states that an abnormal "neurovascular reflex"<a></a> increases blood flow, resulting in bony washout, and hyperemic distensible soft tissue supports, all of which predispose the joint to a destructive process with normal stresses. The high incidence of objective autonomic dysfunction in diabetics lends some support to this theory.<a></a> As stated by Hurzwurm and Barja,<a></a> ". . . a more plausible explanation is that all of the above theories play a role . . . ," but to different degrees in each patient. Simply, relatively minor fractures in an otherwise normal foot or ankle can lead to rapid Charcot arthropathy if neuropathy is present.<a></a> One can think about the insensate foot like the insensate mouth after our friendly dentist mercifully relieves pain. If we insist on eating before the anesthetic wears off, despite his instructions, we can induce a "Charcot mouth." We will have pain for our indiscretion within several hours. The patient with neuropathy will continue to "chew away," oblivious of the damage he creates. <h3>Clinical Features</h3> The foot is the most commonly affected part of the appendicular skeleton.<a></a> However, it should be noted that different distributions of skeletal involvement can be seen, such as primarily upper extremity involvement with syringomyelia. The spine, knee, and hip may also be involved.<a></a> Why one joint in an insensate extremity is involved, while other joints remain normal, has remained unanswered.<a></a> Patients commonly present with the chief complaint of swelling, deformity, or mal perforant ulcers.<a></a> Pain may or may not be present, but is usually dependent upon presence of acute inflammation.<a></a> As described by Charcot and Volkmann,<a></a> the process of joint disruption begins with a period of swelling, erythema, local hyperemia, and effusion. This acute phase presentation is a manifestation of a normal acute inflammatory response to injury. If the injury is not perceived, the already edematous and hyperemic tissues receive continued trauma, recurrent inflammation, and poor, inadequate healing occurs. This eventually, if unchecked, leads to progressive soft tissue and bony deformity,<a></a> more characteristic of the chronic phase. An important distinction must be made between acute inflammation and infection, as both can present with the same local findings of swelling, erythema, and increased skin temperature. In the Charcot joint, however, laboratory studies, such as the white blood and differential counts and sedimentation rate, are normal; and importantly, there are no systemic manifestations such as fever or signs of sepsis.<a></a> Usual deformities include increasing flat foot to complete arch collapse, ankle and hindfoot valgus (or varus), and forefoot external rotation and eversion.<a></a> Mal perforans ulcers are formed intradermally, under heavy callous, caused by abnormal weight bearing.<a></a> A 50% association of diabetic mal perforans with neuroarthropathy has been described,<a></a> usually occurring at the metatarsophylangeal joint level. Patterns of joint involvement have been described in the diabetic. Primary ankle and subtalar joint patterns are frequent, with mid-tarsal joints most frequently involved.<a></a> Tarsometatarsal and metatarsophalangeal involvement have each been described in up to 30% of cases<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-1.jpg">Fig. 1A</a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-2.jpg">Fig. 1B</a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-3.jpg">Fig.1C</a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-4.jpg">Fig. 1D (1)</a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-5.jpg">Fig. 1D (2)</a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-6.jpg">Fig. 1E</a>, and <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-7.jpg">Fig. 2</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-1.jpg">Figure 1A. Initial evaluation of a 54 year old female diabetic. Normal AP, lateral, and oblique views of the left foot.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-2.jpg">Figure 1B. At age 59 years, the lateral view is still normal.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-3.jpg">Figure 1C. Only ten months later, lateral view of same foot shows advanced Charcot changes of the ankle, subtalar, and metatarsalphylangeal joints.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-4.jpg">Figure 1D. AP view.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-5.jpg">Figure 1D. Oblique view.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-6.jpg">Figure 1E. AP and mortise views of the ankle at the same time as 1C and ID.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-7.jpg">Figure 2. The right foot of same patient in Figure 1. Lateral, oblique, and AP views show mid-tarsal, tarsal-metatarsal, as well as interphylan-geal Charcot joint changes—a different pattern of joint involvement in the same patient. Elements of bone fragmentation, joint subluxation and dislocation and bone formation are represented.</a> Radiological characteristics of neuropathic arthropathy progress from debris at the articular margins and periarticular calcifications, to diffuse bony fragmentation which can coalesce to larger fragments and large osteophytes.<a></a> Later changes include bony marginal sclerosis in attempts to reform articulations<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-7.jpg">Fig. 2</a>). Pathologic examination reveals bone and cartilage fragments in the synovial tissues, and fibroblastic reaction with some round cell infiltrates in ligamentous and capsular soft tissues.<a></a> Circulatory status may be good in the Charcot foot,<a></a> but it is crucial to establish the diagnosis of vascular compromise on first evaluation as this can drastically affect treatment and outcome, especially in the diabetic.<a></a> Neuropathic arthropathy can be the presenting problem with previously undiagnosed diabetics.<a></a> Complicating factors in the clinical course are spontaneous fractures, which can hasten the degenerative process; deformity, which can be quite rapid in syringomyelia, tabes dorsalis, and with varus deformities; and soft tissue injury, predominantly neurotrophic plantar ulcers.<a></a> <h3>Treatment</h3> Treatment follows from the recognition that the extremity is injured; and is likely to have continued trauma because of the neuropathy. Early recognition should allow curtailment of the progression, but because of the 'nature of the beast', there is often significant arthropathy at presentation. Control of neuropathy, if this is possible, should be a primary consideration. This should be followed by attention to soft tissue injuries, or skin ulcerations which may require local debridement.<a></a> Evaluation of circulation is also part of the initial evaluation,<a></a> with necessary vascular intervention performed if this is a concomitant problem. Cast immobilization to decrease edema, allow bony and soft tissue healing, and avoid or correct deformity, has been advocated by many authors.<a></a> Prolonged immobilization is essential to allow healing and stabilization.<a></a> Casting should continue until the local temperature has returned to that of the uninvolved or inactive side. It can then be assumed that the acute repair process has abated, and progression to supportive and protective orthoses is possible.<a></a> Because of the potential for rapid progression, periodic x-rays must be obtained to assess progression which may alter therapy<a></a> (Compare <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-2.jpg">Fig. 1B</a> and <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-3.jpg">Fig.1C</a>). The indications for orthopaedic surgical intervention include unacceptable deformity, making shoeing difficult; bony prominences, causing ulceration; concomitant infection, requiring debridement and drainage; and deformities with a high likelihood of progression (i.e. varus).<a></a> "Bumpectomies," decompressive fusions of digits, Keller bunionectomies, and subtalar or ankle debridements and fusions are some of the more commonly indicated procedures.<a></a> Total joint arthroplasty has no place in the neuropathic patient as it will inevitably be disrupted by the same process that destroyed the natural joint.<a></a> <h3>Conclusions</h3> The major problem of the insensate foot is its susceptibility. Ataxia, secondary to neuropathy, imparts abnormal stresses and trauma to an extremity no longer able to detect injury. The neuropathy is usually irreversible, so defensive measures must be taken to control the process of joint destruction. Well fit ankle and foot orthoses to support unstable joints and redistribute weight bearing forces more evenly are the next line of defense once cast immobilization has controlled the injury reaction and allowed healing. Surgery is useful to correct unacceptable or unstable deformities and relieve skin pressures. By understanding the patient's perceptions, and the pathophysiology of the Charcot foot, we can provide treatment to prolong the functional life and avoid the complications of the insensate foot. References: <ol> <li>Curtiss, P.H., "Neurologic Diseases of the Foot," Foot Disorders: Medical and Surgical Management, Editor N.J. Giannestras, Lea & Febiger, Philadelphia, 1973, pp. 500-503.</li> <li>Delano, P.J., "The Pathogenesis of Charcot's Joint," American Journal of Radiology, 2:56, August, 1946, pp. 189-200.</li> <li>Donovan, J.C. and J.L. Rowbotham, "Foot Lesions in Diabetic Patients: Cause, Prevention, and Treatment," Joslins's Diabetes Mellitus, 12th Edition, Editors A. Marble, et al., Lea & Febiger, Philadelphia, 1985, pp. 732-736.</li> <li>Herzwurm, P.J. and R.H. Barja, "Charcot Joints of the Foot," Contemporary Orthopaedics, 3:14, March, 1987, pp. 17-22.</li> <li>Jacobs, R.L., "Neuropathic Foot in the Diabetic Patient," Foot Science, Editor M.E. Bateman, W.B. Saunders Co., 1976, pp. 235-253.</li> <li>Jacobs, R.L. and A.M. Karmody, "The Charcot Foot," The Foot, Editor M. Jahss, W.B. Saunders Co., 1982, pp. 1248-1265.</li> <li>Kristiansen, B., "Ankle and Foot Fractures in Diabetics Provoking Neuropathic Joint Changes," Acta Orthopaedics Scandanavia, 51, 1980, pp. 975-979.</li> <li>Locke, S. and D. Tarsy, "The Nervous System and Diabetes," Joslin's Diabetes Mellitus, 12th Edition, Editors A. Marble, et al., Lea & Febiger, Philadelphia, 1985, pp. 665-685.</li> <li>Mooney, V. and W. Wagoner, "Neurocirculatory Disorders of the Foot," Clinical Orthopaedics, 122, January-February, 1977, pp. 53-61.</li> <li>Podolsky, S. and A. Marble, "Diverse Abnormalities Associated with Diabetes," Joslin's Diabetes Mellitus, 12th Edition, Editors A. Marble, et al., Lea & Febiger, Philadelphia, 1985, pp. 843-866.</li> <li>Salter, R.B., "Degenerative Disorders of Joints and Related Structures," Textbook of Disorders and Injuries of the Musculoskeletal System, Williams & Wilkins Co., Baltimore, 1970, pp. 219-220.</li> </ol> *Richard L. Jacobs, M.D. Division of Orthopedic Surgery at Albany Medical College, Albany, New York *Mitchell E. Kalter, M.D. Division of Orthopedic Surgery at Albany Medical College, Albany, New York Page Number(s) 61 - 66 Year 1988 Volume 12 Issue 2 Figure 1 FIG 1A http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-1.jpg FIG1B http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-2.jpg FIG 1C http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-3.jpg FIG 1D-1 http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-4.jpg FIG 1D-2 http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-5.jpg FIG 1E http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-6.jpg Figure 2 FIG 2 http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-7.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Susceptible Insensate Foot Creator An entity primarily responsible for making the resource Mitchell E. Kalter, M.D. * Richard L. Jacobs, M.D. * https://staging.drfop.org/files/original/0833619f5e725925cd800c92714e217a.pdf f8cc7a22aa74728474f8dd18a422e13a https://staging.drfop.org/files/original/93b6e8e78d28f3a4b19219d5d0780629.jpg 04cc15ee28e53828d5d326dd88090b20 https://staging.drfop.org/files/original/345e28e78e61de9956f328db53407a53.jpg cc7d3094bd8e533f530e57c763d89156 https://staging.drfop.org/files/original/912b1afa69cacdf58a67897a83dcb315.jpg 7d3276d165a85f49bcaa170b6d63d8c2 https://staging.drfop.org/files/original/a336421d18e76b67aa3f15362a01a722.jpg 5424cf6316a027878c7cc16d28562dcd https://staging.drfop.org/files/original/ed019ac44a487f5a4d063bc3257f6613.jpg e0c695cdd2bdf121fba9bca5e8ec4b72 https://staging.drfop.org/files/original/6f79e7026b83de4890fedbf81936bf61.jpg 8829aadb1e7bf6c1a2f5b7ef81380d25 https://staging.drfop.org/files/original/f12ba0f6a5db975123a05a0ecc61bf8c.jpg d49c7e19a6ae87c07570043983a8154b https://staging.drfop.org/files/original/8111a6f2f5c9866102adc00d9369ba3a.jpg b550bebd56a8d3d8b5c4622eb2bfb636 https://staging.drfop.org/files/original/6f66c873f335c178a868bb081b408a99.jpg fee6486ffc1b68ab2e75eb9e394bfca2 https://staging.drfop.org/files/original/1e33291187b5f81e97bd34ef54e5ea18.jpg 0b0317c0877ceedfc4841a2f6b45464d https://staging.drfop.org/files/original/6d31a1a5146ef36443a7083f8fe0dce2.jpg 0e19dfad8f02ba4aba2378536fcc1854 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_02_067.pdf Text Any textual data included in the document <h2>Soft Molded Sandals for Insensitive Foot Care</h2> <h5>William C. Coleman, D.P.M. <a style="text-decoration: none;">*</a> Arthur Plaia, M.A. <a style="text-decoration: none;">*</a></h5> In the United States, the most common cause of sensory loss on the foot is diabetes. Fifty to seventy percent of all non-traumatic amputations in this country are performed on diabetics.<a></a> In Atlanta, Georgia, the amputation rate was lower by half after a program of foot inspection, footcare, and shoe-fitting was instituted. A person with loss of sense of touch and pain in the feet should never walk barefoot. A single step on a sharp object or hot surface with bare feet often results in permanent loss of foot function or eventual amputation of the foot. A comprehensive program of medically-prescribed, therapeutic footware should address the patient's need for appropriate shoes at all times. Once the need for prescribed footwear has been identified, there is a period between the time the prescription is written and time when the definitive shoes are dispensed to the patient. During that period, the feet still need protection. A form of protective, temporary footwear, needs to be worn by the patient until those shoes are ready. There are a wide variety of devices used for this purpose around the country. The form of these devices is largely dependent on the available facilities and footwear expertise. A person with a plantar ulcer on an insensitive foot should never walk in shoes or sandals. The most important therapeutic consideration for a person with no sense of pain is to control the mechanical stresses during the healing of these wounds.<a></a> Shoes and sandals do not provide enough control over these forces. After a wound has been covered completely by skin, the healing and repair of the injury is not complete. A person with sensory loss needs very careful monitoring during this period immediately after closure, because they are at very high risk of reulcerating the area.<a></a> Temporary footwear, which provides a high level of protection, should be worn during this time. Usually, unmodified Plastazote®<a style="text-decoration: none;">*</a> shoes or postoperative wooden soled shoes are used as the temporary protection. Once they have served this temporary function, the shoes are discarded and only the definitive shoes are worn from then on. There are many other times, however, when protection of the insensitive foot is needed and custom molded footwear would be the best form of protection. Other times when protective footwear is needed are listed here. <ol> <li> Many people do not want to wear their street shoes around the house until bedtime. Since a person with insensitive feet should never walk barefoot, protective footwear, for use in the house, should be worn. Most commercial house slippers have thin soles which are not intended for walking on rough surfaces and do not provide any significant protection from sharp objects on the floor. </li> <li> Plantar foot deformity is often present when prescribed footwear is a necessity. With bony prominences or loss of plantar fat-pads, a person should never walk or stand barefoot on hard surfaces. This is a problem, particularly when this person showers and they stand on porcelain, concrete, or tile. </li> <li> A person who needs prescribed footwear should always have at least two pairs. Most people, who need them, do not. This is important during periods of time when these shoes are being repaired or the prescription is changed. </li> </ol> Plastazote® was first used for orthopedic purposes by William Tuck, in England, in 1967.<a></a> He notified Dr. Paul Brand in Carville, Louisiana and the first Plastazote® sandals were constructed soon after. Plastazote® provided a material which was easily molded directly on the foot so protective, interim footware could be quickly constructed. Prior to the introduction of Plastazote®, sandals at Carville were constructed of 5/8" thick microcellular rubber. Microcellular rubber is not a moldable material and foot conformity had to be accommodated by constructing microcellular pads and wedges.<a></a> This was imprecise and time consuming. Over the years, several people have contributed modifications to the design and construction techniques of the "Carville" sandal.<a></a> It has become an integral part of the total foot program. <h3>Materials and Equipment Used to Construct the Sandal</h3> The following is a list of the materials used to build the sandal. Materials for the Plastazote® Foot Bed <ul> <li> 2 pieces of 1/2" x 6" X 12" Plastazote® #1 (medium)<a style="text-decoration: none;">*</a> </li> <li> 2 pieces of 1/2" x 6" x 12" Plastazote® #2 (firm)<a style="text-decoration: none;">*</a> </li> <li> 2 pieces of 1/4" x 5" x 12" Plastazote® #3 (rigid)<a style="text-decoration: none;">*</a> </li> <li> 2 pieces of Plastazote® #2, 5" x 10" X 1/2" thick to provide heel lift </li> <li> 2 pieces of 1/4" x 3" x 33" Plastazote® #3 for wrapping the sides of the sandals </li> </ul> Additional Materials <ul> <li> Neoprene crepe soling (12 iron = 1/4") (24 iron = 1/2") (1" x 9") Spring steel cut to the full length of the sandal's length. </li> </ul> Webbing for Straps <ul> <li> 2 pieces of cotton webbing 1" x 9" </li> <li> 2 pieces of cotton webbing 1" X 8 1/2" </li> <li> 2 pieces of cotton webbing 1 1/2" x 9" </li> <li> 2 pieces of cotton webbing 1 1/2" x 8 1/2" </li> <li> 2 pieces of cotton webbing 1" x 12" </li> </ul> Velcro® to be sewn to webbing <ul> <li> 2 pieces of 1" x 2 1/2" Velcro® hook </li> <li> 2 pieces of 1 1/2" x 2 1/2" Velcro® hook </li> <li> 2 pieces of 1" x 2 1/2" Velcro® pile </li> <li> 2 pieces of 1 1/2" x 2 1/2" Velcro® pile </li> </ul> Glue <ul> <li> Contact Cement or other adhesive </li> </ul> <h3>Tools</h3> <ul> <li> Skiving knife </li> <li> Ruler </li> <li> Scissors </li> <li> Polyfoam block (size 8" high x 12" wide x 18" long) cut at approximately 45° from the top to the base at the front of the block. </li> </ul> <h3>Equipment</h3> <ul> <li> Sewing machine or Patcher machine </li> <li> Finishing sander or grinding wheel </li> <li> Oven </li> </ul> <h3>Pieces of the Sandal Prepared in Advance</h3> Most of the materials used in the construction of a sandal are pre-cut and pre-sewn in the shop to speed the construction process. All pieces of Plastazote® are cut from large sheets into the rectangular sizes listed above. The cotton webbing and Velcro® are purchased on large rolls and cut to the sizes above in advance. A 1 1/2" x 2 1/2" patch of hook Velcro® is sewn to one end of a 1 1/2" x 9" piece of webbing. Approximately 1/2" of cotton webbing is left exposed on the very end so the end can be grasped by the patient to release the strap. A 1 1/2" x 2 1/2" piece of pile Velcro® is sewn to the end of a 1 1/2" x 8 1/2" piece of webbing. This procedure is repeated on the 1" x 8 1/2" and 1" x 9" pieces of cotton webbing. The oven should be preheated to a temperature of 140° Celsius (285° Fahrenheit). This is the temperature at which all polyethylene materials should be heated. Plastazote® is a closed-cell polyethylene foam material. If polyethylene foam materials are overheated, the cell structure is weakened and the material shrinks in all directions. To determine the amount of time a polyethylene foam should be heated, measure the thickness of the material in millimeters and multiply the thickness by twelve (10 mm x 12 = 120 seconds). The answer will be the time of heating in seconds. To mold the Plastazote® directly on the foot, the heated Plastazote® is placed between the foot and a thick foam rubber block. The foot is pressed into the foam and Plastazote®. The foam presses the polyethylene foam up around the sides of the foot and into every plantar hollow and the material cools and remains in this shape. The top/front of the foam a block is cut at a 45° angle to prevent obtaining a deep mold of the toes (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-01.jpg">Fig. 1)</a>. A deep mold would create a ridge distal to the ends of the toes. During gait, the medial foot enlongates with pronation. This elongation could result in distal toe damage on an insensitive foot if this ridge were present. <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-01.jpg">Figure 1. The open-celled foam block used to mold the Plastazote® footbed is cut on the top/ front to prevent deep-molding the toes into the Plastazote®.</a> <h3>Construction of the Sandal</h3> Patients are seated in an adjustable chair to insure the knee and ankle can be maintained at right angles as the Plastazote® is molded to their foot. Patients with insensitive feet are asked to wear socks for heat insulation from the warm polyethylene foam. To begin the sandal, a piece of 6" x 12" x 1/2" thick, medium, Plastazote® #1 is heated according to the above formula. After the Plastazote® has been heated, it is placed on the foam block with the toe region hanging over the 45° cut of the foam block. The foot is aligned over the Plastazote® with the metatarsal heads positioned over the top edge of the cutoff section of the foam block. The patient's foot is then pressed into the Plastazote®. After the Plastazote® foot bed has cooled, but before the patient is asked to lift their foot, an outline is drawn to mark a reference for what will become the outer sides of the sandal (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-02.jpg">Fig. 2</a>). Hold the pen marking this line in a vertical position. Purposely draw the toe area distal to the foot further distal to the toes than needed. Mark the toe of the sandal about 1" distal than the toes of the foot. Material used to wrap the sides of the sandal will pull the distal end of the sandal back. <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-02.jpg">Figure 2. As the first Plastazote® layer is cooling, a line is drawn to mark the outer edge of the sandal.</a> Cut the molded piece of Plastazote® around the outside of the molded portion to remove excess material. Make this cut approximately 1/2" outside the drawn line. This will allow for better control of shaping the sandal during a later grinding process. Apply adhesive to the bottom (convex side) of the molded material and to one side of a 6" x 12" x 1/2" firm, #2 Plastazote® piece. Then heat the #2 Plastazote®. Set the heated #2 piece on the foam block and the molded #1 Plastazote® piece on top of it (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-03.jpg">Fig. 3</a>). Place the foot back into the molded #1 piece and then press down to mold the #2 Plastazote® piece to the bottom of the #1 piece. Plastazote® #1 and #2 are autoadhesive, but this characteristic of the material has not proven to form a dependable bond in these sandals. <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-03.jpg">Figure 3. The molded #1 Plastazote® is set on the glued surface of the heated #2 prior to molding the two together.</a> Then cut the #2 piece to the edge of the # 1 piece and ground both pieces vertically to meet the line drawn earlier. At this time, ground flat some of the roundness on the plantar surface of the molded #2 piece and flatten by grinding the area under the metatarsal heads and toes. Use the 1 1/2" wide webbing to build the strap which will cross over the midfoot region just in front of the ankle. Use the 1" webbing for the strap which will cross over the top of the metatarsals just proximal to the metatarsal heads. Also use 1" strapping behind the heel. Place the patient's foot in the foot bed and "velcro" the straps together and hold them in place over the foot. Align the straps over the foot and mark the Plastazote® and straps (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-04.jpg">Fig. 4</a>). Glue together the Plastazote® footbed and straps, using the marks as a reference. Cut the straps under the sandal so they don't overlap (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-05.jpg">Fig. 5</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-04.jpg">Figure 4. The cotton-webbing straps are held in place while the sandal and straps are marked for later gluing.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-05.jpg">Figure 5. The straps are cut so they do not overlap under the footbed.</a> Coat with glue the 5" x 10" x 1/2" scrap piece of #2 Plastazote® and the bottom of the molded footbed and heat the #2 piece. Glue the #2 piece under the heel arch and metatarsal heads. Ground down the bottom to form a 1/2" high wedge heel which tapers down to the metatarsal heads (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-06.jpg">Fig. 6</a>). This heel lift also serves to fill any remaining arch and curvature under the sides of the molded footbed. <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-06.jpg">Figure 6. The bottom of the sandal is ground flat under heel, arch, and metatarsal heads after the heel wedge is glued on. The area under the toe is ground up to form the rocker.</a> The sole of these sandals should be absolutely rigid. On smaller patients the rigid Plastazote®, which will be added later, will be sufficient to accomplish this. But in larger, heavier patients, it may be necessary to include a rigid steel shank from the heel to the toe. For those patients, glue a piece of leather to the bottom of the footbed to prevent penetration of the steel through the footbed. Bend up the steel from the metatarsal heads to the end of the toe of the sandal in the form of a rocker. Glue the steel shank to the bottom of the leather, and shape and grind flat a filler material around the shank so bumps will not form in the outer sole of the sandal. If the steel shank is not used, coat with glue a piece of 5" x 12" x 1/4" rigid #3 Plastazote® and the bottom of the footbed. Heat the #3 piece and then attach it to the bottom of the footbed. This is done by adhering the heel of the sandal to the #3 piece first and then, in a rolling motion, elevate the heel of the sandal as the toe is pressed down onto the material piece<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-07.jpg"> (Fig. 7</a>). This creates a rocker sole with increased toe spring under the toes. <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-07.jpg">Figure 7. The heel of the sandal is lifted before the front of the heated #3 Plastazote® is glued to the footbed to help form the rocker sole.</a> Skive back one end of a piece of rigid Plastazote® 3" wide by 33" long and 1/4" thick to a distance of 2" and at a shallow angle. Then apply glue over the 2" skived portion and the entire other side of the rigid Plastazote® piece. Coat the sides of the footbed with glue. Heat the rigid Plastazote® and glue it vertically around the perimeter of the sandal (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-08.jpg">Fig. 8</a>). Glue the skived end to the medial arch area of the footbed first. This leaves the glue coated skived area facing out from the sandal. Completely wrap the #3 strip around it, overlapping onto the skived area, and cut off the excess. Trim the bottom flat and round the upper edge level with the top of the footbed by grinding. Then glue neoprene crepe soling to the bottom. <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-08.jpg">Figure 8. The sandal is made more rigid by gluing 1/4" #3 Plastazote® vertically around the footbed.</a> Place the patient's foot into the sandal to fit a heel strap. The strap is 1" cotton webbing. Mark the location of the strap. Remove the sandal and sew the strap into place (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-09.jpg">Fig. 9</a>). Rivets can also be used to attach the strap. <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-09.jpg">Figure 9. The completed sandal with neoprene crepe soling and heel strap attached.</a> For shortened feet, use only a single vertical, instep strap of 1 1/2" to 2" width and attach the heel strap to this single strap (<a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-10.jpg">Fig. 10</a>). For more long-term use, construct the straps and sides of leather (Fig. 11). If the patient's skin is thin and atrophied, softer materials such as beta-pile can be used as straps. <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-10.jpg">Figure 10. For shortened feet a single, broad strap can be used across the instep.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-11.jpg">Figure 11. Leather can be used for sandals intended for long-term or outdoor wear.</a> <h3>Considerations for Insensitive Feet</h3> In a series of 41 diabetic patients with sensory neuropathy in their feet, when measured with pedobarograph, 51% had abnormally high pressure under their metatarsal heads.<a></a> This is compared to only 7% of non-diabetic patients displaying higher pressures. The skin under the metatarsal heads has been shown in many studies to be the most frequently ulcerated part of the insensitive foot.<a></a> The forefoot region of insensitive feet needs a higher level of protection than the rest of the foot. This can be accomplished in the Plastazote® sandal by making the sole rigid and creating a rocker effect in the sole design.<a></a> A rigid sole minimizes shear between the sandal and skin. It also eliminates flexion and extension at the metatarsal-phalangeal joints.<a></a> If the toes of the foot are rigid, a flexible soled shoe will press up into the toes during gait. Rocker soles have been shown to greatly reduce foot pressure during gait. The point on the sole where rocking begins should always be posterior to the metatarsal heads, but ideally would be placed near the middle of the sandal. These rocker styles of sole are also helpful in the rehabilitation of patients with fused ankles.<a></a> <h3>Conclusion</h3> For 20 years at the Gillis W. Long Hansen's Disease Center in Carville, Louisiana, Plastazote® sandals have proven to be an effective form of interim footwear for insensitive patients. The technique is simple and highly adaptable to many types of foot therapy. References: <ol> <li>"A Report of the National Diabetes Advisory Board," NIH Publication No. 81-2284, Bethesda, Maryland, November, 1980. p. 25.</li> <li>Boulton, A.J.M., M.D., C.A. Hardisty, M.D., R.P. Betts, Ph.D., C.I. Franks, Ph.D., R.C. Worth, MD., J.D. Ward, M.D., and T. Duckworth, M.D., "Dynamic Foot Pressure and Other Studies as Diagnostic and Management Aids in Diabetic Neuropathy," Diabetes Care, 6, June, 1983, pp. 26-33.</li> <li>Duckworth, T., M.D., A.J. Boulton, M.D., R.P. Betts, Ph.D.. C.I. Franks, M.D. and J.E. Ward, M.D., "Plantar Pressure Measurements and the Prevention of Ucleration; in the Diabetic Foot," The Journal of Bone and Joint Surgery, 67, January, 1985, pp. 79-85.</li> <li>Karat, S., M.D., "The Role of Microcellular Rubber in the Preservation of Anaesthetic Feet in Leprosy," Leprosy Review, 40, July, 1969, pp. 165-170.</li> <li>Milgram, JE., M.D., "Office Measures for Relief of the Painful Foot," Journal of Bone and Joint Surgery, 46, July, 1964, pp. 1095-1116.</li> <li>Pati, L., M.D. and F. Behera, M.D., "Metatarsal Head Pressure (M.H.P.) Sores in Leprosy Patients," Leprosy in India. 53, October, 1981. pp. 588-593.</li> <li>Price, E.W., M.D., "Studies on Plantar Ulceration In Leprosy VI, The Management of Plantar Ulcers," Leprosy Review, 31:3, July, 1960, pp. 159-171.</li> <li>Reed, J.K., RPT, "Plastazote® Insoles, Sandals, and Shoes for Insensitive Feet," Surgical Rehabilitation in Leprosy, Editors F. McDowell and CD. Enna, Williams and Wilkins, 1974, pp. 323-329.</li> <li>Ross, W.F., M.D., "Footwear and the Prevention of Ulcers in Leprosy," Leprosy Review, 33, February, 1962, pp. 202-206.</li> <li>"Selected Statistics on Health and Medical Care of Diabetics," The National Diabetes Data Group, 1980, pp. A-3.</li> <li>Tuck, W.H., C.P.O., "The Use of Plastazote® to Accommodate Deformities in Hansen's Disease," Leprosy Review, 40, July, 1969, pp. 171-173.</li> </ol> *Footnote The numerical identifications of the different densities of Plastazote® correspond with the designations assigned for these densities by Alimed Inc., 297 High Street, Dedham, Massachusetts 02026. *Footnote Plastazote® is a trademark of BXL Plastics Limited, 675 Mitcham Road, Croydon CR9 3AL England. *Arthur Plaia, M.A. Arthur Plaia, M.S., is Chief of the Orthotic Department, Gillis W. Long Hansen's Disease Center. *William C. Coleman, D.P.M. William C. Coleman, D.P.M., is Chief of the Podiatry Department at the Gillis W. Long Hansen's Disease Center, Carville, Louisiana 70721. <div style="width: 400px;"></div> Page Number(s) 67 - 73 Year 1988 Volume 12 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1988_02_067/1988_02_067-11.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Soft Molded Sandals for Insensitive Foot Care Creator An entity primarily responsible for making the resource William C. Coleman, D.P.M. * Arthur Plaia, M.A. * https://staging.drfop.org/files/original/c9f248aba5f777b90137fc5f653684ca.pdf f8b086eeef728c09345c4e2f59e8dd7e https://staging.drfop.org/files/original/c065f49a310f10a589f0a327d3e553c5.jpg 186d2ba85e30b71c039fa0154657cdce https://staging.drfop.org/files/original/bff051b61f6196998c950cf38167980c.jpg f771a9bfcf3050739cc85923b4f49d6f https://staging.drfop.org/files/original/d9d6a4e0ab4404f5bbe8bc6f1cc09fd1.jpg 1f970c7584285f498d6bf17c65c6f630 https://staging.drfop.org/files/original/febaffd06b576a9e62a93e9a0b40cd51.jpg 6acd7a71a2979ec382b0556569e30af1 https://staging.drfop.org/files/original/2bfcdb6e9deb8c4cf2472673f5174ef5.jpg 89553677fd4b9ef73da3014c83f7f72e https://staging.drfop.org/files/original/3e612a67d3f33d4c3dda57bb05207afc.jpg 23c4714870273c39c3ba99be300cd7c5 https://staging.drfop.org/files/original/8e70952489609f15226daf7eab16de3f.jpg 14e82719d1cbe0351948564744c75375 https://staging.drfop.org/files/original/1376f07c00973223d41d772b54427ee4.jpg 01ff296c026fd5f2d7c9b038490105b2 https://staging.drfop.org/files/original/0613d64bd48e27b9c797a6d197e3e2fc.jpg 106950e908dfdc134018cf1c8ecc0bf6 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_02_074.pdf Text Any textual data included in the document <h2>Orthopedic Walkers: Effect on Plantar Pressures</h2> <h5>James A. Birke, P.T., M.S. <a style="text-decoration: none;">*</a> Deborah A. Nawoczenski, P.T., M.Ed. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> Short leg (SLW) and patellar tendon bearing walkers (PTBW) are orthotic appliances<a style="text-decoration: none;">*</a> which have been recently designed as alternative devices to traditional plaster cast immobilization. The indications for use of lower leg walkers include severe ankle sprains, and ankle and foot fractures. Orthopedic walkers are convenient to use, lightweight, and removable to perform joint range of motion or inspect the extremity. Short leg walkers have been shown to be as effective as walking casts in healing stable ankle fractures, and patients treated with short leg walkers have shown significantly less edema, tenderness, and joint stiffness after six weeks of immobilization.<a></a> The authors feel that orthopedic walkers may also prove to be a beneficial alternative to traditional management of neuropathic fractures and plantar ulcerations, which are commonly seen in diabetes mellitus and Hansen's disease. Neuropathic foot lesions are the result of abnormal or repetitive stress.<a></a> Treatment techniques for neuropathic foot conditions should be effective in reducing pressure and shear stress. Traditional methods of treating neuropathic foot lesions include walking casts, fixed ankle braces, and PTB braces.<a></a> Plaster walking casts and PTB braces have been shown to significantly reduce pressure on the plantar surface of the foot during walking.<a></a> The total contact walking cast is considered effective in reducing pressure on the foot by redistributing forces on the plantar surface of the foot and lower leg. Several features of PTB orthoses shown to be important in achieving maximal weight bearing reduction on the foot include a rigid closure PTB shell, a heel-shoe clearance of 3/8" to 1", a fixed ankle joint, and a rocker sole.<a></a> Orthopedic walkers incorporate these same design features to varying degrees which has generated our interest in studying their effectiveness in reducing pressure on the foot. The SLW has a fixed ankle joint, rocker sole, and a polyurethane liner which is snugly secured to the leg with Velcro® closures (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-1.jpg">Fig. 1</a>). The PTBW incorporates all the features of the SLW, as well as a non-custom molded, semi-rigid polyethylene PTB shell (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-2.jpg">Fig. 2</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-1.jpg">Figure 1. Short Leg Walker.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-2.jpg">Figure 2. Patellar Tendon Bearing Walker.</a> The effectiveness of the SLW or PTBW in reducing pressure or shear stress on the foot has not previously been studied. The potential value of these devices in managing the neuropathic foot may be evaluated by their effectiveness in reducing pressure and shear stress. Currently, there are unreliable methods for measuring shear stress. However, shear is directly related to the perpendicular forces acting on the foot. Pressure equals the perpendicular forces per unit area. Pressure transducers provide a repeatable measurement of relative pressure inside footwear when the material interfacing with the transducers is controlled.<a></a> <h3>Purpose</h3> The purpose of this study was to determine the effectiveness of SLW and PTBW in reducing the pressure distribution on the normal foot during walking. <h3>Method</h3> Ten subjects (6 male and 4 female) without a history of foot pathology participated in this study. Capacitive pressure transducers<a style="text-decoration: none;">*</a> 2mm thick and 1.5cm in diameter were taped to the first metatarsal head (MTH), third MTH, fifth MTH, and plantar heel of the right foot of each subject (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-3.jpg">Fig. 3</a>). The foot was covered with a thin cotton stockinette which remained undisturbed during the study. Transducers were calibrated according to the manufacturer's instructions prior to testing each subject. Pressure recordings were made using a four-channel capacitive impedance bridge amplifier<a style="text-decoration: none;">*</a> and oscillographic recorder<a style="text-decoration: none;">*</a> while subjects walked in a cast shoe (CS-1) (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-4.jpg">Fig. 4</a>), short leg walker (SLW), patella tendon bearing walker (PTBW), and again in a cast shoe (CS-2). All the walking devices were fabricated by the same manufacturer.<a style="text-decoration: none;">*</a> The cast shoe was identical to the foot component of both the SLW and PTBW, utilizing identical rocker out-ersoles and 2.4mm polyurethane material insoles. SLW and PTBW were applied to the leg with a 3/8" heel-shoe clearance. Subjects walked a distance of 100 meters for each treatment condition. The testing order of treatments SLW, PTBW, and CS-2 was randomly assigned to eliminate systematic error. <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-3.jpg">Figure 3. Pressure transducer placement on selected areas of the foot.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-4.jpg">Figure 4. Cast Shoe.</a> Relative pressure was measured in millimeters of peak to peak chart deflection for 24 steps for each treatment condition. The middle distance of each run was used for analysis in order to eliminate pressure variations due to the acceleration and deceleration phases of each trial. Percent pressure change relative to CS-1 was calculated for treatments SLW, PTBW, and CS-2. Means and standard deviations were computed for treatments at each transducer site. An analysis of variance for repeated measures was used to determine whether treatment differences were significant within each site. Duncan's test was used for post-hoc analysis of means. A significance level of 0.05 was used for comparisons. <h3>Results and Discussion</h3> An analysis of variance (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-5.jpg">Table I</a>) for mean percent reduction in pressure was highly significant at all sites tested (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-6.jpg">Fig. 5</a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-7.jpg">Fig. 6</a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-8.jpg">Fig. 7</a>, and <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-9.jpg">Fig. 8</a>). Duncan's test was performed to establish which treatments differed. Significant differences were found between the percent reduction in pressure walking in SLW and PTBW as compared to the CS-2 at all sites. No difference was found between SLW and PTBW at any site. The percent pressure reduction using the walker devices was comparable at all the sites tested. <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-5.jpg">Table I. Analysis of Variance of Percent Pressure Reduction.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-6.jpg">Figure 5. Percent pressure reduction at the first metatarsal head (1 MTH) walking in cast shoe-2 (CS-2), short leg walker (SLW) and patellar tendon bearing walker (PTBW) compared to walking in cast shoe-1.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-7.jpg">Figure 6. Percent pressure reduction at the third metatarsal head (3 MTH) walking in cast shoe-2 (CS-2), short leg walker (SLW) and patellar tendon bearing walker (PTBW) compared to walking to in cast shoe-1.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-8.jpg">Figure 7. Percent pressure reduction at the fifth metatarsal head (5 MTH) walking in cast shoe-2 (CS-2), short leg walker (SLW) and patellar tendon bearing walker (PTBW) compared to walking in cast shoe-1.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-9.jpg">Figure 8. Percent pressure reduction at the heel walking in cast shoe-2 (CS-2), short leg walker (SLW) and patellar tendon bearing walker (PTBW) compared to walking in cast shoe-1.</a> This study demonstrated the effectiveness of the short leg and patellar tendon bearing walkers as compared to the cast shoe in reducing plantar pressure on the foot. Since all the devices in this study had the same sole design and insole materials, treatment differences must be attributable to proximal orthotic components including the polyurethane liner, fixed ankle uprights, and Velcro® closures. The SLW and PTBW differed only by the polyethylene, non-custom molded patellar tendon cuff. Since no treatment difference was seen between these devices, the PTBW cuff design must not have been effective. However, in follow-up, single subject trials, we were not able to change walking pressures by redesigning the PTBW cuff using polyethylene or plaster custom molded PTB cuffs. An alternative conclusion is that the SLW design alone optimally reduced plantar pressure by the fixed ankle joint and uprights snugly supporting the lower leg and calf. In this study, orthopedic walkers were equally effective in reducing pressure at all sites tested on the foot. In previous studies, casts were shown to reduce pressure more effectively in the forefoot than the heel, and PTB orthotics reduced pressure more effectively in the heel than the forefoot.<a></a> Based on the results of this study, othopedic walkers may be effective devices in the reduction of plantar foot pressure in patients with neuropathic conditions of the foot. There is no evidence to show that the PTBW will be more effective than the SLW. Further study utilizing a patient population is recommended. <h3>Conclusions</h3> Within the scope of this study, it is possible to conclude the following: (1) SLW and PTBW orthopaedic walkers are effective in reducing pressure at the first MTH, third MTH, fifth MTH and heel in normal subjects during walking, and (2) there is no difference in pressure distribution between the SLW and PTBW during walking. References: <ol> <li>Anderson, J.G., "Treatment and Prevention of Plantar Ulcers," Leprosy Review, 35, 1964, pp. 251-258.</li> <li>Birke, J.A. and D.S. Sims, "Walking Casts: Effect on Plantar Foot Pressures," Journal of Rehabilitation Research and Developement, 22:3, July, 1985, pp. 18-22.</li> <li>Brand, P.W., "The Insensitive Foot," Editor M.H. Jahss, Disorders of the Foot, Vol. II, W.B. Saunders, 1982, p. 1266.</li> <li>Cterctecko, G.C., M. Dhanendran, W.S. Hutton, and L.P. LeQuesne, "Vertical Forces Acting on the Foot of Diabetic Patients with Neuropathic Ulceration," British Journal of Surgery, 68, 1981, pp. 609-614.</li> <li>Coleman, W.S., P.W. Brand, and J.A. Birke, "The Total Contact Cast: A Therapy for Plantar Ulceration of the Insensitive Foot," Journal of the American Pediatric Medical Association, 74:11, November, 1984, pp. 548-552.</li> <li>Enna, CD., P.W. Brand, J.K. Reed, and D. Welch, "The Orthotic Care of the Denervated Foot in Hansen's Disease," Orthotics and Prosthetics, 30:1, March, 1976, pp. 33-39.</li> <li>Gristina, A.G., A.L.W. Thompson, N. Kester, W. Walsh, and J.A. Gristina, "Treatment of Neuropathic Conditions of the Foot and Ankle with a Patellar-Tendon-Bearing Brace," Archives of Physical Medicine and Rehabilitation, 54, December, 1973, pp. 562-564.</li> <li>Hall, O.C. and P.W. Brand, "The Etiology of the Neuropathic Plantar Ulcer," Journal of the American Pediatric Medical Association, 69:3, March, 1979, pp. 173-177.</li> <li>Helm, P.A., S.C. Walker, and G. Pullium, "Total Contact Casting in Diabetic Patients with Neuropathic Foot Ulcerations," Archives of Physical Medicine and Rehabilitation, 65, 1984, pp. 691-693.</li> <li>Lang-Stevenson, A.I., W. Sharrard, R.P. Betts, and T. Duckworth, "Neuropathic Ulcers of the Foot," Journal of Bone and Joint Surgery, (British) 67B, 1985, pp. 438-442.</li> <li>Lehmann, J.F., CG. Warren, D.R. Pemberton, B.C. Simons, and B.J. DeLateur, "Load-bearing Function of Patellar Tendon Bearing Braces of Various Designs," Archives of Physical and Medical Rehabilitation, 52, August, 1971, pp. 366-370.</li> <li>Patterson, R.P., and S.V. Fisher, "The Accuracy of Electrical Transducers for the Measurement of Pressure Applied to the Skin," IEEE Transactions on Biomedical Engineering, 26:8, August, 1979, pp. 450-456.</li> <li>Polakoff, D.R., S.M. Pearce, D.P. Grogan, and W.Z. Burkhead, "The Orthotic Treatment of Stable Ankle Fractures," Orthopedics, 7, 1984, pp. 1712-1715.</li> <li>Pollard, J.P., and L.P. LeQuesne, "Method of Healing Diabetic Forefoot Ulcers," British Medical Journal, 286, February, 1983, pp. 436-437.</li> <li>Pollard, J.P., L.P. LeQuesne, and J.W. Tappin, "Forces Under the Foot," Journal of Biomedical Engineering, 5, 1983, pp. 37-40.</li> <li>Sabato, S., Z. Yosipovitch, A. Simkin, and J. Sheskin, "Plantar Trophic Ulcers in Patients with Leprosy," International Orthopedics, 6, 1982, pp. 203-208.</li> <li>Soderberg, G., "Follow-up of Application of Plaster-of-Paris Casts for Noninfected Plantar Ulcers in Field Conditions," Leprosy Review, 41, 1970, pp. 184-190.</li> </ol> Footnote 3D Orthopedics, Inc., 10520 Olympic Drive, Dallas, Texas 75220. Footnote Gulton TR-400a, Gulton Industries, Inc., East Greenwich, Rhode Island. Footnote Hercules Orthoflex Data System, Allegany Ballistics Lab, Cumberland, Maryland. Footnote Hercules Orthoflex Data System, Allegany Ballistics Lab, Cumberland, Maryland. *Deborah A. Nawoczenski, P.T., M.Ed. Deborah A. Nawoczenski, P.T., M.Ed., is Assistant Professor at the Department of Physical Therapy for the College of Allied Health Professions at Temple University, Philadelphia, Pennsylvania 19140. *James A. Birke, P.T., M.S. James A. Birke, P.T., M.S., is Chief of the Physical Therapy Department at G.W. Long Hansen's Disease Center, Carville, Louisiana 70721. Page Number(s) 74 - 80 Year 1988 Volume 12 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-4.jpg Figure 5 TABLE I http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 FIGURE 5 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-6.jpg Figure 7 FIGURE 6 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-7.jpg Figure 8 FIGURE 7 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-8.jpg Figure 9 FIGURE 8 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-9.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Orthopedic Walkers: Effect on Plantar Pressures Creator An entity primarily responsible for making the resource James A. Birke, P.T., M.S. * Deborah A. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_02_081.pdf Text Any textual data included in the document <h2>Report From: International Workshop on Above-Knee Fitting and Alignment Techniques</h2> <h5>C. Michael Schuch, C.P.O. <a style="text-decoration: none;">*</a></h5> An "International Workshop on Above-Knee Fitting and Alignment Techniques" was held in Miami, Florida, May 15-19, 1987. Conceived and organized by A. Bennett Wilson, Jr. and Melvin L. Stills, CO., the workshop was supported and sponsored jointly by the International Society for Prosthetics and Orthotics and the Rehabilitation Research and Development Service of the Veteran's Administration. Hosting the workshop was the Prosthetics and Orthotics Education Program of the School of Health Sciences, Florida International University, and more specifically, Dr. Reba Anderson, Dean of Health Sciences and Ron Spiers, Director of Prosthetic Orthotic Education. Approximately 50 invited professionals attended the workshop, representing the United States, England, Scotland, Denmark, Sweden, Israel, the Netherlands, and Germany. Invited professionals included physicians, engineers, educators, and researchers, as well as prosthetic practitioners, all known to be active in the field of prosthetics. The intent of the workshop was an organized sharing and discussion of information and experiences relative to the management of above-knee amputees. Above-knee socket design variables, specifically the accepted and established quadrilateral design and the newer ischial-con-tainment designs known by various acronyms (CAT-CAM, NSNA, Narrow M-L), were discussed in great detail. Goals were to determine differences/similarities, advantages/disadvan-tages, indications/contraindications, as well as to develop recommendations for future action with respect to the various socket designs. While many prosthetists and/or clinics may have considerable experience with the newer above-knee socket designs within the United States, it is true that there are still many questions and concerns on the part of consumers, prescribing physicians, third party paying agencies, and educators in the U.S., as well as a great curiosity on the part of our international colleagues abroad. After introductory remarks from Dr. Anderson, Dean of Health Sciences at Florida International University, Mr. John Hughes, President of ISPO, and Dr. Margaret Gianninni, Director of the Rehabilitation Research and Development Service of the Veteran's Administration, the program began with a presentation by A. Bennett Wilson entitled, "Recent Brief History of AK Fitting and Alignment Techniques." This paper began with the advent of the suction socket in the U.S. shortly after World War II and proceeded with the development of the total contact quadrilateral socket in the early 1960's. The audience was reminded that the total-contact quadrilateral socket, with or without suction suspension, was the socket design of choice from 1964 until very recently, when ischial-containment socket designs emerged. It was noted that, at present, the three senior prosthetic education programs in the U.S. (UCLA, Northwestern University, and New York University), in addition to teaching the application of the standard total contact quadrilateral socket, are offering special courses in what at first glance appear to be radical departures from the quadrilateral design. The technique at UCLA is known as CAT-CAM (Contoured Adducted Trochanteric-Con-trolled Alignment Method), based on work by John Sabolich, C.P.O., and inspired by Ivan A. Long, CP. The technique being presented at Northwestern University is said to be based more directly on the Ivan Long technique and is known as NSNA (Normal Shape-Normal Alignment). The technique taught at New York University is usually referred to as the narrow ML socket design based on a special tool designed by Daniel Shamp to facilitate casting. Mr. Wilson concluded his remarks by saying "unfortunately, none of these techniques has been subjected to an evaluation program independent of the development group, and a great deal of confusion exists among clinicians responsible for amputee care. I hope that this workshop can be helpful in clearing away some of the confusion, and point the way for action that will bring order to the present day practice of above-knee prosthetics." The next speaker on the agenda was Charles Radcliffe, Professor of Mechanical Engineering at the University of California, Berkeley. Professor Radcliff's presentation was entitled, "Review of UCB Quadrilateral Socket and Alignment Theory." Having been a member of the Prosthetic Devices Research Project of UC Berkeley in the 50's and 60's, Professor Rad-cliff is still a strong proponent of the quadrilateral socket. He presented a detailed review of the history and development of the quadrilateral socket and summarized this section of his presentation with the following comments. "The net result of all of this work in the 1950-1963 period was a better understanding of the complex interrelationships between the functional capability of the amputee, the rehabilitation goals, the prosthetic components required in the prescription, the gait of the amputee, the biomechanical forces generated, the socket shape, and the alignment. The socket was no longer described as a cross-section shape at the ischial level, but rather a three-dimensional receptacle for the stump with contours at every level which could be justified on a sound biomechanical basis. ... It should be emphasized again that the quadrilateral type of fitting is not just a socket, it is a complete system which includes the amputee as a most important component. The socket is the interface between stump and prosthesis, and its primary functions are to provide for weight-bearing in the stance phase, allow the use of the stump and hip musculature to control motion and posture of the upper body in the stance phase (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-01.jpg">Fig. 1</a>), and to provide for control of the prosthesis in the swing phase of walking." <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-01.jpg">Figure 1. Biomechanical forces diagram, Above-knee amputee weight-bearing in the stance phase.</a> The next section of Professor Radcliffe's presentation focused on biomechanical and alignment principles of a prosthesis with a quadrilateral socket. Here he related his feelings that many of the biomechanically related claims made by proponents of the newer non-quadrilateral socket designs are equally attainable in the quadrilateral socket if the original biomechanical principles are followed. "Regardless of the fitting method employed, the socket for any patient must provide the same overall functional characteristics, including comfortable weight-bearing, a narrow base gait, and as normal a swing phase as possible consistent with the residual function available to the amputee after amputation. It is possible to provide this with a quadrilateral socket and it is being done routinely in many facilities." Professor Radcliffe went on to say, "In most of the recent articles that I have read, statements have been made which indicate clearly that the author is comparing very poorly fitted quadrilateral sockets to the results obtained using the new technique. They show diagrams of typical fittings and gait deviations which can only be described as a complete list of horror stories describing what not to do in fitting a quadrilateral socket. Any prosthesis with the problems listed in these articles should never have been delivered. If the average pros-thetist in the United States is having the problems described by Long, Shamp, and Sabolich, then I must suggest that something is wrong with the methods being taught and used in daily practice. I am aware that the schools have made significant changes in the way that the principles are taught, with each school emphasizing different aspects of the problem. I suspect that there may have been a shift away from the fundamentals of teaching of overall objectives, including the interrelationships of amputee evaluation, components prescribed, biomechanics, and why sockets are fitted with particular contours." Following Professor Radcliffe was Tim Staats, Director of the UCLA Prosthetics Education Program. Mr. Staats' presentation was on the "UCLA CAT-CAM." UCLA began teaching CAT-CAM above-knee prosthetics with a pilot course in March 1985, which included both John Sabolich and Tom Guth as course instructors. Mr. Staats made it clear that the UCLA CAT-CAM philosophy of 1987 has departed from that of Sabolich, Guth, et al. and that the UCLA philosophy has now evolved to the point where a third edition of a teaching manual was published in March, 1987. To quote Mr. Staats as he spoke about this new manual, "the third edition of the UCLA CAT-CAM Above-Knee Prosthesis teaching manual integrates much additional material, covering the anatomy/socket relationship and how this is best achieved—material not yet fully understood and synthesized at the time of preparation of the previous edition. The UCLA CAT-CAM above-knee socket is a variation of the CAT-CAM design developed by John Sabolich, C.P.O., and Tom Guth, CP., and the NSNA AK prosthesis of Ivan Long, CP. Through countless hours of literature search, discussion, and intensive training given in this and nine foreign countries, and through the results of over 200 students who have fabricated and fit over 1,000 sockets under the guidance of our staff, a new insight has been developed. Our staff has refined the techniques of measurement, casting, and model modification to the point where it is a clearly teachable and viable above-knee fitting method. It is with great respect that we continue to recognize the published contributions of John Sabolich, C.P.O., Tom Guth, CP., and Ivan Long, CP., to the development and evolution of the UCLA technique. We would hope that this manual captures, blends, and enhances their philosophies. We recognize that our technique and CAT-CAM evolved from NSNA and we hope that these professionals can appreciate our efforts to refine and further evolve their clinical approach into a methodical step-by-step teaching manual." At this point I will briefly review the highlights of the UCLA CAT-CAM sequence, beginning with patient evaluation and measurement and proceeding through model modification and bench alignment. For the details, I suggest referencing the third edition of the UCLA manual. The recommended evaluation/measurement protocol is very complete and detailed, covering many of the procedures with which we should all be familiar. Adduction and flexion analysis of the residual limb are emphasized. Some new measurements and/or evaluations are introduced and illustrated: <ul> <li> Skeletal ML dimension, actually measured on patient (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-02.jpg">Fig. 2</a>) <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-02.jpg">Figure 2. UCLA CAT-CAM medial-lateral diameter measurements.</a></li> <li> Soft tissue ML dimension, taken from Ivan Long's chart of circumferences and related ML values (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-02.jpg">Fig. 2</a>) </li> <li> Ilio-femoral angle, actually measured on the patient (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-03.jpg">Fig. 3</a>) <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-03.jpg">Figure 3. Ilio-femoral angle, as measured for UCLA CAT-CAM.</a></li> <li> Public arch angle, evaluated by palpation and captured in the wrap cast (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-04.jpg">Fig. 4</a>) <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-04.jpg">Figure 4. The pubic arch angle, as evaluated for UCLA CAT-CAM.</a></li> <li> Ischial inclination, evaluated by palpation and captured in the wrap cast (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-05.jpg">Fig. 5</a>) <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-05.jpg">Figure 5. The ischial inclination angle, as evaluated for UCLA CAT-CAM.</a></li> </ul> The wrap cast is taken with the patient in a standing position, and all shaping of the cast is accomplished by hand molding. The goal is good definition and containment of the medial and posterior aspects of the ischial tuberosity and ischial ramus within the wrap cast and subsequent socket, as well as allowance for the pubic ramus to exit the socket near the midline of the medial wall (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-06.jpg">Fig. 6</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-06.jpg">Figure 6. Medial view of pelvis-socket relationship, UCLA CAT-CAM.</a> The initial trimlines for the resultant socket are as follows: <ol> <li> Anteriorly, just proximal to the inguinal crease. The anterolateral brim must clear the superior iliac spine when the patient is sitting. </li> <li> Laterally, the brim extends approximately 3" above the trochanter. The final height of this wall will be determined during fitting. </li> <li> Posteriorly, the trim line should begin at least 1" above the level of the inferior border of the ischial tuberosity. The curve that defines the posterior to lateral trim line normally begins at a point between the lateral third and the midline of the socket ML dimension at ischial level. </li> <li> The medial proximal brim will be "V" shaped, with the vortex of the "V" located at the point where the pubic ramus crosses the medial wall. This trim line projects upward from the vortex, posteriorly to encapsulate the medial aspect of the ischial ramus and tuberosity. (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-06.jpg">Fig. 6</a>) A circumference reduction chart is used to attain suction suspension. The values used in this chart are slightly less than those normally used in quadrilateral suction sockets. </li> </ol> For bench alignment, the following references are used: <ol> <li> Posteriorly, bisect the socket at the level of the soft tissue ML, this reference line should fall as a plumb line to the center of the heel. </li> <li> Laterally, bisect the socket AP dimension at ischial level, this reference line should fall as a plumb line between 0" and 1" anterior to the foot bolt. </li> <li> Socket is set in measured adduction, and measured flexion plus 5°. </li> <li> The distal aspect of the medial wall should be on the line of progression. </li> <li> The knee bolt is externally rotated 5°. </li> <li> The top of the foot, as well as the prosthetic shank should lean medially 4°, or alternatively, the socket is hyper-ad-ducted 4° beyond measured adduction with the foot parallel to the floor and the shank perpendicular to the floor. </li> </ol> The UCLA CAT-CAM can be fabricated using rigid socket or flexible socket techniques. If a flexible socket or brim system is desired, the proximal medial trimline in the ischial area must be more aggressive during casting to allow for the linear shrinkage factor known in most thermoplastics. A final comment: the manual reflects the accumulated experience of the UCLA staff and includes a section on problem solving the difficulties that might be experienced in the CAT-CAM socket. Next to speak was Gunther Gehl, CP., Director of Prosthetic Education at Northwestern University in Chicago. Northwestern has been teaching the NSNA AK techniques of Ivan Long for several years now, and it was Mr. Gehl's task to report to the workshop on NSNA and Long's Line. He said that he and his staff taught NSNA as presented by Ivan Long with no changes. Ivan has been fitting Long's Line, now known as NSNA, for more than 12 years, and his approach has been consistent, with few changes. Perhaps changing the name from Long's Line to NSNA in July, 1985 is the most significant change. Mr. Long has published three technical papers describing his technique: "Allowing Normal Adduction of the Femur in Above Knee Amputees," (Orthotics and Prosthetics, December, 1975); "Fabricating the Long's Line Above Knee Prosthesis," (1981); and as a reprint of the Long's Line article with new title, "Normal Shape-Normal Alignment (NSNA) Above Knee Prosthesis," (Clinical Prosthetics and Orthotics, Fall, 1985). These articles were the basis for Gunther Gehl's presentation to the International Workshop. I will attempt to review and highlight the NSNA philosophy as I did the UCLA CAT-CAM. Again, within the limitations of this report, this will only be an overview. With the widespread availability of Ivan's publications, it does not seem necessary to go into details. NSNA is less detailed regarding evaluation and measurements, placing great emphasis on the wrap cast, subsequent model modification, and alignment, all based on Long's Line, which is defined as a straight line, starting approximately at the center of a narrow socket, passing through the distal femur, and on down to the center of the heel (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-07.jpg">Fig. 7</a>). Long's Line is not always vertical because it shifts constantly when the amputee goes from a standing position to a walking position. <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-07.jpg">Figure 7. Long's Line.</a> The wrap cast is taken with the patient in a standing position. The important points about the wrap cast procedure are identification of the ischium and proper alignment. The hand will be held to indicate the medial and posterior surface of the ischium, but not forward of the ischium. The amputee then adducts as tightly as possible and extends his thigh to tighten the hamstrings. At this point a lateral reference line is established. The resultant cast model is oversized and will require considerable modification. Practically all modification will take place on the lateral wall. Following is a brief description of modification goals and resultant trimlines, taken from Mr. Gehl's presentation and from Mr. Long's publications. <ol> <li> The lateral wall is to be shaped to give support over a wide area, and particularly the lateral-posterior aspect of the socket. </li> <li> The medial wall will be lower than seat level, and the wrap cast will be the guideline as to how low. </li> <li> Depth of the socket will be the same as the measured length of the thigh. </li> <li> The seat will be at a right angle to Long's Line. </li> <li> Long's Line is drawn from the center of the seat level ML to the center of the distal femur. The distal femur will be very close to the lateral surface, probably only covered by skin. </li> <li> The top 1" of the medial wall will flare outward at 45°. </li> <li> The lateral wall extends above the trochanter. </li> <li> The ischium will bear on the flare of the socket, both medially and posteriorly. </li> <li> The cast is taken down in the ML as though the trochanter does not exist. In order to achieve the desired ML, many casts will be reduced 2" or more. The desired ML dimension is taken from Ivan's chart of ML values related to the thigh circumference just below the ischium (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-08.jpg">Fig. 8</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-08.jpg">Figure 8. Table of M-L values determined from circumference just below ischium, used in NSNA.</a></li> </ol> Circumference reductions for suction suspension begin at 1" of tension proximally, reducing to 3/4", then 1/2", with the remaining tensions at 1/4". Mr. Long does not advocate use of an alignment device. Bench alignment is critical and is based on Long's Line. The center of the lateral wall is marked at seat level for TKA and the vertical reference line established during casting should parallel the TKA line. Long's Line is marked on the posterior of the socket. For the male, the socket is mounted with the inner aspect of the medial wall (which follows the pubic ramus angle) in 30° internal rotation to the line of progression (the outer edge of the medial trimline is on the line of progression), and with the knee bolt axis 4° higher on the lateral side. This is the same as adding 4° additional adduction to Long's Line. For the female, the socket is mounted with the inner aspect of the medial wall in 40-45° internal rotation to the line of progression (again, the outer edge of the medial trimline is on the line of progression), and with the knee bolt axis 7° higher on the lateral side (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-09.jpg">Fig. 9</a>). Mr. Long emphasizes that it is not necessary to change the alignment. When the amputee is allowed time to adjust to the new prosthesis, then alignment changes will not be necessary. <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-09.jpg">Figure 9. NSNA socket shape and alignment diagram, male and female.</a> Following Gunther Gehl was Daniel Shamp, C.P.O., presenting, "The Shamp Brim, For the Narrow ML Above-Knee Prosthetic Socket." Mr. Shamp's system of brim casting and evaluation is currently the content of a special short course offered by New York University's Prosthetic and Orthotic Education Program. Long and Sabolich, as well as UCLA, advocate that the hand casting technique is the most successful in their experience with the narrow ML, wide AP, or ischial-containment socket for above-knee amputees. In response, Mr. Shamp stated, "Experience with the Shamp Brim system has proven to make the procedure more uniformly successful and more easily learned and applied by the practitioner who has spent years working with the brim method for quadrilateral socket casting and modification." Mr. Shamp went on to present detailed biomechanical rationale for the narrow ML socket. Biomechanical descriptions such as bony lock on the ischium, ischial containment within the socket, retention of normal adduction, etc., are consistently relevant to Mr. Shamp's socket system, as well as all of the latest ischial-containment socket designs. Two noticeably different aspects of Mr. Shamp's technique are (1) the brim forming system itself, which allows for evaluation of brim design under weight bearing conditions before proceeding with the wrap cast, and (2) what Mr. Shamp refers to as centralization of the femur. To accomplish centralization of the femur, during the casting procedure, the prosthetist pulls the distal medial tissue in a lateral direction while stabilizing the femur with the other hand by means of a 45° force against the lateral shaft of the femur (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-10.jpg">Fig. 10</a>). Mr. Shamp stated that this centralization procedure is essential to prevent a large medial-distal bulge with resultant cosmetic problems when the femur is maintained in a position of maximum adduction in the AK prosthesis. <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-10.jpg">Figure 10. Centralization of the femur, as proposed by Dan Shamp for Narrow ML Socket.</a> Again, I will present an overview of the Shamp Narrow ML technique, summarizing from Mr. Shamp's presentation and from the "Manual for use of The Shamp Brim," which was provided for the workshop attendees. This manual was produced by Prosthetic Consultants, Incorporated of Akron, Ohio in cooperation with the Department of Prosthetics and Orthotics, New York University Post-Graduate Medical School, and is published by the Ohio Willow Wood Company. The measurement and evaluation procedure includes a careful observation and recording of the characteristics, lengths, and circumferences requested on the Narrow ML AK Information Chart. Review of this information chart will show the practitioner who is familiar with the technique for the quadrilateral socket that only a small number of measurements are different for the Narrow ML socket. It is important to note that three ML measurements must be taken precisely as follows: <ol> <li> Distal Ischial Tuberosity (DIT): firm ML measurement of the anatomy taken 1" to 2" distal to the ischial tuberosity (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-11.jpg">Fig. 11</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-11.jpg">Figure 11. Distal Ischial Tuberosity (DIT), medial-lateral diameter measurement for Narrow ML Socket</a>.</li> <li> Oblique ML (OB): firm ML measurement taken from the medial side of the ramus of the tuberosity to a point just superior to the greater trochanter of the femur (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-12.jpg">Fig. 12</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-12.jpg">Figure 12. Oblique ML (OB), medial-lateral diameter measurement for Narrow ML Socket.</a></li> <li> Ischial Tuberosity ML (IT): firm ML measurement taken from the medial border of the ramus of the ischial tuberosity to the subtrochanteric area of the femur (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-13.jpg">Fig. 13</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-13.jpg">Figure 13. Ischial Tuberosity ML (IT), medial-lateral diameter measurement for Narrow ML Socket.</a></li> </ol> The Shamp Brim, which is compatible with the Berkley brim stand, is now set up and adjusted to the patient's measurements. As stated earlier, the brim allows for weight-bearing evaluation of the patient with regard to socket design before the actual wrap cast is taken. As with all of the ischial-containment socket designs discussed at the Workshop, the location of the ischial tuberosity in the socket is essential to both a comfortable fit and a stable femur in maximum adduction. For the Shamp technique, the ideal location is 1/2" inside the medial-proximal wall of the prosthesis and indicates the area referred to as the IT ML measurement. The medial wall has a 45° angle that assists the wedge effect in stabilizing the femur and so the location of the tuberosity on this slope is important. The trimlines are similar to both NSNA and the UCLA CAT-CAM, including the low anterior wall with clearance for the ASIS, the relatively horizontal posterior wall, and the high lateral wall, which extends generously above the trochanter. Although, not as exaggerated as the UCLA CAT-CAM, the medial wall is lowered as it approaches the anterior wall, allowing for the pubic ramus to pass from within the socket. Alignment follows generally accepted quadrilateral alignment principles for TKA and knee bolt external rotation. For alignment in the frontal plane (posterior view, ML plane), Mr. Shamp advocates the principles of Long's Line. Dr. Hans Lehneis, C.P.O., of the Rusk Institute of Rehabilitation Medicine was the next speaker and his presentation covered work done at the Rusk Institute and the New York Veterans Administration. Dr. Lehneis and associates are investigating anatomical, physiological, and biomechanical characteristics of geriatric above-knee amputees in an attempt to develop a set of design criteria for geriatric above-knee sockets. As this project is still in the developmental stages, I will not elaborate on this subject. Following Dr. Lehneis was OssÃ¼r Kris-tinsson of Iceland. As the developer of the flexible socket-rigid frame system, he was the first to speak on flexible sockets. Mr. Kris-tinsson reported that he was continuing development of flexible sockets, including walls and brims. He is conducting an extensive materials search in hopes of finding the materials that will make possible the ultimate flexible socket design. Mr. Kristinsson went on to say that we need some simple definition of flexible socket characteristics. "To label a socket as flexible, I would say that you should be able to deform it by your hands, and the material should not be elastic enough to stretch under the loads it will be subjected to." Concerning flexible socket design, Mr. Kristinsson stated, "When designing a flexible socket system, the most critical aspect for the comfort of the wearer is how the frame is designed. It has to be capable of supporting the flexible socket, preventing permanent deformation, and the socket-frame combination has to be structurally strong and stable enough to counteract the reaction forces." Mr. Kristinsson made a final, important point: "There may be doubt among professionals and users about the value of the flexible wall. I am, however, totally convinced that the flexible socket is here to stay. If anything, I think it will get more flexible as we gain access to more suitable materials than we are using today, and some obstacles on the way to proper understanding of the socket-stump interaction are overcome." Continuing the flexible socket presentations was Norman Berger of New York University's Prosthetic Orthotic Program. Mr. Berger's presentation was the ISNY (Icelandic-Swedish-New York) flexible socket design as taught by NYU. Mr. Berger described the socket and frame fabrication technique used in the ISNY. Three interesting points are worthy of mention: <ol> <li> The flexible socket is fabricated with polyethylene, which has a known shrinkage factor. </li> <li> The desired wall thickness of the flexible socket is 60/1000". </li> <li> Lateral distal support for the femur is not provided for by the frame. </li> </ol> The final presentor on the topic of flexible sockets was Charles Pritham, C.P.O. of Durr Fillauer Medical Company. A co-author and co-developer of Durr-Fillauer's flexible socket technique, Mr. Pritham described the biomechanical function of the flexible walled ischial-gluteal bearing quadrilateral socket as follows: <ol> <li> Ischial/gluteal weight bearing; </li> <li> Stabilization of the distal femur laterally; </li> <li> Total contact; and </li> <li> Flexible walls. </li> </ol> Note the mention of stabilization of the distal femur laterally; this is provided for by the frame design of the Scandinavian Flexible Socket. Mr. Pritham went on to say, "It will be appreciated that the design is actually not fundamentally different, flexible walls aside, from a similarly designed socket in the rigid walls. Indeed one of the factors that undoubtedly hastened its acceptance was the fact that previously learned methods of casting and fitting quadrilateral sockets were fully acceptable when fitting a flexible walled socket. While the advantages cited are formulated with the quadrilateral socket in mind, there is no reason to suspect that they are significantly different from non-quadrilateral above-knee sockets. Indeed, flexibility is often considered by the designers of one another of the various designs as an integral factor in their success." Mr. Pritham listed advantages of flexible walled sockets as: <ol> <li> Flexible walls; </li> <li> Improved proprioception; </li> <li> Conventional fitting techniques; </li> <li> Minor volume changes readily accommodated; </li> <li> Temperature reduction; and </li> <li> Enhanced suspension. </li> </ol> Indications for use of the flexible wall socket are: <ol> <li> Mature stumps (where frequent socket changes are not anticipated); </li> <li> Medium to long stump (where a significant portion of the wall will be left exposed and flexible); and </li> <li> Suspension is not a factor. </li> </ol> While the use of flexible wall sockets has been well accepted, Mr. Pritham pointed out that questions have arisen in at least three areas. Material Both Surlyn® and low density polyethylene (in a variety of types and name brands) have been used successfully and each has its advocates. Mr. Pritham and colleagues at Durr Fillauer prefer Surlyn® for three reasons: clarity, no shrinkage, and ease of rolling the edge. Thickness Originally socket walls of 30/1000" thickness were specified, however, this proved to lack durability. Subsequently, thickness in the neighborhood of 80-90/1000" were specified and are preferred. (Note: NYU prefers 60/1000".) Frame configuration At least three different configurations have been described for quadrilateral sockets. The differences center on the lateral wall and the amount of support considered necessary for the femur. A variety of designs have been put forth in order to achieve specific features in non-quadrilateral sockets, including the well known total flexible brim. Mr. Pritham concluded his presentation by saying, "the crucial point would seem to be that flexibility is independent of socket shape and can be modified to provide specific design features in a socket-frame system. The specific configuration depends upon the prosthetist's experience and fitting philosophy and the needs of the individual patient." Rounding out the first day of presentations was Dr. Robin Redhead, Senior Medical Officer at the Roehampton Limb Fitting Centre in London. Dr. Redhead's paper was entitled "Experience With Total Surface Bearing Sockets." This presentation centered more on weight-bearing distribution and biomechanics than on socket design or shapes. Dr. Redhead and associates maintain that regardless of socket shape or design, well distributed weight-bearing can eliminate the need for single point, bony weight bearing (such as ischial weight-bearing). This system of well distributed weight-bearing was referred to as a total-surface-bearing socket. It infers a hydrostatic type of socket fit utilizing the incom-pressibility of the fluids in an above-knee residual limb. This presentation brought a reaction from of Professor Radcliffe, who doesn't agree with the hydrostatic concept of weight-bearing in prosthetics. He stated that "you need a closed system for hydrostatics and the AK residual limb is not a closed fluid system. With an open fluid system, the fluids are pushed out." There was considerable discussion on this topic, both pro and con, and it was never resolved. Beginning the morning of the second day, John Sabolich, C.P.O., from Oklahoma City, and Glenn Hutnick, CP., from New York, presented another view of CAT-CAM. As stated earlier, Tim Staats, C.P.O. reported that the UCLA CAT-CAM is evolving independently of the CAT-CAM technique of the original developers. Sabolich and Hutnick report that the original CAT-CAM is continuing to evolve and develop. Sabolich stated that, "it took five to six years to develop the current medial wall design, which has become increasingly more aggressive in enclosing and capturing the ischial ramus." They advocate use of the total flexible brim. "The key is the flexible brim system—it is totally flexible in the proximal area, where most patients complain." Aside from 100% use of the total flexible brim, the Sabolich/Guth CAT-CAM differs from NSNA and the UCLA CAT-CAM by not advocating the 4° to 7° medial lean of the foot, pylon, and knee bolt in bench alignment as proposed by Long and UCLA. John Sabolich went on to say "this additional adduction or tilting of the knee bolt is a cover-up for lost stability due to inadequate ischial containment." Mr. Long's response was that this was incorrect. Probably the most noticeable aspect of design that separates the Sabolich/Guth CAT-CAM apart from the other recent ischial-containment designs is the earlier mentioned aggressive capture of the ischial tuberosity and ramus. Sabolich claimed that they are enclosing more and more of the ischial ramus, as much as possible and still allow pubic ramus comfort. This ramus enclosure provides two biomechanical functions: (1) a medial bony stop for ML stability, and (2) rotational control, especially on soft fleshy residual limbs. Other than these departures, the Sabolich/Guth CAT-CAM differs very little from the UCLA CAT-CAM, especially in terms of brim shape, trimlines, and biomechanics. Sabolich, unlike Long, does advocate the use of dynamic alignment devices. At this point in the Workshop, Professor Radcliffe returned to the podium in an attempt to present and clarify the comparative biomechanical principles of both quadrilateral and ischial-containment sockets. The following biomechanical analyses are taken from Professor Radcliffe's discussion and from the paper he later submitted reviewing his presentations. "It has been demonstrated that pressure against the medial aspect of the pubic ramus can be used to supplement the weight-bearing on the tuberosity of the ischium and contribute to medial stabilization in the upper one-third of the above-knee socket. In taking advantage of the weight-bearing potential on the medial aspect of the ramus, the prosthetist is creating a situation much like weight-bearing on the seat of a racing bicycle. To prevent the ramus from sliding laterally and downward into the socket, the prosthetist must exaggerate the counterpres-sure from the lateral side. This has been done by a reduction in the M-L dimension particularly in the area just distal to the head of the trochanter. The soft tissue must be accommodated. Therefore, the A-P dimension is correspondingly increased as compared to the quadrilateral socket. As compared to the quadrilateral fitting, the height of the anterior brim is typically lowered and flared and the gluteal area is filled in and fitted higher as a result of the ischium being encased deeper into the socket." "The medial brim of the socket must slope forward and downward to the point where the pubic ramus crosses the medial brim and emerges from the socket. The ischial ramus clearly is capable of providing medial counter-pressure which supplements the medial pressure on the adductor musculature. Since the socket slopes downward and inward along the entire medial brim, this contour is flared into the medial wall of the socket, which gives the impression of exaggeration of the medial coun-terpressure in the upper one-third of the socket." "The adduction of the socket and the use of lateral stabilization should not differ from that achieved by a properly fitted quadrilateral socket. There is an apparent exaggeration of the modification of the lateral wall, but this is primarily limited to the area just below the trochanter where the M-L dimension has been reduced to insure that the encased pubic ramus and ischium are maintained in the desired position on the medial brim. The exaggeration of the medial flare and reduction of the M-L dimension in the upper third of the socket leads to the impression of a greater angle of femur adduction, but the actual angle of the femur should be similar in both types of fittings if the quadrilateral socket is properly fitted and aligned." "Long's Line as proposed by Ivan Long is the anatomical axis of the lower extremity as described in anatomy textbooks. Placing the fe-mural stump in an advantageous position for normal use of the hip musculature by adduction and flexion of the socket has been a part of good prosthetic practice for at least 40 years in the United States and perhaps longer in certain European centers. Mr. Long's Line appears to be most useful in the cast taking procedure and subsequent modifications of the model rather than have any fundamental bearing on the alignment of the prosthesis. It appears to offer no new concepts useful in the bench or dynamic alignment of the prosthesis." Professor Radcliffe told the Workshop attendees that the use of "catchy names" should be avoided, and he therefore proposed the terminology of Ischial-Ramal weight-bearing socket, as well as Ischial-Gluteal weight-bearing socket. Professor Radcliffe continued his biomechanical analysis by saying "The biomechanics of the ischial-ramal weight-bearing socket are similar to the ischial-gluteal weight-bearing quadrilateral socket. The major differences are in the manner in which the ischium is maintained in position within or on the brim of the socket. In each case, there must be vertical support with a combination of lateral and anterior counterpressure to maintain the ischium in position" . . . "Some of the socket shape diagrams I have seen published are so crude and inaccurate as to be almost meaningless. The level of the cross section shown is often not indicated and a section at ischial level is sometimes compared to a section which is obviously higher or lower." Professor Radcliffe then sketched on the blackboard what he believed to be a more accurate comparison with emphasis on the three-dimensional shape both above and below the level of the tuberosity of the ischium. In each case, he showed a cross section of the socket at, (1) ischial level with the medial wall projected upward to this level; and (2) the outline of the highest points on the brim (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-14.jpg">Fig. 14</a> and <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-15.jpg">Fig. 15</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-14.jpg">Figure 14. Socket contours for an Ischial-Gluteal weight-bearing socket using the UC Berkeley Brims.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-15.jpg">Figure 15. Socket contours for an Ischial-Ramal weight-bearing socket of the NSNA type provided by Ivan Long.</a> This concluded all presentations of current fitting techniques. The remaining presentations were concerned with evaluation techniques. Bo Klasson of Een-Holmgren Company in Sweden presented on "Socket Fit With Reference to Soft Tissue Force Transmission." Briefly, Mr. Klasson's theory is that we should attempt to design sockets with physical characteristics that match the physical characteristics of the residual limb. In other words, where the tissues of the residual limb are firm, so should the matching area of the socket material be; where the tissues are soft and flexible, so should the socket be. Mr. Klasson refers to this as "surface matching." The next speaker was Professor George Murdoch of Dundee, Scotland, presenting "A Method for the Description of the Amputation Stump." Professor Murdoch's paper was based on his premise that there is a need for an international classification system for residual limbs to be developed in order to compare one publication with another, one patient with another, one fitting technique with another. The final presentation was made by A. Bennett Wilson on "Physiological Monitoring Equipment in Evaluation of Lower Limb Prosthetic Components and Techniques." He reported on a system of physiological monitoring originally developed by MacGregor of the University of Strathclyde in the 1970's. Recently modified for use by the University of Virginia Division of Prosthetics and Orthotics, this system consists of a compact tape recording component worn on a waist belt that records electronically, step count, walking velocity, standing versus sitting, and heart rate, plotted against time up to 24 hours. The tapes are then analyzed by a special micro-computer program, which subsequently prints the information in digital and graphic format. Under some circumstances the heart rate data can be useful in providing an energy index, but probably more importantly, the step count, standing versus sitting, and velocity data provide specific information about the activity of the subject. Mr. Wilson and colleagues have recently developed a solid state device which is less costly and more reliable. The new system has 17 information gathering channels. Mr. Wilson concluded by saying, "At this point, we do not have sufficient experience to know how many subjects have to be monitored and how much data is needed to show significant differences, but it certainly appears that at last we have a breakthrough in instrumentation for evaluation of prosthetic devices and other treatments involving the function of the musculoskeletal system. With all presentations complete, the plenary group was divided into six panels of six to nine members with the following charges: <ol> <li> Determine similarities </li> <li> Determine differences </li> <li> What is the role of flexible walls? </li> <li> Indications and contraindications </li> <li> Recommendations for future action <ol> <li> Evaluation </li> <li> Education </li> <li> Application </li> </ol> </li> </ol> This first group of panels reported back on Sunday morning. The reports were quite consistent among the different panels. A synopsis of these reports will be presented in concluding this report. On Monday, new panels were formed to re-study the rationale for and possibly develop protocol for evaluation. The reports from this second group of panels was heard in plenary session on Tuesday morning. The meeting was adjourned Tuesday, May 19, 1987 at noon. What follows here is a synopsis of the conclusions and recommendations of the panel reports. <ol> <li> Similarities & Differences <ol> <li> Biomechanics <ol> <li> Ischial Containment: <ol> <li> similarities: <ul> <li> all ischial containment sockets advocate and utilize varying degrees of ischial containment </li> </ul> </li> <li> differences: <ul> <li> quads do not utilize ischial containment </li> <li> ischial containment sockets, amount of ischial containment </li> </ul> </li> </ol> </li> <li> Weight Bearing Distribution: <ol> <li> similarities: <ul> <li> ischial containment sockets, combination of ischial tuberosity and ramus, and peripheral (soft tissue) </li> </ul> </li> <li> differences: <ul> <li> quads, ischial-gluteal weight bearing </li> </ul> </li> </ol> </li> <li> ML Stability—maintenance of adduction <ol> <li> similarities: <ul> <li> goal of all AK socket systems </li> <li> greater success and maintenance in ischial containment sockets due to ischium acting as bony stop or lock </li> </ul> </li> <li> differences: <ul> <li> quad, soft tissue lock only, no bony lock </li> <li> less successful maintenance of adduction, thus less ML stability </li> </ul> </li> </ol> </li> <li> Socket Shape—ischial level cross section <ol> <li> similarities: <ul> <li> ischial containment sockets, narrow ML, wider AP, concave post-trochanteric shape </li> </ul> </li> <li> differences <ul> <li> quad, wider ML, narrower AP </li> </ul> </li> </ol> </li> <li> Trimlines: <ol> <li> similarities: <ul> <li> ischial containment sockets, generally; especially anterior, posterior, and lateral wall trimlines </li> </ul> </li> <li> differences: <ul> <li> quads, especially higher anterior, lower posterior and lateral wall trimlines </li> <li> medial wall of CAT-CAM </li> </ul> </li> </ol> </li> <li> Suspension: <ol> <li> similarities: <ul> <li> all compatible with suction </li> </ul> </li> <li> differences: <ul> <li> ischial containment sockets, unclear about auxiliary suspension </li> </ul> </li> </ol> </li> <li> Alignment: <ol> <li> similarities: <ul> <li> all but NSNA utilize alignment devices </li> <li> ischial containment sockets, medial wall not on line of progression </li> <li> NSNA & UCLA CAT-CAM, tilting of knee bolt in bench alignment </li> <li> Shamp Narrow ML & NSNA, use of Long's Line </li> <li> ischial containment sockets,TKA bench alignment, socket midline </li> </ul> </li> <li> differences: <ul> <li> NSNA does not use dynamic alignment device </li> <li> quad medial wall on LOP </li> <li> not all tilt knee bolt </li> <li> NSNA, varying degrees of knee bolt tilt, 7°, female, 4°, male </li> <li> quad, bench alignment, more stable TKA, T reference point is located at posterior l? of socket </li> </ul> </li> </ol> </li> <li> Rotational Control: <ol> <li> similarities: <ul> <li> ischial containment sockets, bony lock of Ischium and post-trochanteric concavity </li> </ul> </li> <li> differences: <ul> <li> quad, muscular-soft tissue cross-section </li> </ul> </li> </ol> </li> </ol> </li> <li> Method of Obtaining Cast <ol> <li> similarities: <ul> <li> quad and Shamp Narrow ML utilize a casting brim </li> <li> UCLA CAT-CAM & Sabolich/Guth CAT-CAM, hand molding technique </li> <li> NSNA & UCLA CAT-CAM, standing </li> </ul> </li> <li> differences: <ul> <li> CAT-CAM & NSNA, hand molding technique </li> <li> Sabolich/Guth CAT-CAM, sometimes cast lying down </li> </ul> </li> </ol> </li> <li> Anatomical Considerations <ol> <li> UCLA CAT-CAM detail about pelvic differences: <ul> <li> ischial inclination </li> <li> pubic arch angle </li> <li> ilio-femoral angle </li> </ul> </li> <li> NSNA male, female alignment differences: <ul> <li> bolt tilt </li> </ul> </li> </ol> </li> </ol> </li> <li> Role of Flexible Walls <ul> <li> not linked to any one philosophy of designing an AK socket </li> <li> vital to the success of the Sabolich/Guth CAT-CAM </li> <li> improved sitting comfort </li> <li> improved proprioception </li> <li> better heat dissipation </li> <li> improved muscle activity </li> <li> reduced weight </li> <li> ease of socket change within frame, no loss of alignment </li> <li> enhanced suspension, if suction suspension </li> </ul> All participants agreed there is great need for improved flexible materials. </li> <li> Indications and Contraindications <ul> <li> there were no specific contraindications noted for any socket design </li> <li> some advocated not changing successful quad wearers </li> <li> quads are most successful on long, firm residual limbs with firm adductor musculature </li> <li> ischial containment sockets are more successful than quads on short, fleshy residual limbs </li> <li> ischial containment sockets are the better recommendation for high activity/sports participation/running </li> <li> lack of agreement on best recommendation for bilateral above-knee </li> </ul> </li> <li> Recommendations The panels' conclusions and recommendations were remarkably consistent. Most consistent was the recommendation for improved terminology, lumping what I have referred to as ischial containment into a single, workable term. Suggestions ranged from "Narrow ML" to Ischial/ Ramus Containment (IRC) and Non-Ischial Containment (Non-IRC). Due to time constraints, arguments about this recommendation were never resolved. It is hoped that all recommendations can be addressed in a future workshop or through some other form of action. <ol> <li> Evaluation There was unanimous agreement for formal evaluation of the newer above-knee techniques (NSNA, CAT-CAM, Shamp Narrow ML) as well as evaluation of implications of the inferiority of the quadrilateral technique. <ol> <li> A program for scientific/laboratory evaluation should be set up at a center or multiple centers, depending upon resources. This study might include: cinematography, force plate, motion analysis, gait mat and other "gait lab" studies as well as radiographical data on alignment and containment, physiological data, residual limb/socket force analysis, and/or any other relevant laboratory studies. </li> <li> A program of clinical evaluation, based on previous fittings and continuing fittings in clinics already utilizing new fitting techniques. This would be a more subjective study, and would require a greater effort for coordination and pooling of data. </li> <li> Complete manuals should be developed for each individual technique, unless the developers can find it mutually agreeable to work together and blend the new techniques. The panels found the latter option to be most desirable. </li> <li> Evaluation should be independent of the developers. </li> <li> Any evaluation needs to be coordinated by an authoritative group. ISPO and/or the U.S. Veterans Administration were recommended. The American Academy of Ortho-tists and Prosthetists should also be involved. </li> <li> Possible funding sources within the states include the Veterans Administration and the National Institute on Disability and Rehabilitation Research (NIDRR). </li> </ol> </li> <li> Education The post-graduate, specialized courses for experienced practitioners appear to be most appropriate for teaching these newer techniques at this time. Incorporation into entry level education programs should follow as well written, experience based manuals are developed. Any teaching course should include "hands-on", patient contact, fitting, and management as part of the curriculum. </li> <li> Application The application of these new techniques, while certainly not as widespread and accepted as the quadrilateral technique, or even the flexible socket technique, is occurring at this time. Growing acceptance and application will most certainly follow. It is hoped that this workshop, as well as future workshops, will aid in safe and proper application of these and future advances and developments in prosthetics. </li> </ol> </li> </ol> References: <ol> <li>UCLA AK Teaching Manual, 1977-1978.</li> <li>UCLA CAT-CAM Above Knee Prosthesis, Teaching Manual, Third Edition, March 1987.</li> <li>Fabricating The Long's Line Above-Knee Prosthesis, by Ivan long, 1981.</li> <li>Ivan Long's business card.</li> <li>Manual for use of THE SHAMP BRIM for the Narrow ML Above-Knee Prosthetic Socket, The Ohio Willowwood Co., 1987.</li> <li>By Charles Radcliffe. Re-drawn by A. Bennett Wilson, Jr.</li> </ol> *C. Michael Schuch, C.P.O. C. Michael Schuch, C.P.O., is Assistant Professor of Orthopaedics and Rehabilitation and Associate Director of the Department of Prosthetics and Orthotics at the University of Virginia Medical Center, Box 467, Charlottesville, Virginia 22908. Page Number(s) 81 - 98 Year 1988 Volume 12 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Report From: International Workshop on Above-Knee Fitting and Alignment Techniques Creator An entity primarily responsible for making the resource C. Michael Schuch, C.P.O. * https://staging.drfop.org/files/original/f97cfd5235b0aee89a8a246f3bb36a96.pdf 0611831203afbaea806f867bafac8a09 https://staging.drfop.org/files/original/c4503bd0ade204d8bd8febe76bbb6f56.jpg 19fcf5623ec96a54d6f85f8b60b2d008 https://staging.drfop.org/files/original/fb7cc1d43658e6003753aaa44c247f01.jpg 4ff3ceb12158adbee0cf9b90e7a640f2 https://staging.drfop.org/files/original/3fa04d3962c39877277abfdfa7e54654.jpg c5e9b43e7d407777ca340bd7247b7a56 https://staging.drfop.org/files/original/48dff4cea5f12c24f5a7ec7718c459fe.jpg 78b79fa22696174683179cfcb09a400f https://staging.drfop.org/files/original/01326057960c319c4b1259bcd805ddd3.jpg d07268216e98fea759014f362be88ab8 https://staging.drfop.org/files/original/d9b33408099151592c9792c42710a205.jpg 18fbe3ca5c7150b3dfecd879beced63b https://staging.drfop.org/files/original/62b4779e67198aad3af7f94c6224cfa5.jpg 97a440c22672ac2d9f3359115cf894d0 https://staging.drfop.org/files/original/14d93f4c4979723e691b143fa14c65ef.jpg 910dfa8cf554c1cb90120318e8acf61b Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_03_099.pdf Text Any textual data included in the document <h2>Component Selection Criteria: Lower Limb Disarticulations</h2> <h5>John Michael, M.Ed., C.P.O. <a style="text-decoration: none;">*</a></h5> Because disarticulations comprise only a small percentage of the lower limb amputations performed each year,<a></a> questions sometimes arise regarding the most appropriate components to select. This paper will present a brief overview in an effort to clarify the criteria involved. <h3>Hip Disarticulation/Hemipelvectomy Components</h3> For the hip disarticulation or hemipelvectomy case, component selection is generally analogous to the more familiar above-knee patient. Endoskeletal components are preferred for the high level amputee because they offer light-weight and enhanced cosmetic appearance. A clear trend away from steel components to the much lighter titanium or carbon fiber versions is apparent. Most systems (particularly the Otto Bock "Modular") also permit subtle realignment, even in the definitive prosthesis. This can be an advantage due to the complex interplay between the mechanical hip, knee, and foot mechanisms. <h3>Hip Joint Mechanisms</h3> In general, a free motion hip joint is preferred, as originally proposed by McLaurin in 1954.<a></a> Careful attention to alignment details results in a very stable configuration by virtue of the weight line and reaction line forces. This permits very safe weight-bearing, yet allows easy hip flexion during swing phase. Stride length is generally controlled by a spring or elastic flexion limiting apparatus, sometimes called an "extension bias." In modern practice, the joint is placed near the anterodistal quadrant of the socket, which sometimes requires a slightly shorter thigh segment for the best appearance when sitting. Manual locking hip joints are also available but should be reserved as the component of last resort, even for bilateral amputees. In addition to disrupting swing phase, locked joints require the use of one hand on the unlocking mechanism during sitting. This often makes a difficult task more complicated, particularly for the double amputee. More importantly, a locked hip joint may place the patient in a more dangerous position during a fall backwards. If the joint prevents flexion at the hips, the head rather than the buttocks may strike the ground first. In our last 50 consecutive fittings at Duke, both unilateral and bilateral hip/hemi patients have never required a locked joint to ambulate securely. Two variations in hip joint design warrant mention. Peter Tuil of the Netherlands advocates the use of a reversed polycentric knee disarticulation joint (Otto Bock 3R21) as a hip joint.<a></a> Benefits claimed are parallel to those expected from a polycentric knee unit: increased ground clearance during swing phase due to the inherent "shortening" of the linkage in flexion and enhanced stability at heel strike (Fig. 1). <a href="/files/original/c4503bd0ade204d8bd8febe76bbb6f56.jpg">Figure 1</a>. Prosthesis utilizing reversed polycentric knee disarticulation mechanism at the hip, as proposed by Peter Tuil of the Netherlands. (Courtesy of Orthotics & Prosthetics, 38/1, p. 33.) This view has been corroborated in a number of fittings over the past few years at the Royal Ottawa Regional Rehabilitation Centre in Canada.<a></a> Such a technique has also worked well in our hands at Duke, although we are not certain the benefits fully justify the special effort involved. An even more intriguing concept is the "Hip Flexion Bias" modification promulgated by Haslem, et al. of Houston, Texas.<a></a> In this system, hip extension from heel strike to mid-stance compresses a specially selected spring, which encircles the endoskeletal pylon. At toe-off, this kinetic energy is released and the thigh segment is propelled briskly forward (Fig. 2). <a href="/files/original/fb7cc1d43658e6003753aaa44c247f01.jpg">Figure 2</a>. Hip Flexion Bias system designed by Haslam et al. of Houston, Texas. Note compression spring encircling thigh tube, which propels the limb forward during swing phase. (Redrawn from reference 5) Not only does this result in a much more cosmetically "normal" gait, it also significantly improves ground clearance in swing phase. One of the inherent limitations of the Canadian hip disarticulation alignment system is the prosthesis must be significantly short (1cm+) to avoid forcing the amputee to vault for toe clearance. Fig. 3 and Fig. 4 illustrate the biomechanics of the Canadian design. At toe-off, the heel rises up during knee flexion and pulls the hip joint firmly against its posterior (extension) stop. The thigh segment remains vertical until the knee has reversed its direction of motion and contacted the knee stop. Only then does the thigh segment rotate anteriorly, causing the hip joint to flex. In essence, the prosthesis is at its full length during midswing. Since the patient has no voluntary control over any of the passive mechanical joints, the prosthetist is forced to shorten the limb for ground clearance. <a href="/files/original/3fa04d3962c39877277abfdfa7e54654.jpg">Figure 3</a>. Canadian prosthesis in early swing phase. Hip joint remains neutral as shank swings forward. (Redrawn from reference 13) <a href="/files/original/48dff4cea5f12c24f5a7ec7718c459fe.jpg">Figure 4</a>. Canadian prosthesis just after mid-swing. Hip joint does not flex until shank motion is arrested by terminal extension stop. Prosthesis is fully extended at the instant of mid-swing. (Redrawn from reference 13) The hip flexion bias system neatly avoids this dilemma. As a result, the prosthesis can be lengthened to a nearly level configuration in most cases. However, two potential problems have been noted with this approach. One is the development of annoying squeaks in the spring mechanism after a few months of use, which sometimes tend to recur inexorably. A more significant concern is that as the spring compresses between heel strike and midstance, it creates a strong knee flexion moment. Unless this is resisted by a stance control knee with friction brake or a polycentric knee with inherent stability, the patient may fall. Since the friction brake mechanisms lose their effectiveness as the surface wears, the polycentric knee is the preferred component with this hip mechanism.<a></a> <h3>Knee Joint Mechanisms</h3> Other than the exception discussed above, knee mechanisms are selected by the same criteria as for above-knee amputees. The single axis/constant friction design remains the most widely utilized due to its light weight, low cost, and excellent durability. The friction resistance is often removed to ensure the knee reaches full extension as quickly as possible. A strong knee extension bias enhances this goal, offering the patient the most stable biomechanics possible with this mechanism. Although this was proposed as the knee of choice for the Canadian hip disarticulation design, more sophisticated mechanisms have proven their value and are gradually becoming more common. The friction brake stance control knee (Otto Bock 3R15 or equivalent) is probably the second most frequently utilized component. Because there is very little increase in cost or weight and reliability has been good, many clinicians feel the enhanced knee stability justifies this approach—particularly for the novice amputee. Mis-steps causing up to 15° knee flexion will not result in knee buckle, making gait training less difficult for the patient or therapist. The major drawback to this knee is that the limb must be non-weight-bearing for knee flexion to occur. Although this generally presents no problem during swing phase, some patients have difficulty mastering the weight shift necessary for sitting. It should be noted that use of such knee mechanisms bilaterally must be avoided. Since it is impossible for the amputee to simultaneously unload both artificial limbs, sitting with two stance control knees also becomes nearly impossible. A third class of knee mechanisms which has proven advantageous for this level of amputation is the polycentric group (Otto Bock 3R20 or equivalent). Although slightly heavier than the previous two types, this component offers maximum stance phase stability. Because the stability is inherent in the multi-linkage design, it does not erode as the knee mechanism wears during use. In addition, all polycentric mechanisms tend to "shorten" during swing phase, adding slightly to the toe clearance at that time. Many of the endoskeletal designs feature a readily adjustable knee extension stop. This permits significant changes to the biomechanical stability of the prosthesis, even in the definitive limb. Because of the powerful stability, good durability, and realignment capabilities of the endoskeletal polycentric mechanisms, they are particularly well suited for the bilateral amputee.<a></a> All levels of amputation, up to and including bilateral hemipelvectomy (hemicorporectomy), have successfully ambulated with these components. At first glance, a manual locking knee seems a logical choice. However, experience has shown this is rarely required, and should be reserved as a prescription of last resort. Only multiple medical disabilities (e.g. concomitant blindness) will require this mechanism. The complications in unlocking a joint for sitting by the unilateral have been discussed previously; expecting a bilateral amputee to cope with dual locking knees and dual locking hips can be an overwhelming task. For many years, the use of fluid controlled knee mechanisms for high level amputees was considered unwarranted, since these individuals obviously walked at only one (slow) cadence. The development of the hip flexion bias mechanism and more propulsive foot designs have challenged this assumption. Furthermore, a more sophisticated understanding of the details of prosthetic locomotion has revealed an additional advantage for the hip/hemi amputee. It is well accepted that any fluid control mechanism (hydraulic or pneumatic) results in a smoother gait.<a></a> Motion studies conducted at Northwestern University revealed that a more normal gait for the hip/hemi patient is also a by-product.<a></a> The preferred mechanism has separate knee flexion and extension resistance adjustments. A relatively powerful flexion resistance limits heel rise and initiates forward motion of the shank more quickly. In essence, the limb steps forward more rapidly. As the shank moves into extension, the fluid resistance at the knee transmits the momentum up the thigh segment, pushing the hip joint forward into flexion. In essence, the fluid controlled knee results in a hip flexion bias effect (Fig. 5). <a href="/files/original/01326057960c319c4b1259bcd805ddd3.jpg">Figure 5</a>. Canadian prosthesis with fluid controlled knee mechanism at mid-swing. Hydraulic extension resistance allows shank momentum to flex hip joint. Increased ground clearance may result. (Adapted from reference 13) Sophisticated gait analyses have demonstrated that this results in significantly more normal range of motion at the hip joint during the walking cycle.<a></a> Clinical observations suggest that a more varied cadence is possible, and the prosthesis can usually be fabricated to nearly full length without swing phase difficulties. Richard Lehneis, et al. have reported on a coordinated hip-knee hydraulic linkage using a modified hydrapneumatic unit.<a></a> This was designed to create a hip extension bias, and resulted in a smooth gait. We have no experience with this particular component at Duke. Finally, a number of new components have been developed recently which combine the characteristics of some of the above classes of knee mechanisms. For example, Teh Lin manufactures a "Graphlite" knee consisting of a polycentric set-up with pneumatic swing phase control in a carbon fiber receptacle. <h3>Foot Mechanisms</h3> Traditionally, the Solid Ankle Cushion Heel (SACH) has been considered the foot of choice for the Canadian hip disarticulation design due to its light weight, low cost, and excellent durability.<a></a> Provided the heel durometer is very soft, knee stability with this foot has generally been quite acceptable. In those cases where slightly more knee stability was desired, a single axis foot with a very soft plantar flexion bumper was preferred.<a></a> Added weight, maintenance, and cost, plus reduced cosmesis are the liabilities of this component. Multi-axis designs (such as the Greissinger) have similar liabilities to the single axis versions, but add extra degrees of freedom via hindfoot inversion/eversion and transverse rotation. In addition to accommodating uneven ground, absorbing some of the torque of walking, and protecting the patient's skin from shear stresses, multi-motion feet seem to decrease the wear and tear on the prosthetic mechanisms as well.<a></a> In the last five years, more sophisticated foot mechanisms have reached the market, and all have been demonstrated to function successfully for the high level amputee. The Solid Ankle Flexible Endoskeleton (SAFE) foot inaugurated a class that could be termed "Flexible Keel" designs.<a></a> Other members of this class include the STEN foot and the Otto Bock 1D10 Dynamic foot. All are characterized by a softer, more flexible forefoot, resulting in a smoother rollover for the patient. The SAFE version offers some transverse rotation as well.<a></a> In general, a softer forefoot requires special care during dynamic alignment to ensure that knee buckle does not occur inadvertently. However, when used in concert with a polycentric knee, the reverse occurs: the prosthesis actually becomes safer during late stance phase. The polycentric knee mechanism strongly resists a bending moment, which leads to its powerful stability at heel strike. It flexes during swing phase only if the forefoot remains firmly planted on the floor as the body "rides" the prosthesis over it.<a></a> This creates a shearing force which disrupts the linkage and permits easy flexion of the knee. Because the softer flexible keel delays this shearing moment, the polycentric knee is actually more stable in late stance than with a more rigid foot. Dynamic Response feet, which provide a subjective sense of active push-off, can also be used to advantage for the hip/hemi amputee.<a></a> Carbon Copy II, Seattle foot, and Flex-Foot(tm) have all been successfully utilized for this type of patient. They seem to provide a more rapid cadence, as evidenced by one long-term hip disarticulation wearer, who stated after receiving a Seattle foot, "For the first time in my life, I can pass someone in a crowd."<a></a> Once again, the interaction between the foot and knee must be carefully monitored. In general, the more responsive the foot mechanism, the more important the knee unit resistances become. Many practitioners prefer a fluid controlled knee, or at least one with powerful friction cells.<a></a> Otherwise, much of the forward momentum of the shank can be wasted as abrupt terminal impact of the knee. Presumed reductions in energy consumption have not yet been documented by scientific studies. In addition to the foot mechanisms, several ankle components have recently reached the American market. These can be paired with most of the feet mentioned above, adding additional degrees of motion as desired. Examples include the SwePro ankle from Sweden, the Blatchford (Endolite) Multifiex ankle from England, and the recently announced Seattle ankle. Torque absorbing units are often added to hip/hemi prostheses to reduce the shear forces transmitted to the patient and components.<a></a> Ideally, they are located just beneath the knee mechanism. This increases durability by placing the mechanism away from the sagittal stresses of the ankle, yet avoids the risk of introducing iatrogenic swing phase whips. The major justification for such a component is that the high level amputee has lost three biological joints and, hence, has no way to compensate for the normal rotation of ambulation. Torque absorbers can be combined with virtually any foot available, if desired. Finally, transverse rotation units originally developed for the Oriental world have become available. Installed above the knee mechanism, these devices permit the amputee to press a button and passively rotate the shank 90° or more for sitting comfort. They not only facilitate sitting cross-legged upon the floor, but also permit much easier entry into automobiles and other confined areas. <h3>Knee Disarticulation Components</h3> Although it is generally agreed that knee disarticulation offers the possibility of increased function over an above-knee amputation,<a></a> it clearly restricts patients' options in knee mechanisms and results in cosmetic compromises as well. For these reasons, its advisability remains hotly contested among knowledgeable surgeons and prosthetists. <h3>Knee Mechanisms</h3> The traditional knee mechanism for disarticulation has been the single pivot external hinges. Inherent disadvantages have been the lack of swing phase control (no friction adjustments) and rapid wear due to the small bearing surface compared to the typical 4" long axle of the above-knee set-up. Even with the addition of a posterior "back check" to limit extension, rapid wear of the extension stops is common. The major virtues of this design are its simplicity and low cost. It probably functions best for small children. Although the knee ball does not protrude when sitting, external hinges result in a slightly wider mediolateral configuration which some patients find objectionable. Heavy duty wearers can quickly destroy these relatively slender joints. One manufacturer provides a yoke attachment permitting the use of a fluid-controlled cylinder with these hinges (Fig. 6). This improves swing phase significantly, but long-term durability remains problematic. <a href="/files/original/d9b33408099151592c9792c42710a205.jpg">Figure 6</a>. Cut-away drawing of special hydraulic mechanism with yoke, permitting swing phase control for knee disarticulations with single pivot external hinges. (Redrawn with permission of Hosmer-Dorrance Corporation) The only other type of knee possible is a special polycentric design. By using longer linkage arms, the shank appears to fold back under the thigh when sitting, thus minimizing the apparent protrusion of the knee (Fig. 7). Since no mechanism is alongside the knee, the me-diolateral silhouette is more acceptable as well. <a href="/files/original/62b4779e67198aad3af7f94c6224cfa5.jpg">Figure 7</a>. Polycentric knee disarticulation mechanism flexed to 90°. Note how linkage "folds up" beneath the thigh segment, effectively shortening the shank and minimizing anterior protrusion when sitting. Several manufacturers offer the option of fluid controlled units along with the polycentric mechanism, and almost all have friction control options as well. For this reason, swing phase functioning is much better than the simple external hinge design (Fig. 8). <a href="/files/original/14d93f4c4979723e691b143fa14c65ef.jpg">Figure 8</a>. Example of polycentric mechanism permitting interchange of mechanical and fluid control swing phase units. (Designed by Orthopedic Hospital of Copenhagen; redrawn with permission of United States Manufacturing Company) All polycentrics offer powerful inherent stance phase control, and this group is no exception. However, because distal weight-bearing dramatically simplifies the biomechanics of knee control, this feature is seldom of great value to the patient. One manufacturer offers a manual locking module as well, but this should be used only as a last resort. One subtle problem with knee disarticulation polycentrics is that the relative "shortening" of the shank in sitting may lift the foot completely off the floor, particularly for husky individuals who are less than 5' 6" tall. The resulting sense of insecurity can be very disconcerting to the amputee and may result in rejection of the prosthesis. Durability can sometimes be a problem, although it is generally better than for external hinges. Most knee disarticulation polycentrics work quite well for geriatric patients but can become increasingly problematic for extremely vigorous individuals. In some cases, the only effective solution to chronic breakage problems is to switch to a conventional above-knee set-up. This results in protrusion of the knee ball by at least 2", making sitting in tight spaces (such as bus seats) nearly impossible. Although the function and durability are excellent, the cosmetic liability of such malalignment is obvious to the casual observer as well. <h3>Foot Mechanisms</h3> Knee disarticulates can utilize all the feet and ankle options of the higher level amputee, as previously discussed. Knee stability is rarely a concern, but reducing stress on the relatively fragile knee mechanism is a concern. For that reason, the author favors flexible keel designs, with or without a torque absorbing unit, since these components reduce the forces transmitted to the limb. <h3>Ankle Disarticulation (Symes)</h3> Like his knee disarticulate brethren, the Symes amputee has a very limited range of choices in prosthetic componentry. In addition, a significantly poorer cosmetic result is inevitable. These disadvantages must be weighed against the functional advantages of distal weightbearing and the documented reduction in energy consumption over the below-knee amputee.<a></a> <h3>Foot Mechanisms</h3> The Symes amputation generally precludes the use of any articulated ankle mechanism, due to space limitations. The heavy metal frame of yesteryear is virtually extinct. Most of today's Symes amputees are fitted with a SACH foot. The specially designed Symes version suffers from reduced durability due to the greater stresses the end-bearing residual limb can exert on the prosthesis. However, it can often be replaced economically if broken. The external keel SACH design limits inversion and eversion almost completely but can be more durable and more cosmetically pleasing than the standard SACH. Since its use precludes any alteration of alignment after transfer and finishing, great care must be exercised during the fitting. The Stationary Ankle Flexible Endoskeleton (SAFE) foot, discussed earlier, has a Symes version. This offers a flexible keel and much smoother roll-over. This reduces the forces transmitted to the prosthetic socket, increasing both patient comfort and socket durability. Reliability is adequate, and replacement is possible. The author prefers this design for Symes amputees for the reasons cited. The Carbon Copy II has recently developed a dynamic response design suitable for many adult male Symes. Patient response has been favorable, as they sense the dynamic push-off it offers. External appearance is excellent, as is the weight reduction. Our experience at Duke is too short to comment at this time on durability of this component or its effect on socket stresses. <h3>Summary</h3> Although disarticulations represent less than five percent of the lower limb amputees fitted annually,<a></a> appropriate components can be selected based on logical criteria. Both Symes and knee disarticulates, however, have limited component options, often with decreased reliability plus cosmetic limitations compared to more conventional amputation levels. Hip disarticulates and hemipelvectomies have as broad an array of choices as the above-knee, prescribed for generally analogous reasons. As our understanding of biomechanics has improved, more sophisticated mechanisms have been successfully provided to this group of patients. Current state-of-the-art requires careful consideration of the subtle interactions between the foot, ankle, hip, and ancillary mechanisms to ensure the optimum result for each patient. References: <ol> <li><a href="al/1963_01_005.asp">Glattly, Harold W., "A Preliminary Report on the Amputee Census," Artificial Limbs, 7(1), 1963, pp. 5-10.</a></li> <li>McLaurin, C.A., "Hip Disarticulation Prosthesis," Report No. 15, Prosthetic Services Centre, Department of Veterans Affairs, Toronto, Canada, 1954.</li> <li>Webster, B. and P. Tuil, "Heupexarticulates Onder De Loep," Infortho, August, 1982.</li> <li>Van der Waarde, Tony, "Ottawa Experience with Hip Disarticulation Prostheses," Orthotics and Prosthetics, 38(1), 1984, pp. 29-33.</li> <li>Haslam, T. and M. Wilson, "Hip Flexion Bias," Concept 80, Medical Center Prosthetics, Houston, Texas, 1980.</li> <li>Ibid.</li> <li>McLaurin, op. cit.</li> <li>Greene, Michael, "Four Bar Knee Linkage Analysis," Orthotics and Prosthetics, 37(1), 1983, pp. 15-24.</li> <li>Mooney, Vert, in Atlas of Limb Prosthetics, C.V. Mosby Company, St. Louis, 1981, pp. 391-395.</li> <li>Van Vorhis, Robert, "Clinical Analysis of Hip Disarticulation Prostheses," 31st Scientific Meeting, Midwest Chapter, AAOP, Lincolnshire, Illinois, 1981.</li> <li>Ibid.</li> <li>Lehneis, H.R. et al., Prosthetics Management for High Level Lower Limb Amputees, Institute of Rehabilitation Medicine, New York, New York, 1980.</li> <li>Hampton, F., A Hemipelvectomy Prosthesis, Northwestern University Prosthetic Research Center, Chicago, Illinois, 1964, p. 32.</li> <li>Gehl, Gunter, "Proper Selection of Prosthetic Components," Northwestern University Prosthetic Orthotic Center, Certificate course, Chicago, Illinois, 1976.</li> <li>Ibid.</li> <li>Michael, John, "Analysis of Energy Storing Feet," AAOP Annual Meeting and Scientific Symposium, Newport Beach, California, 1988.</li> <li>Campbell, J. and C. Childs, "The S.A.F.E. Foot," Orthotics and Prosthetics, 34(3), 1980, pp. 3-17.</li> <li>Nader, Max et al., "Polycentric, Four Bar Linkage Knee Joint," Technical Information Bulletin No. 45, Otto Bock Industries, Duderstadt, West Germany, 1988, p. 3.</li> <li>Michael, op. cit.</li> <li>Michael, J., "Energy Storing Feet: A Clinical Comparison," Clinical Prosthetics and Orthotics, 11(3), 1987, pp. 154-168.</li> <li>Leal, J., personal communication, 1987.</li> <li>Nader, Max et al., "Torsion Adapter With Tube," Technical Information Bulletin No. 2.6.1, Otto Bock Industries, Duderstadt, West Germany, 1986, p. 3.</li> <li><a href="poi/1983_02_119.asp">Jensen, J.S. and T. Mandrup-Poulsen, "Success Rate of Prosthetic Fitting After Major Amputations of The Lower Limb," Prosthetics and Orthotics International, 7(2), 1983, pp. 119-122.</a></li> <li>Waters, R.L. et al., "Energy Costs of Walking of Amputees: The Influence of Level of Amputation," Journal of Bone and Joint Surgery, 58A, 1976, p. 46.</li> <li>Glattly, op. cit.</li> </ol> *John Michael, M.Ed., C.P.O. John W. Michael, M.Ed., C.P.O., is Director and Assistant Clinical Professor at Duke University Department of Prosthetics and Orthotics, Duke University Medical Center, P.O. Box 3885, M04 Davison, Durham, North Carolina 27710; (919) 684-2474. Page Number(s) 99 - 108 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-7.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-8.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Component Selection Criteria: Lower Limb Disarticulations Creator An entity primarily responsible for making the resource John Michael, M.Ed., C.P.O. * https://staging.drfop.org/files/original/730cd988b459c0470f09d2a2b1c901c0.pdf c64b39002b638752f02a6481b5256f6c https://staging.drfop.org/files/original/f5b53660057bef0aa5062375e0944618.jpg 71c691b1acd762609be7aef78e31a615 https://staging.drfop.org/files/original/507f8e598d697564a8825ef436c9831f.jpg 8c2dab42f1da4a77dd5b8083f04dce69 https://staging.drfop.org/files/original/541b427a8b6b0e194b041e8cc2c59da1.jpg 6919d95465a51c86db5c65678cb30502 https://staging.drfop.org/files/original/3d90295042f79f041d671c5d41f0392d.jpg 7d59e48c5e8c4047578f190b6e516375 https://staging.drfop.org/files/original/71925d0bb446f6b649060c3ce4462e59.jpg 9b323c95c211ec10d01e7feee755cd18 https://staging.drfop.org/files/original/3396fe9730b14b2e8657689fe74865b5.jpg 643294f08d5a592e58d3ea194294785d https://staging.drfop.org/files/original/b9a09fc152979d703b46c792aed66798.jpg a101cb269531ad4c2ddca3abe3c64fb3 https://staging.drfop.org/files/original/a310a604046c1382bc0c3548b947c299.jpg 0c5f822f77e1f2a66fd8f148fb0fb1b0 https://staging.drfop.org/files/original/2a80303457c8a42d0517fa0e01a299e9.jpg 44668a6d1b6a2b3675ba14074520a508 https://staging.drfop.org/files/original/3df94aa6ab1f93ff4d20a470503069ef.jpg f0c64be6e5bbae5c7b28834975248ee8 https://staging.drfop.org/files/original/3afb84d3903ae00d345a76156822ebc2.jpg c8495b91e25a321f39294efe21e110ad Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_03_109.pdf Text Any textual data included in the document <h2>The Hip Disarticulation Prosthesis as Developed by the O.I.M. Noord Nederland</h2> <h5>Peter Tuil <a style="text-decoration: none;">*</a></h5> What characterizes the hip disarticulation prosthesis of the O.I.M. Noord Nederland is the use of a four-bar Otto Bock knee joint as a hip joint. O.I.M. Noord Nederland has used this variation with much success over the last five years. At first, it was questionable whether the joint would be strong enough, but this has proven not to be an issue. There have been some problems with the 3R21, but only when it is used as a knee joint. These complications have been due to extreme flexion, lamination sections that were too thick and caused the joint to tear apart during flexion, or too much external rotation. There are two advantages in the use of the four-bar hip joint. First, the patient walks with a lower energy expenditure because the prosthesis shortens the swing phase. In contrast to patients who have worn older style hip disarticulation prostheses (for years patients used to be fitted with a tilting-table prosthesis or later with a wooden "Canadian hip" prosthesis), the patients with the new style prosthesis walk more and have indicated that they use less energy. Second, there is hardly any strain on the cosmetic cover, so much less damage is done. An additional advantage of the four-bar joint is that the construction can be less critical. Besides, the whole prosthesis can be readily adjusted. <h3>Description of the Fabrication Method</h3> To make the plaster impression, two wooden blocks are mounted on a table or casting stand. (Editorial note: Presumably this stand is adjustable in height.) These wooden blocks have sloped planes so that a wedge-formed gap is created between them (Fig. 1). In the back, the sloped side forms a 60° angle. In the front, the sloped side is divided into two different angles (Fig. 2). Both blocks can rotate around their vertical axles with regard to the table to which they are attached. They can also be shifted with regard to each other in the sagittal plane by means of a spindle (worm gear mechanism). The blocks are primarily meant to provide a good fitting of the residual limb and pressure relief in the places where that is necessary. <a href="/files/original/f5b53660057bef0aa5062375e0944618.jpg">Figure 1</a>. Apparatus used for casting. <a href="/files/original/507f8e598d697564a8825ef436c9831f.jpg">Figure 2</a>. Side view of the wooden blocks. The four-bar joint is attached to the socket by means of a specially manufactured adaptor (Fig. 3 and Fig. 4). The adaptor, which will later be incorporated into the socket, mimics the wedged shape of the wooden blocks (Fig. 5). <a href="/files/original/541b427a8b6b0e194b041e8cc2c59da1.jpg">Figure 3.</a> The adaptor. <a href="/files/original/3d90295042f79f041d671c5d41f0392d.jpg">Figure 4</a>. Shows how the adaptor, which will later be laminated into the socket, relates to the wedged form of the wooden blocks. <a href="/files/original/71925d0bb446f6b649060c3ce4462e59.jpg">Figure 5.</a> The apparatus forms a good plane of reference. Finally, the impression of the wooden table provides a good plane of reference for the plaster model (Fig. 6). <a href="/files/original/3396fe9730b14b2e8657689fe74865b5.jpg">Figure 6</a>. Position of the adaptor as related to the pelvic socket. This impression of the horizontal plane must remain horizontal during the construction process. During plaster modification, one should maintain unchanged the medial of the plaster model in the transverse plane, so that the impression of this edge will always indicate the line of progression of the plaster model. The socket is laminated in three layers. First though, a layer of Pe-Lite™ is put on the plaster model, followed by a layer of stockinette, and finally a layer of P.V.A. foil. The layer of stockinette is always applied under the first layer of foil. This will provide better suction, absorb some moisture, and the plaster model need not be as smooth. The first layer is laminated from flexible resin with two layers of Perlon stockinette, which is elastic in two directions. Subsequently the adaptor is located as shown in Fig. 7. <a href="/files/original/b9a09fc152979d703b46c792aed66798.jpg">Figure 7</a>. Reinforcement of the socket. The space between the adaptor and the plaster model is filled with "leichtspatel" (filler). The base of the plaster model must stand horizontally. The adaptor is placed approximately 4 to 5cm lateral of the groin. The maxim is to get the adaptor directly underneath the ischial tuberosity. However, this is influenced by the needs of the cosmetic cover. The adaptor is then covered with two layers of stockinette and a reinforcing layer of carbon fiber matting to prevent the adaptor breaking loose from the forces generated at heel strike. A strip of carbon fiber is put in the front to prevent the pelvis socket from curling inward. A reinforcing band of glass fiber is placed diagonally as shown in Fig. 8. Over this, two layers of stockinette are placed. First, rigid lamination resin is applied on those areas where the socket must be rigid. The rest is laminated with flexible resin. An adjustable "jig" is necessary in order to be able to turn the model around in the bench-vice quickly. The final layer is done with flexible resin and two layers of stockinette. <a href="/files/original/a310a604046c1382bc0c3548b947c299.jpg">Figure 8</a>. Alignment is first considered with the patient seated. A layer of stockinette and P. V. A. foil are put on the socket. Then, the little cap needed to finish the cosmetic cover is laminated with three or four layers of stockinette and one layer of carbon fiber. The extra time needed to form this cap will later save a lot of time during the finishing of the cosmetic cover. The prosthesis is completed with a four-bar knee joint (3R21), a single axis ankle joint foot, and a rotation adaptor. The alignment of the prosthesis is first considered in the sitting position. One must take into account the symmetry in comparison to the healthy limb (Fig. 9 and Fig. 10). The definitive alignment is settled upon during stance and walking exercises (Fig. 10). The adjustment of the 3R21 knee joint is very important. Mistakes in alignment can cause malfunctions of the knee joint. Many adjustments are possible with regard to rotation in the hip joint itself. The lack of facility to adjust abduction has never been a problem. <a href="/files/original/2a80303457c8a42d0517fa0e01a299e9.jpg">Figure 9</a>. Side view of the patient sitting and wearing the prosthesis. <a href="/files/original/3df94aa6ab1f93ff4d20a470503069ef.jpg">Figure 10</a>. The realization of definitive alignment. The freedom of movement when seated is considerable (Figs. 11 and 12). <a href="/files/original/3afb84d3903ae00d345a76156822ebc2.jpg">Figure 11 and 12.</a> Freedom of movement when seated. The cosmetic cover is shaped in the hip area, as well as in the knee area, so that less tension will be induced in the cover during flexion and when seated. Finally, a long elastic strip is glued to the inner anterior wall of the cover. This is done to protect the foam-cover. The construction process for a prosthesis for a hemipelvectomy is similar. *Peter Tuil Peter Tuil can be contacted at Stitchting Orthopedische Instrumentmakerij, Noord-Nederland Dilgtweg 5, 9751 ND Haren (Gn), The Netherlands. Page Number(s) 109 - 113 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-10.jpg Figure 11 FIGURE 11 & 12 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-11.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Hip Disarticulation Prosthesis as Developed by the O.I.M. Noord Nederland Creator An entity primarily responsible for making the resource Peter Tuil * https://staging.drfop.org/files/original/f27b5d0368f4e859eccd1d6f3bbc38f3.pdf 2f3ebf3eaaf369545618afd8223fa39a https://staging.drfop.org/files/original/f035dc301e4fd1b9f7d498b18103cf33.jpg bc8736187d5b1cf372db15bae5fecbd1 https://staging.drfop.org/files/original/2f7fa7cb9146f525c58ba9d5bcdceee4.jpg d214434a7961b9d5b14e264027271d7a https://staging.drfop.org/files/original/3a3c0bf2056231987373ba4f3814cbdf.jpg 23890f5cc143cafe9297a430b85fd568 https://staging.drfop.org/files/original/1a23101ee14ed4cb9aada341d3d3c26e.jpg 93936696164a3d915c3460beb861e616 https://staging.drfop.org/files/original/448a0c6b9b0421ba2d64bccc76c9c0ea.jpg d170fb3ae9f4307cbf7564df55fca257 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_03_114.pdf Text Any textual data included in the document <h2>The UCLA Anatomical Hip Disarticulation Prosthesis</h2> <h5>David H. Littig, B.A., CP. <a style="text-decoration: none;">*</a> Judd E. Lundt, B.S., A.E. <a style="text-decoration: none;">*</a></h5> This article discusses a new approach to hip disarticulation and hemipelvectomy fittings developed at the UCLA Prosthetics Education Program. It employs fundamental principles and methods in a new and different combination to produce a more complex and more natural biomechanical system. The results include: <ul> <li> a smoother, and apparently less energy consuming gait </li> <li> improved stability </li> <li> improved suspension </li> <li> improved wearer comfort </li> </ul> <h3>Introduction</h3> For several years now, the UCLA Prosthetics Education Program has been involved in an effort to understand, develop, and refine a teaching method for the CAT-CAM Socket,<a></a> the anatomically shaped above-knee socket. The very essence of this effort is a broader and more detailed understanding of the pelvic anatomy and its optimal containment within the socket. With the dramatic above-knee results that have been achieved through this understanding has come a compelling and obvious need to examine the application of the same principles to hip disarticulation fittings. It was felt that a hip disarticulation socket design, which would encapsulate the ischium and ischial ramus in a more anatomical contour than previous socket designs, might produce an improved prosthetic fitting.<a></a> Since much of the CAT-CAM experience alluded to employed a frame supported flexible polyethylene socket, the flexibility of such a design applied to a hip socket seemed a reasonable way to provide more comfort. These factors formed the basis for this work. To date, three hip disarticulation patients and one complete hemipelvectomy patient have been successfully fit with the design described. The hemipelvectomy application followed the hip patient fittings by a number of months and was tried only as a whimsical experiment. Based upon the initial understanding of the biomechanics, this fitting was not expected to succeed. However, the results were quite surprising and motivated another look at the biomechanical analysis. Two of the hip cases and the hemipelvectomy case will be described in this article along with the biomechanics. <h3>Patient Experience</h3> The first hip disarticulation patient is a 23 year old male who had an amputation on the right side at age five for tumor, and who has rejected a prosthesis since age ten because it was too limiting and cumbersome. Owing to immature muscular and skeletal development at the time of amputation, he is significantly atrophied on the amputated side. This individual is extremely active, participates and excels in athletics as an equal with the able-bodied, and is impressively agile on crutches. Consequently, his remaining limb is hyperdeveloped to the extent that the thigh musculature extends well past the midline of the body. The second hip case, a right amputee as well, could be described as a more typical patient. He is a 40 year old professional, amputated at age 28, also due to a tumor. He has worn a prosthesis continuously since his amputation, the most recent being an Otto Bock en-doskeletal design. When this project was begun, he had recently taken delivery of a new one-piece flexible socket prosthesis which combined a Flex-Foot™ with Otto Bock endo-skeletal knee and hip components. The hemipelvectomy case was a 26 year old male who had undergone complete amputation on the left side for a massive tumor in the hip joint. At the time of the work described here, which was six months post-surgery, he had not yet been fit for a definitive prosthesis, but was wearing a socket only for sitting comfort. This patient was first seen as a demonstration subject for prosthetic certificate students at UCLA. For that program, he was fit with a fairly conventional design. However, since his level of amputation is somewhat uncommon, and because the patient was willing to experiment, the design was altered to include the suspension system that had been found to be so successful with the hip disarticulation patients. <h3>Fabrication</h3> The hip patients were cast using a similar technique with splints, circular wrap, iliac crest definition, anterior and posterior compression, and ischial weight-bearing while the plaster hardened. Since this was an attempt at a more anatomical socket, contours detailing the ischial ramus angle and the medial inclination of the ischium were included in the cast. Unlike the above-knee socket which flexes and extends with the femur through each stride, the hip socket is expected to remain relatively fixed, relative to the pelvic anatomy. Thus, the medial brim need not extend as high or contain as much of the ischial ramus. If properly executed, a cast which includes the bony contours of the pelvis will take much of the guesswork out of cast modification and fitting and should reduce the number of check sockets needed to attain an optimum result. The initial concept for a hip disarticulation socket was a one-piece polyethylene design with a laminated frame to which the hip joint would be attached. Accordingly, such a system was fabricated for the first fitting. The results were reasonably successful. However, sound side comfort and piston action of the resulting prosthesis were not wholly satisfying. Since this was an experiment, it was decided to push further. Through several reiterations of socket size, volume and shape, and through several experiments with suspension, the design described in this article was arrived at: a two-piece system composed of a laminated anatomically shaped socket, encompassing only the amputated side and connected to a polyethylene suspension segment for the sound side waist with Dacron® webbing (Fig. 1). <a href="/files/original/f035dc301e4fd1b9f7d498b18103cf33.jpg">Figure 1</a>. Posterior view of suspension system showing "X" pattern strapping. Fabrication of the socket for the hip patients was relatively simple because of the two-piece design. The original model was split and only the amputated side laminated. For the contralateral side, a shell of Aliplast®-lined polyethylene was vacuum formed over that half to serve as the suspension system. Since the initial fitting of the hemipelvectomy patient was meant to instruct the certificate students in basic prosthetics for this level of amputation, the approach was very straightforward. He was cast in a suspended attitude with a simple circular wrap. Modification involved little more than smoothing of the model. A total flexible polyethylene socket was vacuum formed over the entire model. Following this, a frame for mounting the hip joint was laminated over the amputated side only of the polyethylene socket. As this was a demonstration fitting with no intent to finish, the hip joint was only temporarily attached. Prostheses for all patients were assembled with Otto Bock endoskeletal 7E7 hip joints and 3R20/3R36 knee units. Several feet were experimented with on the first patient until an Otto Bock single axis foot proved optimum. The Flex-Foot™ that had been included with the second patient's recently delivered prosthesis was incorporated into his set-up. The hemipelvectomy patient was also fit with an Otto Bock single axis foot. The socket and sound side suspension segment for the hip disarticulations were joined posteriorally with Dacron® webbing. Using temporarily attached four-bar buckles and the webbing, the proximal and distal aspects of the socket and the polyethylene segment were connected with the webbing to form an "X" pattern across the posterior gap (Fig. 1). At their cross point, the straps are not connected but are allowed to freely move with respect to each other. The buckles were found to be necessary for "fine tuning" adjustments of the suspension during fitting and alignment. Anteriorly, a single strap attached at the distal aspect of the laminated socket was passed through a loop on the polyethylene portion and back to a roller buckle on the anterior proximal socket (Fig. 2). <a href="/files/original/2f7fa7cb9146f525c58ba9d5bcdceee4.jpg">Figure 2</a>. Anterior view of suspension system. <h3>Functional Results</h3> Results achieved with this combination of socket and suspension were dramatic. After some adjustments, the hip patients felt no discomfort from the socket, despite the obvious upward curve of the medial brim in the perineum. This edge, along with the distal portion of the socket, particularly under the ischium, were lightly padded with 1/8" Pe-Lite™, as is customary in most hip sockets. Neither patient perceived any piston action or discomfort from the proximal brim of the socket or the polyethylene waist segment. The most obvious benefit was a significant reduction in lateral trunk bending that is so common with hip disarticulation amputees. In fact, this gait anomaly was reduced beyond that usually seen with many above-knee amputees. Both patients were impressed with the comfort and secure feeling that the design afforded. With the adjustable diagonal posterior straps, which in the finished prosthesis are replaced with buckleless double Dacron® webbing, the socket can be optimally positioned under the pelvis to more effectively encapsulate the bony pelvic anatomy. This is somewhat akin to adducting an above-knee socket of similar medial brim design (CAT-CAM). By a careful balance in the strap length adjustments, comfort and suspension in the entire system can be achieved. Because of the success that had been achieved with the hip disarticulation patients with this suspension technique, it was decided to try it on the hemipelvectomy patient. His reasonably comfortable and functional single piece socket was modified by removing the center portion of polyethylene in the posterior and rejoining the two separate segments with Dacron® webbing in the same cross strap pattern. An anterior closure as previously described was also employed (Fig. 3). The result was about 1/8" of piston action and improved comfort over the one-piece design, probably because the prosthetic socket could more accurately follow the body contours. <a href="/files/original/3a3c0bf2056231987373ba4f3814cbdf.jpg">Figure 3.</a> Posterior view of hemipelvectomy setup showing adjustable cross strapping. <h3>Biomechanics</h3> In all cases, it appears that during the gait cycle the polyethylene segment that encompasses the contralateral hip will tilt from the vertical as it follows the changing sound side body contour. The forces thus imposed on each of the posterior straps will vary alternately, and their crosspoint will shift slightly with each stride. For example, as the amputee reaches heel strike on the prosthesis, tension in the strap originating at the posterior proximal socket (the lateral support strap) will build as the body moves forward, and the center of gravity begins to shift laterally. As the patient progresses, this force reaches its maximum at mid-stance (Fig. 4) and then begins to fall off. Tension in the other (suspension strap) is at its lowest at mid-stance on the prosthetic side and then begins to build toward its peak when the amputee reaches mid swing-through (Fig. 5). The cycle then repeats itself with each successive stride. This alternating action in the straps, coupled with an accurately contoured socket, provides a continuously snug and secure suspension without the need for excessive tightness. <a href="/files/original/1a23101ee14ed4cb9aada341d3d3c26e.jpg">Figure 4</a>. Suspension system forces at mid-stance. <a href="/files/original/448a0c6b9b0421ba2d64bccc76c9c0ea.jpg">Figure 5</a>. Suspension system forces during swing. At the outset of these efforts, it was believed that much of the success of the suspension system depended upon a well-contoured medial brim, which accurately encapsulated the ischium and ischial ramus. The hemipelvectomy fitting quickly dispelled this consideration as a major factor. However, all hip disarticulation patients fit to date have perceived far greater comfort and control when in a socket so described. The idea behind ischial containment is to provide greater mediolateral stability in the prosthesis. It appears that the cross strap suspension is contributing the better part of this stability. Results to date suggest that the two-part socket and posterior cross strapping provide a mechanism which more closely conforms to changing soft tissue and muscle contours through the gait cycle. With a one-piece socket, regardless of flexibility, slight and subtle motions about all three body axes are not fully accommodated by "give" in the socket, as well as they seem to be in the one described here. Thus, the body must either move inside the socket or limit its movements due to the restrictions imposed by the rigidity of the socket. In either case, the result is a less natural gait and a greater apparent expenditure of energy. With this new approach, these shortcomings of the hip and hemipelvectomy fittings seem to be significantly reduced. References: <ol> <li>Sabolich, John, "Contoured Adducted Trocanteric Controlled Alignment Method (CAT-CAM): Introduction and Basic Principles," Clinical Prosthetics and Orthotics, Vol. 9, No. 4, Fall, 1985, pp. 15-26.</li> <li>Sabolich, John and Tom Guth, "CAT-CAM Innovations," Ability, Vol. 6, No. 3, Winter, 1986, p. 48.</li> </ol> *Judd E. Lundt, B.S., A.E. UCLA Prosthetics Education Program, Rehabilitation Center, 1000 Veteran Avenue, Room 22-41, Los Angeles, California 90024. *David H. Littig, B.A., CP. UCLA Prosthetics Education Program, Rehabilitation Center, 1000 Veteran Avenue, Room 22-41, Los Angeles, California 90024. Page Number(s) 114 - 118 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The UCLA Anatomical Hip Disarticulation Prosthesis Creator An entity primarily responsible for making the resource David H. Littig, B.A., CP. * Judd E. Lundt, B.S., A.E. * https://staging.drfop.org/files/original/0f0eaf91a93d152fbbcaca14c3b43ebf.pdf 55a8a6c2698543a33379820f8c99af27 https://staging.drfop.org/files/original/9176ea93fc7422b272a48674e92598f3.jpg 64903f5b4a3cce6fe54c1ab66a83c375 https://staging.drfop.org/files/original/51e118cc092de53ecec3404a4302acab.jpg 9678319e36fff07a4dd43313518ea0b2 https://staging.drfop.org/files/original/b3a726660b994c9bbde0c48f30f4337c.jpg fb3cc03c33fbe565141cc63e008bcd97 https://staging.drfop.org/files/original/c0c5f86b34e55516bbefc6ca2d8b9f3c.jpg 0187a66c7a3b525a915dd5b9ad929a30 https://staging.drfop.org/files/original/3bb0b814dfe7768034c9b39057177e31.jpg 3520f17845a67a7b7af87cc94edfc339 https://staging.drfop.org/files/original/48af58273ca7d023d458415c3ede334c.jpg 73e1144efc791b010d100d5826ea86b0 https://staging.drfop.org/files/original/3e10a6a4eb37fe679d8d7dc788e153c7.jpg 2ac620871d4d7649e10c2cd6805c9efa https://staging.drfop.org/files/original/e190fcba30937120ad5a9a8f6b348187.jpg 7fb7b789229f3de781290a709a8c9c1c Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_03_119.pdf Text Any textual data included in the document <h2>The CAT-CAM-H.D.(tm) A New Design for Hip Disarticulation Patients</h2> <h5>John Sabolich, B.S., C.P.O. <a style="text-decoration: none;">*</a> Thomas Guth, B.A., C.P.O. <a style="text-decoration: none;">*</a></h5> The innovative features of the CAT-CAM™ above-knee socket design were outlined in the Fall, 1985 issue of Clinical Prosthetics and Orthotics, Volume 9, Number 4. Shortly afterwards, RGP of San Diego and the Sabolich Prosthetic Research Center in Oklahoma City combined efforts to develop a CAT-CAM™ type hip disarticulation prosthetic socket design. It was intended that this new socket would hold the ischial tuberosity and descending ramus in a special compartment of the socket. RGP worked primarily on the suspension system, and Sabolich worked on the ischial ramus containment. The conventional hip disarticulation socket differs from the CAT-CAM™ type in that the old design has a flat inferior floor upon which the ischial tuberosity sits. Even worse, many times the tuberosity sits on the very edge of this table. As described in the original 1985 CAT-CAM™ article and in terms of the above-knee socket, this is not a desirable biomechanical situation because, first, the bone is touching a flat tangential surface rather than a contoured surface that conforms to the complex bony shape and thus distributes the load over a wider area and, second, because it does not provide medial-lateral stability. The new socket affords much more bony contact not only to the ischial tuberosity, but to the descending pubic ramus as well (Fig. 1and Fig. 2). Experience has shown that the ramus turns out to be of more importance than the ischial tuberosity when it comes to enhancing medial-lateral and rotational stability. Only the inferior pubis-ramus is allowed to exit the socket at the medial inferior dip of the medial wall (Fig. 3). <a href="/files/original/9176ea93fc7422b272a48674e92598f3.jpg">Figure 1.</a> Demonstrates depth of ischial seat area relative to medial brim. Also shows how the ischium and ramus are in the socket. <a href="/files/original/51e118cc092de53ecec3404a4302acab.jpg" target="_blank" rel="noopener">Figure 2.</a> Postero-medial view of transparent diagnostic test socket on the patient with a patch of white paper delineating the ischial-ramus compartment. <a href="https://staging.drfop.org/files/original/b3a726660b994c9bbde0c48f30f4337c.jpg" target="_blank" rel="noopener">Figure 3.</a> Medial view with rulers at the inferior-most point in the dip of the medial brim. In order to better understand the new hip disarticulation design, it must first be understood that the CAT-CAM™ above-knee design is not a narrow ML socket at the proximal portion. On the contrary, the proximal ML diameter of the CAT-CAM™ above-knee socket, which contains the pelvic bones, is wider than the mid and distal portions of the socket, which then narrows to conform to the medial-lateral thigh dimension in order to supply soft tissue compression. The new hip disarticulation socket follows this SCAT-CAM™ principle. Thus, it provides a better bony locking effect. Also, these bony pelvic structures are more fully encapsulated as a result of a V-shaped medial contouring of the socket and provide the hip disarticulation patient with a feeling akin to the above-knee socket, rather than that which results simply from sitting on a flat hard seat. Some of the principles of the CAT-CAM™ total flexible brim are also utilized in this type of hip socket. The entire socket is flexible except in the area where the hip joint is attached. This can be accomplished in two ways: first, with a rigid frame and a flexible inner socket much like with the CAT-CAM™ and SCAT-CAM™ above-knee design; second, by a heterogeneous monolithic polyester socket that is rigid in the joint area and then gradually becomes flexible throughout the remainder of the socket (Fig. 4 and Fig. 5). <a href="/files/original/c0c5f86b34e55516bbefc6ca2d8b9f3c.jpg" target="_blank" rel="noopener">Figure 4.</a> Laminated socket demonstrating flexibility of the contralateral portion of the socket. Superior portion of amputated side is flexible as well. <a href="https://staging.drfop.org/files/original/3bb0b814dfe7768034c9b39057177e31.jpg">Figure 5.</a> View similar to Figure 4 showing flexibility of socket. Also shows "V"-shaped contour of medial brim in sagittal plane. Like the SCAT-CAM™ design, the hip socket is more bone and muscle contoured than the traditional bucket shaped hip disarticulation design (Fig. 6). The new socket has a concave contour in the area of the ilium on the amputated side. On the contralateral side, there is a concave contour between the ilium and trochanter. This increases medial-lateral stability and results in improved gait when combined with the containment of the ilium, ischium, and ramus bones within the socket. This is contrasted to most conventional designs which bulge out and follow the flow of the soft tissue on both lateral sides of the socket rather than conforming to the body contours. <a href="/files/original/48af58273ca7d023d458415c3ede334c.jpg" target="_blank" rel="noopener">Figure 6.</a> Schematic cross-section through the frontal plane. Vectors 1 and 2 demonstrate the suspension principle and also refer to the dark lines which represent the socket walls. Notice how the superior edges of the socket do not come above the ilium crests and the concave contouring inferior to the illiae. Vector 3 refers to the bony lock. The "Inter Ilio Trochanteric Effect"<a style="text-decoration: none;">*</a> is one of the reasons it has been possible to suspend the socket in most cases without extending it above the iliac crests of the pelvis. Instead, the suspension is gained by conforming the socket into the notch between the ilium and trochanter and creating a counter pressure with the opposite concave shaped side of the socket. Of course, it is more difficult to suspend the socket in this manner when fitting heavy people with excessive adipose tissue. Normally with a conventional hip disarticulation, it is easy for a prosthetist to pull the prosthesis off the patient by sliding it into abduction, away from contact with the residual limb and the ischial tuberosity, when the prosthetic pylon is abducted off the floor. However, with the CAT-CAM-H.D.™ design, this maneuver is more difficult, and the socket resists this abduction tendency due to the bony lock about the ramus (Fig. 7). <a href="/files/original/3e10a6a4eb37fe679d8d7dc788e153c7.jpg">Figure 7.</a> Medial view of the transparent diagnostic test socket showing height of medial brim relative to inferior most portion of the socket. In the last four years, a combined number of 67 CAT-CAM hip disarticulation sockets have been fit in Oklahoma City and San Diego. These patients report that they do not feel like they are "sloshing around in a bucket" and have a "greater feeling of security and stability" (Fig. 8). Three of these patients can run with their new prosthesis in a hop, skip fashion which has been recorded during video gait analysis. Two patients have been able to manage limited step over step running. <a href="https://staging.drfop.org/files/original/e190fcba30937120ad5a9a8f6b348187.jpg" target="_blank" rel="noopener">Figure 8.</a> Posterior view of completed socket. <h3>Acknowledgments</h3> It should be noted that Mike Wilson, C.P.O., was the first person who suggested to me the principles of lateral pressure between the ilium and the trochanter on the contralateral side. He called it an "Inter Ilio Trochanter Effect." Appreciation is given to Don Landis, B.S., R.P.T., for his editorial help in preparing this manuscript. Appreciation is also given to Glenn Hutnick, C.P.O., and Alan Finnieston, CP., who will be contributing to the next phase of research in hip disarticulation designs. Footnote See acknowledgments. *Thomas Guth, B.A., C.P.O. Thomas Guth, M.D., C.P.O., is with RGP Orthopedic Appliance Co., 6147 University Avenue, San Diego, California 92115. *John Sabolich, B.S., C.P.O. John Sabolich, B.S., C.P.O., is President of Sabolich Prosthetic and Research Center, 1017 N.W. 10th Street, Oklahoma City, Oklahoma, 73106. <div style="width: 400px;"></div> <div style="width: 400px;"></div> Page Number(s) 119 - 122 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-7.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_03_119/1988_03_119-8.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The CAT-CAM-H.D.(tm) A New Design for Hip Disarticulation Patients Creator An entity primarily responsible for making the resource John Sabolich, B.S., C.P.O. * Thomas Guth, B.A., C.P.O. * https://staging.drfop.org/files/original/666cfa2a8d900d4b2efb1a009252fa73.pdf f59717a74400ff0ab5095ddffea74b4f https://staging.drfop.org/files/original/17e8a00f37ae987d6c843c8412d4b0e2.jpg b63ddbe760c50ee253d76f42eca4d956 https://staging.drfop.org/files/original/46d862f73b2e9fc9ec844c2b951ca24e.jpg 748745d3b330d67f707679ee011a6836 https://staging.drfop.org/files/original/4242f12d317f1a7ab6d8045a8876497b.jpg 5402ccb72158719c003f664b4fd179c5 https://staging.drfop.org/files/original/8ee7cd25050f94773cb45ef98356241f.jpg 126d19241c60416ec37fa343f5b67a70 https://staging.drfop.org/files/original/bd0b9a100a09d924db2ddcfafb0bce26.jpg d56eb7f7a83a1e97e40b5c0d1717d804 https://staging.drfop.org/files/original/380a58ec4d8724fa7bfcaedf4a69050a.jpg 2c05e9d4f88546fe77cdbf7e84fd5833 https://staging.drfop.org/files/original/65a023e3490a43a115438d29c1640630.jpg 3b5b83d904e8f0092b48ac81539603f6 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_03_123.pdf Text Any textual data included in the document <h2>Technical Note: Cosmesis and the Knee Disarticulation Prosthesis</h2> <h5>Robert Gilley, CP. <a style="text-decoration: none;">*</a></h5> One central problem confronts the prosthetist when fabricating a knee disarticulation prosthesis with side joints, regardless of the socket style (laminated, molded, leather, or flexible frame) used. As the knee flexes, the space anterioraly between the thigh section and the inner edge of the shin increases in width (Fig. 1). The result is cosmetically unacceptable. The gap develops because the radial distance from the knee joint center to the periphery of the socket gradually decreases from anterior to posterior (Fig. 2). Resolution of the problem may be achieved by building up the distal end of the socket so as to maintain a constant spherical shape through the full range of motion (Fig. 3). Observation over the years has led me to conclude that many younger prosthetists are not as familiar with the process as perhaps they should be. Therefore, these few notes are offered in hopes of redressing the situation. <a href="/files/original/17e8a00f37ae987d6c843c8412d4b0e2.jpg" target="_blank" rel="noopener">Figure 1.</a> As the knee flexes, the gap anterioraly increases. <a href="/files/original/46d862f73b2e9fc9ec844c2b951ca24e.jpg" target="_blank" rel="noopener">Figure 2.</a> This problem results from the fact that the radial distance from the knee joint center to the periphery of the thigh decreases from anterior to posterior. <a href="/files/original/4242f12d317f1a7ab6d8045a8876497b.jpg" target="_blank" rel="noopener">Figure 3</a>. The distal end of the thigh has been built up so that the space between the thigh and shin is constant throughout the range of motion. Fabrication of the prosthesis begins by mounting the proximal portion of both joints to the thigh, and similarly, mounting the distal portions in a suitably sized block of wood. Obviously, every effort should be made to maintain the narrowest possible medial-lateral diameter at the knee joint center and to keep the joints square. Wood is removed from between the distal joint sections to permit proper mating of the shin block to the thigh and full range of motion. The interior inner edge of the shin block should fit closely to the thigh in the fully extended position while allowing sufficient space distal to the edge for the material to be added to the thigh during finishing. The distal end of the thigh is then built-up with rigid urethane foam. The convex shape of the anterior socket from medial to lateral, and at the level of the proximal anterior edge of the shin block, is repeated radially about the knee joint axis from anterior to posterior. This can be accomplished, rather laboriously, by first removing enough extra material from the thigh to permit it to be assembled with the shin block in the fully extended position. Then, as the knee is gradually flexed through the full range of motion, the anterior edge of the shin is used as a guide to judge how much material to remove at each successive position of flexion. Sufficient material is removed to permit full range of flexion. Care must be taken to maintain a smooth, even surface from medial to lateral and to not remove too much material. Nonetheless, it will doubtlessly be necessary to add material. The posterior surface of the distal thigh is finished off flat from medial to lateral, so as to fill most of the posterior knee opening. It should not rise above the anterior rim of the shin in the fully flexed position, and at the same time, should not protrude too far posteriorly when in the fully extended position. The process can be greatly expedited if the following simple apparatus is used. Two aluminum plates are modified so that a piece of stiff paper or cardboard can be clamped between them (Fig. 4 and Fig. 5). The plates are cut away on one edge so as to span the largest socket. At the leading edge of the cut away side, two threaded rods with tapered points are mounted on a common axis (Fig. 6). These two rods permit the device to be mounted on the proximal knee joints and swung around the distal end of the thigh section (Fig. 7). The stiff paper clamped between the two plates of the device is cut to match the shape of the anterior surface of the thigh at the requisite level. The resulting template is then used to duplicate the shape through the full range of motion. (Some prosthetists will of course identify the device as a simple adaptation of the templates that were formerly used when shaping the ball of the knee of a handmade knee-shin set-up for an above-knee prosthesis.) The device described has been in use by us now for over a year. It greatly speeds up the process of finishing a knee disarticulation prosthesis. <a href="/files/original/8ee7cd25050f94773cb45ef98356241f.jpg" target="_blank" rel="noopener">Figure 4</a>. Knee spanning template holder. Six inch rule included in photograph to give a sense of scale. <a href="/files/original/bd0b9a100a09d924db2ddcfafb0bce26.jpg" target="_blank" rel="noopener">Figure 5</a>. Template holder with stiff cardboard template clamped between the two plates of the holder. <a href="/files/original/380a58ec4d8724fa7bfcaedf4a69050a.jpg" target="_blank" rel="noopener">Figure 6.</a> Exploded parts view of template holder and template. <a href="/files/original/65a023e3490a43a115438d29c1640630.jpg" target="_blank" rel="noopener">Figure 7</a>. Template holder in place mounted on the knee bolt of a conventional above-knee prosthesis (for illustrative purposes only, a knee disarticulation prosthesis was not available at the time this article was prepared). In conclusion, it is hoped that these comments on the matter will aid a prosthetist confronted for the first time with the task of finishing a knee disarticulation prosthesis-a task that is rather infrequently confronted in the United States and not always addressed by the schools. *Robert Gilley, CP. Robert Gilley, CP., is with Durr-Fillauer Medical, Inc., 2710 Amnicola Highway, Chattanooga, Tennessee 37406. Page Number(s) 123 - 127 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_03_123/1988_03_123-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Technical Note: Cosmesis and the Knee Disarticulation Prosthesis Creator An entity primarily responsible for making the resource Robert Gilley, CP. *