1 20 371 https://staging.drfop.org/files/original/a4f59375f598279295c7fa943e156114.pdf 38aeeeab3d42cf740c3e04155a23deb3 https://staging.drfop.org/files/original/e9b5c21d0675e1f7f78eeae1cab0bf9b.jpg 4a5774b4db78fc684a6a1a7c148f1652 https://staging.drfop.org/files/original/179a4b1fdbe7af47f8671ad8dfc3b633.jpg 8d23f991b42aaa11f4865388aa37f444 https://staging.drfop.org/files/original/9e2dbd2dfdbf18308f14c16deffde187.jpg 516724a853eb79700fcc8b01fd9f4d84 https://staging.drfop.org/files/original/1ab8a3dcf922e1807accda3da54464e0.jpg 9a39560b010e50dd6076068288acd2a6 https://staging.drfop.org/files/original/8048c3cccd316e71ba2b766352368f1c.jpg e4881b396eb266d26e006c1872396510 https://staging.drfop.org/files/original/408763c312b92eca57665f96ace6e393.jpg f061728c01505d148eeca0704ad78939 https://staging.drfop.org/files/original/5539898a198c7a2106d020b39fbb42c9.jpg 7c5b6091748cc36c772f24eaec77668d https://staging.drfop.org/files/original/0fcd332e5c3c16557b9d2e6c049ab526.jpg 70ce52088e0c35f7c9c26b4762c38040 https://staging.drfop.org/files/original/4055a7a2c59d5a522d1e6cf32a0024af.jpg 64c5a270fedf2bd0199cd04498816491 https://staging.drfop.org/files/original/3ae56f5fbb8bf7c542f880fa056513da.jpg 3870cc3795e9a198097bd24bce53b023 https://staging.drfop.org/files/original/315fe14538fad0ed846aa9c5779de2f4.jpg a38b7afdc54124fb2c4fdfaa676a7eb4 https://staging.drfop.org/files/original/f0655872a5389e27f34b64a4975e5f09.jpg 0324b1ddac21e26db1e4d683035350a4 https://staging.drfop.org/files/original/8dc1c46b125a02cfeaac768c7a8b3ff9.jpg 8d644d9b4b557aa4e149b1a298c9728d https://staging.drfop.org/files/original/bc33be62f16216b29a7eefb543073589.jpg eec0b67878c0c03d1f20ca9558e7d867 https://staging.drfop.org/files/original/6741c4989a97f0face9bfbec1b477e07.jpg 6ee4529dba31e6b50c907a3dd975d190 https://staging.drfop.org/files/original/9f8219b9d8441382f6dcedfb9b985f4e.jpg e45df92748138be34e0abfdcfa199ecd https://staging.drfop.org/files/original/4988df0c10cb9d476fd01c9cd3d02880.jpg f3a2809feeb174dec5bc561ff1952898 https://staging.drfop.org/files/original/8d2b6ba0f09f64fc07ef921be89bd5bb.jpg 07fd87bdc0fe603f9a655fd89e76b987 https://staging.drfop.org/files/original/0307da51d6e620c88a84df6a0b08adde.jpg 231b3dc0a2ed2ee57dfe1165c2a9a695 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_01_001.pdf Year 1970 Volume 14 Issue 1 Page Number(s) 1 - 52 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>1970 Limb Prosthetics</h2> <h5>A. Bennet Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>Loss of limb has been a problem as long as man has been in existence. Even some prehistoric men must have survived crushing injuries resulting in amputation, and certainly some children were born with congenitally deformed limbs, with effects equivalent to those of amputation. In 1958 the Smithsonian Institution reported the discovery of a skull dating back about 45,000 years of a person who, it was deduced, must have been an arm amputee, because of the way his teeth had been used to compensate for lack of limb. Leg amputees must have compensated partly for their loss by the use of crude crutches and, in some instances, by the use of peg legs fashioned from forked sticks or tree branches (<b>Fig. 1</b> and <b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Mosaic from the Cathedral of Lescar, France, depicts an amputee supported at the knee by a wooden pylon. Some authorities place this in the Gallo-Roman era. From Putti, V., <i>Historic Artificial Limbs, </i>1930. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Pen drawing of a fragment of antique vase unearthed near Paris in 1862 which shows a figure whose missing limb is replaced by a pylon with a forked end. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The earliest known record of a prosthesis being used by man was made by the famous Greek historian, Herodotus. His classic <i>History, </i>written about 484 B.C., contains the story of the Persian soldier, Hegesistratus, who, when imprisoned in stocks by the enemy, escaped by cutting off part of his foot, and replaced it later with a wooden version.</p> <p>A number of ancient prostheses have been displayed in museums in various parts of the world. The oldest known is an artificial leg unearthed from a tomb in Capua in 1858, thought to have been made about 300 B.C., the period of the Samnite Wars. Constructed of copper and wood, the Capua leg was destroyed when the Museum of the Royal College of Surgeons was bombed during World War II. The Alt-Ruppin hand (<b>Fig. 3</b>), recovered along the Rhine River in 1863, and other artificial limbs of the 15th century are on display at the Stibbert Museum in Florence. Most of these ancient devices were the work of armorers. Made of iron, these early prostheses were used by knights to conceal loss of limbs as a result of battle, and a number of the warriors are reported to have returned successfully to their former occupation. Effective as they werefor their intended use, these specialized devices could not have been of much use to any group other than the knights, and the civilian amputees for the most part must have had to rely upon the pylon and other makeshift prostheses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Alt-Ruppin Hand (circa 1400). The thumb is rigid; the fingers move in pairs and are sprung by the buttons at the base of the palm; the wrist is hinged. From Putti, V., <i>Chir. d. org di movimento, </i>1924-25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the use of ligatures was set forth by Hippocrates, the practice was lost during the Dark Ages, and surgeons during that period and for centuries after stopped bleeding by either crushing the stump or dipping it in boiling oil. When Ambroise Pare, a surgeon in the French Army, reintroduced the use of ligatures in 1529, a new era for amputation surgery and prostheses began. Armed with a more successful technique, surgeons were more willing to employ amputation as a life-saving measure and, indeed, the rate of survival must have been much higher. The practice of amputation received another impetus with the introduction of the tourniquet by Morel in 1674, and removal of limbs is said to have become the most common surgical procedure in Europe. This in turn led to an increase in interest in artificial limbs. Pare, as well as contributing much in the way of surgical procedures, devised a number of Limb designs for his patients. His leg (<b>Fig. 4</b>) for amputation through the thigh is the first known to employ articulated joints. Another surgeon, Verduin, introduced in 1696 the first known limb for below-knee amputees that permitted freedom of the knee joint (<b>Fig. 5</b>), in concept much like the thigh-corset type of below-knee limb still used by many today. Yet, for reasons unknown, the Verduin prosthesis dropped from sight until it was reintroduced by Serre in 1826 and, until recently, was the most popular type of below-knee prosthesis used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Artificial leg invented by Ambroise Pare (middle sixteenth century). From Pare A., <i>Oeuvres Completes, </i>Paris, 1840. From the copy in the National Library of Medicine. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Verduin Leg (1696). From MacDonald, J., <i>Amer.J. Surg., </i>1905. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After Pare's above-knee prosthesis, which was constructed of heavy metals, the next real advance seems to be the use of wood, introduced in 1800 by James Potts of London. Consisting of a wooden shank and socket, a steel knee joint, and an articulated foot, the Potts invention (<b>Fig. 6</b>) was equipped with artificial tendons connecting the knee and the ankle, thereby coordinating toe lift with knee flexion. It was made famous partly because it was used by the Marquis of Anglesea after he lost a leg at the Battle of Waterloo. Thus it came to be known as the "Anglesea leg." With some modifications the Anglesea leg was introduced into the United States in 1839. Many refinements to the original design were incorporated by American limb fitters and in time the wooden above-knee leg became known as the "American leg."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Anglesea Leg (1800). Below knee at left, above knee at right. Knee, ankle, and foot are articulated. From Bigg, H., <i>Orthopraxy, </i>1877. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The American Civil War produced large numbers of amputees and consequently created a great interest in artificial limbs, no doubt inspired partly by the fact that the federal and state governments paid for limbs for amputees who had seen war service.</p> <p>J. E. Hanger, one of the first Southerners to lose a leg in the Civil War, replaced the cords in the so-called American leg with rubber bumpers about the ankle joint, a design used almost universally until rather recently. Many patents on artificial limbs were issued between the time of the Civil War and the turn of the century, but few of the designs seem to have had must lasting impact.</p> <p>During this period, with the availability of chloroform and ether as anesthetics, surgical procedures were greatly improved, and more functional amputation stumps were produced by design rather than by fortuity.</p> <p>World War I stirred some interest in artificial limbs and amputation surgery but, because the American casualty list was relatively small, this interest soon waned and, because of the economic depression of the Thirties, some observers think, very little progress was made in the field of limb prosthetics between the two World Wars. Perhaps the most significant contributions were the doctrines set forth and emphasized by Thomas and Haddan,<a></a> a prosthetist-surgeon team from Denver-that fit and alignment of the prosthesis were the most critical factors in the success of any limb and that much better end results could be expected if prosthetists and physicians worked together.</p> <p>Early in 1945, the National Academy of Sciences, at the request of the Surgeon General of the Army, initiated a research program in prosthetics<a></a>. The initial reaction of the research personnel was that the development of a few mechanical contrivances would solve the problem. However, it soon became evident that much more must be known about biomechanics and other matters before real progress could be made.<a></a> Devices and techniques based on fundamental data have materially changed the practice of prosthetics during the past 15 years. However, the best conceivable prosthesis is but a poor substitute for a live limb of flesh and blood, and so the research program is still continuing. Fiscal support for research and development by some 30 laboratories is provided by the Veterans Administration, the Social and Rehabilitation Service, the National Institutes of Health, the Children's Bureau, the Department of the Army, and the Navy Department.</p> <p>The overall program is coordinated by the Committee on Prosthetics Research and Development of the National Academy of Sciences. The committee publishes twice a year the journal <i>Artificial Limbs</i> and serves as an information center, not only in limb prosthetics but for orthotics as well.</p> <p>In England and Europe, research in artificial limbs was resumed after World War II at Queen Mary's Hospital, Roe-hampton, London, by the Ministry of Health, and a new program was started in Russia. The "thalidomide tragedy" of 1959-60 gave incentive for governments to support research, and now there are effective programs in Canada, Denmark, Holland, Scotland, and Sweden, and the studies in England and Germany have been greatly expanded. Under Public Law 480, the United States supports prosthetics research in a number of foreign countries.</p> <p>Soon after the close of World War II, the Artificial Limb Manufacturers Association, which had been formed during World War I, engaged the services of a professional staff to coordinate more effectively the efforts of individual prosthetists. Known today as the American Orthotic and Prosthetic Association,<a style="text-decoration:none;">*</a> this organization consists of some 500 limb and brace shops, and plays a large part in keeping individual prosthetists and orthotists advised of the latest trends and developments in prosthetics and orthotics.</p> <p>In 1949, upon the recommendation of the association, the American Board for Certification in Orthotics and Prosthetics, Inc.,<a style="text-decoration:none;">*</a> was established to ensure that prosthetists and orthotists met certain standards of excellence, much in the manner that certain physicians' specialty associations are conducted. Examinations are held annually for those desiring to be certified. In addition to certifying individuals as being qualified to practice, the American Board for Certification approves individual shops, or facilities, as being satisfactory to serve the needs of amputees and other categories of the disabled requiring mechanical aids. Certified prosthetists wear badges and shops display the symbol of certification (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Symbol of certification by the American Board for Certification in Orthotics and Prosthetics, Inc. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The research program, with the cooperation of the prosthetists, has introduced a sufficient number of new devices and techniques to modify virtually every aspect of the practice of prosthetics. To reduce the time lag between research and widespread application, facilities have been established within the medical schools of three universities for short-term courses in special aspects of prosthetics. Courses are offered to each member of the prosthetics-clinic team-the physician, the therapist, and the prosthetist. Also, special courses are offered to vocational rehabilitation counselors and administrative personnel concerned with the welfare of amputees.</p> <p>Short-term, continuing-education courses are offered by the University of California, Los Angeles, Northwestern University, and New York University. Two-year courses in prosthetics are offered by Cerritos Junior College (Norwalk, Calif.) and Chicago City College, and a four-year course is available at New York University.</p> <p>Prior to 1957, medical schools offered little in the way of training in prosthetics to doctors and therapists. To encourage the inclusion of prosthetics in medical and paramedical curricula, the National Academy of Sciences organized the Committee on Prosthetics Education and Information, and as a result of the efforts of this group, many schools have adopted courses in prosthetics at both undergraduate and graduate levels.</p> <p>Today, there are more than 400 amputee-clinic teams in operation throughout the United States. Each state, with assistance from the Social and Rehabilitation Service, carries out programs that provide the devices and training required to return the amputee to gainful employment. The Children's Bureau, working through a number of states, has made it possible for child amputees to receive the benefit of the latest advances in prosthetics. The Veterans Administration provides all eligible veterans with artificial limbs. If the amputation is related to his military service, the beneficiary receives medical care and prostheses for the remainder of his life. The Public Health Service, through its hospitals, provides limbs and care to members of the Coast Guard and to qualified persons who have been engaged in the maritime service.</p> <p>In July 1965, the 89th Congress passed Public Law 89-97, the Medicare bill, which includes provision for artificial limbs at essentially no cost for persons 65 years of age and over. The bill also assists individual states in providing artificial limbs for persons who are medically indigent at any age. A number of states have enacted legislation to take advantage of the offer by the federal government.</p> <p>In addition to the government agencies that are concerned with the amputee, there are several hundred rehabilitation centers throughout the United States that assist amputees, especially those advanced in age, in obtaining the services needed for them to return to a more normal life.</p> <p>Thus, through the cooperative efforts of government and private groups, considerable progress has been made in the practice of prosthetics, and there is little need for an amputee to go without a prosthesis.</p> <h3>Reasons for Amputation</h3> <p>Amputation may be the result of an accident, or may be necessary as a lifesaving measure to arrest a disease. A small but significant percentage of individuals are born without a limb or limbs, or with defective limbs that require amputation or fitting (like that of an amputee).</p> <p>In some accidents, a part or all of the limb may be completely removed; in other cases, the limb may be crushed to such an extent that it is impossible to restore sufficient blood supply necessary for healing. Sometimes, broken bones cannot be made to heal, and amputation is necessary. Accidents that cause a disruption in the nervous system and paralysis in a limb may also be cause for amputation, even though the limb itself is not injured. The object of amputation in such a case is to improve function by substituting an artificial limb for a completely useless though otherwise healthy member. Amputation of paralyzed limbs is not performed very often, but has in some cases proven to be very beneficial. Accidents involving automobiles, farm machinery, and firearms seem to account for most traumatic amputations. Freezing, electrical burns, and the misuse of power tools also account for many amputations.</p> <p>Improved medical and surgical procedures introduced in recent years have resulted in the preservation of many limbs that would have been amputated. Infection, once a cause of a high fraction of amputations, can usually be controlled with antibiotics. Newer methods of vessel and nerve suturing make it possible to save limbs that would have had to be amputated some years ago. Highly qualified surgical teams have demonstrated during the last few years that it is possible to replace a completely severed limb.</p> <p>Diseases that may make amputation necessary fall into one of three main categories: vascular, or circulatory, disorders, cancer, and infection. The diseases that cause circulatory problems most often are arteriosclerosis, or hardening of the arteries, diabetes mellitus, and Buerger's disease. In these cases, not enough blood circulates through the limb to permit body cells to replace themselves, and unless the limb or part of it is removed, the patient cannot be expected to live very long. In nearly all these cases, the leg is affected because it is the member of the body farthest from the heart and, in accordance with the principles of hydraulics, blood pressure in the leg is lower than in any other part of the body. Vascular disorders are, of course, much more prevalent among older persons. Considerable research is being undertaken to determine the cause of vascular disorders so that amputation for these reasons may at least be reduced if not eliminated, but at the present time vascular disorders are the cause of a large number of lower-extremity amputations.</p> <p>In many cases, amputation of part or all of a limb has arrested a malignant or cancerous condition. In view of present knowledge, the entire limb is usually removed. Malignancy may affect either the arms or legs. Much time and effort are being spent to develop cures for the various types of cancer.</p> <p>Since the introduction of antibiotic drugs, infection has been less and less the cause for amputation. Moreover, even though amputation may be necessary, control of the infection may allow the amputation to be performed at a lower level than would otherwise be the case.</p> <p>"Thalidomide babies" born between 1958 and 1961 have been given extensive press coverage; however, thalidomide is by no means the sole cause of congenital malformations. Absence of all or part of a limb at birth is not an uncommon occurrence. Many factors seem to be involved in such occurrences, but what these factors are is not clear. The most frequent case is absence of most of the left forearm, which occurs slightly more often in girls than in boys. However, all sorts of combinations occur, including complete absence of all four extremities. Sometimes intermediate parts such as the thigh or upper arm are missing, but the other parts of the extremity are present, usually somewhat malformed. In such cases, amputation may be indicated; however, even a weak, malformed part is sometimes worth preserving if sensation is present and the partial member is capable of controlling some part of the prosthesis. Extensive studies are being carried out to determine the reasons for congenital malformations.</p> <p>As far as it can be determined, there are approximately 311,000 amputees in the United States, exclusive of those patients residing in institutions. There are about six lower-extremity amputees for every upper-extremity amputee.</p> <h3>Losses Incurred</h3> <p>Many of the limitations resulting from amputation are obvious, others less so. An amputation through the lower extremity makes standing and locomotion without the use of an artificial leg or crutches difficult and impracticable except for very short periods. Even when an artificial leg is used, the loss of joints and the surrounding tissues, and consequently loss of the ability to sense position, is felt keenly. The sense of touch of the absent portion is also lost, but in the case of the lower-extremity amputee, this is not quite as important as it might seem, because the varying pressure occurring between the stump and the socket indicates external loading. In the upper-extremity amputee, sense of touch is more important.</p> <p>Most lower-extremity amputees cannot bear the total weight of the body on the end of the stump, and other parts of the anatomy must be found for support.</p> <p>Muscles attached at each end to bones are responsible for movement of the arms and legs. Upon a signal from the nervous system, muscle tissue will contract, thus producing a force which can move a bone about its joint (<b>Fig. 8</b>). Because muscle force can be produced only by contraction, each muscle group has an opposing muscle group so that movement in two directions can take place. This arrangement also permits a joint to be held stable in any one of a vast number of positions for relatively long periods of time. How much a muscle can contract is dependent upon its length, and the amount of force that can be generated is dependent upon its circumference.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Schematic drawing of muscular action on skeletal system. The motion shown here is flexion, or bending, of the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Muscles that activate the limbs must of course pass over at least one joint to provide a sort of pulley action; some pass over two. Thus, some muscles are known as one-joint muscles, others as two-joint muscles. When muscles are severed completely, they can no longer transmit force to the bone and, when not used, wither away or atrophy. It will be seen later that these facts are very important in the rehabilitation of amputees.</p> <h3>Types of Amputation</h3> <p>Amputations are generally classified according to the level at which they are performed (<b>Fig. 9</b>). Some amputations levels are referred to by the name of the surgeon credited with developing the amputation technique used. The general rule in selecting the site of amputation is to save all length that is medically possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Classification of amputation by level. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>LOWER-EXTREMITY AMPUTATIONS</h4> <p><i>Syme's Amputation</i></p> <p>Developed about 1842 by James Syme, a leading Scottish surgeon, the Syme amputation leaves the long bones of the shank (the tibia and fibula) virtually intact, only a small portion at the very end being removed (<b>Fig. 10</b>)<a></a> (The tissues of the heel, which are ideally suited to withstand high pressures, are preserved, and this, in combination with the long bones, usually permits the patient to bear the full weight of his body on the end of the stump. Because the amputation stump is nearly as long as the unaffected limb, a person with Syme's amputation can usually get about the house without a prosthesis, even though normal foot and ankle action has been lost. Atrophy of the severed muscles that were formerly attached to bones in the foot to provide ankle action results in a stump with a bulbous end which, though not of the most pleasing appearance, is quite an advantage in holding the prosthesis in place.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Excellent Syme stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since its introduction, Syme's operation has been looked upon with both favor and disfavor by surgeons. It seems to be the consensus now that "the Syme" should be performed in preference to an amputation at a higher level, if possible. In the case of most women, though, "the Syme" is undesirable because of the difficulty of providing a prosthesis that matches the shape of the other leg.</p> <p><i>Below-Knee Amputations</i></p> <p>Any amputation above the Syme level and below the knee joint is known as a below-knee amputation. Because circulatory troubles have often developed in long below-knee stumps, and because the muscles that activate the shank are attached at a level close to the knee joint, the below-knee amputation is usually performed at the junction of the upper and middle third sections (<b>Fig. 11</b>). Thus, nearly full use of the knee is retained-an important factor in obtaining a gait of nearly normal appearance. However, it is rare for a below-knee amputee to bear a significant amount of weight on the end of the stump; therefore, the design of prostheses must provide for weight-bearing through other areas. Several types of surgical procedures have been employed to obtain weight-bearing through the end of the below-knee stump, but none has found widespread use.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical, well-formed, right below-knee stump. <i>Courtesy Veterans Administration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Knee-Bearing Amputations</i></p> <p>Complete removal of the lower leg, or shank, is known as a knee disarticulation. When the operation is performed properly, the result is an efficient, though bulbous, stump (<b>Fig. 12</b>), capable of carrying the weight-bearing forces through the end.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Typical knee-disarticulation stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Unfortunately, the length causes some problems in providing an efficient prosthesis because the space used normally to house the mechanism needed to control the artificial shank properly is occupied by the end of the stump. Nevertheless, excellent prostheses can be provided the knee-disarticulation case.</p> <p>Several amputation techniques have been devised in an attempt to overcome the problems posed by the length and shape of the true knee-disarticulation stump. The Gritti-Stokes procedure entails placing the kneecap, or patella, directly over the end of the femur after it has been cut off about two inches above the end. When the operation is performed properly, excellent results are obtained, but extreme skill and expert postsurgical care are required. Variations of the Gritti-Stokes amputation have been introduced from time to time but have never been used widely.</p> <p><i>Above-Knee Amputations</i></p> <p>Amputations through the thigh are among the most common (<b>Fig. 13</b>). Because of the high pressures exerted on the soft tissues by the cut end of the bone, total body weight cannot be taken through the end of the stump but can be accommodated through the ischium, that part of the pelvis upon which a person normally sits.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Typical well-formed above-knee stump. <i>Courtesy Veterans Administration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Hip Disarticulation and Hemipelvectomy</i></p> <p>A true hip disarticulation (<b>Fig. 14</b>) involves removal of the entire femur, but, whenever feasible, the surgeon leaves as much of the upper portion of the femur as possible, in order to provide additional stabilization between the prosthesis and the wearer, even though no additional function can be expected over the true hip disarticulation.<a></a> Both types of stump are provided with the same type of prosthesis. With slight modification, the same type of prosthesis can be used by the hemipelvectomy patient, that is, when half of the pelvis has been removed. It is surprising how well hip-disarticulation and hemi-pelvectomy patients have been able to function when fitted with the newer type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Patient with true hip-disarticulation amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>UPPER-EXTREMITY AMPUTATIONS</h4> <p><i>Partial-Hand Amputations</i></p> <p>If sensation is present, the surgeon will save any functional part of the hand in lieu of disarticulation at the wrist. Any method of obtaining some form of grasp, or prehension, is preferable to the best prosthesis. If the result is unsightly, the stump can be covered with a plastic glove, lifelike in appearance, for those occasions when the wearer is willing to sacrifice function for appearance. Many prosthetists have developed special appliances for partial-hand amputations that permit more function than any of the artificial hands and hooks yet devised and, at the same time, permit the patient to make full use of the sensation remaining in the stump. Such devices are usually individually designed and fitted.</p> <p><i>Wrist Disarticulation</i></p> <p>Removal of the hand at the wrist joint was once condemned because it was thought to be too difficult to fit so as to yield more function than a shorter forearm stump. However, with plastic sockets based on anatomical and physiological principles, the wrist-disarticulation case can now be fitted so that most of the pronation-supination of the forearm-an important function of the upper extremity- can be used. In the case of the wrist disarticulation (<b>Fig. 15</b>), nearly all the normal forearm pronation-supination is present. Range of pronation-supination decreases rapidly as length of stump decreases; when 60 per cent of the forearm is lost, no pronation-supination is possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. A good wrist-disarticulation stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Amputations Through the Forearm</i></p> <p>Amputations through the forearm are commonly referred to as below-elbow amputations, and are classified as long, short, and very short, depending upon the length of stump (<b>Fig. 9</b>). Stumps longer than 55 per cent of total forearm length are considered long, between 35 and 55 per cent as short, and less than 35 per cent as very short.</p> <p>Long stumps retain the rotation function in proportion to length; long and short stumps without complications possess full range of elbow motion and full power about the elbow, but often very short stumps are limited in both power and motion about the elbow. Devices and techniques have been developed to make full use of all functions remaining in the stump.</p> <p><i>Disarticulation at the Elbow</i></p> <p>Disarticulation at the elbow consists of removal of the forearm, resulting in a slightly bulbous stump (<b>Fig. 16</b>), but usually one with good end-weight-bearing characteristics. The long bulbous end, while presenting some fitting problems, permits good stability between socket and stump and thus allows use of nearly all the rotation normally present in the upper arm-a function much appreciated by the amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Amputation through the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Above-Elbow Amputation</i></p> <p>Any amputation through the upper arm is generally referred to as an above-elbow amputation (<b>Fig. 9</b>). In practice, stumps in which less that 30 per cent of the humerus remains are treated as shoulder-disarticu-lation cases; those with more than 90 per cent of the humerus remaining are fitted as elbow-disarticulation cases.</p> <p><i>Shoulder Disarticulation and Forequarter Amputation</i></p> <p>Removal of the entire arm is known as shoulder disarticulation, but, whenever feasible, the surgeon will leave intact as much of the humerus as possible, to provide stability between the stump and the socket (<b>Fig. 17</b>). When it becomes necessary to remove the clavicle and scapula, the operation is known as a forequarter, or interscapulothoracic, amputation. The very short above-elbow, the shoulder-disarticulation, and the forequarter cases are all provided with essentially the same type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. A true shoulder disarticulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Postsurgical Period</h3> <p>The period between the time of surgery and time of fitting the prosthesis is an important one if a good functional stump, and thus the most efficient use of a prosthesis, is to be obtained. The surgeon and others on his hospital staff will do everything possible to ensure the best results, but ideal results require the wholehearted cooperation of the patient.</p> <p>It is not unnatural for the patient to feel extremely depressed during the first few days after surgery, but after he becomes aware of the possibilities of recovery, the outlook becomes brighter, and he generally enters cooperatively into the rehabilitation phase.</p> <p>It has been generally agreed through the years that the earlier a patient could be fitted, the easier would be the rehabilitation process. However, until a few years ago, virtually no patients were provided with a prosthesis before six weeks after amputation, and such cases were rare - the average time probably being closer to four months.</p> <p>With the advent of improved cast-taking methods, and temporary legs in which alignment can be easily adjusted, Duke University, about 1960, began an experiment to determine the earliest practical time after surgery for providing amputees with limbs. By 1963, it had been shown clearly that it was not only practical but desirable to fit a temporary, but well-fitted limb as soon as the sutures were removed, some two to three weeks after surgery. In 1963, Dr. Marian Weiss of Poland, in an address in Copenhagen, reported success with fitting amputees immediately after surgery while the patient was still anesthetized, and beginning ambulation training the day afterward.<a></a> Dr. Weiss's work stimulated similar work in this country, notably at the University of California, San Francisco; the Oakland Naval Hospital; the Prosthetics Research Study, Seattle, Washington; Duke University; the University of Miami; Marquette University; and New York University. Records on several thousand patients of all types have shown immediate postsurgical fitting of prostheses to be the method of choice when possible. Healing seems to be accelerated; postsurgical pain is greatly alleviated; contractures are prevented from developing; phantom pain seems to be virtually nonexistent; fewer psychological problems seem to ensue; and patients are returned to work or home at a much earlier date than seemed possible only a few years ago.</p> <p>The procedure consists essentially of providing a rigid plaster dressing over the stump which serves as a socket, and the use of an adjustable leg which can be removed and reinstalled easily (<b>Fig. 18</b>).<a></a> The cast-socket is left in place for 10 to 12 days, during which ambulation is encouraged. At the end of this time, the cast-socket is removed, the stitches are usually taken out, and a new cast-socket is provided immediately. The original prosthetic unit is replaced and realigned. The second cast-socket is left in place for eight to ten days, at which time a new cast can be taken for the permanent, or definitive, prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Schematic cross section showing the major elements of a prosthesis as applied immediately following surgery to a below-knee amputee. The suture line, silk dressing, and drain are not shown. The fluffed gauze does not extend beyond the area indicated in "A." <i>Inset: </i>A below-knee amputee fitted with the immediate postsurgical prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Special courses in immediate postsurgical fitting and early fitting are being offered to qualified prosthetics clinic teams by Northwestern University, the University of California at Los Angeles, and New York University.</p> <h4>CONTRACTURES</h4> <p>When immediate postsurgical fitting is employed, there is little opportunity for contractures to develop. When these procedures are not used, it is most important to avoid the development of muscle contractures. They can be prevented easily, but it is most difficult, and sometimes impossible, to correct them. At first, exercises are administered by a therapist or nurse; later, the patient is instructed concerning the type and amount of exercise that should be undertaken. The patient is also instructed in the methods and amount of massage that should be given the stump to aid in the reduction of the stump size. Further, to aid shrinkage, cotton-elastic bandages are wrapped around the stump (<b>Fig. 19</b>) and worn continuously until a prosthesis is fitted. The bandage is removed and reapplied at regular intervals-four times during the day and at bedtime. It is most important that a clean bandage is available for use each day.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Compression wrap for above-knee amputation. The wrap of elastic bandage aids in shrinking the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee is taught to apply the bandage unless it is physically impossible for him to do so, in which case some member of his family must be taught the proper method for use at home.</p> <p>To reduce the possibility of contractures, the lower-extremity stump must not be propped upon pillows. Wheelchairs should be used as little as possible; crutch walking is preferred, but the above-knee stump must not be allowed to rest on the crutch handle (<b>Fig. 20</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Actions to be avoided by lower-extremity amputees during the immediate postoperative period. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>THE PHANTOM SENSATION</h4> <p>After amputation, the patient almost always has the sensation that the missing part is still present. The exact cause of this is as yet unknown. The phantom sensation usually recedes to the point where it occurs only infrequently or disappears entirely, especially if a prosthesis is used. In a large percentage of cases, moderate pain may accompany the phantom sensation, but in general this too eventually disappears entirely or occurs only infrequently. In a small percentage of cases, severe phantom pain persists to the point where medical treatment is necessary.<a></a></p> <h4>DEFINITIONS</h4> <p><i>Preparatory Prosthesis</i></p> <p>A cosmetically unfinished functional replacement for an amputated extremity, fitted and aligned in accordance with sound biomechanical principles, which is worn for a limited period of time to expedite prosthetic wear and use and to aid in the evaluation of amputee adjustment.</p> <p><i>Pylon</i></p> <p>A rigid supporting member, usually tubular, that is attached to the socket or knee unit of a prosthesis. The lower end of the pylon should be connected to a foot-ankle assembly.</p> <p><i>Rigid Dressing</i></p> <p>A plaster stump wrap, usually applied in the operating or recovery room immediately following operation for the purpose of controlling edema and pain. It is preferably shaped in accordance with the basic patellar-tendon-bearing (PTB) or quadrilateral designs, but is not necessarily so.</p> <p><i>Immediate Postsurgical Prosthetic Fitting</i></p> <p>A procedure wherein a functional socket, designed for weight-bearing and walking, is fitted to the patient immediately after operation in the operating or recovery room, or at some time prior to removal of sutures. As distinct from the rigid dressing, referred to above, this socket should be shaped in accordance with the basic PTB or quadrilateral design; it incorporates provision for easy attachment and detachment of a pylon and foot-ankle assembly.</p> <p><i>Early Prosthetic Fitting</i></p> <p>A procedure wherein a preparatory prosthesis, as defined above, is provided for the amputee immediately following removal of sutures.</p> <p><i>Permanent Prosthesis</i></p> <p>A replacement for a missing limb, which meets accepted checkout standards for comfort, fit, alignment, function, appearance, and durability.</p> <h3>Prostheses for Various Types of Amputation</h3> <p>Much time and attention have been devoted to the development of mechanical component, such as knee and ankle units, for artificial limbs, yet by far the most important factors affecting the successful use of a prosthesis are the fit of the socket ot the stump and the alignment of the vairous parts of the limb in relation to the stump and other parts of the body.</p> <p>Thus, though many parts of a prosthesis may be mass-produced, it is necessary for each limb to be assembled in correct alignment and fitted to the stump to meet the individual requirements of the intended user. To make and fit artificial limbs properly requires a complete understanding of anatomical and physiological principles and of mechanics; craftsmanship and artistic ability are also required.</p> <p>In general, an artificial limb should be as light as possible and still withstand the loads imposed upon it. In the United States, willow and woods of similar characteristics have formed the basis of construction for more limbs than any other material, although aluminum, leather-and-steel combinations, and fiber have been used widely. Today, plastic laminates so popular in small-boat construction form the basis for construction of most artificial limbs. Some artificial legs are made of wood, and occasionally leather is used for sockets, but the trend is toward the plastic laminates. They are light in weight, easy to keep clean, and do not absorb perspiration. They may be molded easily and rapidly over contours such as those found on a plaster model of a stump. Plastic laminates can be made extremely rigid or with any degree of flexibility required in artificial-limb construction.</p> <p>A procedure for making a porous plastic laminate has been developed for use when perspiration presents a difficult problem. A new material, synthetic balata, which can be molded directly over the stump, is now being used in some clinics, primarily to form temporary prostheses.</p> <p>As in the case of the tailor making a suit, the first step in fabrication of a prosthesis is to take the necessary measurements for a good fit. If the socket is to be fabricated of a plastic laminate, an impression of the stump is made. Most often this is accomplished by wrapping the stump with a wet plaster-of-paris bandage and allowing it to dry, as a physician does in applying a cast when a bone is broken (<b>Fig. 21</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Steps in the fabrication of a plastic prosthesis for a below-knee amputation: <i>A, </i>taking the plaster cast of the stump; <i>B, </i>pouring plaster in the cast to obtain model of the stump; C, introducing plastic resin into fabric pulled over the model to form the plastic-laminate socket; <i>D, </i>the plastic-laminate socket mounted on an adjustable shank for walking trials; <i>E, </i>a wooden shank block inserted in place of the adjustable shank after proper alignment has been obtained; <i>F</i>, the prosthesis after the shank has been shaped. To reduce weight to a minimum, the shank is hollowed out and the exterior covered with a plastic laminate. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A number of devices have been introduced in recent years to aid the prosthe-tist in obtaining accurate casts rapidly.<a></a> Most use an apparatus that permits the patient to absorb some of the weight-bearing load through the affected side while the cast is being formed (<b>Fig. 22</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Special jig developed by the Veterans Administration Prosthetics Center to facilitate casting above-knee stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast, or wrap, is removed from the stump and filled with a plaster-of-paris solution to form an exact model of the stump which-after being modified to provide relief for any tender spots, to ensure that weight will be taken in the proper places, and to take full advantage of the remaining musculature-can be used for molding a plastic-laminate socket. Often a "check" socket of cloth impregnated with beeswax is made over the model and tried on the stump to determine the correctness of the modifications.</p> <p>For upper-extremity cases, the socket is attached to the rest of the prosthesis, and a harness is fabricated and installed for operation of the various parts of the artificial arm. For the lower-extremity case, the socket is fastened temporarily to an adjustable, or temporary, leg for walking trials (<b>Fig. 23</b>). With this device, the prosthetist can easily adjust the alignment until both he and the amputee are satisfied that the optimum arrangement has been reached. A prosthesis can now be made, incorporating the same alignment achieved with the adjustable leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Using the above-knee adjustable leg and alignment duplication jig. <i>Top, </i>adjusting the adjustable leg during walking trials; <i>center, </i>the socket and adjustable leg in the alignment duplication jig; <i>bottom, </i>replacement of the adjustable leg with a permanent knee and shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A more refined procedure uses the "Staros-Gardner" coupling (<b>Fig. 24</b>) <a></a>. Not only is the need for the alignment jig eliminated, but in the case of above-knee fittings the alignment adjustments can be made with the knee unit that is to be used permanently, an important factor when sophisticated knee units are used because the present adjustable leg is available with only a single-axis, constant-friction joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Adjustable coupling used for alignment of artificial legs. This unit was designed by the Veterans Administration Prosthetics Center and is suitable for below-knee as well as above-knee legs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An even more refined procedure consists of using one of the adjustable pylon types of prostheses that were originally designed for use in immediate postsurgical fitting. These units are strong enough and sufficiently inexpensive so they can form part of the permanent, or definitive, prosthesis (<b>Fig. 25</b> and <b>Fig. 26</b>). A light, removable, cosmetic cover is used over the pylon. This arrangement permits the prosthetist to change alignment easily at any time. An added feature of the VAPC above-knee "standard" pylon is provision for inter-changeability of a number of knee units, ranging from the simple constant-friction unit to complex hydraulic units. Thus, the patient may try a number of different methods of knee control, at little expense, in order to determine which meets his needs the best.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. An adjustable below-knee pylon with cosmetic cover. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. An adjustable above-knee prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>There are many kinds of artificial limbs available for each type of amputation, and much has been written concerning the necessity for prescribing limbs to meet the needs of each individual. This of course is particularly true in the case of persons in special or arduous occupations, or with certain medical problems, but limbs for a given type of amputation actually vary to only a small degree. Following are descriptions of the artificial limbs most commonly used in the United States today.</p> <h4>LOWER-EXTREMITY PROSTHESES</h4> <p><i>Prostheses for Syme's Amputation</i></p> <p>Perhaps the major reason Syme's amputation was held in such disfavor in some quarters was the difficulty in providing a comfortable, sufficiently strong prosthesis with a neat appearance. The short distance between the end of the stump and the floor made it extremely difficult to provide for ankle motion needed. Most Syme prostheses were made of leather reinforced with steel side bars, resulting in an ungainly appearance. Research workers at the Prosthetic Services Centre at the Department of Veterans Affairs of Canada were quick to realize that the use of the proper plastic laminate might solve many of the problems long associated with the Syme prosthesis. After a good deal of experimentation, the Canadians developed a model in 1955 which, with a few variations, is used almost universally in both Canada and the United States today (<b>Fig. 27</b>)<a></a>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. The Syme prosthesis adopted by the Canadian Department of Veterans Affairs. The posterior opening extends the length of the shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Necessary ankle action is provided by making the heel of the foot of sponge rubber. The socket is made entirely of a plastic laminate. A full-length cutout in the rear permits entry of the bulbous stump. When the cutout is replaced and held in place by straps, the bulbous stump holds the prosthesis in place. In the American version (<b>Fig. 28</b>), a window-type cutout is used on the side because calculations show that smaller stress concentrations are present with such an arrangement. An increasing number of prosthetists have been using a double-wall socket with an expandable inner wall in order to eliminate the need for the window.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Two views of the Canadian-type Syme prosthesis as modified by the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In those cases where, for poor surgery or other reasons, full body weight cannot be tolerated on the end of the stump, provisions can be made to transfer all or part of the load to the area just below the kneecap.<a></a> </p> <p><i>Prostheses for Below-Knee Amputations</i></p> <p>Until recently, most below-knee amputees were fitted with wooden prostheses carved out by hand (<b>Fig. 29</b>). A good portion of the body weight was carried on a leather thigh corset, or lacer, attached to the shank and socket by means of steel hinges. The shape of the corset and upper hinges also held the prosthesis to the stump. The distal, or lower, end of the socket was invariably left open. Other versions of this prosthesis used aluminum, fiber, or molded leather as the materials for construction of the shank and socket, but the basic principle was the same. Many thousands of below-knee amputees have gotten along well with this type of prosthesis, but there are many disadvantages. Because the human knee joint is not a simple, single-axis hinge joint (<b>Fig. 30</b>), relative motion is bound to occur between the prosthesis and the stump and thigh during knee motion when single-jointed side hinges are used, resulting in some chafing and irritation. To date it has not been possible to devise a hinge to overcome this difficulty. Edema, or accumulation of fluid, was often present at the lower end of the stump. Most of these prostheses were exceedingly heavy, especially those made of wood.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Below-knee prosthesis with wood socket-shank, thigh corset, and steel side bars. <i>Courtesy Veterans Administration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Section through the medial condyles of the femur and tibia. The center of curvature is shown for three parts of the articular surface. As gliding occurs in the joint, the instant center moves along the curve connecting these three centers. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In an attempt to overcome these difficulties, the Biomechanics Laboratory of the University of California, in 1958, designed what is known as the patellar-tendon-bear-ing (PTB) below-knee prosthesis (<b>Fig. 31</b>). In the PTB prosthesis no lacer and side hinges are used, all of the weight being taken through the stump by making the socket high enough to cover all the tendon below the patella, or kneecap.<a></a> The patellar tendon is an unusually inelastic tissue which is not unduly affected by pressure. The sides of the socket are also made much higher than has usually been the practice in the past, in order to give stability against side loads. The socket is made of molded plastic laminate that provides an intimate fit over the entire area of the socket, and is lined with a thin layer of sponge rubber and leather. Because it is rare for a below-knee stump to bear much pressure on its lower end, care is taken to see that only a very slight amount is present in that area. This feature has been a big factor in eliminating the edema problem in many instances. The PTB prosthesis is generally suspended by means of a simple cuff, or strap, around the thigh just above the kneecap, but sometimes a strap from the prosthesis to a belt around the waist is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Cutaway view of the patellar-tendon-bearing leg for below-knee amputees. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A number of variations have been introduced during the past few years which make the PTB even more versatile. Many prosthetists feel that not only can many of the problems associated with perspiration be ameliorated by elimination of the soft inner liner, but that a better physiological fit can be obtained with the "hard socket" PTB. Two methods of eliminating the suspension have been introduced from Europe. From France, there is the "pro-these tibiale a emboitage supracondylien," popularly known as the PTS, in which the proximal border extends above the patella anteriorally and the femoral condyles medially and laterally (<b>Fig. 32</b>). Not only does this arrangement eliminate the need for other means of suspension, but it also provides a certain amount of mediolateral stability when required. Another means for eliminating the need for suspension straps was introduced from Germany, known as the wedge-suspension system. In this variation, a molded removable plastisol wedge is inserted between the wall of the proximal area of the socket and the area of the stump along the medial condyles of the femur (<b>Fig. 33</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. A below-knee amputee wearing a PTS-socket prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. The supracondylar-wedge suspension method. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In an effort to develop a socket that would permit the stump to bear the optimum amount of the weight load over its distal end, the University of California designed the air-cushion socket, consisting of a rigid outer socket and an elastic inner sleeve (<b>Fig. 34</b>). Stump support is provided by the tension of the sleeve and by compression of the air between the sleeve and socket. Nearly all of these innovations are compatible with each other, and the Committee on Prosthetics Research and Development has prepared a chart for use by clinical teams in prescribing for the below-knee amputee (<b>Fig. 35</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Cutaway view of the air-cushion socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the PTB socket has been made, it is installed on a special adjustable leg (<b>Fig. 36</b>) or one of the newer pylons (<b>Fig. 37</b>) so that the prosthetist can try various alignment combinations with ease. When both prosthetist and patient are satisfied, the leg is completed, utilizing the alignment determined with the adjustable unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Trial below-knee adjustable leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Below-knee pylon-type prostheses that can be used for fitting immediately after surgery. <i>A, </i>Hosmer Postoperative Pylon; <i>B, </i>Northwestern Pylon (Hosmer); C, Veterans Administration Prosthetics Center (VAPC) "Standard" Pylon; <i>D, </i>Canadian "Instant" Prosthesis (Hosmer); <i>E, </i>U.S. Manufacturing Co. Pylon; <i>F, </i>Finnie-Jig (Arthur Finnieston Co.), <i>Courtesy of Veterans Administration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The shank for the definitive prosthesis is usually made of wood reinforced with plastic laminate. When the new light pylons are used, a cosmetic cover is often provided. The foot prescribed in most instances is the SACH (solid-ankle, cushion-heel) design, but any other type may be used.</p> <p>It is now general practice in many areas to prescribe the PTB prosthesis in most new cases and in many old ones, and if side hinges and a corset are indicated later, these can be added.</p> <p>Stumps as short as two and one-half inches have been fitted successfully with the PTB prosthesis.</p> <p>In special cases such as extreme flexion contracture, the so-called kneeling-knee, or bent-knee, prosthesis may be indicated. The prosthesis used is similar to that used for the knee-disarticulation case.</p> <p><i>Prostheses for the Knee-Disarticulation and Other Knee-Bearing Cases</i></p> <p>Because of the bulbous shape of the true knee-disarticulation stump, it is not possible to use a wooden socket of the type used on the tapered above-knee stump. To allow entry of the bulbous end, a socket is molded of leather to conform to the stump, and is provided with a lengthwise anterior cutout that can be laced to hold the socket in position (<b>Fig. 38</b>). The length of the knee-disarticulation and supracondylar stump makes it difficult to install any of the present knee units designed for above-knee prostheses; therefore, heavy-duty below-knee joints are generally used. Most prosthetists try to provide some control of the shank during the swing phase of walking by inserting nylon washers between the mating surfaces of the joint to provide friction and by using checkstraps. Some prosthetists in the past have installed commercially available piston-type hydraulic swing-phase control units (<b>Fig. 39</b>), a procedure that requires extreme care to achieve the proper result. To make this task easier, the Hosmer Corporation has recently made available a special boring fixture for use in installing the Hosmer-DuPaCo hydraulic knee unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Typical knee-disarticulation prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. DuPaCo swing-phase control unit installed in a knee-bearing prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for Above-Knee Cases</i></p> <p>The articulated above-knee leg is in effect a compound pendulum actuated by the thigh stump. If the knee joint is perfectly free to rotate when force is applied, the effects of inertia and gravity tend to make the shank rotate too far backward and slam into extension as it rotates forward, except at a very slow rate of walking. The method most used today to permit an increase in walking speed is the introduction of some restraint in the form of mechanical friction about the knee joint. The limitation imposed by constant mechanical friction is that for each setting there is only one speed that produces a natural-appearing gait. When restraint is provided in the form of hydraulic resistance, a much wider range of cadence can be obtained, without introducing into the gait pattern awkward and unnatural motions.</p> <p>In recent years, a number of hydraulic units have been made available for control of the shank during the swing phase. Among them are the DuPaCo, the Henschke-Mauch Type S<a style="text-decoration:none;">*</a> (<b>Fig. 40</b>), and the Hydra-Knee. These units are all of the piston-cylinder type, provide for swing-phase control only, and are designed so that they can be incorporated into the more conventional leg structures. The Hydra-Cadence leg (<b>Fig. 41</b>), a complete knee-shin-foot unit, in addition to providing swing-phase control hydraulically, uses the hydraulic system to control ankle action in concert with knee motion. After the knee is flexed 20 degrees, the toe of the foot is lifted as the knee is flexed further, thereby giving more clearance between the foot and the floor as the leg swings through.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. The Henschke-Mauch Type S hydraulic unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. The Hydra-Cadence leg without cosmetic cover. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Throughout the past century, much time and effort have been spent in providing an automatic brake or lock at the knee in order to provide stability during the stance phase and to reduce the possibility of stumbling. Stability during the stance phase can be obtained by aligning the leg so that the axis of the knee is behind the hip and ankle axes. For most above-knee amputees in good health, such an arrangement has been quite satisfactory, but an automatic knee brake is indicated for the weaker or infirm patients.</p> <p>When an automatic brake is indicated, the Bock, the "Vari-Gait" 100, and the Mortensen knee units (<b>Fig. 42</b>) are the ones most generally used. All are actuated upon contact of the heel with the ground. The Bock and Vari-Gait units can be used with almost any type of foot, while a foot of special design is necessary when the Mortensen mechanism is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42/ Some examples of weight-actuated knee units. <i>A, </i>Bock "Safety-knee"; <i>B, </i>Vari-Gait knee; C, Mortensen leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The most sophisticated stance-phase control unit is the Henschke-Mauch Type S-N-S hydraulic unit. It has been thoroughly evaluated by the Veterans Administration and is now available commercially. The Type S-N-S unit contains the same swing-phase control device as the Type S and in addition provides a braking action about the knee when there is a tendency to buckle. The braking action is brought about by the attitude of a pendulum which in turn is controlled by the inertia forces in the shank. The "S" and "S-N-S" units are interchangeable.</p> <p>A number of methods for suspending the above-knee leg are available. For younger, healthy patients, the suction socket (<b>Fig. 43</b>A) has generally been the method of choice. In this design, the socket is simply fitted tightly enough to retain sufficient negative pressure, or suction, between the stump and the bottom of the socket when the leg is off the ground. Special air valves are used to control the amount of negative pressure created so as not to cause discomfort. No stump sock is worn with the suction socket. A major advantage of this type of suspension is the freedom of motion permitted the wearer, thus allowing the use of all the remaining musculature of the stump. Another important advantage is the decreased amount of piston action between stump and socket. Additional comfort is also obtained by elimination of all straps and belts.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Above-knee sockets and methods of suspension: <i>A, </i>total-contact suction socket; <i>B, </i>above-knee leg with Silesian bandage for suspension; C, above-knee leg with pelvic belt for suspension. Most above-knee sockets have a quadrilateral-shaped upper portion as shown. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In some cases, additional suspension is provided by adding a Silesian bandage (<b>Fig. 43</b>B), a light belt attached to the socket in such a way that there is very little restriction of motion of the various parts of the body.</p> <p>Patients with weak stumps and most of those with very short stumps often will require a pelvic belt connected to the socket by means of a "hip" joint (<b>Fig. 43</b>C). Because the connecting joint cannot be placed to coincide with the normal joint, certain motions are restricted. Pelvic-belt suspension is generally indicated for the older patient because of the problems encountered in donning the suction socket, especially that of bending over to remove the donning sock.</p> <p>Shoulder straps, at one time the standard method of suspending above-knee prostheses are still sometimes indicated for the elderly patient.</p> <p>Prior to the introduction of the suction socket into the United States soon after the close of World War II, virtually all above-knee sockets had a conical-shaped interior and were known as plug fits, most of the weight being borne along the sides of the stump. Such a design does not permit the remaining musculature to perform to its full capabilities. In the development of the suction socket, a design known as the quadrilateral socket (see <b>Fig. 43</b>) evolved, and it now is virtually the standard for above-knee sockets, regardless of the type of suspension used. When the pelvic belt or suspender straps are used, the socket is fitted somewhat looser than in the case of the suction socket, and the stump sock is generally worn to reduce skin irritation from the pumping action of the loose socket. A good part of the body weight is taken on the ischium, that part which assumes the load when an individual is sitting.</p> <p>The quadrilateral socket, because of the method employed to permit full use of the remaining muscles, does not resemble the shape of the stump, but, as the name implies, is more rectangular in shape. Until recently, the standard method of fitting a quadrilateral socket called for no contact over the lower end of the stump, a hollow space being left in this area. Although this method was quite successful, there remained a number of cases that persistently developed ulcers or edema over the end of the stump. Experiments involving the use of slight pressure over the stump end led to the development of what is known as the plastic total-contact socket<a></a> (<b>Fig. 43</b>A). As the name implies, the socket is in contact with the entire surface of the stump. In taking some pressure over the end of the stump, the pressure on the ischial area is reduced, thereby providing more comfort to the patient. It also appears that the pressure over the end of the stump helps circulation and improves proprioception. Today the total-contact socket is the method of choice for use by above-knee amputees.</p> <p>In fitting the wooden above-knee prosthesis, the prosthetist carves the interior of the socket, using measurements of the stump as a guide. When a satisfactory fit has been achieved the socket is usually mounted on an adjustable leg for alignment trial, after which the wooden shank and the knee are substituted for the adjustable unit, and the leg is finished by applying a thin layer of plastic laminate over the shank and the thigh piece.</p> <p>In the case of the total-contact socket, the prosthetist obtains a plaster cast of the stump, usually with the aid of a special casting jig (see <b>Fig. 22</b>), and thus obtains a model of the stump over which the plastic socket can be formed.</p> <p>Special adjustable pylon-type legs are available for fitting immediately after surgery, or use as a temporary leg. Provisions are made for all necessary adjustments, and a manually operated knee lock is provided for use by infirm patients.</p> <p><i>Prostheses for Hip-Disarticulation and Hemipeluectomy Cases</i></p> <p>A prosthesis (<b>Fig. 44</b>) developed by the Canadian Department of Veterans Affairs in 1954, and modified slightly through the years, is used almost universally. In the Canadian design, a plastic-laminate socket is used, and the "hip" joint is placed on the front surface in such a position that, when used with an elastic strap connecting the rear end of the socket to a point on the shank ahead of the femur, stability during standing and walking can be achieved without the use of a lock at the hip joint. The location of the hip joint in the Canadian design also facilitates sitting, a real problem in earlier designs.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Hip-disarticulation prosthesis, known as the Canadian type because its principle was originally conceived by workers at the Department of Veterans Affairs of Canada. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A constant-friction knee unit is most often used with the hip-disarticulation prosthesis, but some prosthetists have reported successful use of hydraulic knee units.</p> <p>The hemipelvectomy patient is provided with the same type of prosthesis, but the socket design is altered to allow for the loss of part of the pelvis.</p> <h4>Upper-Extremity Prostheses <a></a></h4> <p>The major role of the human arm is to place the hand where it can function and to transport objects held in the hand. The energy for operation of the hand-substitute in upper-extremity prostheses is generally derived from relative motion between two parts of the body. Energy for operation of the elbow joint, when necessary, can be obtained in the same way. The stump, of course, is also a source of energy for control of the prosthesis in all except the shoulder-disarticulation and forequarter cases. Force and motion can be obtained through a cable connected between the device to be operated and a harness across the chest or shoulders.</p> <p>In recent years artificial arms powered by electricity and by compressed gas have received considerable publicity. An artificial hand powered by electricity and controlled by electrical signals from muscles was developed first in Russia for below-elbow amputees. Versions of the Russian design are manufactured in England, Canada, Germany, and elsewhere. However, the below-elbow patient, of all the types of upper-extremity amputees, is the least handicapped and therefore is less in need of sophisticated devices. The devices are expensive, and in their present state of development seem to offer no real advantage over the simpler conventional devices. The real need is for powered devices for patients with amputations above the elbow and higher.</p> <p>A number of electrically powered elbow units are now being tested, including the so-called Boston Arm, but none are available for general clinical use. To date, no truly satisfactory method of controlling externally powered prostheses has been developed. A good deal of effort is being made both in the United States and abroad to overcome the control problem <a></a>.</p> <p>Sockets for artificial arms are usually made of plastic laminate formed over a modified plaster model of the stump. Synthetic balata, which is molded directly over the stump, is now being used in a few centers.</p> <p><i>Hand Substitutes</i>-<i>Terminal Devices</i></p> <p>All upper-extremity prostheses for amputation at the wrist level and above have in common the problem of selection of the terminal device, a term applied to artificial hands and substitute devices such as hooks. In some areas of the world, there is a tendency to supply the arm amputee with a number of devices, each designed for a specific task such as eating, shaving, hair grooming, etc. In the United States, such an approach has been considered too clumsy, and opinion has been that the terminal device should be designed so that most upper-extremity amputees can perform the activities of daily living with a single device, or at most with two devices.</p> <p>The so-called split hooks are much more functional than any artificial hand devised to date. The arm amputee must rely heavily upon visual cues in handling objects, and the hook offers more visibility. The hook also offers more prehension facility and can be more easily introduced into and withdrawn from pockets than a device in the form of a hand. Therefore, the hook is used in manual occupations and those avocations requiring manual dexterity. When extensive contact with the public is necessary and for social occasions, the hand is of course generally preferred. Many amputees have both types of devices, using each as the occasion warrants.</p> <p>Two basic types of mechanisms have been developed for terminal-device operation—voluntary-opening and voluntary-closing. In the former, tension on the control cable opens the fingers against an elastic force; in the latter, tension in the control cable closes the fingers against an elastic force. Each type of mechanism has its advantages and disadvantages, neither being superior to the other when used in a wide range of activities. Both hands and hooks are available with either type of mechanism.</p> <p>The major types of terminal devices are shown in <b>Fig. 45</b> and <b>Fig. 46</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Voluntary-closing terminal devices. <i>A, </i>APRL-Sierra Hand; <i>left, </i>cutaway view showing mechanism; <i>right, </i>assembled hand without cosmetic glove; <i>B, </i>APRL-Sierra Hook. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Voluntary-opening terminal devices. The wide range of models offered by the D. W. Dorrance Company includes sizes and designs for all ages. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Wrist-Disarticulation Case</i></p> <p>One of the problems in fitting the wrist disarticulation in the past has been to keep the overall length of the prosthesis commensurate with the normal arm. The development of very short wrist units, especially for wrist-disarticulation cases, has materially reduced this problem. However, these units are available in only the screw, or thread, type and cannot be obtained in the bayonet type which lesds itself to quick interchange of terminal devices.</p> <p>The socket for the wrist-disarticulation case need not extend the full length of the forearm, and is fitted somewhat loosely at the upper, or proximal, end to permit the wrist to rotate. A simple figure-eight harness and Bowden cable are used to operate the terminal device (<b>Fig. 47</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Typical methods of fitting below-elbow amputees with medium to long stumps. <i>Top, </i>the figure-eight, ring-type harness is most generally used. Where possible, flexible leather hinges and open biceps cuff or pad are used. When more stability between socket and stump is required, rigid (metal) hinges and closed cuffs can be used <i>(A </i>and <i>B). C </i>shows fabric straps that are used for suspension in lieu of a leather billet. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Long Below-Elbow Case</i></p> <p>The prosthesis for the long below-elbow case is essentially the same as that for the wrist-disarticulation patient except that the quick-disconnect wrist unit can be used when desired.</p> <p><i>Prostheses for the Short Below-Elbow Case</i></p> <p>The socket for the short below-elbow stump, where there is no residual rotation of the forearm, is usually fitted snugly to the entire stump, and rigid hinges connecting the socket to a cuff about the upper arm are often used to provide additional stability. Either the figure-eight harness or the chest-strap harness may be used, the latter being preferred when heavy-duty work is required, since it tends to spread the loads involved in lifting over a broader area than is the case with the figure-eight design.</p> <p>A wrist-flexion unit, which permits the terminal device to be tilted in toward the body for more effective use, can be provided in the short below-elbow prosthesis, but it is seldom prescribed for unilateral cases.</p> <p><i>Prostheses for the Very Short Below-Elbow Case</i></p> <p>Often the very short below-elbow amputee cannot control the prosthesis of the short below-elbow type through the full range of motion, either because of a muscle contracture or because the stump is too short to provide the necessary leverage.</p> <p>When a contracture is present that limits the range of motion of the stump, a "split-socket" and "step-up" hinge may be used. With this arrangement of levers and gears, movement of the stump through one degree causes the prosthetic forearm to move through two degrees; thus, a stump that has only about half the normal range of motion can drive the forearm through the desired 135 degrees. However, when the step-up hinge is used, twice the normal force is required. When the stump is incapable of supplying the force required, it can be assisted by employing the "dual-control" harness, wherein force in the terminal-device control cable is diverted to help lift the forearm. When the elbow stump is very short or has a very limited range of motion, an elbow lock operated by stump motion is employed to obtain elbow function.</p> <p>Recently, a number of prosthetists have reported success in fitting very short be-low-elbow cases with an arm which is bent to give a certain amount of preflex-ion. This type of fitting, which was developed in Münster, West Germany, eliminates the necessity for using the rather clumsy step-up hinges and split socket, thus providing improved prosthetic control without a disadvantageous force feedback. Furthermore, the harness is not necessary for suspension of the prosthesis. The maximum forearm flexion may be limited to about 100 degrees, but this does not appear to be a significant disadvantage to unilateral amputees (<b>Fig. 48</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Comparison of split socket and Miinster-type fitting of short below-elbow case. <i>A, </i>split socket and step-up hinge provides 140 deg of forearm flexion; <i>B, </i>Münster-type fitting permits less forearm flexion but enables the amputee to carry considerably greater weight with flexed prosthesis unsupported by harness. <i>Courtesy New York University College of Engineering Prosthetic and Orthotic Research.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Elbow-Disarticulation Case</i></p> <p>Because of the length of the elbow-disarticulation stump, the elbow-locking mechanism is installed on the outside of the socket. Otherwise the prosthesis and harnessing methods (<b>Fig. 49</b>) are identical to those applied to the above-elbow case.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Typical prosthesis for the elbow-disarticulation case. The chest-strap harness with shoulder saddle is shown here, but the above-elbow figure-eight is also used. See Figure 50. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Above-Elbow Case</i></p> <p>For the above-elbow prosthesis to operate efficiently, it is necessary that a lock be provided in the elbow joint, and it is, of course, preferable that the lock is engaged and disengaged without resorting to the use of the other hand or pressing the locking actuator against an external object such as a table or chair.</p> <p>Several elbow units that can be locked and unlocked alternately by the same motion are available. This action is usually accomplished by the relative motion between the prosthesis and the body when the shoulder is depressed slightly and the arm is extended somewhat. The motion required is so slight that with practice the amputee can accomplish the action without being noticed. These elbow units contain a turntable above the elbow axis that permits the forearm to be positioned with respect to the humerus, supplementing the normal rotation remaining in the upper arm and thus allowing the prosthesis to be used more easily close to the midline of the body.</p> <p>The elbow units described above are available with an adjustable coil spring to assist in flexing the elbow when this is desired. The flexion-assist device may be added or removed without affecting the other operating characteristics.</p> <p>The socket of the above-elbow prosthesis covers the entire surface of the stump. The most popular harness used is the figure-eight dual-control design, wherein the terminal-device control cable is also attached to a lever on the forearm so that when the elbow is unlocked, tension in the control cable produces elbow flexion, and when the elbow is locked, the control force is diverted to the terminal device (<b>Fig. 50</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Typical prosthesis for the above-elbow case. The figure-eight harness is shown here but the chest-strap harness with shoulder saddle may also be used. See Figure 49. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The chest-strap harness may also be used in the dual-control configuration.</p> <p><i>Prostheses for the Shoulder-Disarticulation and Forequarter Cases</i></p> <p>Because of the loss of the upper-arm motion as a source of energy for control and operation of the prosthesis, restoration of the most vital functions in the shoul-der-disarticulation case presents a formidable problem; for many years, a prosthesis was provided for this type of amputation only for the sake of appearance. In recent years, however, it has been possible to make available prostheses which provide a limited amount of function (<b>Fig. 51</b>). To date it has not been possible to devise a shoulder joint that can be activated from a harness, but a number of manually operated joints are available. Various harness designs have been employed, but because of the wide variation in the individual cases and the marginal amount of energy available, no standard pattern has developed, each design being made to take full advantage of the remaining potential of the particular patient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. Typical prosthesis for the shoulder-dis-articulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for Bilateral Upper-Extremity Amputees</i></p> <p>Except for the bilateral, shoulder-dis-articulation case, fitting the bilateral case offers few problems not encountered with the unilateral case. The prostheses provided are generally the same as those prescribed for corresponding levels in unilateral cases. Artificial hands are rarely used by bilateral amputees, because hooks afford so much more function. Many bilateral cases find that the wrist-flexion unit, at least on one side, is of value. The harness for each prosthesis may be separated, but it is the general practice to combine the two (<b>Fig. 52</b>). In addition to being neater, this arrangement makes the harness easier for the patient to don unassisted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 52. Harness for the bilateral below-elbow/ above-elbow case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Some prosthetists have claimed success in fitting bilateral shoulder-disarticulation cases with two prostheses. Because of the lack of sufficient sources of energy for control, most cases of this type are provided with a single, functional prosthesis and with a plastic cap over the opposite shoulder, which provides an anchor for the harness and also fills this area to present a better appearance (<b>Fig. 53</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 53. Special harness arrangement for the bilateral shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Learning to Use the Prosthesis</h3> <p>To derive maximum benefit from his prosthesis, the amputee must understand how it functions and learn the best means of controlling it. A patient may be of the opinion that he is getting along very well when, in reality, he could do much better.</p> <p>Use of the prosthesis can best be learned under the supervision of an instructor who has had special training.</p> <p>All amputees using an artificial limb for the first time will need some instruction. In some instances, when a prosthesis is replaced with one of a different design, special instruction will be required. The time required for training depends upon the complexity of the device and the physical condition and degree of coordination of the patient. The time required will vary from a few hours to several weeks. In many instances, amputees themselves have become excellent trainers, but more often such training is given by physical or occupational therapists. Usually, physical therapists instruct lower-extremity patients, and occupational therapists teach upper-extremity cases.</p> <p>During the period of instruction, the trainer is careful to observe any effects the use of the prosthesis has on the patient, especially at points where the prosthesis is in contact with the body. Any changes are reported immediately to the physician in charge.</p> <h4>Lower-Extremity Cases</h4> <p>One of the major goals in training the leg amputee<a></a> is to enable him to walk as gracefully as possible. Training is begun as soon as the amputee is provided with a comfortable prosthesis. In the case of immediate postsurgical fitting,<a></a> training is often begun on the day following surgery and an adjustable leg is used. There is a growing tendency to train lower-extremity amputees on legs with adjustable features, even though they have not been fitted immediately after surgery. Some other goals of training are to teach the patient proper methods of donning the prosthesis, caring for the stump, arising after a fall, and using canes and crutches when necessary. The type of training will, of course, depend upon the level of amputation.</p> <p>A patient with a Syme amputation needs a minimum of training. The average below-knee case will require somewhat more, though usually not a great deal unless other medical problems are present. The training required is usually considerable for patients who have lost the knee joint.</p> <p>The ability to balance oneself is the first prerequisite in learning to walk, and so it is balance that is taught first to the above-knee amputee. Two parallel railings are used to give the patient confidence and to reduce the possibility of falling (<b>Fig. 54</b>). Balancing on both legs is practiced first, then on each leg. Walking in a straight line between the parallel bars is repeated until the patient no longer requires use of the hands for support. Walking in a straight line is practiced until the gait is even and smooth.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 54. Above-knee patient being trained to walk by a physical therapist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a rhythmic gait has been accomplished, more difficult tasks are learned, such as pivoting, turning, negotiating stairs and ramps, and sitting on and arising from the floor.</p> <p>Most unilateral above-knee patients can use their prostheses quite well without the necessity for a cane. However, in the case of short, weak stumps, it may be advisable to employ a cane for additional support and stability. If a cane is necessary, it should be selected to meet the needs of the patient, and it must be used properly if ungainly walking patterns are to be avoided. Canes with curved handles and made from a single piece of wood should be used. The shaft should not show any signs of buckling under the full load of the body weight, and should be just long enough so that the elbow is bent slightly when the bottom of the cane rests near the foot. The cane is used on the side opposite the amputation to help maintain balance, but it is not used to the extent that body weight is centered between the good leg and the cane (<b>Fig. 55</b>). Continued use of the cane in this manner usually results in a limp that is difficult to overcome. It has been found that, for biomechanical reasons, it is helpful for the amputee to carry a briefcase or purse on the side of the amputation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 55. Above-knee patient being taught correct use of cane. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Training The Hip-Disarticulation Cases</i></p> <p>The training of hip-disarticulation cases follows much the same pattern as that of above-knee cases. With the advent of the Canadian-type prosthesis, the training procedure has been considerably simplified. Some special precautions must be taken to avoid stumbling while ascending stairs.</p> <p><i>Special Considerations for Bilateral-Leg Cases</i></p> <p>As would be expected, bilateral-leg cases pose special problems in addition to those of the unilateral cases, and therefore a good deal of time will usually be required in training. Patients with two good below-knee stumps will seldom require canes. Some bilateral above-knee amputees can get along without canes, but as a general rule, at least one cane is required.</p> <h4>Upper-Extremity Cases</h4> <p>The first objective in the training program for upper-extremity amputees is to ensure that the patient can perform the activities encountered in daily living, such as eating, grooming, and toilet care. When this goal has been attained, attention is devoted to any special training that might be required in vocational pursuits (<b>Fig. 56</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 56. Upper-extremity amputees performing vocational tasks. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Before the prosthesis is put to useful purposes, the patient is shown how the various mechanisms are controlled, and is made to practice these motions until they can be performed in a graceful manner and without undue exertion. In general, the arm amputee soon becomes so adept in these procedures that they are carried out without conscious thought. During this period, the functioning of the prosthesis, especially of the harness and control cables, is watched carefully by the instructor and constantly rechecked to ensure maximum performance.</p> <p>Only when the patient has mastered use of the various controls is practice in handling objects and performing activities of daily living undertaken.</p> <h3>Care of the Stump</h3> <p>Even under the most ideal circumstances, the amputation stump, when called upon to operate a prosthesis, is subjected to certain abnormal conditions which, if not compensated for, may lead to physical disorders which make the use of a prosthesis impossible.</p> <p>Lack of ventilation as a result of encasing the stump in a socket with impervious walls causes an accumulation of perspiration and other secretions of glands found in the skin. In addition to the solid matter in the secretions, bacteria will accumulate in the course of a day. Both the solid matter and bacteria can lead to infection, and the solid matter, though it may appear to be insignificant, may result in abrasions and the formation of cysts. For these reasons, cleanliness of the stump and anything that comes in contact with it for any length of time is of the utmost importance, even when sockets of the newer porous plastic laminate are used.</p> <p>Therefore, the stump should be washed thoroughly each day, preferably just before retiring. A soap or detergent containing hexachlorophene, a bacteriostatic agent, is recommended, but strong disinfectants are to be avoided. To be fully effective, the bacteriostatic agent must be used daily. Some six or seven daily applications are necessary before full effectiveness is obtained, and any cessation of this routine lowers the agent's ability to combat the bacteria. A physician who is himself an amputee has suggested that, after an amputee takes a bath, the stump should be dried first, in order to minimize the risk of introducing infection to it by the towel.</p> <p>When the prosthesis is used without a stump sock, the stump should be thoroughly dry, as moisture may cause swelling that will result in rubbing and irritation. For such cases, it is especially desirable for the stump to be cleansed in the evening.</p> <p>The stump sock should receive the same meticulous care as the stump. The socks should be changed daily and washed as soon as they are taken off. In this way, the perspiration salts and other residue are easier to remove. A mild soap and warm water are used to keep shrinkage to a minimum. Woolite (a cold-water soap) and cold water in recent trials have given excellent results. A rubber ball inserted in the "toe" during the drying process ensures retention of shape.</p> <p>Elastic bandages should be washed daily in the same manner as stump socks, but should not be hung up to dry; rather, they should be laid out on a flat surface away from excessive heat and out of the direct rays of the sun. Hanging places unnecessary stresses on the elastic threads, and heat and sunlight accelerate deterioration.</p> <p>It is of the utmost importance that any skin disorder of the stump—no matter how slight—receive prompt attention, because such disorders can rapidly worsen and become disabling. The amputee should see a physician for treatment. He should also see his prosthetist; it may be that adjustment of the prosthesis will eliminate the cause of the disorder. In no case should iodine or any other strong disinfectant be used on the skin of the stump.</p> <p>Sometimes the skin of the stump is rubbed raw by socket friction. When this happens, the skin should be gently washed with a mild toilet soap. After the stump has been rinsed and dried, bacitracin ointment or some other antibacterial agent should be applied, and the area covered with sterile gauze. The prosthesis should be completely dry before it is put on. If such abrasions occur frequently, the prosthetist should be informed. If there is the slightest sign of infection, the amputee should see a physician.</p> <p>Small painless blisters should not be opened; they should be washed gently with a mild soap and left alone. Large, painful blisters should be treated by a physician.</p> <h4>Bandaging the Stump</h4> <p>The stump is usually kept wrapped in an elastic bandage from the time healing permits until the time the prosthesis is delivered. Also, bandaging is recommended when for some reason it is impracticable or impossible for the patient to wear his limb routinely. It is therefore highly desirable for the amputee, or at least one member of his family, to be able to apply the bandages. Many amputees can wrap their stumps unaided and, indeed, prefer to do so. Others prefer, and in some instances require, the help of another person.</p> <p>Recommended methods for applying elastic bandages for below-knee, above-knee, below-elbow, and above-elbow patients are shown in <b>Fig. 57</b>, <b>Fig. 58</b>, and <b>Fig. 59</b>. These illustrations first appeared in a booklet entitled <i>Industrial Amputee Rehabilitation, </i>prepared by Dr. C. O. Bechtol under the sponsorship of Liberty Mutual Insurance Company of Boston.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 57. Recommended method of applying elastic bandage to the below-knee stump. The bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 58. Recommended method of applying elastic bandage to the above-knee stump. The stump is kept in a relaxed position, and the bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 59. Elastic bandages applied properly to upper-extremity stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Care of the Prosthesis</h3> <p>In addition to the care required in keeping the inside of the socket clean, which has been stressed, best results can be obtained only if the prosthesis is maintained in the best operating condition. Like all mechanical devices, artificial limbs can be expected to receive wear and be discarded for a new device, but the length of useful life can be extended materially if reasonable care is taken in its use. An example often quoted is that of two identical automobiles. The car given the maintenance recommended by the manufacturer and operated with care will outlast many times the vehicle given spotty maintenance and operated with disregard for the heavy stresses imposed. So it is with artificial limbs. Some amputees require a new prosthesis every few years or even more often, while others who follow the manufacturer's instructions, apply preventive maintenance practices, and have minor problems corrected without delay have received satisfactory service from their limbs for periods as long as twenty years.</p> <p>Manufacturers' instructions vary with the design of the device. They consist mainly of lubrication practices, and should be followed closely. Too much lubricant can sometimes produce conditions as troublesome as excessive wear. Looseness of joints and fastenings should be corrected as soon as it is detected, for the wear rate increases rapidly under such a condition. Any cracks that appear in supporting structures should be reinforced immediately, in order to avoid complete failure and the necessity for replacement. The foot should be examined weekly for signs of excessive wear.</p> <p>A point often overlooked by leg amputees, but nevertheless one of the factors affecting optimum use of the artificial limb, is the condition of the shoe. Badly worn or improper shoes can alter alignment and therefore have adverse effects on the stability and gait of the wearer. This is a matter that requires especially close attention in the case of child amputees.</p> <p>Hooks and artificial hands should be treated with the same care that the normal hand is given. Because the sensation of feeling is absent in the terminal device, the upper-extremity amputee is all too prone to use hooks to pry and hammer and to handle hot objects that are deleterious to the hook materials. Hands with cosmetic gloves should be washed daily, and of course hot objects and staining materials should be avoided.</p> <h3>Special Considerations in Treatment of Child Amputees<a></a></h3> <p>Only a few years ago, it was seldom that a child amputee was fitted with a prosthesis before school age, and often not until much later. In recent years, experience has shown that fitting at a much earlier age produces more effective results.</p> <p>If there are no complicating factors, children with arm amputations usually should be provided with a passive type of prosthesis soon after they are able to sit alone, which is generally at about six months of age. Certain gross two-handed activities are thus made possible, crawling is facilitated, and the child becomes accustomed to using and wearing the prosthesis and moves easily into using a body-operated prosthesis as his coordination develops soon after his second birthday.</p> <p>Lower-extremity child amputees should be fitted with prostheses as soon as they show signs of wanting to stand. The development of muscular coordination of child amputees is the same as for non-handicapped children, and therefore this phase may take place as early as eight months or as late as twenty or more months.</p> <p>Children, especially when fitted at an early age, almost always adapt readily to prostheses. As the child grows, the artificial limb seems to become a part of him in a manner seldom seen in adults (<b>Fig. 60</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 60. Children with upper-extremity amputations performing two-handed activities. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Except for the very young, children's prostheses follow much the same design as those for the adult group. Special devices and techniques have been developed for initial fitting of infants and problem cases.</p> <p>Regardless of where the child amputee resides, or the extent of his parents' financial resources, he need not go without the treatment and prostheses required to make full use of his potentials. To ensure that such services are available, the Children's Bureau of the Department of Health, Education, and Welfare has assisted a number of states in establishing well-organized child-amputee clinics, and the facilities of those states are available to residents of states where such specialized services are not to be had. There is an agency in each state that can advise the parents of the proper course of action.</p> <p>Most children can be treated on an out-patient basis, but for the more severely handicapped, many of the clinics have facilities for in-patient treatment. The clinic team for children is often augmented by a pediatrician and a social worker, and sometimes by a psychologist.</p> <p>Training very young children is one of the most difficult problems of the clinic team. Although the learning ability of young children may be rapid, their attention span is of such short duration that extreme patience is required. Regardless of the ability of the therapist, successful results cannot be achieved without complete cooperation of the parents. The mental attitude of the parents is reflected in the child, and all too often children have rejected prostheses because the parents, consciously or subconsciously, could not accept the fact that a prosthesis was needed. Parents of children born with a missing or deformed limb often experience a sense of guilt, a feeling that only adds to an already difficult problem. The guilt feeling is unwarranted, inasmuch as the knowledge of the causes of congenital defects—and appropriate preventive measures—is very limited. The recent discovery of the effects of thalidomide suggests that other causes may be found.</p> <p>As a rule, lower-extremity amputees present fewer problems than the upper-extremity cases. It is natural for the child to walk, and almost invariably the lower-extremity patient adapts rather quickly. However, parents should keep close observation of the walking habits of the child, the condition of his stump, and the state of repair of his prosthesis, and above all they should present the child at the clinic at the recommended times. A gradual change in walking habit may indicate that the child has outgrown the prosthesis or that excessive wear of the prosthesis has taken place. Any unusual appearance of the stump should be reported to the physician immediately so that remedial steps may be taken, thereby avoiding more complicated medical problems at a later date. Children give a prosthesis more wear and tear than do adults, and it is important that the prosthesis be examined carefully at regular intervals and needed repairs made as soon as possible—not only to ensure the safety of the child but to avoid the necessity for major repairs at a later date.</p> <p>Many upper-extremity child amputees adapt readily to artificial arms (some even want to sleep with the arm in place), but in many cases the child will need a great deal of encouragement before he will accept the device and make use of it. At first, the unilateral amputee may feel that the prosthesis is a deterrent rather than an aid, but with the proper encouragement, this feeling is reversed.</p> <p>Parents can help by continuing the training given in the clinics. From the beginning, the artificial arm should be worn as much as possible. Young children should be given toys that require two hands for use, and older children should be given household chores that require two-handed activities. In the latter case, not only does the child learn to appreciate the usefulness of the prosthesis, but he also gains a feeling of being a useful member of the family and thus a better mental attitude is created.</p> <p>The child amputee should not be sheltered from the outside world, but should be encouraged to associate with other children and, to the extent that he can, to take part in their activities. Of course there are certain limitations, but the number of activities that can be performed with presently available prostheses is amazing. It goes almost without saying that the child should receive no more special attention than is necessary and should be made to perform the activities of daily living of which he is capable.</p> <p>It has been shown that it is preferable for the child amputee to attend a regular school, rather than one for the handicapped. Most child amputees can and do take their place in society, and the transition from school to work is much easier if they are not shown unnecessary special consideration. Nonhandicapped children soon accept the amputee and make little comment after the initial reaction.</p> <p>Here again, the arm amputee is apt to be faced with the most problems. Some public school officials have hesitated to admit arm amputees wearing hooks, for fear the child may use them as weapons. This attitude is unrealistic. If such incidents have occurred, they are rare indeed. However, arm prostheses should be removed when the child is engaged in body-contact sports such as football.</p> <p>Cleanliness of the stump, prosthesis, and stump sock is just as important for children as for adults. The same procedures as those outlined on pages 43-46 are recommended.</p> <h3>Special Considerations in the Treatment of Elderly Patients</h3> <p>Persons who have had amputations during youth or middle age seldom encounter additional problems in wearing their prostheses as they become older. However, for those patients who have an amputation in later life, many unusual problems are apt to be present. Most amputations in elderly patients are necessary because of circulatory problems, almost always affecting the lower extremity. For many years, the wisdom of fitting such patients with prostheses was debatable, the thought being that the remaining leg, which in most cases was subject to the same circulatory problems as the one removed, would be overtaxed and thus the need for its removal would be hastened. Energy studies in recent years have shown that crutch-walking is more taxing than use of an artificial limb. Experience with rather large numbers of elderly leg amputees has shown that failure of the remaining leg has not been accelerated by use of a prosthesis, and stumps that have been fitted properly have not been troublesome. As a result, more and more elderly patients are benefiting by the use of artificial limbs. A rule of thumb that is used in some clinics to decide whether or not to fit the elderly patient is that, if he can master crutch-walking, he should be fitted. This measure should be used with discretion because, in some instances, patients who could not meet the crutch-walking requirement have become successful wearers of prostheses.</p> <p>The patient should be fitted as soon as possible, to avoid such complications as the development of contractures. The availability of adjustable pylon-type legs and the use of plaster or plastic sockets now makes early fitting practical, and this approach is being adopted by more and more centers. Many geriatric patients have benefited from the immediate postsurgical fitting procedures.</p> <p>Most clinic teams feel that, if the patient can use the prosthesis to make him somewhat independent around the house, the effort is fully warranted.</p> <p>Artificial legs for the older patients, as a rule, should be as light as possible. Except for the most active patients, only a small amount of friction is needed at the knee for control of the shank during the swing phase of walking because the gait is apt to be slow. Suction sockets have rarely been used, because of the effort required in donning them. A quadrilateral-shaped socket is often used with one stump sock and a pelvic belt. Silesian bandages have been used successfully, allowing more freedom of motion and increased comfort.</p> <p>A new approach introduced recently by the University of Miami offers the geriatric amputee the possibility of using a suction socket by reducing the effort required in donning.<a></a> The flexible plastic inner liner, which contains a suction valve, is put on over the stump first, and then the stump and inner liner are inserted into the outer socket of rigid plastic and latched in place.</p> <p>For the elderly below-knee cases, the patellar-tendon-bearing prosthesis is being used quite successfully.</p> <h3>Cineplasty<a></a></h3> <p>In 1896, the Italian surgeon Vanghetti conceived the idea of connecting the control mechanism of a prosthesis directly to a muscle. Several ideas involving the formation of a club-like end or a loop of tendon in the end of a stump muscle were tried out in Italy. Just prior to World War I, the German surgeon Sauerbruch devised a method of producing a skin-lined tunnel through the belly of the muscle. A pin through the tunnel was attached to a control cable, and thus energy for operation of the prosthesis was transferred directly from a muscle group to the control mechanism. With refinements, the Sauerbruch method is available for use today, but it must be used cautiously.</p> <p>Although tunnels have been tried in many muscle groups, the below-elbow amputee is the only type who can be said to benefit truly from the cineplasty procedure. A tunnel properly constructed through the biceps can supply power for operation of a hand or hook, and there need be no harnessing above the level of the tunnel. Thus, the patient is not restricted by a harness, and the terminal device can be operated with the stump in any position. Training the tunneled muscle and care of the tunnel require a great deal of work by the patient; therefore if the cineplasty procedure is to be successful, the patient must be highly motivated.</p> <p>Some female below-elbow amputees have been highly pleased with results from a biceps tunnel, but as a rule, cineplasty does not appeal to women.</p> <p>Cineplasty is not indicated for children. Sufficient energy is not available for proper operation of the prosthesis, and the effects of growth on the tunnel are not known.</p> <p>Tunnels have been tried in the forearm muscles, but the size of these muscles is such that the energy requirements for prosthesis operation are rarely met. While tunnels in the pectoral muscle are capable of developing great power, in the light of present knowledge the disadvantages tend to outweigh the advantages. It is extremely difficult to harness effectively the energy generated, and very little, if any, of the harness can be eliminated. It is true that an additional source of control can be created, but with the devices presently available, little use can be made of this feature.</p> <p>No application for cineplasty has been found in lower-extremity amputation cases.</p> <p>Still another type of cineplasty procedure is the Krukenberg operation, whereby the two bones in the forearm stump are separated and lined with skin to produce a lobster-like claw. The result, though unattractive in appearance, permits the patient to grasp and handle objects without the necessity of a prosthesis. Because sensation is present, the Krukenberg procedure has been found to be most useful for blind bilateral amputees. Although prostheses can be used with Krukenberg stumps when appearance is a factor, the operation has found little favor in the United States.</p> <h3>U.S. Agencies That Assist Amputees</h3> <p>For several centuries at least, governments have traditionally cared for military personnel who received amputations in the course of their duties. But only in recent years, except in isolated cases, has the amputee in civilian life had much assistance in making a comeback. Today, there are available services to meet the needs of every category of amputee. Aside from the humanitarian aspects of such programs, it has been found to be good business to return the amputee to productive employment and, in the case of some of the more debilitated, to provide them with devices and training to take care of themselves.</p> <p>The armed services provide limbs for military personnel who receive amputations while on active duty, and many of these cases are returned to active duty. After the patient has been discharged from military service, the Veterans Administration assumes responsibility for his medical care and prosthesis replacement for the remainder of his life. The U.S. Public Health Service, through its marine hospitals, cares for the prosthetics needs of members of the U.S. Maritime Service.</p> <p>Each state provides some sort of service for child amputees. If sufficient facilities are not available within a state, provisions can be made for treatment in one of the regional centers set up in a number of states with the help and encouragement of the Children's Bureau of the Department of Health, Education, and Welfare. With assistance from the Social and Rehabilitation Service of the Department of Health, Education, and Welfare, every state operates a vocational rehabilitation program designed to help the amputee return to gainful employment. Some of these programs render assistance to housewives as well.</p> <p>The Medicaid and Medicare programs sponsored by the federal government make it possible for the elderly and indigent to be supplied with artificial limbs.</p> <p>Private rehabilitation centers, almost universally nonprofit and sponsored largely by voluntary organizations, greatly augment the state and federal programs.</p> <p>Information concerning rehabilitation centers serving a particular area may be obtained from the International Association of Rehabilitation Facilities, 7979 Old Georgetown Rd., Bethesda, Md., 20014.</p> <!--References Removed--> <p><b>References:</b></p> <ol> <li>Artif. Limbs, 4:2, Autumn 1957.</li> <li>Artif. Limbs, 6:1, April 1961.</li> <li>Artif. Limbs, 6:2, June 1962.</li> <li>Bechtol, Charles 0., and George T. Aitken, <i>Cineplasty, </i>in <i>Orthopaedic appliances atlas, </i>Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>5. Blakeslee, Berton, Ed., <i>The limb-deficient child,</i> University of California Press, Berkeley and Los Angeles, 1963.</li> <li>6. Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., <i>Immediate postsurgical prosthetics in the management of lower-extremity amputees, </i>TR 10-5, Prosthetic and Sensory Aids Service, Veterans Administration, Washington, D.C., April 1967.</li> <li>Committee on Artificial Limbs, National Research Council, Washington, D.C., <i>Terminal research reports on artificial limbs, </i>covering the period from 1 April 1945 through 30 June 1947.</li> <li>Feinstein, Bertram, James C. Luce, and John N. K. Langton, <i>The influence of phantom limbs, </i>in Klopsteg, Wilson, <i>et al., Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Foort, J., <i>Adjustable-brim fitting of the total contact above-knee socket, </i>No. 50, Biomechanics Laboratory, University of California, San Francisco and Berkeley, March 1963,</li> <li>Foort, James, <i>The patellar-tendon-bearing prosthesis for below-knee amputees, a review of technique and criteria, </i>Artif. Limbs, 9:1:4-13, Spring 1965.</li> <li>Hampton, Fred, <i>Suspension casting for below-knee, above-knee, and Syme's amputations, </i>Artif. Limbs, 10:2:5-26, Autumn 1966.</li> <li>Klopsteg, P. E., <i>The functions and activities of the Committee on Artificial Limbs of the National Research Council, </i>J. Bone Joint Surg., 29:538-540, 1947.</li> <li>National Academy of Sciences-National Research Council, <i>The control of external power in upper-extremity rehabilitation, </i>Publication 1352, 1966.</li> <li>Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, <i>A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, </i>Artif. Limbs, 10:1:52 55, Spring 1966.</li> <li>Sinclair, William F., <i>A suction socket for the geriatric above-knee amputee, </i>Artif. Limbs, 13:1:69-71, Spring 1969.</li> <li>Staros, Anthony, <i>Dynamic alignment of artificial legs with the adjustable coupling, </i>Artif. Limbs, 7:1:31-43, Spring 1963.</li> <li>Taylor, Craig L., <i>Control design and prosthetic adaptations to biceps and pectoral cineplasty, </i>in Klopsteg, Wilson, <i>et al., Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Thomas, Atha, and Chester C. Haddan, <i>Amputation prosthesis, </i>Lippincott, Philadelphia, 1945.</li> <li>Vultee, Frederick E., <i>Physical treatment and training of amputees, </i>in <i>Orthopaedic appliances atlas, </i>Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>Weiss, Marian, <i>Neurological implications of fitting artificial limbs immediately after amputation surgery, </i>in Report of Fifth Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences- National Research Council, February 1966.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bechtol, Charles 0., and George T. Aitken, Cineplasty, in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Sinclair, William F., A suction socket for the geriatric above-knee amputee, Artif. Limbs, 13:1:69-71, Spring 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">5. Blakeslee, Berton, Ed., The limb-deficient child, University of California Press, Berkeley and Los Angeles, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">6. Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Immediate postsurgical prosthetics in the management of lower-extremity amputees, TR 10-5, Prosthetic and Sensory Aids Service, Veterans Administration, Washington, D.C., April 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Vultee, Frederick E., Physical treatment and training of amputees, in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">National Academy of Sciences-National Research Council, The control of external power in upper-extremity rehabilitation, Publication 1352, 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, in Klopsteg, Wilson, et al., Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total contact above-knee socket, No. 50, Biomechanics Laboratory, University of California, San Francisco and Berkeley, March 1963,</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The Type S replaces Model B. It provides the same function but is shorter and lighter.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Artif. Limbs, 6:2, June 1962.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Foort, James, The patellar-tendon-bearing prosthesis for below-knee amputees, a review of technique and criteria, Artif. Limbs, 9:1:4-13, Spring 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, Artif. Limbs, 10:1:52 55, Spring 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Artif. Limbs, 6:1, April 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Staros, Anthony, Dynamic alignment of artificial legs with the adjustable coupling, Artif. Limbs, 7:1:31-43, Spring 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Hampton, Fred, Suspension casting for below-knee, above-knee, and Syme's amputations, Artif. Limbs, 10:2:5-26, Autumn 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, in Klopsteg, Wilson, et al., Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">6. Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Immediate postsurgical prosthetics in the management of lower-extremity amputees, TR 10-5, Prosthetic and Sensory Aids Service, Veterans Administration, Washington, D.C., April 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Weiss, Marian, Neurological implications of fitting artificial limbs immediately after amputation surgery, in Report of Fifth Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences- National Research Council, February 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Artif. Limbs, 4:2, Autumn 1957.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Artif. Limbs, 6:1, April 1961.</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, Artif. Limbs, 10:1:52 55, Spring 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">1440 N St., N.W., Washington. D.C. 20005.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">1440 N St., N.W., Washington. D.C. 20005.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Klopsteg, P. E., The functions and activities of the Committee on Artificial Limbs of the National Research Council, J. Bone Joint Surg., 29:538-540, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Committee on Artificial Limbs, National Research Council, Washington, D.C., Terminal research reports on artificial limbs, covering the period from 1 April 1945 through 30 June 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Thomas, Atha, and Chester C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennet Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Ave., N.W., Washington, D.C. 20418</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource 1970 Limb Prosthetics Creator An entity primarily responsible for making the resource A. Bennet Wilson, Jr. * https://staging.drfop.org/files/original/02af16250516ded97985a715859e1d48.pdf 65d14eece6f79ba597a6dae38a00de2a https://staging.drfop.org/files/original/e39a0401f8bbfac0d7ecc2b81b69051f.jpg 8d0aee0aac22824b626b3f8d2b09410b https://staging.drfop.org/files/original/ec0662366f6e7d988cba99c4979f2001.jpg 107421598388ffad0c304b8ffb5f9550 https://staging.drfop.org/files/original/1270e5e0a05e215c9e3ce92571815ce9.jpg 1c1fe45517ca27d04646ba18f75d20c9 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_01_053.pdf Year 1970 Volume 14 Issue 1 Page Number(s) 53 - 64 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_01_053.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_01_053.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A Material for Direct Forming of Prosthetic Sockets</h2> <h5>A. Bennett Wilson, Jr. <br /></h5> <p>For a number of years, prosthetics research groups have been attempting to develop a method of forming sockets directly on amputation stumps, in order to reduce the time required to produce a satisfactory socket and to eliminate the messy working conditions inherent in the use of plaster of paris.<a></a></p> <p>Direct forming requires a material that: (<i>a</i>) is plastic at temperatures moderately above ambient, but which requires reasonably high temperatures for subsequent softening; <i>(b) </i>is easily handled under conditions found in most limb shops; (<i>c</i>) exhibits minimum creep or deformation under normal loads, even at temperatures slightly above body temperature; (<i>d</i>) is nontoxic; and (<i>e</i>) has a reasonable strength-to-weight ratio.</p> <p>Recently, research and development groups in Canada and the United States have developed successful techniques for direct forming of some types of sockets by using a synthetic balata, Polysar<a style="text-decoration:none;">*</a> X-414.</p> <p>Polysar X-414 has been found to possess the properties most essential for direct forming: (a) it becomes plastic at temperatures between 160 and 180 deg F; <i>(b) </i>it can be applied to the amputation stump within a minute or two after heating; (c) it remains reasonably plastic after its surface temperature drops 20 to 30 deg; <i>(d) </i>after it cools and becomes nonplastic, it maintains its shape, even under stress and subsequent heating to temperatures of 120 deg F; and (e) it can be reheated and reformed to permit socket modification after fabrication. In the plastic state, it exhibits cohesive properties which facilitate fabrication. It yields a slightly flexible socket which is considered desirable by most patients, and it is practical to use all conventional components and accessories with Polysar X-414.</p> <p>Clinical findings indicate that the sockets remain durable, provided they are not exposed to excessive heat <i>(e.g., </i>leaving the prosthesis in the sun, in the trunk of a car on a hot day, or leaning against a house radiator). Also, excessive contact with perspiration may cause erosion of the material in a year's time; however, stump socks normally provide an adequate barrier.</p> <p>The socket-forming procedure is relatively simple. The need for making a plaster-of-paris wrap cast, pouring a positive cast, and modifying the positive cast is eliminated. Thus, not only is fabrication time reduced, but the chance of the errors that are likely to occur when fabricating a socket with conventional materials also is lessened.</p> <h4>Lower-Extremity Sockets</h4> <p>A practical method for direct forming of sockets over the below-knee stump has been developed recently at the Veterans Administration Prosthetics Center. Early attempts included the use of a pneumatic bag over a tube of synthetic rubber to provide the pressure necessary for forming the socket over the stump (<b>Fig. 1</b>) <a></a>, a procedure which worked satisfactorily for bony, mature stumps but which often produced sockets that were too loose when molded over flabby stumps. Further experimentation resulted in a technique in which pressure is provided by wrapping pressure-sensitive tape spirally around the tube of Polysar X-414 and molding it with the hands as the tube cools (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Pneumatic pressure was applied to the softened synthetic rubber to form the socket on the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Direct forming of a below-knee socket with a pressure-sensitive tape wrap and hand molding of the softened synthetic rubber tube. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This method, described in the article beginning on page 57, has proved to be successful in a number of clinics, especially for use in temporary, or preparatory, prostheses. If a pylon is used, the patient can be provided with a well-fitted prosthesis in a very few hours. If subsequent socket modifications are required, they can usually be carried out readily, and if one of the adjustable pylons is used, alignment can be changed easily when required. A satisfactory cosmetic effect (<b>Fig. 3</b>) can be achieved relatively easily, to provide a "permanent" prosthesis. Such a prosthesis has proved to be quite successful as a "permanent" prosthesis for many patients in the old-age group.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. A "permanent" below-knee prosthesis, consisting of a synthetic rubber socket, adjustable pylon, foam-block covering (note cutout for access to the adjustment mechanism), and stocking. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Because of the size of the above-knee socket and the usual need for rather drastic modification of the socket with respect to the shape of the stump, a successful method of molding sockets directly over the above-knee stump has not yet been developed. However, work is continuing at VAPC.</p> <h4>Upper-Extremity Sockets</h4> <p>A technique for satisfactorily forming sockets for permanent prostheses directly over below-elbow stumps has been developed, also at VAPC. Again, extruded tubing of Polysar X-414 is used. All pressure necessary for forming is provided by the prosthetist's hands. Several types of cosmetic coverings are available when further cosmetic treatment is desired. The time required for fabrication of a typical below-elbow prosthesis can be reduced by half. The VAPC technique is described fully in the article beginning on page 65.</p> <p>The Ontario Crippled Children's Centre, Toronto, Canada, has been routinely using Polysar X-414 in fabrication of the open-shoulder, above-elbow socket, described in <i>Artificial Limbs </i>for Autumn 1969. Sockets preformed roughly to the shape required are heated and applied over the stump.</p> <p>The Prosthetics Research Center, Northwestern University, has developed a successful method for forming more conventional above-elbow sockets directly over the stump. An article describing this technique is scheduled for publication in the next issue of <i>Artificial Limbs.</i></p> <h4>Implications</h4> <p>Forming sockets with synthetic balata offers the prosthetist and orthotist the opportunity to provide quicker service to the patient, and also opens up many possibilities for improving the designs of sockets and orthotic components. The use of temporary prostheses can now be made routine, giving the clinic team ample time to determine the optimum prescription for the patient. Errors can be rectified easily, and new ideas can be tried with a minimum expenditure of time. Orthotists are already using synthetic balata for cuffs and molded supports. It is expected that many more uses for this remarkable material will be developed in the future.</p> <p><b>References:</b></p> <ol> <li>Committee on Prosthetics Research and Development, <i>Fracture bracing, </i>A report of a workshop, National Academy of Sciences, Washington, D.C., February 1969. </li> <li>The Staff, Veterans Administration Prosthetics Center, <i>Direct forming of below-knee patellar-tendon-bearing sockets with a thermoplastic material, </i>Orth. and Pros., 23:1:36-61, March 1969.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">The Staff, Veterans Administration Prosthetics Center, Direct forming of below-knee patellar-tendon-bearing sockets with a thermoplastic material, Orth. and Pros., 23:1:36-61, March 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Registered trademark of the Polymer Corporation Limited.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Fracture bracing, A report of a workshop, National Academy of Sciences, Washington, D.C., February 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_01_053/tmp399-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_01_053/tmp399-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_01_053/tmp399-3.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Material for Direct Forming of Prosthetic Sockets Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr.  https://staging.drfop.org/files/original/c3460a2dab08b833441c25bf7385221d.pdf 07ff006625669bcbaab152e35ddbab6e 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/1982_02_007.pdf Text Any textual data included in the document <h2>Letter To The Editor: A Return To Research?</h2> <h5>A. Bennett Wilson, Jr.&nbsp;</h5> <p>Thirty-seven years ago, with funds from the United States Government, the National Academy of Sciences initiated a research and development program in artificial limbs because amputees in Army and Navy hospitals expressed quite vociferously their dissatisfaction with the artificial limbs provided at that time, and because there had never been, in this country, any concerted scientific effort to solve the problems of amputees. Although the research program, funded until the late 1950's largely by the Veterans Administration, was not looked upon with favor by many prosthetists during its early stages, with the help of a few of the more progressive prosthetists and orthopaedic surgeons sufficient progress was made by 1952 to warrant the initiation of a formal education project at the University of California at Los Angeles, which set the pattern for the present education program in prosthetics and orthotics.</p> <p>The Department of Health, Education, and Welfare, about 1955, joined the VA in supporting research, development, evaluation, and education; orthotics was added to the mission in the late 50's; and progress continued to the point that by the early 70's nearly every aspect of prosthetics had been replaced by newer techniques and devices, and work in orthotics was progressing rapidly. Although it was, and is, recognized by many that further, continuing research was needed, the government agencies have all but abandoned research and development in prosthetics and orthotics, and as a result very few improvements have been introduced to the practice of prosthetics and orthotics during the last few years.</p> <p>This unfortunate situation has been brought about because of a number of factors: the decision by the National Academy of Sciences to withdraw from the program; reorganization by the VA in 1973 that resulted in transferring research and development responsibility from the Prosthetic and Sensory Aids Service to general medical research, and to conduct most of the research and development in VA hospitals; and an unbelievable proliferation in all government agencies of "red tape" required in awarding contracts and grants.</p> <p>During these 37 years, the prosthetics and orthotics profession has become healthy and strong, in part because the research and development program has provided a teachable body of knowledge and an education program that has produced a group of practitioners who are capable of communicating effectively among themselves and with other groups.</p> <p>Given this set of circumstances, it seems reasonable that the prosthetists and orthotists in this country should consider taking responsibility for research, development, and evaluation, and relieve the government of most of the responsibility it has assumed in this area for the last 37 years. Certainly a program administered by AAOP-AOPA could be more efficient and more effective than one administered by the government. One way to finance this undertaking is to include in the price of each new prosthesis and orthosis an appropriate percentage of the price to be set aside for the research program. This sum would, of course, be a legitimate business expense.</p> <p>The coordination and "clearing-house" functions would reside in the National Office, and R&amp;D would be carried out in appropriate facilities and institutions. If properly managed such a program would have many obvious advantages, not the least of which would be improved patient care.</p> Page Number(s) 7 - 7 Year 1982 Volume 6 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Letter To The Editor: A Return To Research? Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr.  https://staging.drfop.org/files/original/51f5adc7b73ba20f64f5b1072208d97e.pdf 22b566ecc169422c3f86252d9a20be5e https://staging.drfop.org/files/original/3af9a5ff106766a98f790a31724a2a1f.jpg f6e27c5ae43c78cb08a394d78fa3b275 https://staging.drfop.org/files/original/2aff81bed2e3b007be1b8792137c5788.jpg 28e771b1094c0b1209ef81372fd82ce6 https://staging.drfop.org/files/original/41beee5399a82e0e40acfda675701aad.jpg f1003cc7f042f683207455f6a189e513 https://staging.drfop.org/files/original/90ef2a1233e04d701819d9715038383f.jpg 4d02c130bcdd0706cf18f7b6fc0dd0be https://staging.drfop.org/files/original/634d5ee7cc369045d31e39da291ee0d3.jpg d7e48a87b19caa8b90142027b54ae166 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1978_01_001.pdf Text Any textual data included in the document <h2>Externally Powered Upper-Limb Prostheses</h2> <h5>A. Bennett Wilson, Jr.&nbsp;</h5> <p>The earliest reference to externally powered upper-limb prostheses seems to be in connection with experiments that took place in Germany about 1918 in which electromagnets were used to close the fingers of an artificial hand <a></a>. The next reported effort apparently is the research and development program proposed and carried out by Alderson <a></a> on electrically powered arm systems during 1946-1952 with support from International Business Machines, Inc. and the Veterans Administration.</p> <p>Initial results of the Alderson-IBM project (<b>Fig. 1</b>) were quite impressive with respect to operation, but an extensive evaluation at UCLA in 1951 revealed that a disproportionate amount of mental effort by the wearer was required for use of the various systems<a></a>. As a result of the findings of the UCLA study, and because only a limited amount of money was available for work in artificial limbs, the Advisory Committee on Artificial Limbs (later the Committee on Prosthetics Research and Development) of the National Academy of Sciences recommended that development of actuators be delayed until sufficient research could be carried out concerning the control problem so as to provide means for control of the prosthesis without conscious thought by the wearer.</p> <strong><a href="/files/original/3af9a5ff106766a98f790a31724a2a1f.jpg">Fig. 1</a>. An early model of the Alderson-IBM Electric Arm.</strong><br /> <p>A project was initiated at UCLA about 1953 to explore various control methods. Among the various studies conducted at UCLA was an evaluation of the so-called Vaduz hand (<b>Fig. 2</b>)<a></a>, a design that originated in Lichtenstein which used bulging of the residual muscles in a forearm stump to provide control of an electrically actuated artificial hand. Some rather positive findings were overshadowed by the poor quality of the one unit that was available at the time, and perhaps by the introduction by Russia in 1958 of a "thought control" electric arm<a></a>. The Russian device actually consisted of an electric hand controlled by myoelectric signals from the residual forearm agonists and antagonists of a below-elbow amputee.</p> <strong><a href="/files/original/2aff81bed2e3b007be1b8792137c5788.jpg">Fig. 2</a>. The "Valduz" hand and control system.</strong><br /> <p>The "Thalidomide tragedy"<a></a> in 1958-1962 prompted England and Canada to secure manufacturing rights to the Russian design, but fabrication and distribution was not successful in either country. The "Thalidomide tragedy" also encouraged work at the University of Heidelberg in the development of pneumatically powered artificial arm systems<a></a>, and an agreement was obtained by Kessler and Kiessling<a></a> for continuation of this work in the U.S. (<b>Fig. 3</b>). This project was carried out between 1960 and 1969. Again the problem of control was the primary reason for discontinuing the work.</p> <strong><a href="/files/original/41beee5399a82e0e40acfda675701aad.jpg">Fig. 3</a>. On the pneumatic above-elbow systems developed by Kiessting at the American Institute for Prosthetic Research.</strong><br /> <p>Because of the Thalidomide tragedy, Sweden<a></a> also launched a modest program in development of externally powered upper-limb prostheses about 1960. Work in this area has been carried out continuously since, but with no commercially available devices resulting, as far as is known at this time.</p> <p>The Russian design caused an Austrian group, Viennatone, and the Otto Bock Company in Germany to develop and market about 1962 similar devices. A few years later Hannes Schmidl began fitting externally powered artificial arms on a relatively large scale at the INAIL Center, Budrio, Italy and continues to do so to the present time<a></a>. Pneumatic models were used initially, but all designs used now are electric.</p> <p>Simpson<a></a>, at the Princess Margaret Rose Hospital, Edinburgh, Scotland uses routinely pneumatic prostheses for a group of "Thalidomide" children, but his design is not widely available elsewhere.</p> <p>In 1960 while on Sabbatical study at the University of Southern California Tomovic from the Institute Pupin, Belgrade, suggested the use of electromechanical pressure sensitive systems to aid in solution to the control problem by introducing closed-loop feedback systems<a></a>. A number of prototypes (<b>Fig. 4</b>) were designed and fabricated upon the return of Tomovic to Yugoslavia. Results of evaluation were also overshadowed by poor workmanship and engineering, and work on this was abandoned about 1968.</p> <strong><a href="/files/original/90ef2a1233e04d701819d9715038383f.jpg">Fig. 4.</a> The "Belgrade" hand and control system.</strong><br /> <p>McLaurin, while at Northwestern University, designed the so-called Michigan feeding arm about 1960 which used a linkage to coordinate motions about the elbow and the wrist to make it possible for young bilateral children amputees to feed themselves<a></a>. This device met with considerable success in the clinical setting, but never became a commercial success.</p> <p>McLaurin continued work in electrical arms for children at the Ontario Crippled Childrens Centre, Toronto, between 1963 and 1975. Although he was able to persuade the Variety Club to develop a facility for manufacturing, at cost, some of the products of research as a philanthropic endeavor, to date only an electric elbow has been made available, but because of the low volume the cost is extremely high in spite of subsidization.</p> <p>In the late sixties a number of efforts in the U.S. were directed toward the development of electric elbows. By 1969 three designs were considered ready for clinical evaluation, the "Boston" elbow developed by M.I.T. and Liberty Mutual Insurance Co., the AMBRL elbow, developed by the Army Medical Biomedical Research Laboratory, and a design by Rancho Los Amigos Hospital. The clinical evaluation program was organized and coordinated by CPRD in 1969-70<a></a>.</p> <p>Of 20 subjects in the study only 3 elected to retain the electric device. Two of these subjects had physical problems that made operation of the body powered prosthesis more difficult than would have been the case otherwise. Out of this experience came a revised set of design criteria and objectives.</p> <p>In addition to all of these efforts, research and development programs in externally powered artificial arms have been carried out in the U.S. at Temple University - Moss Rehabilitation Hospital <a></a>, Northwestern University (<b>Fig. 5</b>)<a></a>, Veterans Administration Prosthetic Center, Duke University, Rancho Los Amigos Hospital, University of California at Los Angeles, the University of Colorado, and Johns Hopkins University<a></a>.</p> <strong><a href="/files/original/634d5ee7cc369045d31e39da291ee0d3.jpg">Fig. 5</a>. The self-contained and self-suspended below-elbow system using myoelectric controls developed at Northwestern University.</strong><br /> <p>Sweden, Great Britain, Italy, Germany, Russia, and others have continued to support research and development in this field.</p> <p>Yet today it is very difficult to obtain an electric or pneumatic arm in the United States, other than the electrically operated hands that are suitable for below-elbow patients. We will be pleased to hear the opinions of readers of the NEWSLETTER concerning the reasons for this.<br /><br /><i>A. Bennett Wilson, Jr.</i><br />March 16, 1978</p> <p><b>References:</b></p> <ol> <li>Alderson, Samuel W., <i>The electric arm</i>, (Chapter 13 in Klop-steg and Wilson's "Human Limbs and Their Substitutes," McGraw-Hill, 1954, reprinted by Hafner Press, 1969).</li> <li>Battye, C.K., A. Nightingale, and J. Whillis, <i>"The use of myoelectric currents in the operation of prostheses,"</i> J. Bone Joint Surg., 37-B, 506, Aug. 1955.</li> <li>Berger, N., and CR. Huppert, <i>The use of electrical and mechanical muscular forces for the control of an electrical prosthesis</i>, Amer. J. Occup. Ther., 6:110-14, 1952.</li> <li>Childress, D.S., et al., <i>Myoelectric immediate postsurgical procedure: A concept for fitting the upper-extremity amputee</i>, Artif. Limbs, Vol. 13, No. 2, Autumn, 1969.</li> <li>Committee on Prosthetics Research and Development, <i>Externally powered prosthetic elbows - a clinical evaluation</i>, Report E-4 National Academy of Sciences, 1970.</li> <li>Committee on Prosthetics Research and Development, <i>The application of external power in prosthetics and orthotics</i>, National Academy of Sciences, Publication 874, 1961.</li> <li>Committee on Prosthetics Research and Development, <i>The control of external power in upper-extremity rehabilitation</i>, National Academy of Sciences, Publication 1352, 1966.</li> <li>Dankmeyer, Charles H., Sr., Charles H. Dankmeyer, Jr., and Martin P. Massey, <i>An externally powered modular system for upper-limb prosthesis</i>, Orth, and Pros., 26:3, Sept. 1972.</li> <li>Frantz, CH., <i>An evolution in the care of the child amputee</i>, Artif. Limbs, Vol. 10, No. 1, Spring 1966.</li> <li>Kadefors, R., et al., <i>Stryning av armprotes med myosignaler</i>, Electronic 3:42-49, 1967.</li> <li>Kessler, H.H., and Kiessling, E.A., <i>Pneumatic arm prosthesis</i>, Am J. Nursing, 65:6: June 1965</li> <li>Kobrinski, A.E., Bolkhovit-in, S.V., Voskoboinikova, L.M., Ioffe, D.M., Polyan, E.P., Popov, B.P., Slavutski, Y.L., Sysin, A.Y., and Yakobson, Y.S.: <i>Problems of bioelectric control in automatic and remote control</i>. Proceedings of the First International Congress of the International Federation of Automatic Control, Moscow, 1960, London, Butterworth &amp; Co. (Publishers) Ltd., 1961, Vol. 2, p. 619.</li> <li>Marquardt, E., <i>Heidelberg pneumatic arm prosthesis</i>, J. Bone and Joint Surgery, 47-B:3:425-434, August 1965.</li> <li>Rakic, M., Practical design of a hand prosthesis with sensory elements, Proceedings of the Interna-, tional Symposium of the Application of Automatic Control in Prosthetics Design, 103-119, August 27-31, 1962, Belgrade, Yugoslavia.</li> <li>Reiter, R., <i>Eine neue electro-kuntshand</i>, Grenzgeb. Med., 4, 133, 1948.</li> <li>Schlesinger, G., <i>Der Mechanische aufbau der kunst-chanische aufbau der kunstlichen glieder</i>, in Ersatzglieder und Arbeitshilfen, Borchartd, M., et al., Eds., J. Springer, Berlin, 1919.</li> <li>Schmeisser, Gerhard, Wood-row Seamone, and C. Howard Hoshall, <i>Early clinical experience with the Johns Hopkins externally powered modular system for upper-limb prostheses</i>, Orth, and Pros. 26:3, Sept. 1972.</li> <li>Schmidl, Hannes, <i>The I.N.A.I.L. experience fitting upper-limb dysmelia patients with myoelectric control</i>, Bull Pros. Res. 10-27, Spring 1977.</li> <li>Scott, R.N., <i>Myo-electric control</i>, Science J., 2-7, March 1966.</li> <li>Simpson, D.C., <i>An experimental design for a powered prosthesis for children</i>, Health, Scottish Home and Health Department Bulletin, 22:4:75-78, October 1964.</li> <li>Tomovic, R., and G. Boni, <i>An adaptive artificial hand</i>, IRE Transactions on Automatic Control, 3-10, April 1962.</li> <li>Wirta, R.W., Taylor, D.R., and Finley, F.R., <i>Engineering principles in the control of external power by myoelectric signals</i>. Archives of Physical Medicine, 49:294-296, 1968.</li> </ol> Page Number(s) 1 - 4 Year 1978 Volume 2 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1978_01_001/1978_01_001-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1978_01_001/1978_01_001-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1978_01_001/1978_01_001-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1978_01_001/1978_01_001-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1978_01_001/1978_01_001-5.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 Externally Powered Upper-Limb Prostheses Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr.  https://staging.drfop.org/files/original/3448d7dd1f3b869e445982db2d59f981.pdf 56435bb25ac8133541df9f7615933fde https://staging.drfop.org/files/original/b92e747ec2d4c7fcbfb142f3b21fe188.jpg 15743c372ab5f5bfd9b131b52786f267 https://staging.drfop.org/files/original/162bfd1cff0200013041316cd03e4205.jpg 503fcd8d3eb91b82ee443d8c094e848d https://staging.drfop.org/files/original/649c45f292a3e6abbcfd67f3e7cad646.jpg bc5d177879ac5d8d63ba74148f139e50 https://staging.drfop.org/files/original/f8c103b59e1186b3debc06b41e7fa8da.jpg ff5d40912d24dc4437c5e3e86637ad0f https://staging.drfop.org/files/original/5bd55cdc8130e022cb74e9ef9310851c.jpg 877f6a2bef161af85baa70b0a7e0fc56 https://staging.drfop.org/files/original/5a13f50435edc580bd20bc0b92e39199.jpg f36ffbe912c1327a31adc0871b9584a2 https://staging.drfop.org/files/original/09f2f692fb4fb8baed50b8c404c39ff4.jpg 95dc00e192231965d2df32a4557237c3 https://staging.drfop.org/files/original/98186d2e80f51ab2c05b8e921e8b4a7c.jpg 6a7d4c0dc2f96f891e8d6f648eccb65a https://staging.drfop.org/files/original/cfb1f9e83cd52dba6e8367990403d0e7.jpg cb6459e8aa8f964867d06e310b8fb963 https://staging.drfop.org/files/original/a7526ae779090df35051bf5f19108e0f.jpg 157c3ae9edb18f10067093236eef0ecd https://staging.drfop.org/files/original/6000d92905f47758878821ee2247dd59.jpg 97191c9616d9b52f95fe7c1f3d48d26d https://staging.drfop.org/files/original/05be51461b9c231a36fab727850aafb9.jpg d2ac320312732a0ac60358b403acf8c6 https://staging.drfop.org/files/original/3d81a73baf2da2320112f7beab21a3f5.jpg 79eaca67e92aeaf4a3255846ed2f5c2d https://staging.drfop.org/files/original/3d6a53a092ad8f47d3ba47cba434cce8.jpg 0b274fe90d766da8a3eca6a1f8cbb030 https://staging.drfop.org/files/original/645ce73fcf7da4e641a02f0187a49867.jpg 7ce207a9c89481e48d4da20607137601 https://staging.drfop.org/files/original/e1898cc9379d33c5f9b2be176e2cdc18.jpg 674e6e6f3c9cfc86f882142cd90c70ad https://staging.drfop.org/files/original/1706a0b2db516be5330eec15cb82cf18.jpg 87ba92355dc1039809f33e711d681192 https://staging.drfop.org/files/original/1078a3e62aee9846acde9c3a5e792575.jpg b6a854f1571ededd167b2be93409c9d2 https://staging.drfop.org/files/original/90c35927fcd50eee702738338ce53b66.jpg da617dcbd9573aa9f0636c23afc99e41 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1961_01_052.pdf Year 1961 Volume 6 Issue 1 Page Number(s) 52 - 75 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1961_01_052.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1961_01_052.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Prostheses for Syme's Amputation</h2> <h5>A. Bennett Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>Whereas detailed information on Syme prostheses prior to the turn of the 20th century is not readily to be had, the catalogs issued by limb manufacturers in the early 1900's seem invariably to include a description of a prosthesis for the Syme stump. Of many different designs offered, some used articulated ankles (if space were available below the stump and socket), some used rubber feet without ankle joint. Wood sockets, steel-reinforced leather sockets, and even cast aluminum sockets were available. Though most manufacturers showed prostheses with a full-length anterior opening for entry of the stump, there also were designs employing a partial anterior opening, and at least one used a full-length posterior opening.</p> <p>The descriptions accompanying the catalog presentation of these devices indicate that the originators were themselves aware of most of the problems involved in designing a prosthesis for the Syme stump. One design of the Winkley Artificial Limb Co.<a></a> had no ankle joint because, according to the designer, in many cases no known ankle unit small enough to fit into the available space could withstand the high stresses involved. When ankle joints were provided (<b>Fig. 1.</b>, left), a steel-reinforced leather socket was used; when space limitations precluded use of an ankle joint (<b>Fig. 1.</b>, right), use was made of a willow wood socket, presumably to provide a base for attaching the felt or sponge-rubber feet available at the time.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Two types of Syme prostheses offered by the Winkley Artificial Limb Company, Minneapolis, <i>circa </i>1910. Design at left incorporates an articulated ankle, that at right a foot without ankle joint, presumably of rubber. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Gaines-Erb<a></a> used a wood socket with a full below-knee socket at the top and only a partial opening on the anterior aspect so that it was possible to make any desired distribution of weight-bearing between distal and proximal areas of the stump <b>Fig. 2.</b>. Marks<a></a> was aware of the need for distributing uniformly along each side of the tibia the loads developed on the stump during roll-over and, realizing that this requirement was rarely met with an anterior opening and lacing, attempted to solve the problem by using a cast aluminum socket with appropriate relief for the tibial crest and other sensitive areas <b>Fig. 3.</b>. A leather cuff closing the posterior opening encircled the shank to an anterior lacing, and the Marks rubber foot must have permitted a good cosmetic effect. An earlier version of the Marks foot, one of wood, illustrates the extent to which the inventor went to achieve resistance to the high forces developed in the area of the ankle <b>Fig. 4.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Syme prosthesis offered by the Gaines - Erb Company, Denver, <i>circa </i>1915. Note provision for weight-bearing about the proximal portion of the shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Syme prosthesis offered by A. A. Marks, Inc., New York, early in the 20th century. The shank-socket, cast from aluminum, contained a posterior opening. A rubber foot was used routinely. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. An early version (<i>circa</i> 1889) of a Syme prosthesis manufactured by A. A. Marks, Inc. Socket and keel were formed from a single piece of wood so selected that the grain afforded maximum strength. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In a 1919 design by Bowler,<a></a> dorsiflexion bumpers were replaced by a strap between the posterior surfaces of the socket and the foot <b>Fig. 5.</b>, a feature also suggesting an appreciation of the high stresses involved in the ankle-joint mechanism. Not only were the unit stresses in the resisting material thus reduced but during dorsiflexion the forces on the ankle joint itself remained compressive instead of becoming tensile, a condition favoring longer life. Instead of being in the usual medial and lateral positions, the metal straps reinforcing the leather socket were anterior and posterior, where they were least bulky and most effective structurally. A Syme prso-thesis available from the Columbus Artificial Limb Company<a></a> employed the posterior strap patented by Bowler and added an anterior elastic strap, presumably to maintain compressive forces on the ankle joint during plantar flexion <b>Fig. 6.</b>, but the idea of anterior and posterior reinforcing straps, as proposed by Bowler, was discarded.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Syme prosthesis patented by Bowler<a></a> in 1919. First known attempt to improve appearance by use of an opening on the side of the socket, reinforcing straps on the anterior and posterior surfaces. A flexible cable, another novel feature, provided resistance to dorsiflexion without placing the ankle parts in a state of tension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Syme prosthesis offered by the Columbus Artificial Limb Company, Columbus, Ohio, <i>circa </i>1925. Some of the features of the Bowler patent<a></a> are incorporated. Cf. Fig. 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In almost all cases, lack of materials easily molded and with adequate strength but light in weight resulted in a certain bulkiness and heaviness that tended to produce a certain amount of discomfort for the wearer even if the fit itself were comfortable. In an effort to decrease weight and size, some prosthetists fabricated devices with marginal strength characteristics, devices which seldom lasted as long as comparable ones intended for leg amputations at other levels. The prosthesis that by 1940 seems to have been fitted almost routinely in both the United States and Canada consisted of a leather socket, reinforced with steel straps along the medial and lateral sides and made with a lacer and soft leather tongue along its anterior aspect <b>Fig. 7.</b>. Feet were generally of the so-called "conventional" type employing a single-axis ankle joint (often placed lower than usual) and incorporating foreshortened rubber bumpers. It was often uncomfortable, usually bulky because the sidebars projected beyond the bulbous end of the stump, and highly subject to mechanical failure of the sidebars.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Syme prosthesis typical of the era before introduction of plastic laminates into the fabrication of Syme prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the introduction of plastic laminates<a></a> into the practice of prosthetics, research workers at the Prosthetic Services Centre of the Department of Veterans Affairs, Toronto, were quick to realize that the use of plastic laminates might well result in the development of a Syme prosthesis to a great extent free from the shortcomings of Syme prostheses previously used. Prior attempts to use laminated wood-veneer sockets had failed to produce practical prostheses owing to the difficulty of molding about the bulbous end, but the results encouraged the investigators to proceed with the then newly developed fabric-plastic laminates. The first model that showed promise<a></a> consisted of a socket molded of a polyester-Fiberglas laminate with a neoprene-crepe foot reinforced by a polyester-Fiberglas keel extending from the distal end of the socket <b>Fig. 8.</b>. To provide more comfort along the anterior aspect of the stump, the opening for entry of the stump was cut out of the rear section of the socket, stability being obtained by replacing the cutout section and holding it in place by a metal fitting at the bottom and a strap and buckle at the top.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. An early version of the Canadian-type plastic prosthesis for Syme's amputation. The nonarticulated foot was in this instance constructed of a neoprene crepe of uniform density. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although use of plastic laminate materially reduced bulkiness, and although the nonartic-ulated foot eliminated many of the problems associated with the so-called "conventional" unit, mechanical failure in the socket where the cutout was largest occurred too frequently for the new prosthesis to be adopted as a standard item.<a></a> Fiberglas roving (loosely spun cords of Fiberglas molded in place along the edges of the cutout) increased the strength of the socket, but it was necessary to substitute epoxy resins (much better adhesion to the glass fibers) for the polyesters before fully adequate strength could be obtained. With a few refinements, this prosthesis <b>Fig. 9.</b> is in use routinely today by the Canadian Department of Veterans Affairs.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The Syme prosthesis now adopted as standard by the Canadian Department of Veterans Affairs. The plastic laminate consists of Fiberglas cloth and roving impregnated with an epoxy resin, and the posterior opening extends the length of the shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Attempts by workers in the Artificial Limb Program in the United States to employ the Canadian technique using polyester-Fiberglas laminates led to the same kinds of mechanical failures experienced by the Canadians.<a></a> In addition, a good proportion<a></a> of the Syme cases fitted could not continue to assume full end-bearing comfortably throughout the entire day. This experience, coupled with a reluctance to employ Fiberglas if the more convenient nylon stockinet<a></a> could be used, or to use the first-available epoxy resins because of the inherent toxicity of the wet, uncured resin when mixed with the hardener, [*The recent introduction of polyamide hardeners has since greatly reduced the risk of the fabricator's contracting dermatitis.] led to the development of the "Medial-Opening Plastic Syme Prosthesis" <b>Fig. 10.</b> at the Veterans Administration Prosthetics Center.<a></a> To reduce the unit stresses along the periphery of the cutout necessary for entry of the stump, the cutout was made in the medial wall of the socket (page 68). Unlike the posterior cutout in the Canadian version, the medial opening does not extend upward to the brim of the socket but resembles a door, an arrangement which permits the Syme case to be so fitted that all or any part of the weight may be carried along the brim of the socket. The foot is a commercially available version of the SACH foot.<a></a>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Syme prosthesis developed by the Veterans Administration Prosthetics Center, New York. The nylon-dacron-polyester socket is provided with an opening in the medial wall. Weight-bearing may be divided, in any proportion, between the proximal rim and the distal portion of the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Concurrent with the development of the medial-opening plastic Syme prosthesis at the Veterans Administration Prosthetics Center, the Prosthetics Research Center of Northwestern University introduced into the Canadian technique a number of refinements which might also be applied in fabricating and fitting the medial-opening type of prosthesis. Of especial interest are a new method of obtaining casts of Syme stumps and a method of attaching a SACH foot to permit greater latitude in alignment of the foot with respect to the socket, including also a method of reinforcing the keel of a SACH foot should that be necessary in individual cases.</p> <p>Manuals<a></a> containing detailed, step-by-step procedures for fabricating, fitting, and aligning the Canadian and the medial-opening Syme prostheses are available, and details of the Northwestern techniques have been published.<a></a> An outline of all of these procedures is given here so that any might be adopted singly or in combination to meet the requirements of individual patients.</p> <h3>THE CANADIAN-TYPE PLASTIC SYME PROSTHESIS</h3> <h4>TAKING THE MEASUREMENTS AND MAKING THE MODEL</h4> <p>All anatomical measurements necessary for constructing the Canadian-type plastic Syme prosthesis are taken while the patient bears his body weight on the end of the stump. Placed under the stump is a block of wood of such thickness as to maintain the pelvis in a horizontal position, and the anteroposterior dimension, the width, and the circumference of the stump are recorded, all at the level of the largest part.[*A special device, consisting of two wedges that can be moved with respect to each other so as to provide for rapid adjustment <b>Fig. 11.</b>, has been found to be a useful improvement over the single wood block.] For use later on in the alignment procedure, a line perpendicular to the floor and passing through the mediolateral center of the patella <b>Fig. 12.</b> is marked on the stump with indelible pencil for eventual transfer to the plaster model.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Special device used in taking measurements of the Syme stump while the stump is bearing weight. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Stump measurements required for fabrication of socket for the Canadian-type plastic Syme prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After all sensitive areas and bony prominences, including the tibial crest throughout its length, have been similarly marked with indelible pencil, a cast is made using plaster-impregnated bandage, a longitudinal cut being made along the posterior mid-line to permit removal of the cast. Thereafter, a model of the stump is made by filling the cast with liquid plaster of Paris, a bar or pipe being inserted in the soft plaster at the proximal end to provide an extension to be used later in holding and handling the model.</p> <h4>MODIFICATION OF THE MODEL</h4> <p>Upon removal of the cast, a finishing nail <b>Fig. 13.</b> is driven all but 1/4 in. into the bottom of the model at the intersection of an anteroposterior extension of the vertical reference line and a medio-lateral line bisecting the area on the bottom of the model. The bulbous end is now built up by adding plaster until the dimensions conform to those recorded while the stump was bearing weight. At the same time, in order to allow space for a sponge-rubber pad in the finished socket, a layer of plaster 1/8 in. thick is added to the bottom portion and faired in, leaving the nail protruding 1/8 in. So that a recess to receive a foot nut will be formed in the finished socket, a piece of leather or other suitable material 1/8 in. thick and 1 1/4 in. in diameter is pierced at its center and positioned on the protruding nail. To provide relief for the sensitive areas and bony prominences, skived leather patches are added to the model as appropriate.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Plaster model of stump just before application of Fiberglas. It is easier to modify the model before the plaster has hardened completely. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The path of the sawline to be used in forming the cutout for stump entry is marked on the model, and metal wedges <b>Fig. 14.</b> are inserted to facilitate the later re-establishment of the sawline on the exterior of the socket. The saw-line itself is located by establishing on each side of the model a point 3/8 in. behind the anteroposterior mid-line of the model at the top and another point 1/4 in. behind the same mid-line at the level where the stump begins to bulge <b>Fig. 13.</b>. Two metal wedges are inserted well apart on each of these lines, 1/4 in. being left to protrude. After the model has dried thoroughly and three coats of cellulose-acetate lacquer have been applied, it is ready for use in fabricating the prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Steel wedge used to outline cutout, shown twice actual size. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>LAMINATION</h4> <p>In the lamination of Fiberglas with epoxy resins, rapid work is essential to obtain the best structural results, and accordingly it is desirable here that this operation be performed by two persons working together. The model is held vertically in a vise, a brush coat of epoxy resin is applied, and a length of 10-strand Fiberglas roving is laid along the anterior side of each of the vertical portions of the sawline and fanned out over the end of the bulbous portion of the model <b>Fig. 15.</b>. The multiple-strand roving is held in place by encircling the model and roving with a piece of single-strand roving.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. First layup of Fiberglas roving and cloth. Note that roving is fanned out over ball of model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A piece of Fiberglas cloth 4 in. longer than the length of the model and 2 in. wider than its circumference at the largest part is laid up over the model so that the surplus length is placed distal to the bulbous end, and the whole is tied in place with single-strand roving <b>Fig. 15.</b>. The surplus length is then slit vertically every 2 in. along the periphery and laid over the bulbous end of the model, and the entire piece of cloth is saturated with the resin. Three additional pieces of Fiberglas cloth of the same size are applied in the same manner but are so placed that none of the vertical overlaps coincide.</p> <p>To complete the lamination, four pieces of Fiberglas cloth 2 in. wide and about 2 in. longer than twice the length of the model are applied, one at a time, with the transverse centers of the strips located over the bulbous end and positioned approximately 45 deg. apart <b>Fig. 16.</b>. The entire assembly is held in place by a spiral wrapping of single-strand roving, and after application of a final brush coat of resin a snugly fitting sleeve of polyvinyl alcohol film (PVA) is pulled over the layup, the lower end being tied snugly to the holding rod, the top end model. To compress the laminate and to re-trimmed to a point 5 in. from the end of the move air and excess resin, the layup is wrapped tightly in spiral fashion with a strip of PVA 2 in. wide, the wrap starting from the holding end of the model <b>Fig. 17.</b>. To the excess resin thus forced upward into the top end of the sleeve there is now added as much chopped roving as possible so as to form an extension around which the foot may be fabricated.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Layup of longitudinal strips of Fiberglas cloth just before application of PVA bag. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Lamination for socket, ready for curing. Note extension for keel, formed by introducing resin and chopped Fiberglas roving into end of PVA bag. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After curing for 30 min. at room temperature (or 45 min. at 250° F. if time is important),[*In an alternate, and preferable, procedure, the layup is allowed to gel at room temperature overnight and then, after the cutout has been made, replaced over the model, fastened in place by suitable straps, and cured for 30 min. at 225° F.] the laminate is cut, with a cast cutter or other suitable device, along the lines defined by the protruding wedges. At the lower portion of the cutout, large radii are used, and the lowest point reached is just proximal to the point of maximum anteroposterior socket diameter.</p> <h4>MAKING THE FOOT</h4> <p>After the laminated parts, socket and cutout, have been removed from the model, the extension is so shaped by grinding that the foot may be built around it. By means of a standard foot nut and a bolt 1 1/4 in. in diameter <b>Fig. 18.</b>, the keel <b>Fig. 19</b>, formed from a strip of aluminum alloy (7075-T6) 1 1/4 in. wide and 0.128 in. thick, is fastened to the extension at the point indicated by the recess formed in the bottom of the socket. For most adults, two thirds of the length of the keel is placed ahead of the center of the socket, but the proportion may be varied to suit individual cases. To provide reinforcement during the fitting procedure, a piece of wood is bonded temporarily to the keel and socket extension by use of epoxy paste.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Standard steel foot nut used by the Canadian Department of Veterans Affairs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Cross-section of foot and lower end of Canadian-type plastic Syme prosthesis. Before final assembly, the wood block is replaced by epoxy resin and chopped Fiberglas roving. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A 4-ply rubber-fabric belting 4 in. wide and four pieces of 18-iron neoprene sponge are now laminated (with Barge's cement) to the configuration shown in <b>Fig. 19</b>, the neoprene layers being slotted to receive the keel. A wood block 4 in. wide and shaped to conform to curve A-A in <b>Fig. 19</b> should be used to assist in holding the layers in place while bonding is effected.</p> <p>When the initial bonding of the neoprene and belting is fully set, a layer of 9-iron neoprene sponge is bonded to the underside of the belting, and a wedge of some resilient material is added to form the heel. Material for the heel, selected to meet the particular requirements of the individual patient, may be neoprene sponge, rubber sponge, solid rubber, or some other elastomer. Finally, the foot is cut and ground to the shape necessary to fit the shoe.</p> <h4>ALIGNMENT AND ASSEMBLY</h4> <p>Temporary attachment of the foot to the keel <b>Fig. 20</b> is effected by driving a 1/8-in. steel pin transversely through the heel section just ahead of the end of the keel <b>Fig. 19</b>. The corset, the portion of the socket that has been cut out, is now provided with the means for holding it in place-a tongue-and-slot arrangement at the bottom <b>Fig. 21.</b> and an encircling leather strap in the calf area <b>Fig. 9.</b>. Details of the parts required are shown in <b>Fig. 22.</b>, <b>Fig. 23.</b>, and <b>Fig. 24.</b>. The metal pieces are bonded and riveted to the laminated parts. Two buckles are recommended as a precaution against the possible loss of use of a particular eye in the strap <b>Fig. 9.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Insertion of keel into neoprene portion of foot. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Tongue-and-slot method of holding corset in place. Tongue and slot are held in place temporarily by the bolts and wing nuts. Epoxy resin and rivets are used for permanent attachment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Slot, shown actual size. Aluminum 0.040 in. thick. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Tongue, shown actual size. Aluminum 0.125 in. thick. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Double-buckle assembly used to secure corset in place. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After a pad of felt or neoprene sponge, carved to fit the bottom of the socket and the end of the stump, has been placed in position, the prosthesis is ready for final alignment. The relationship between the keel and the socket may be changed by removing the attaching bolt and keel and changing the configuration of the socket extension, either by grinding or by adding shims. When the desired alignment has been obtained, a 1/8-in. hole is drilled through the aluminum keel into the socket extension, and a 1/8-in. dowel of cold-rolled steel <b>Fig. 19</b> is driven into the hole. The established alignment may thus be reproduced upon reassembly during the finishing process. To achieve maximum rigidity of the keel, the temporary wood block is removed, two steel rods each 1/8 in. diameter are inserted into holes drilled in the anterior surface of the socket extension and allowed to extend into the cavity, and the cavity is filled with a mixture of epoxy resin and chopped Fiberglas roving.</p> <p>The aluminum surfaces must be clean to ensure an adequate bond. All gaps between keel and neoprene are filled with epoxy resin, and a fairing between the foot and socket is fashioned from a mixture of epoxy resin and fine sawdust, which after curing can be ground and sanded to shape. If desired, small holes may be drilled through the socket wall to furnish ventilation. When, after sanding, the outside of the socket and corset have received a coat of enamel, and when the neoprene parts of the foot have been sealed with two light coats of cellulose-acetate lacquer, the prosthesis is ready for use <b>Fig. 25.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Completed Canadian-type plastic Syme prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>THE MEDIAL-OPENING PLASTIC SYME PROSTHESIS</h3> <h4>TAKING THE MEASUREMENTS</h4> <p>The anatomical data considered necessary for fabrication of the medial-opening socket are somewhat more extensive than are those suggested as being needed in the Canadian technique. In addition to determining the distance from the end of the stump to the floor while the stump is bearing half of body weight,[*Because a neoprene sponge-rubber pad will be used later in the end of the socket, it is recommended by VAPC that a sponge-rubber pad 1/4 in. thick be used between the stump and the supporting block <b>Fig. 26.</b>.] circumferential measurements of the stump are made at 1-in. intervals in the first 5 in. of the stump while it is in the weight-bearing condition. Besides this, circumferences at these five levels and also circumferences at 2-in. intervals from a point 5 in. from the end of the stump to the medial tibial plateau are read while the stump is free of weight-bearing. At each level measured, marks are made with indelible pencil. A form for recording the required information is shown in <b>Fig. 26.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Form for recording measurements and other information necessary for fabrication and fitting of a Syme prosthesis (VAPC type). From Iuliucc.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>MAKING THE CAST AND THE MODEL</h4> <p>To protect the stump from the plaster of Paris used in making the cast, a length of cotton stockinet, sewed at one end, is pulled over the stump and secured by an elastic band above the knee. Outlines of sensitive areas and bony prominences are made on the stockinet with an indelible pencil so that they will be transferred to the cast and in turn to the model for guidance in making appropriate modifications.</p> <p>Although the particular method of obtaining a cast is not critical provided a faithful model of the stump can be obtained ultimately, the Veterans Administration Prosthetics Center suggests a method wherein the cast is made in two pieces, so as to eliminate the need for cutting the plaster to remove the stump.[*The same technique can, of course, be applied in obtaining any cast that requires separation for removal of the stump.] To obtain the two-piece mold, the end of the stump is first wrapped with 3-in. plaster bandage to the level of greatest circumference <b>Fig. 27.</b>. A slab of five layers of plaster bandage 6 in. wide is then molded against the entire anterior half of the stump and secured in place by a few turns of 3-in. plaster bandage at the narrow part of the shank and again at the area just below the patella <b>Fig. 28.</b>. So that the cast, and hence the model, will approach the configuration of the stump in the weight-bearing condition, the plaster is allowed to harden while the patient bears weight through the distal end <b>Fig. 29.</b>, a sponge-rubber pad being placed between the bottom of the cast and the supporting block. As the plaster hardens, the edges should be faired to the stump. Lateral and medial centerlines are now drawn on the anterior portion of the cast for guidance in forming the parting line, petrolatum is applied to the exposed stockinet, and a similar slab of plaster bandages is molded to the posterior portion of the stump up to the lateral and medial centerlines <b>Fig. 30.</b>. Lines drawn transversely across the seams at several levels serve at reference points for proper reassembly of the cast after removal from the stump. Before pouring of the model is started, the indelible marks on the interior of the cast should be retraced to ensure a satisfactory transfer. For the pouring operation, the two halves may be held together by a wrapping of plaster bandage.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. First step in obtaining a plaster impression of a Syme stump. A plaster bandage 3 in. wide is applied over the end of the stump to the level of greatest circumference. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Application of a slab of plaster bandage to anterior surface of stump to provide one half of a two-piece casting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Stump under weight-bearing conditions while anterior and distal portions of plaster impression are allowed to harden. The posterior portion of the impression is applied later. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Application of plaster-bandage slabs to form posterior portion of two-piece casting. Note parting line drawn on anterior casting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>MODIFICATION OF THE MODEL</h4> <p>So that the finished socket will fit snugly along the sides of the tibia and yet not press unduly on its crest, plaster is removed from the model along each side of the area representing the tibial crest <b>Fig. 31.</b>, and a long leather patch, skived in the usual manner, is glued in place on the plaster. Skived leather patches also are attached at the points representing the malleoli, over areas corresponding to the flare of the condyles, and at any other points that will require relief in the finished socket <b>Fig. 32.</b>. Then the posteroproximal end of the model is flattened somewhat to provide for stability between socket and stump about the longitudinal axis. Finally, to make certain that the distal end of the socket will be of the proper volume to accommodate a sponge-rubber pad for cushioning the end of the stump, a circular piece of sponge rubber 1/4 in. thick is skived and glued to the distal end of the model (<b>Fig. 33.</b>) All modifications of the model are made with reference to the circumferential measurements taken earlier, <i>i.e., </i>the measurements over the distal 5 in. of the stump during weight-bearing and those above during relaxation are maintained.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Model showing where plaster should be removed so that in finished socket forces may be taken along each side of the tibial crest. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Model with skived leather patches applied to provide in finished socket relief for sensitive areas. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Model with socket liner and sponge-rubber pad applied. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>THE SOFT SOCKET LINER</h4> <p>To provide more comfort for those patients expected to take some or all weight-bearing along the proximal end of the socket, a liner of neoprene sponge rubber covered with horse-hide is provided. When a liner is to be used, a horsehide sleeve is molded around the model upward from a point 5 in. below the medial tibial plateau. Sponge-rubber sheet 1/8 in. thick is formed over the horsehide, 3/4 in. of the distal end of the leather being left exposed <b>Fig. 33.</b>. The distal end of both the horsehide and neoprene are skived.</p> <h4>LAMINATION</h4> <p>Unlike the procedure described for fabrication of the Canadian-type plastic Syme prosthesis, wherein the corset (or cover for the cutout) consists of the laminate that was cut from the socket, in the VAPC prosthesis the socket and the cover for the cutout may be laminated separately. Thus, it is here possible to begin with a socket cutout a little too small, trim away only as much material as necessary to permit easy entry of the stump, and still have available a piece of laminate large enough for a cover.</p> <p>To prevent adherence of laminate to the sponge-rubber pad (and to the soft socket liner if one is used), a snugly fitting sleeve of polyvinyl alcohol is pulled over the model and tied neatly at each end. The recommended laminate filler consists of two layers of dacron felt inside and ten layers of nylon stockinet outside. Like the PVA, the dacron felt must also be tailored into snugly fitting sleeves. If the nylon stockinet is cut into lengths slightly more than twice the length of the model, and if each length is then sewed transversely at the middle, a very neat layup can be obtained by successively pulling one half of a length over the model as far as possible and then pulling the other half over while turning it inside out. Instead of coinciding with one another, the individual transverse stitchings should be spaced equally as spokes in a wheel, the second being 36 deg. away from the first, the third 36 deg. away from the second, and so on <b>Fig. 34.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Application of stockinet over model in preparation for laminating. Two layers of dacron felt have already been applied. Note seam sewed across stockinet to form neat layup at distal end of socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A sleeve of PVA film is now drawn over the layup, and a polyester resin is introduced. To date, best strength characteristics have been obtained from a mixture of 70 percent of the "rigid" type of resin and 30 percent of the "flexible" type.<a></a></p> <p>Material for the medial cover is made by laminating three layers of nylon stockinet over the socket layup after it has been allowed to stand for one hour at room temperature. Resin is introduced on the medial side only (or only in that area selected for the cutout). After an additional hour of curing at room temperature, the entire assembly is subjected to a temperature of 180-190° F. for 25 min. The outer shell can now be cut and removed and the impregnated portion saved for use later <b>Fig. 35.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Removal of laminate to be used later in fabrication of cover for opening in socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>MAKING THE OPENING</h4> <p>The socket opening can best be cut out while the laminate is still warm. In order that the opening shall be the minimum needed for introduction of the stump, the initial aperture is deliberately made undersize, later enlarged by trimming the edges little by little until the patient can insert the stump without experiencing discomfort. The outline of the initial opening is determined by a horizontal line 1 in. above the point of maximum circumference of the bulbous portion of the socket, two lines parallel to and medial to the line of the tibial crest (one being 3/4 in. medial, the other medial by 3/4 in. plus 1/4 of the circumference of the bulbous portion 1 in. above its maximum circumference), and a horizontal line at that point on the socket where the circumference is the same as that 1/4 in. above the point of maximum circumference at the bulbous end <b>Fig. 36.</b>. Because further trimming will be necessary, the dimensions of the radii at the corners are not critical at this stage.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Outline of initial cutout in socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the initial cutout has been made, the excess material trimmed away, the plaster removed, and the proximal border of the socket trimmed, the cutout is enlarged enough that the patient can introduce his stump <b>Fig. 37.</b>. The radii of the corners should now be kept as large as possible, and the edges of the cutout should be smooth so as to contribute to the strength of the finished product by eliminating the high-stress areas commonly associated with mechanical nicks and notches.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Introduction of stump in socket to determine trim lines of cutout and, later, of proximal border. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>ALIGNMENT AND ASSEMBLY</h4> <p>In most instances, satisfactory use can be made of one of the commercially available SACH feet constructed especially for Syme prostheses. If not, a suitable SACH foot can be fabricated in accordance with the instructions given in the Canadian manual<a></a> or in the University of report, or use can be made of the reinforcement technique introduced by Northwestern University.<a></a> <!-- (page 71) --></p> <p>When the commercial version is used, it is first shaped to fit the shoe, and a guide hole 1 1/4 in. in diameter is drilled in the keel to a height above the heel sole equal to the height of the block used while the anatomical measurements were taken <b>Fig. 38.</b>. The keel and neo-prene crepe are then hollowed out to receive the bulbous end of the socket. Because of the tendency of Syme stumps to bow toward the cen-terline of the body, usually both guide hole and hollow should be offset medially. Moreover, the foot should be placed as far forward as possible with respect to the socket and be set in a small amount of dorsiflexion <b>Fig. 39.</b>, and care should be taken to ensure that the bottom surface of the heel is parallel to the floor <b>Fig. 40</b>. Such alignment should be effected by actually having the patient don the socket, place the distal end into the recess in the SACH foot, and assume a position of normal standing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Simplified cross-section of SACH foot showing certain modifications needed for use in Syme prosthesis. A hole 1 1/4 in. in diameter is drilled in keel to a depth corresponding to the height of the block used when measurements were taken [link26]. The hole is used as a guide in removing material at top of foot to accommodate socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Alignment of foot and socket in lateral view. Usually a slight amount of dorsiflexion results in best performance. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. Alignment of foot and socket in posterior view. The foot must be so located that the sole is parallel to the floor when the wearer stands in his own habitual position with hips level. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When initial, or static, alignment has been achieved, reference marks are made on the socket and foot to be used as a guide in reassembly, and masking tape <b>Fig. 41.</b> is applied around the juncture of the two units to hold them in place while a 3/8-in. hole is drilled through the keel and socket to receive the attaching bolt. The hole in the socket is now enlarged to 5/8 in., and the hole in the keel is provided at the bottom with a 5/8-in. countersink to accommodate the nut <b>Fig. 42.</b>, both operations best being done with the prosthesis disassembled. A cover that will overlap the socket opening 3/4 in. around the periphery is cut from the section of laminate made for the purpose. After two single-buckle straps have been riveted to the cover, a felt pad exactly fitting the opening is glued to the concave side, and the entire inner surface of the closure is lined with thin horsehide, care being taken to effect a rabbetlike contour along the periphery of the felt <b>Fig. 43.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Application of masking tape to secure foot to socket for drilling alignment hole through socket. Note reference marks used to ensure same alignment upon reassembly. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Simplified cross section of foot and lower end of VAPC prosthesis showing attachment of foot to socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Final step in fabrication of cover for opening in side of socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the prosthesis has been assembled, dynamic alignment is effected under conditions of actual walking. Inserted into the socket in the form of contoured discs of sponge rubber is enough distal padding to distribute the forces as desired between the proximal end of the socket and the end of the stump. Slight changes in alignment can be brought about by enlarging the hole in the end of the socket.</p> <p>Final finishing of the prosthesis includes bonding the foot to the socket, building up a smooth transition between foot and socket by use of a mixture of epoxy resin and chopped Fiberglas, and gluing the soft liner in place in the proximal area of the socket.</p> <h3>DEVELOPMENTS AT NORTHWESTERN UNIVERSITY</h3> <h4>TAKING THE CAST</h4> <p>Plaster of Paris in one form or another has been used for nearly a century in making impressions of limb stumps, and especially with the relatively new, quick-setting formulations it has proved to be fairly satisfactory. There are nevertheless certain disadvantages inherent in the use of plaster. Unless a separating medium is used, plaster will adhere to the skin. Cured plaster of Paris is extremely rigid, so that when plaster is used to take a cast of a stump like the Syme it is necessary either to cut the cast or to form it in two pieces. Furthermore, plaster is very dense and therefore heavy and comparatively hard to manage.</p> <p>In an effort to overcome some of the difficulties associated with plaster, the Prosthetics Research Center at Northwestern University's Medical School has developed a procedure for taking a cast of a Syme stump with alginate, a material used by dentists in taking impressions of the gums and teeth. Because when mixed with water alginate gels rather rapidly into a rubbery solid, it seems especially useful in taking casts of bulbous stumps and of those intended to take end-bearing. To enable the gelled material to yield when the stump is withdrawn, the impression is made in a rigid, tapered cylinder lined with an oversize canvas bag which can be withdrawn so that the rubbery alginate is left free to be displaced as the bulbous portion is pulled through the narrow section of the impression <b>Fig. 44.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Removal of stump, alginate mold, and canvas bag from canister. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since alginate solidifies so rapidly, and since so many factors (such as temperature and various impurities in the water used[*In certain areas best results can be obtained only with distilled water.]) affect the rate of gelling, it is important always to check the gelling time on a small sample before actually taking an impression. The correct mixture should gel in about six minutes. A tapered can about 20 in. long, 5 1/2 in. in diameter at the bottom, and 6 1/4 in. in diameter at the top has been found satisfactory for taking impressions in adults. The impression is taken while half of the body weight is borne by the stump, <i>i.e.,</i> while the pelvis is level and the patient is standing with feet together.</p> <p>After the stump has been removed, the bag and alginate are replaced in the conical can for pouring of the model, which should take place as soon as possible because the alginate has a tendency to shrink rather rapidly after gelling.</p> <h4>INSTALLATION OF THE SACH FOOT</h4> <p>To provide for wider degree of alignment adjustment than has been the case heretofore between the socket and the commercially available SACH foot, there has been developed a method of attachment employing a bolt with a spherical head <b>Fig. 45.</b>. Combined with an oversize hole in the socket, it permits some swivelling action between socket and foot. Adequate bearing area for the spherical bolt head is provided by laminating into the end of the socket a spherical washer <b>Fig. 45.</b> having the same spherical radius as the head of the bolt.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Spherical-head bolt (top) and spherical washer used in attaching SACH foot to plastic socket to permit relatively wide range of adjustment. Spherical washer and spherical part of bolt head can be made using plastic-laminating techniques. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Both washer and bolt head can be fabricated easily by use of plastic-laminating techniques. A mold suitable for forming both pieces can be made by immersing in wet plaster of Paris a PVA-covered rubber ball, or other spherical object of suitable size, to a depth equal to about a third of its diameter <b>Fig. 46.</b>. The washer is formed by placing in the mold about eight layers of Fiberglas cloth saturated with epoxy resin, then placing the ball in the cavity and weighting it, and then curing the resin. Trimming the periphery of the washer and drilling a 1-in. hole in the center completes the job. The spherical bolt head is constructed by placing under the head of a standard 3/8-in. machine bolt 10 discs of Fiberglas cloth drilled with 3/8-in. holes, screwing the bolt into a hole drilled into the plaster mold, filling the cavity to the top of the bolt head with epoxy resin, and curing the plastic. When curing is complete, the top may be finished by sanding.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Mold used in fabricating spherical washer and spherical bolt head. Convex portion consists of a rubber ball covered with PVA film. Concave portion is formed from wet plaster of Paris by pressing the ball in to a depth equal to approximately one third its diameter. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>So that the spherical washer may be laminated into the socket, it is attached to the plaster model of the stump with beeswax <b>Fig. 47.</b>, care being taken at this point because the location of the washer with respect to the model determines the location of the foot with respect to the socket in a horizontal plane.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Placing the spherical washer on the plaster model of the stump so that it may be laminated into the socket. Beeswax is used both to support it in the proper position and to fasten it to the model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To enable the socket to be attached to the foot, a bandsaw is used to make in the keel of the foot a cutout conforming to the radius of the bulbous portion of the socket <b>Fig. 48.</b>. When the length of the stump dictates that the keel be so cut away as to weaken it significantly, the keel must be reinforced. In such a case, a wood screw is used to fasten the socket to the remaining portion of the keel <b>Fig. 49.</b>. The heel wedge and balata belting are peeled back, some nine layers of Fiberglas cloth, tailored to fit the keel and the end of the socket (which is covered with PVA film to prevent adherence), are laid up and saturated with epoxy resin, and the balata belting is screwed back in place <b>Fig. 50.</b>. After curing of the resin has been effected, a 3/8-in. hole is drilled through the keel reinforcement and the socket at the center of the spherical washer, the foot is removed, and that part of the hole which is in the socket is enlarged to 1 in. so as to match the hole in the spherical washer <b>Fig. 51.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. View showing the type of cut made in the top portion of a SACH foot to accommodate a Syme socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Fastening the socket to the keel of the SACH foot with a wood screw. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Fiberglas cloth, used to reinforce keel of SACH foot, being tailored to fit bottom of keel and socket. Note PVA film placed over socket to prevent adherence to Fiberglas during laminating process. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. Cross-section of completed prosthesis showing spherical head bolt, spherical washer, modified keel, and laminated Fiberglas reinforcement. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Finally, a hole 1 1/4 in. in diameter is formed in the heel wedge and sole in such a way as to receive the wrench needed to tighten the attachment nut <b>Fig. 51.</b>. The heel wedge having been modified to fit the contours of the reinforced keel and then cemented in place, the socket and foot can be assembled for walking trials. When all necessary adjustments have been made, the socket is bonded to the foot with epoxy resin and the space around the socket is filled with a mixture of resin and sawdust which, when cured, is ground and sanded to provide a suitable contour.</p> <h3>CONCLUSION</h3> <p>The several methods presented here for fabrication of a prosthesis for Syme's amputation have all been found to be useful. It seems reasonable to believe that some of the features of each method may be combined in order to suit the equipment of the individual prosthetist as well as to meet most effectively the requirements of the individual patient. For example, the technique offered by VAPC for fabrication of a cover for the cutout might well be applied to fabrication of a prosthesis with a full-length posterior cutout as used by the Prosthetic Services Centre. The use of alginate as an impression material may be the method of choice for some prosthetists, while others may find the two-piece mold best for their use, especially if the local water supply contains certain minerals. The measurement-and-modification techniques described might be combined advantageously. Thus most of the individual methods are interchangeable between the basic prostheses described.</p> <h3>ACKNOWLEDGMENT</h3> <p>Any reliable article on the recommended methods of construction of a limb prosthesis must necessarily be based on the cumulative experience and the collective judgment of many workers in many places. Most of the material for this article was drawn from three pre-existing publications-<i>Construction of the Plastic Symes Appliance </i>(Technical Bulletin No. 32, Prosthetic Services Centre, Canadian Department of Veterans Affairs, Toronto, August 1959), <i>VAPC Technique for Fabricating a Plastic Syme Prosthesis with Medial Opening </i>(U. S. Veterans Administration, New York, September 1959), and <i>Recent Developments in the Fitting and Fabrication of the Syme Prosthesis (Orthopedic and Prosthetic Appliance Journal,</i> March 1960). Much valuable advice and counsel was forthcoming from a number of highly accomplished persons, among them R. M. Turner, of the Canadian Department of Veterans Affairs, Ottawa, and C. S. Boccius, of the Prosthetic Services Centre, Toronto; Colin A. McLaurin and Fred Hampton, of the Prosthetics Research Centre of Northwestern University in Chicago; and Anthony Staros and Louis Iuliucci, of the U. S. Veterans Administration Prosthetics Center, New York City. Of the 51 illustrations, the drawings not credited to original publications are the work of Annette Kissel, illustrator for the Veterans Administration Prosthetics Center in New York City, and of George Rybczynski, freelance artist of Washington, D. C. Miss Kissel executed Figures 26 through 43. Mr. Rybczynski prepared Figures 11, 12, 13, 14, 15, 16, 17, 19, 22, 23 and 24. The cooperative efforts of all these individuals are gratefully acknowledged and duly appreciated.</p> <p><b>References:</b></p> <ol> <li>Bowler, Bartholomew, U. S. Patent 1,323,444, Dec. 2, 1919.</li> <li>Columbus Artificial Limb Company, catalog, Columbus, Ohio, ca. 1925.</li> <li>Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, <i>Syme's amputation and prosthesis, </i>January 1, 1954.</li> <li>Department of Veterans Affairs, Prosthetic Services Centre, Toronto, Canada, <i>Construction of the plastic Symes appliance, </i>Technical Bulletin No. 32, August 1959.</li> <li>Foort, J., <i>The Canadian type Syme prosthesis</i>(Series 11, Issue 30), Lower-Extremity Amputee Research Project, Institute of Engineering Research, University of , Berkeley, December 1956.</li> <li>Gaines-Erb Company, catalog, Denver and Pueblo, Colo., ca. 1915.</li> <li>Gardner, Henry F., <i>A report of the checkout of the UC-Berkeley Syme prosthesis and fabrication manual. </i>Veterans Administration Prosthetics Center, New York, January 31, 1958.</li> <li>Gardner, Henry F., <i>First addendum to the January 31, 1958, report of the checkout of the UC-Berkeley Syme prosthesis and fabrication manual, </i>Veterans Administration Prosthetics Center, New York, May 1, 1958.</li> <li>Hampton, Fred, <i>Recent developments in the fitting and fabrication of the Symes prosthesis, </i>Orthopedic and Prosthetic Appliance Journal, March 1960, p 45.</li> <li>Iuliucci, Louis, <i>VAPC technique for fabricating a plastic Syme prosthesis with medial opening, </i>Veterans Administration Prosthetics Center, New York, September 1959.</li> <li>Kay, H. W., and A. Staros, <i>Plastic laminate. Syme prosthesis, </i>Prosthetic Devices Study, New York University, and Veterans Administration Prosthetics Center, New York, January 1960.</li> <li>Marks, A. A., Inc., <i>Manual of artificial limbs, </i>New York, 1889.</li> <li>Marks, A. A., Inc., <i>Manual of artificial limbs, </i>New York, 1931.</li> <li>New York University, Prosthetic Devices Studies, College of Engineering, <i>Progress report, test of the Canadian type plastic Syme prosthesis (modified)</i>, New York, December 1958.</li> <li>University of (Los Angeles), Department of Engineering, <i>Manual of upper extremity prosthetics, </i>2nd ed., William R. Santschi, ed., 1958.</li> <li>Winkley Artificial Limb Company, <i>Artificial legs with the patent adjustable double slip socket, </i>descriptive catalog, Minneapolis, Minn., ca. 1910.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Foort, J., The Canadian type Syme prosthesis(Series 11, Issue 30), Lower-Extremity Amputee Research Project, Institute of Engineering Research, University of , Berkeley, December 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, Prosthetic Services Centre, Toronto, Canada, Construction of the plastic Symes appliance, Technical Bulletin No. 32, August 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Kay, H. W., and A. Staros, Plastic laminate. Syme prosthesis, Prosthetic Devices Study, New York University, and Veterans Administration Prosthetics Center, New York, January 1960.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">University of (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed., 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Iuliucci, Louis, VAPC technique for fabricating a plastic Syme prosthesis with medial opening, Veterans Administration Prosthetics Center, New York, September 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Hampton, Fred, Recent developments in the fitting and fabrication of the Symes prosthesis, Orthopedic and Prosthetic Appliance Journal, March 1960, p 45.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, Prosthetic Services Centre, Toronto, Canada, Construction of the plastic Symes appliance, Technical Bulletin No. 32, August 1959.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Iuliucci, Louis, VAPC technique for fabricating a plastic Syme prosthesis with medial opening, Veterans Administration Prosthetics Center, New York, September 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Foort, J., The Canadian type Syme prosthesis(Series 11, Issue 30), Lower-Extremity Amputee Research Project, Institute of Engineering Research, University of , Berkeley, December 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Iuliucci, Louis, VAPC technique for fabricating a plastic Syme prosthesis with medial opening, Veterans Administration Prosthetics Center, New York, September 1959.</td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Kay, H. W., and A. Staros, Plastic laminate. Syme prosthesis, Prosthetic Devices Study, New York University, and Veterans Administration Prosthetics Center, New York, January 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">University of (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed., 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Studies, College of Engineering, Progress report, test of the Canadian type plastic Syme prosthesis (modified), New York, December 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Foort, J., The Canadian type Syme prosthesis(Series 11, Issue 30), Lower-Extremity Amputee Research Project, Institute of Engineering Research, University of , Berkeley, December 1956.</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Gardner, Henry F., A report of the checkout of the UC-Berkeley Syme prosthesis and fabrication manual. Veterans Administration Prosthetics Center, New York, January 31, 1958.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Gardner, Henry F., First addendum to the January 31, 1958, report of the checkout of the UC-Berkeley Syme prosthesis and fabrication manual, Veterans Administration Prosthetics Center, New York, May 1, 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, Prosthetic Services Centre, Toronto, Canada, Construction of the plastic Symes appliance, Technical Bulletin No. 32, August 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">University of (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed., 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bowler, Bartholomew, U. S. Patent 1,323,444, Dec. 2, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bowler, Bartholomew, U. S. Patent 1,323,444, Dec. 2, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Columbus Artificial Limb Company, catalog, Columbus, Ohio, ca. 1925.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bowler, Bartholomew, U. S. Patent 1,323,444, Dec. 2, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Marks, A. A., Inc., Manual of artificial limbs, New York, 1889.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Marks, A. A., Inc., Manual of artificial limbs, New York, 1931.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Gaines-Erb Company, catalog, Denver and Pueblo, Colo., ca. 1915.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Winkley Artificial Limb Company, Artificial legs with the patent adjustable double slip socket, descriptive catalog, Minneapolis, Minn., ca. 1910.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Staff Engineer, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Ave., Washington 25, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1961_01_052/c001.jpg Figure 2 http://www.oandplibrary.org/al/images/1961_01_052/c002.jpg Figure 3 http://www.oandplibrary.org/al/images/1961_01_052/c003.jpg Figure 4 http://www.oandplibrary.org/al/images/1961_01_052/c004.jpg Figure 5 http://www.oandplibrary.org/al/images/1961_01_052/c005.jpg Figure 6 http://www.oandplibrary.org/al/images/1961_01_052/c006.jpg Figure 7 http://www.oandplibrary.org/al/images/1961_01_052/c007.jpg Figure 8 http://www.oandplibrary.org/al/images/1961_01_052/c008.jpg Figure 9 http://www.oandplibrary.org/al/images/1961_01_052/c009.jpg Figure 10 http://www.oandplibrary.org/al/images/1961_01_052/c010.jpg Figure 11 http://www.oandplibrary.org/al/images/1961_01_052/c011.jpg Figure 12 http://www.oandplibrary.org/al/images/1961_01_052/c012.jpg Figure 13 http://www.oandplibrary.org/al/images/1961_01_052/c013.jpg Figure 14 http://www.oandplibrary.org/al/images/1961_01_052/c014.jpg Figure 15 http://www.oandplibrary.org/al/images/1961_01_052/c015.jpg Figure 16 http://www.oandplibrary.org/al/images/1961_01_052/c016.jpg Figure 17 http://www.oandplibrary.org/al/images/1961_01_052/c017.jpg Figure 18 http://www.oandplibrary.org/al/images/1961_01_052/c018.jpg Figure 19 http://www.oandplibrary.org/al/images/1961_01_052/c019.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 Prostheses for Syme's Amputation Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/563b7e3d5e654828605f04deb909797d.pdf bdd8ac1d4ea751b6467591119d581c32 https://staging.drfop.org/files/original/06192bdad0f19b8b8f1a62b6de034970.jpg b1d165ad8953da55d9ae82c37eb333fa https://staging.drfop.org/files/original/11faed39014403a6dc246e19447a1e04.jpg e053bf6273abb66dfc3e4b534d6f0ef2 https://staging.drfop.org/files/original/ab3f22ae3bf0b961414fc0148beb8ad2.jpg c8cc8b308e2f932c66508ebcb3918fe5 https://staging.drfop.org/files/original/a98488decd50e21af69363b9e67475e2.jpg 8ae2865195228b7aca7c75f753e4584b https://staging.drfop.org/files/original/3104c38e2e1fdde67ea076415c929bf7.jpg ce62f98c13cdfb73a43c7b2f673348df https://staging.drfop.org/files/original/1bfb3db8f0a4653731d81faa29559635.jpg bc64124b91d9ba11eef6f8356c5d0319 https://staging.drfop.org/files/original/1a846b2a0fe0a6fddc0540823690ccff.jpg d1f0c1cb1a48e93b1be62020126a530d https://staging.drfop.org/files/original/54f4c041c313324c6dd89aba4c7335e8.jpg 1a38657457516471793399d4f2ade79f https://staging.drfop.org/files/original/c5555a3c031f1ad854aeee2c5fbd1376.jpg 836517a1021bc3d397aab93236925ba2 https://staging.drfop.org/files/original/ddd6cf419da77ba7ed5f5f1bcf7c62b3.jpg adca9e2f32b00a97ee7de032d4c3efc4 https://staging.drfop.org/files/original/8a780fa990993d128a1889acb02fe387.jpg a021a16bcf45de281a02a47e05ebe5a8 https://staging.drfop.org/files/original/1657876e7ff4af53ca8144dee7ddb077.jpg 9dd2ddab021621e602392a91ed65eae6 https://staging.drfop.org/files/original/7da95365c1b01ff987fb41f4868ee168.jpg e09de561d7cb9a7fe09ddbb9766aafe6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_02_001.pdf Year 1969 Volume 13 Issue 2 Page Number(s) 1 - 12 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1969_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Recent Advances in Below-Knee Prosthetics</h2> <h5>A. Bennett Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>The concept of constructing a below-knee prosthesis with side joints and a thigh lacer was set forth by the Dutch surgeon Verduin in 1696 (<b>Fig. 1</b>) and followed universally until the advent of the patellar-tendon-bearing prosthesis in the late 1950's. <a></a> Although other innovations such as contact over the distal end of the stump, suction suspension, and "muley" sockets were introduced from time to time, they were never widely used, possibly because principles governing their use were not set forth in a systematic manner.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Verduin leg (1696). From MacDonald, J., Amer.J. Surg., 1905. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In 1957, the predecessor of CPRD, the Advisory Committee on Artificial Limbs, encouraged the University of California at Berkeley to study the problems of the below-knee amputee and to improve the then current management practices. As a result, some of the leading prosthetists in this country were invited to Berkeley later in 1957 for the express purpose of examining in detail the prosthetics practices for BK amputees and rationales for those practices. <a></a> An analysis of the findings of that conference led to the development of the patellar-tendon-bearing prosthesis, known now as the PTB prosthesis.</p> <p>The original version of the PTB prosthesis was a plastic laminate socket which was formed over a modified plaster-of-Paris model of the stump, and which contained a soft inner liner that contacted the entire surface of the stump. <a></a> The major weight was borne by the medial flares of the tibia and the patellar tendon. No knee joints or thigh corsets were used, suspension being effected by a fabric strap around the thigh just above the femoral condyles (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Cutaway view of the original patellar-tendon-bearing (PTB) prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The PTB concept was offered in formal education programs in this country and gradually gained acceptance, so that by 1961 slightly more than half of the below-knee prostheses provided in the United States were of that type. <a></a> The concept also has been accepted widely in other countries, and the PTB now is generally considered to be the standard prosthesis for below-knee amputations.</p> <p>In recent years, research groups and individual prosthetists have introduced improvements to the basic concept. <a></a> This article describes the advanced practices in the management of the below-knee amputee that have been developed since the introduction of the PTB prosthesis.</p> <h3>The Hard Socket</h3> <p>The original PTB socket design called for a lining of leather or Naugahyde backed by sponge rubber. Perspiration caused problems in many instances, however, because Naugahyde does not "breathe" and leather deteriorates rapidly in the presence of sweat. This problem prompted some prosthetists to eliminate the liner, and the "hard" PTB socket has become increasingly popular.</p> <h3>The PTS Socket</h3> <p>The suspension strap for the PTB prosthesis, as designed originally, was usually satisfactory, but there were enough dissatisfied amputees to prompt a number of prosthetists to seek improved suspension methods. In addition to developing different strap designs (<b>Fig. 3</b>) <a></a>, several groups experimented with new configurations for the proximal border of the socket. The research team at Nancy, France, introduced the "prothese tibiale a emboitage supracondylien," popularly known as the PTS, in which the proximal border extends above the patella and the femoral condyles (<b>Fig. 4</b>), <a></a> thus holding the socket on the stump. This concept was introduced into the United States by Nitschke and Marschall <a></a> and the PTS prosthesis is being used at an increasing rate in the United States. The technique may be used with or without a liner. Hamontree <a></a>, in reporting his experiences with 94 cases, noted that, although he believed that the majority of the patients could have been satisfied with the original version of the PTB, a certain percentage could have been successfully fitted only with the PTS version.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Left, continuous-strap suspension arranged in a figure eight with Velcro for adjustment; right, anterior view of two inverted V-straps looped through a ring and attached inside a hard socket close to the brim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. A right, below-knee stump and the amputee wearing a PTS-socket prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Wedge Suspension Socket</h3> <p>Another attempt to improve upon the strap type of suspension resulted in the KBM (Kondylen Bettung Munster) prosthesis <a></a>, in which a small wedge is inserted between the proximal area of the socket and the area of the stump along the medial condyles of the femur (<b>Fig. 5</b>). Developed at the University of Munster, this concept was introduced into the United States by Fillauer <a></a> and is now known as the supracondylar-wedge suspension system. The wedge system may be used with or without a socket liner, but generally no liner is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The supracondylar-wedge suspension method. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Air-Cushion Socket</h3> <p>In an effort to develop a socket that would permit the stump to bear the optimum amount of the weight load over its distal end, Wilson and his associates <a></a> designed and developed the "air-cushion socket" (<b>Fig. 6</b>), which reduces the magnitude of the vertical components of weight-bearing forces at other points on the stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Cutaway view of the air-cushion socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The air-cushion PTB consists of an elastic inner sleeve (stockinet impregnated with silicone rubber) suspended from the level of the tibial tubercle in a rigid outer shell that is closed distally. Stump support is provided by the tension of the sleeve itself and by the compression of the air in the chamber between the inner sleeve and outer cap.</p> <p>Trials in the United States, Denmark, and Yugoslavia <a></a> have shown that the air-cushion version of the PTB is particularly useful for patients with very sensitive stumps. In fact, there appear to be few, if any, contraindications to the use of the air-cushion socket, the only disadvantages being that slightly more time is required to fabricate the socket and that few modifications can be made after it has been fabricated.</p> <h3>Porous Socket</h3> <p>In seeking ways to alleviate the problems caused by perspiration, the U. S. Army Medical Biomechanical Research Laboratory developed a porous plastic laminate. <a></a> Conventional epoxy resins and filler materials are used in the fabrication, but special care must be taken in controlling the proportions of the ingredients and in curing. The first porous laminates developed by AMBRL were satisfactory for upper-extremity sockets, but they were not strong enough for routine use in lower-extremity sockets. Subsequently, the technicians developed a fabrication technique using epoxy resins that overcame the major shortcomings of the earlier laminates. <a></a> New York University, after studying 20 children and young adults, reported that the porous-laminate socket appeared to be a "significant and worthwhile addition" to below-knee prosthetics specifically and to limb prosthetics generally. <a></a> There were fewer problems with perspiration, and skin eruptions were ameliorated. In addition, the prostheses with porous-laminate sockets weighed less. When perspiration was a major problem, the two disadvantages cited-slightly increased fabrication time and greater difficulty in maintaining socket cleanliness-were far outweighed by the advantages.</p> <p>Because most of the innovations to the original PTB design are not mutually exclusive, it was possible to develop a chart showing the combinations of features that can be used to devise a below-knee prosthesis that best meets the needs of the individual patient (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Casting Methods</h3> <p>The method for obtaining a model of the stump for fabrication of the PTB socket, as described in the original manuals, consisted of wrapping the stump with plaster-of-Paris bandages, shaping the wrap with the fingers, and subsequently modifying the male mold produced from the female cast, or wrap. Any number of attempts have been made to devise a procedure that would require less skill. One such method that has been accepted by many prosthetists is the sling-casting, or suspension-casting, technique developed by Hampton <a></a> (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Ring and sock for suspension casting of the below-knee stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the suspension-casting technique, the stump is wrapped while it is held in a vertical position that simulates weight-bearing during standing. Felt patches to provide relief for sensitive areas of the stump can be applied directly to the stump, and a minimum amount of modification is necessary, although the need for modification is not eliminated entirely.</p> <p>Research workers and clinicians have been searching for years for a material that will enable the prosthetist to form a socket directly over the stump, thereby eliminating the need for plaster wraps and male molds. Experience with a synthetic rubber, Polysar<a style="text-decoration:none;">*</a> X-414, has shown that this material definitely has a place in the fabrication of sockets. <a></a> Temporary, or provisional, below-knee prostheses consisting of a synthetic-balata socket and pylon-type components are proving to be useful. Because it becomes pliable at temperatures easily tolerated by the skin, synthetic balata can be applied directly over the stump. Extruded tubing of various diameters with walls 1/4-in. thick is available. A piece of tubing slightly smaller in diameter than the stump is heated in water to about 160 deg F, then forced over the stump, which has been padded in appropriate areas (<b>Fig. 9</b>). To give proper shape to the socket, a length of pressure-sensitive tape, 1 in. wide, is wrapped over the outside, and final forming is carried out manually. To provide total contact, the distal end is filled with "foam-in-place" silicone. The socket is easily mounted on a pylon unit for use as a temporary prosthesis, or a more permanent one if desired. The prosthesis can be given a natural appearance by applying and shaping semirigid blocks of Koroseal "Spongex"<a style="text-decoration:none;">*</a> (<b>Fig. 10</b>). Contours of the socket can be changed at any time by heating the area with a heat gun and reshaping it manually.<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Top, application of socket tube to the stump; bottom, trimming of socket brim prior to final molding. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Foam blocks for fitting over pylon and socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Time of Fitting</h3> <p>During the past decade, the advantages of fitting a prosthesis as soon after amputation as possible have been demonstrated repeatedly. Goldner and his associates <a></a> demonstrated that "early" fitting-that is, providing the patient with a temporary prosthesis as soon as the wound has healed rather than waiting for a maximum amount of shrinkage to take place-could drastically reduce time and costs of rehabilitation. Even more dramatic results have been obtained by fitting artificial limbs immediately after surgery, especially with below-knee amputees <a></a> (<b>Fig. 11</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Schematic cross section showing the major elements of a prosthesis as applied immediately following surgery to a below-knee amputee. The suture line, silk dressing, and drain are not shown. The fluffed gauze does not extend beyond the area indicated in "A." Inset: A below-knee amputee fitted with the immediate postsurgical prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The technique of immediate postsurgical fitting was originated in France by Berlemont, was carried further by Weiss in Poland, and, after a considerable experimentation period in the United States, is now being taught routinely in the prosthetics education programs in this country. <a></a> The technique consists of applying a rigid dressing over the stump and attaching an adjustable pylon and foot. Standing and ambulation is begun as soon as the patient's condition permits. For young, otherwise healthy patients, some ambulation can begin on the day following amputation.</p> <p>Usually the rigid dressing is left in place until the wound has healed and the sutures can be removed-about 10-14 days postoperatively. A second rigid dressing is provided for another 10- to 14-day period, at which time a "permanent," or definitive, limb can be provided. The advantages of immediate postsurgical fitting include reduction of edema, less pain, shorter periods of hospitalization and therapy, and fewer contractures. The technique has become standard practice in many centers with trained teams. <a></a></p> <h3>Hardware</h3> <p>To make early fitting and immediate postsurgical fitting easier, a number of adjustable pylons have been developed. Those currently available are shown in <b>Fig. 12</b>. Some of their characteristics are given in <b>Table 1</b>. These units are strong enough and light enough for extended usage with or without some sort of cosmetic cover. A number of approaches to cosmetic treatment such as the use of Spongex, mentioned above, have been offered, but none have been accepted widely by prosthetists. Work on this problem is continuing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Below-knee pylon-type prostheses that can be used for fitting immediately after surgery. A, Hosmer Postoperative Pylon; B, Northwestern Pylon (Hosmer); C, Veterans Administration Prosthetics Center (VAPC) "Standard" Pylon; D, Canadian "Instant" Prosthesis (Hosmer); E, United States Manufacturing Co. Pylon; F, Finnie-Jig (Arthur Finnieston Co.). Metal straps for attachment to a plaster-of-Paris socket are available, but not shown. Courtesy of Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Education and Research Needs</h3> <p>At the December 1968 "Symposium on Below-Knee Prosthetics", <a></a> sponsored by the Committee on Prosthetics Research and Development, a number of suggestions for improving prosthetics education and practice were offered.</p> <ol> <li>The body of knowledge about BK prosthetics that has been developed in recent years should be made available to practicing prosthetists and other clinicians.</li><li>All institutions offering prosthetics-education courses should include the information presented at the symposium in their curricula.</li><li>Opportunities for continuing education, such as postgraduate-type courses for clinic teams in the latest prosthetics techniques, should be provided.</li><li>Additional manuals and other instructional materials should be prepared. In addition, a central group that would be responsible for the orderly preparation and dissemination of technical information is needed.</li><li>Current research efforts in BK prosthetics should be continued, but with emphasis placed on the development of a truly refined theory of fitting.</li></ol> <p>Because most of the recent improvements to the design of the below-knee socket, especially in suspension techniques, have been accomplished by practicing prosthetists, there is little need for the research centers to devote their time to developing additional improvements. On the other hand, there is very little knowledge about the basic principles underlying optimum fitting of prostheses. Therefore, the research centers should be encouraged to obtain basic information about the effects of pressure and shear forces on tissues, and to more clearly indicate the biomechanical forces required in the various phases of walking. Following that work, methods by which those principles could be put into practice should be developed, including the use of hydrostatic sockets and other methods that might provide automatic adjustment.</p> <p>As a result of these suggestions, a pilot course in advanced below-knee prosthetics practices was held at Northwestern University (see "News and Notes") on August 4-13, 1969, for prosthetist instructors from the University of California at Los Angeles, New York University, and Northwestern University. The University Council on Prosthetics Education is now developing a curriculum for short-term postgraduate courses in below-knee prosthetics. The advanced techniques will also be offered in regular courses in below-knee prosthetics.</p> <p><b>References:</b></p> <ol> <li>The American Academy of Orthopaedic Surgeons, Inc.,<i> Historical development of artificial limbs</i>, Chap. 1 in <i>Orthopaedic appliances atlas</i>, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>Burgess, Ernest M., <i>The below-knee amputation</i>, Inter-Clinic Inform. Bull., 8:4:1-22, January 1969.</li> <li>Burgess, Ernest M., and Joseph H. Zettl, <i>Amputations below the knee</i>, Artif. Limbs, 13:1:1-12, Spring 1969.</li> <li>Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., <i>Immediate postsurgical prosthetics in the management of lower extremity amputees</i>, TR 10-5, Prosthetic and Sensory Aids Service, Veterans Administration, Washington, D. C, April 1967.</li> <li>Caldwell, Jack L., <i>Inverted V-strap suspension for PTB prosthesis</i>, Artif. Limbs, 9:1:23-26, Spring 1965.</li> <li>Committee on Prosthetics Research and Development, <i>Below-knee prosthetics</i>, A report of a symposium, National Academy of Sciences, Washington, D. C, December 1968.</li> <li>Committee on Prosthetics Research and Development, <i>Immediate postsurgical fitting of prostheses</i>, A report of a workshop, National Academy of Sciences, Washington, D. C, May 1968.</li> <li>Compere, Clinton L., <i>Early fitting of prostheses following amputation</i>, Surg. Clin. N. Amer., 48:1:215-226, February 1968.</li> <li>Dolan, Clyde M. E., <i>The Army Medical Biomechanical Research Laboratory porous laminate patellar-tendon-bearing prosthesis</i>, Artif. Limbs, 12:1:25-34, Spring 1968.</li> <li>Fillauer, Carlton, <i>Supracondylar wedge suspension of the P T.B. prosthesis</i>, Orth. and Pros., 22:2:39-44, June 1968.</li> <li>Goldner, J. Leonard, Frank W. Clippinger, and Bert R. Titus, <i>Use of temporary plaster or plastic pylons preparatory to fitting a permanent above knee or below knee prosthesis</i>, Final Report of Project RD-1363-M, Duke University Medical Center, Durham, N. C, circa 1967.</li> <li>Hamontree, Sam E., Howard J. Tyo, and Snowdon Smith, <i>Twenty months experience with the "PTS"</i>, Orth. and Pros., 22:1:33-39, March 1968.</li> <li>Hampton, Fred, <i>Suspension casting for below knee, above-knee, and Syme's amputations</i>, Artif. Limbs, 10:2:5-26, Autumn 1966.</li> <li>Hill, James T., Henry Mouhot, and Robert E. Plumb, <i>Manual for preparation of a porous PTB socket with soft distal end</i>, Tech. Rep. 6804, U. S. Army Medical Biomechanical Research Laboratory, Washington, D. C, May 1968.</li> <li>Kuhn, G. G., S. Burger, R. Schettler, and G. Fajal, <i>Kondylen Bettung Munster am Unter-schenkel Stumpf</i>, "KBM-Prothese," Atlas d'Appareillage Prothetique et Orthopedique, No. 14, 1966.</li> <li>Litt, Bertram D., and LeRoy Wm. Nattress, Jr., <i>Prosthetic services USA-1961</i>, American Orthotics and Prosthetics Association, Washington, D. C, October 1961.</li> <li>Lower-Extremity Amputee Research Project, Minutes of symposium on BK prosthetics, University of California, Berkeley, April 1957.</li> <li>Marschall, Kurt, and Robert Nitschke, <i>Principles of the patellar tendon supra-condylar prosthesis</i>, Orthop. Pros. Appl. J., 21:1:33-38, March 1967.</li> <li>Marschall, Kurt, and Robert Nitschke, <i>The P.T.S. prosthesis (Complete enclosure of patella and femoral condyles in below knee fittings)</i>, Orthop. Pros. Appl. J., 20:2:123-126, June 1966.</li> <li>Pierquin, L., G. Fajal, and J. M. Paquin, <i>Prothese tibiale a emboitage supracondylien</i>, Atlas d'Appareillage Prothetique et Orthopedique, No. 1, January 1964.</li> <li>Plumb, Robert E., and Fred Leonard, <i>Patella-tendon-bearing below-knee porous socket with soft Silastic distal end</i>, Tech. Rep. 6311, U S. Army Medical Biomechanical Research Laboratory, Washington, D. C, June 1963.</li> <li>Radcliffe, C. W., and J. Foort, <i>The patellar-tendon-bearing below-knee prosthesis</i>, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1961.</li> <li>The Staff of the Prosthetics Research Group, Biomechanics Laboratory-University of California, <i>Manual of below knee prosthetics</i>, The Regents of the University of California, November 1959.</li> <li>The Staff, Veterans Administration Prosthetics Center, <i>Direct forming of below-knee patellar-tendon-bearing sockets with a thermoplastic material</i>, Orth. and Pros., 23:1:36-61, March 1969.</li> <li>Wilson, L. A., E. Lyquist, and C. W. Radcliffe, <i>Air-cushion socket for patellar-tendon-bearing below-knee prosthesis</i>, Tech. Rep. 55, Department of Medicine and Surgery, Veterans Administration, Washington, D. C, May 1968.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Below-knee prosthetics, A report of a symposium, National Academy of Sciences, Washington, D. C, December 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Immediate postsurgical fitting of prostheses, A report of a workshop, National Academy of Sciences, Washington, D. C, May 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Immediate postsurgical fitting of prostheses, A report of a workshop, National Academy of Sciences, Washington, D. C, May 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Burgess, Ernest M., The below-knee amputation, Inter-Clinic Inform. Bull., 8:4:1-22, January 1969.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Burgess, Ernest M., and Joseph H. Zettl, Amputations below the knee, Artif. Limbs, 13:1:1-12, Spring 1969.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Immediate postsurgical prosthetics in the management of lower extremity amputees, TR 10-5, Prosthetic and Sensory Aids Service, Veterans Administration, Washington, D. C, April 1967.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Compere, Clinton L., Early fitting of prostheses following amputation, Surg. Clin. N. Amer., 48:1:215-226, February 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Goldner, J. Leonard, Frank W. Clippinger, and Bert R. Titus, Use of temporary plaster or plastic pylons preparatory to fitting a permanent above knee or below knee prosthesis, Final Report of Project RD-1363-M, Duke University Medical Center, Durham, N. C, circa 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Sockets of this material should not be left near radiators or in an abnormally warm environment, such as the interior of a closed automobile parked in sunlight on a warm day, because synthetic balata becomes pliable at temperatures as low as 120 deg F.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">B. F. Goodrich Co.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">The Staff, Veterans Administration Prosthetics Center, Direct forming of below-knee patellar-tendon-bearing sockets with a thermoplastic material, Orth. and Pros., 23:1:36-61, March 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Registered trademark of Polymer Corporation Limited.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Hampton, Fred, Suspension casting for below knee, above-knee, and Syme's amputations, Artif. Limbs, 10:2:5-26, Autumn 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Dolan, Clyde M. E., The Army Medical Biomechanical Research Laboratory porous laminate patellar-tendon-bearing prosthesis, Artif. Limbs, 12:1:25-34, Spring 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Plumb, Robert E., and Fred Leonard, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, Tech. Rep. 6311, U S. Army Medical Biomechanical Research Laboratory, Washington, D. C, June 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Dolan, Clyde M. E., The Army Medical Biomechanical Research Laboratory porous laminate patellar-tendon-bearing prosthesis, Artif. Limbs, 12:1:25-34, Spring 1968.</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Hill, James T., Henry Mouhot, and Robert E. Plumb, Manual for preparation of a porous PTB socket with soft distal end, Tech. Rep. 6804, U. S. Army Medical Biomechanical Research Laboratory, Washington, D. C, May 1968.</td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Plumb, Robert E., and Fred Leonard, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, Tech. Rep. 6311, U S. Army Medical Biomechanical Research Laboratory, Washington, D. C, June 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Below-knee prosthetics, A report of a symposium, National Academy of Sciences, Washington, D. C, December 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Wilson, L. A., E. Lyquist, and C. W. Radcliffe, Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, Tech. Rep. 55, Department of Medicine and Surgery, Veterans Administration, Washington, D. C, May 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Fillauer, Carlton, Supracondylar wedge suspension of the P T.B. prosthesis, Orth. and Pros., 22:2:39-44, June 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Kuhn, G. G., S. Burger, R. Schettler, and G. Fajal, Kondylen Bettung Munster am Unter-schenkel Stumpf, 'KBM-Prothese,' Atlas d'Appareillage Prothetique et Orthopedique, No. 14, 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hamontree, Sam E., Howard J. Tyo, and Snowdon Smith, Twenty months experience with the 'PTS', Orth. and Pros., 22:1:33-39, March 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Marschall, Kurt, and Robert Nitschke, Principles of the patellar tendon supra-condylar prosthesis, Orthop. Pros. Appl. J., 21:1:33-38, March 1967.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Marschall, Kurt, and Robert Nitschke, The P.T.S. prosthesis (Complete enclosure of patella and femoral condyles in below knee fittings), Orthop. Pros. Appl. J., 20:2:123-126, June 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Pierquin, L., G. Fajal, and J. M. Paquin, Prothese tibiale a emboitage supracondylien, Atlas d'Appareillage Prothetique et Orthopedique, No. 1, January 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Caldwell, Jack L., Inverted V-strap suspension for PTB prosthesis, Artif. Limbs, 9:1:23-26, Spring 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Below-knee prosthetics, A report of a symposium, National Academy of Sciences, Washington, D. C, December 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Litt, Bertram D., and LeRoy Wm. Nattress, Jr., Prosthetic services USA-1961, American Orthotics and Prosthetics Association, Washington, D. C, October 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and J. Foort, The patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1961.</td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">The Staff of the Prosthetics Research Group, Biomechanics Laboratory-University of California, Manual of below knee prosthetics, The Regents of the University of California, November 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Lower-Extremity Amputee Research Project, Minutes of symposium on BK prosthetics, University of California, Berkeley, April 1957.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">The American Academy of Orthopaedic Surgeons, Inc., Historical development of artificial limbs, Chap. 1 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Research Council, 2101 Constitution Ave., N. W., Washington, D.C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-13.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Recent Advances in Below-Knee Prosthetics Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/dac6e2c4c77d922124f665142308ab03.pdf 07ba4022d5e4a00af7689393d53a592c https://staging.drfop.org/files/original/b6bc3b3683b2300e9b27ae2ed97f13dc.jpg ed1395ee4b4bcc598159c9a0fbf84376 https://staging.drfop.org/files/original/371604048f3ca3974f54163916203dbc.jpg 783624f0922a0b6f959baf9245307c2c https://staging.drfop.org/files/original/4ef0a8b46b25cfcaf6599240c376a532.jpg fcd99d6ba6cfc086b4508d4150bdf886 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_02_058.pdf Year 1970 Volume 14 Issue 2 Page Number(s) 58 - 67 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_02_058.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_02_058.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Evaluation of Synthetic Balata for Fabricating Sockets for Below-Knee Amputation Stumps</h2> <h5>A. Bennett Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>At the present time, most sockets for artificial limbs are made of a plastic laminate (usually polyester resin and Dacron) which has been molded over a modified replica of the stump. A replica of the stump is required because human tissues cannot withstand the temperatures generated by the exothermic reaction of the plastic as it cures. The replica is modified, using general rules established by research groups, in order to achieve a relationship between the stump and socket that is physiologically satisfactory, yet permits weight-bearing and provides stability. In addition, reliefs must be provided to accommodate bony prominences and any tender spots. A simple plaster-of-paris wrap will usually be too loose for normal use. Therefore, fabrication of plastic-laminate sockets with presently available materials involves at least the following steps <b>Fig. 1</b>: (a) development of a female mold of the stump by wrapping the stump with plaster-of-paris bandages, (b) casting a male model of the stump by filling the female mold with plaster of paris, (c) modification of the male model by trimming away plaster in selected areas and building it up in other areas when necessary, and (d) lay-up and cure of the plastic laminate. The average time required to make a hard socket below-knee plastic prosthesis is eight man-hours.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Steps in the fabrication of a plastic prosthesis for a below-knee amputation. <i>A, </i>taking the plaster cast of the stump; <i>B, </i>pouring plaster in the cast to obtain model of the stump; <i>C, </i>introducing plastic resin into fabric pulled over the model to form the plastic-laminate socket; <i>D, </i>the plastic-laminate socket mounted on an adjustable shank for walking trials; <i>E, </i>a wooden shank block inserted in place of the adjustable shank after proper alignment has been obtained; <i>F, </i>the prosthesis after the shank has been shaped. To reduce weight to a minimum, the shank is hollowed out and the exterior covered with a plastic laminate. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It has been the goal of a number of research workers to find a simpler and less time-consuming method for fabricating satisfactory sockets for all levels of amputation. After many experiments involving a number of casting methods and a variety of materials, the Veterans Administration Prosthetics Center<a style="text-decoration:none;">*</a> by 1961 had developed a technique for molding a socket of synthetic balata directly over a below-knee stump. The first successful results were achieved by using an air-pressure sleeve over a tube of synthetic balata,<a style="text-decoration:none;">*</a> which had been softened by immersion in hot water (160 deg F) and then pulled over the stump<a></a> <b>Fig. 2</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The air-pressure method of forming synthetic balata sockets for PTB prostheses: application of the tube to the lubricated sleeve of the stump; application of pressure to the sock-covered pressure sleeve; and the socket and bonded tubing attached with screws to the pylon. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Upon the recommendations of the CPRD Subcommittee on Design and Development, the Subcommittee on Evaluation undertook responsibility for the evaluation of the new technique.</p> <p>The claims of the development laboratory were: (a) a substantial decrease in elapsed time between measurement of the stump and production of a wearable limb, thereby speeding the rehabilitation process, (b) a substantial reduction in man-hours involved, (c) a capability for easy adjustment of the prosthesis at any time, and <i>(d) </i>a decrease in the amount of skill and training required to produce an adequate socket.</p> <h4>Procedure</h4> <p>A protocol (given at the end of this article) was developed and five clinics<a style="text-decoration:none;">*</a> were asked to participate in the evaluation. The prosthetists from the clinics were trained as a group at the Veterans Administration Prosthetics Center on November 6-8, 1968. Each clinic was requested to fit five new amputees and five amputees who had worn PTB prostheses before, and provided with sufficient material and equipment to carry out the fittings.</p> <h4>Results</h4> <p>Follow-up in the spring of 1969 revealed that all the prosthetists were encountering difficulty in obtaining adequate fits in nearly all cases except those with long tapered stumps, most of the sockets being too loose proximally. To overcome this problem, the VAPC devised a method whereby the air bag was eliminated, and molding pressure was brought about by wrapping the softened balata tube with one-inch-wide elastic webbing and controlling the shape of the socket with the hands and fingers as it cooled.</p> <p>All of the participating prosthetists were instructed in the revised method, and other prosthetists were instructed in the new procedure at the same time. Shortly afterwards, plastic pressure-sensitive tape was substituted for the elastic webbing <b>Fig. 3</b>.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The tape-wrap method of forming synthetic balata sockets: application of pressure with elastic, pressure-sensitive tape; molding by hand to define the medial tibial flare and tibial crest; and the heated socket bottom joined to the pylon by an elastic tape wrap. (Courtesy Veterans Administration Prosthetics Center. New York, NY) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The results with the revised procedure were considerably better. The average synthetic balata prosthesis, with pylon but without cosmetic treatment, weighed 3 1/2<i> </i>lb, and could be made in 2 1/2 hr. All of the claims of the developer were substantiated with the exception of the relative amount of skill required, a factor that would be very difficult to measure at this stage of development. At any rate, it is safe to say that no more skill is required for the new technique than for older methods.</p> <p>All prosthetists who used the technique, with one exception, felt that synthetic balata is quite useful for temporary prostheses. Some have adopted the method as standard procedures where procurement practices permit use of temporary prostheses of this type.</p> <h4>Conclusions</h4> <p>When this technique is used, a considerable saving in time can be effected, and the patient can be provided with a prosthesis within a few hours. Furthermore, the use of synthetic balata permits easier adjustment of the socket later, and the adjustable pylon permits adjustment in alignment at any time.</p> <p>It is therefore recommended that use by federal and state agencies of the VAPC technique for fabricating below-knee temporary prostheses be encouraged, and that the technique be included in the curricula of all below-knee prosthetics courses.</p> <p><b>References:</b></p> <ol> <li>Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, <i>Artif. Limbs, </i>6:2:25-73, June 1962.</li> <li>The Staff, Veterans Administration Prosthetics Center, Direct forming of below-knee patellar-tendon-bearing sockets with a thermoplastic material, <i>Orth. and Pros., </i>23:1:36-61, March 1969.</li> <li>Staros, Anthony, and Henry F. Gardner, Direct forming of below-knee PTB sockets with a thermoplastic material, <i>Bull. Pros. Res., </i>10-12:34-47, Fall 1969.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Staros, Anthony, and Henry F. Gardner, Direct forming of below-knee PTB sockets with a thermoplastic material, Bull. Pros. Res., 10-12:34-47, Fall 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Rancho Los Amigos Hospital, Duke University, the University of Miami, the Veterans Administration Hospital/Los Angeles, and the Veterans Administration Hospital/Buffalo</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, Artif. Limbs, 6:2:25-73, June 1962.</td></tr><tr><td class="clsTextSmall"><b>2 .</b> </td><td class="clsTextSmall">The Staff, Veterans Administration Prosthetics Center, Direct forming of below-knee patellar-tendon-bearing sockets with a thermoplastic material, Orth. and Pros., 23:1:36-61, March 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">From Polysar X-414 resin produced by thePolymer Corporation Limited, Sarnia, Ontario,Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">252 Seventh Ave., New York, N.Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_02_058/tmp64A-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_02_058/tmp64A-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_02_058/tmp64A-3.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Evaluation of Synthetic Balata for Fabricating Sockets for Below-Knee Amputation Stumps Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/09fe10baa626726ecfda342c957103aa.pdf d19f909aad10c8d77d23f58e47708607 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/1980_02_007.pdf Text Any textual data included in the document <h2>Editorial: To Fill a Void</h2> <h5>A. Bennett Wilson, Jr.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>I believe that everyone familiar with the recent history of prosthetics and orthotics will agree that the results of the research program in artificial limbs initiated in 1945 by the National Academy of Sciences at the insistence of the Surgeon General of the Army has been very beneficial to amputees and to the prosthetists that serve them. Patients requiring orthopaedic bracing and orthotists have also benefited from this program, which has been supported from the beginning by the Veterans Administration and since about 1956 by the Department of Health, Education &amp; Welfare. Yet for the first five years, or so, of the program, prosthetists and orthotists, not knowing how it would affect their "business," were quite wary of the government-supported research and development teams, and it was not an easy matter to induce practicing private prosthetists to attend the first series of formal education programs offered by the government at UCLA in 1953, even when their attendance was heavily subsidized.</p> <p>Today, the prosthetics and orthotics education programs are considered by all to be essential to the maintenance of a healthy prosthetics and orthotics service, and students pay substantial tuitions to obtain an education in this field. In recent years the AAOP has come forth with continuing education programs that are being improved steadily, and I am sure the younger practitioners probably find it difficult to imagine a world without formal education programs in prosthetics and orthotics.</p> <p>Although the original purpose of the educational programs was to introduce the results of research to practitioners as soon as possible, the government agencies, for reasons known only to the bureaucrats involved, have in recent years essentially abandoned support of research in prosthetics and orthotics. A review of the latest issue of the Bulletin of Prosthetics Research (BPR #10-32) which contains progress reports on all of the research and development efforts in prosthetics and orthotics supported by the VA and DHEW, indicates that less than a quarter of the projects devoted to "Rehabilitation Engineering" relate to prosthetics and orthotics. The percentage in terms of fiscal support is probably even less. This circumstance is reflected also in the source of manuscripts submitted to "Orthotics and Prosthetics." In the past, most of the articles were submitted by workers involved in government-supported research programs. Today, the majority of articles are being received from private practitioners.</p> <p>Perhaps this is as it should be, even though medical research is heavily subsidized, and maybe the prosthetics and orthotics profession has grown to the point where it can assume the leadership in the research, development, evaluation, and education needed if it is to continue to provide the increasingly better services expected of professional groups.</p> <p>In addition to the role of the AAOP in providing opportunities for continuing education, an encouraging signal seems to be coming recently through many of the manuscripts submitted to "O &amp; P" in which practicing prosthetists and orthotists describe their own innovations. However, almost without exception, the authors include only their own experiences with patients, and it never fails to occur to me, as editor, what a pity it is that there exists no group to which these excellent ideas can be submitted for a non-biased evaluation conducted under typical clinical conditions, and thus, be channelled with confidence into the formal educational programs.</p> <p>Even if the federal bureaucrats feel that research and development in prosthetics and orthotics is not important or glamorous enough for support, perhaps AAOP could persuade them that it would be in the public interest to support, at least partially, a clinical evaluation program to be conducted by the Academy. I am confident that Academy members will gladly cooperate by fitting patients on a controlled, experimental basis, and, thus, the government will need to support only staff, travel expenses, and in some instances the cost of materials and devices in connection with this much needed function.</p> <p>If such a project is proposed, I recommend strongly that the universities and colleges offering educational programs in prosthetics and orthotics be given the opportunity to participate, for, in that way, any recommendation that a device or technique be added to their respective programs will come as no surprise, and therefore be accepted more readily.<br /><br /><b>*<em>A. Bennett Wilson, Jr. </em></b><em> Director, Rehab. Engineering Program, University of Texas Health Science Center at Dallas; Editor, O &amp;P Journal</em></p> Page Number(s) 7 - 7 Year 1980 Volume 4 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Editorial: To Fill a Void Creator An entity primarily responsible for making the resource 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/1987_02_082.pdf Text Any textual data included in the document <h2>Wheelchairs for Paraplegic Patients</h2> <h5>A. Bennett Wilson, Jr.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The best current estimates of the incidence and prevalence of spinal cord injury in the U.S. is 30-32 and 900 cases per million of population respectively.<a></a> About half of these cases are paraplegic. Added to this are paraplegics due to spina bifida, a few polio cases, etc. By definition, paraplegics have to rely on one or more assistive devices if mobility is to be achieved.</p> <p>Only a small segment of the paraplegic population make use of lower-limb orthoses, and even those who do have orthoses, and use them, need a wheelchair as well, in order to make the most of their available energy. For the very few who can "walk" enough not to feel the need for a wheelchair in work and activities of daily living, wheelchairs permit participation in athletic activities that would otherwise be impossible.</p> <p>Wheelchairs can be classified as either "manual" or "powered". The manual wheelchair is designed to be propelled by the occupant or by an attendant. Tests have shown that the energy cost of using a manual wheelchair for mobility on a smooth, level surface can be appreciably less than that of unimpaired persons walking on the same type of surface.<a></a> The conditions, of course, are reversed when uneven surfaces or ascending surfaces are encountered. The "powered" wheelchair is designed to be propelled by a battery-powered electric motor or motors. Originally conceived to be used by patients unable to propel themselves, powered chairs are sometimes indicated so that a paraplegic can make more effective use of his own energy.</p> <p>The basic manual wheelchair has two side-frames connected by a cross-bar that is pivoted about its intersection and a flexible seat and back to allow folding, two large driving wheels at the rear, and two caster wheels at the front (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-01.jpg"><b>Fig. 1</b></a>).<a></a> This is a configuration that has evolved over the years since the original patented design of Everest and Jennings<a></a> in 1936 for the folding mechanism, and represents a rather elegant compromise between maneuverability, stability, and portability. Many concerted attempts, especially in recent years, to develop better designs have not been very successful. The use of new materials has made it possible to produce significantly lighter wheelchairs, but the original configuration is basically the same.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-01.jpg"><strong>Figure 1. The basic wheelchair-folding frame, 24-inch diameter wheels in the rear, 8-inch diameter casters in the front, flexible seat and back.</strong></a><br /> <p>It must be remembered that a change in the design to emphasize one feature generally affects adversely one or more of the other features. An example is when the wheelbase of the basic chair is lengthened to provide more stability for the bilateral leg amputee; maneuverability is sacrificed. Designers of some of the "sports" chairs, in order to reduce weight, have eliminated the folding mechanism. Portability is achieved by connecting and disconnecting driving wheels for transport in an automobile.</p> <h3>Prescription Considerations</h3> <p>Variations of the basic chair are available for amputees, hemiplegics, and others, but the basic chair of proper dimensions is generally the most suitable for paraplegic patients. The range of dimensions of the basic wheelchairs available in the United States are shown in<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-02.jpg"> <b>Fig. 2</b>.</a></p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-02.jpg"><strong>Figure 2. Dimension ranges for the basic adult wheelchairs from major U.S. manufacturers.</strong></a><br /> <p>Even when sensation is present, the hammock type seat is seldom used without cushions, which are needed to provide a better distribution of pressure over the thighs and buttocks for comfort, if for no other reason.</p> <p>Cushions and other seating systems affect the relationship between the user and the chair and, therefore, must be selected and taken into account before the final dimensions of the chair are determined.</p> <p>The importance of selecting the most appropriate chair and seat cushion cannot be over emphasized. The dimensions of the chair must distribute the forces of the body properly while also placing the user in a position, with respect to the driving wheels, to provide maximum efficiency during propulsion.</p> <h3>Seat Width And Depth</h3> <p>Selection of the proper seat width is important to comfort and stability. A seat that is too narrow is not only uncomfortable, but access to the chair is made difficult. Furthermore, the chances of pressure sores developing is increased. A seat that is too wide encourages the user to lean toward one side, thus promoting scoliosis and increased pressure over the buttocks on one side. In addition, a seat wider than is necessary makes propulsion more difficult.</p> <p>A seat that is too shallow reduces the area in contact with the buttocks and thighs and causes more pressure on the soft tissues in contact with the seat than is necessary or safe. Furthermore, the location of the footrests is changed so that the feet and legs are not supported properly, and the balance of the user can be affected.</p> <p>A seat that is too long can restrict circulation in the legs.</p> <h3>Seat Height</h3> <p>The height of the seat above the ground of the basic adult chair is 19 1/2 - 20 1/2 inches. Tall persons require a seat that is higher and deeper; short persons require a seat that is lower. Usually these requirements can be met by a stock chair; if not, properly dimensioned units can be had on special order. Obviously, the cushion or seating system to be used will affect the end result.</p> <h3>Seat Type</h3> <p>Seats available from wheelchair manufacturers are sling or hammock types, made of a flexible material, and solid seats which are generally removable (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-03.jpg"><b>Fig. 3</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-03.jpg"><strong>Figure 3. Seat types-a. hammock or sling; b. solid.</strong></a><br /> <p>The sling seats are, by far, the type most used. A solid seat installed to permit folding is available, or a removable solid wooden seat may be purchased or made.</p> <h3>Backrest</h3> <p>The backrest of the basic chair is made of a flexible material stretched between the two side frames which are fixed with respect to the seat. The backrest should be high enough to provide support without inhibiting motion, yet not so low that the scapulae can hang over the back of the chair and cause discomfort.</p> <h3>Arms</h3> <p><a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-04.jpg"><b>Fig. 4</b></a></p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-04.jpg"><strong>Figure 4. The basic wheelchair with the most popular types of arms-removable full-length, removable desk-type, and removable, adjustable desk-type.</strong></a><br /> <p>The lightest chairs have fixed arms or none at all. But an overriding factor in wheelchair prescription is transfer into and from the wheelchair, especially when the patient is unable to stand for a brief period. For this reason, most patients require chairs with arms that can be removed easily.</p> <p>Chair arms not only provide support for the patient's arms in a resting attitude, but also provide lateral support and a reaction point for the hands when the asensitive patient elevates his body at regular intervals to prevent restriction of circulation and thus pressure sores.</p> <p>Both removable and fixed arms are available in full-length and desk models; both of these styles are available with the height fixed or adjustable.</p> <p>The desk models are foreshortened to permit the user to get closer to a desk or table top. The removable desk arm is by far the most popular type. The full length models are indicated when the forepart is needed to support the arms of the user in rising from the chair, or when lordosis, obesity, or some other physical factor makes it necessary to use the front part of the arm for support. The standard removable desk model can be reversed to provide this feature.</p> <h3>Wheels And Tires</h3> <p>The basic chair has two 24 inch diameter rear wheels and two eight inch caster wheels in the front (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-05.jpg"><b>Fig. 5</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-05.jpg"><strong>Figure 5. Basic wheelchair with standard 24-inch diameter wire-spoke wheel and two options: the cast magnesium wheel and a wheel with special built in hand rim.</strong></a><br /> <p>The standard rear wheel for many years has been a wire spoke wheel, but wheels of cast metal alloy and wheels of cast plastic have been made available recently to overcome the maintenance problems inherent in the wire wheel design without adding more weight.</p> <p>Three types of tires are available in several widths and tread types. Pneumatic, semi-pneumatic, and solid tires are available (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-06.jpg"><b>Fig. 6</b></a>). The eight inch diameter wheel with solid rubber tires is standard on the basic chair, and is suitable for use on smooth surface and indoors. The semi-pneumatic and pneumatic tires provide shock absorption, and, thus, are more suitable for rough surfaces and outdoor use.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-06.jpg"><strong>Figure 6. Basic wheelchair and optional casters available. Shown on the chair is the standard 8-inch diameter wheel with solid rubber tire. Next in order are: the 8-inch wheel with the semi-pneumatic tire; the 8-inch wheel with pneumatic tire; a 5-inch diameter wheel with solid rubber tire.</strong></a><br /> <p>Pneumatic tires provide a more cushioned ride and their shock absorber action tends to prolong the life of a wheelchair when kept inflated properly.</p> <h3>Handrims</h3> <p>Handrims are attached to the driving wheels of wheelchairs to permit control without soiling the hands. The standard handrim is a circular steel tube. For users who have problems gripping the smooth surface of a metal ring, vinyl coated rings and a variety of knobs and projections can be added to the ring.</p> <h3>Casters</h3> <p>Casters make steering possible and are available in two diameters: eight inches and five inches. The five inch model is available only with solid tires, and is used on children's chairs and in special circumstances on adult chairs and basketball chairs, when more maneuverability is desired.</p> <h3>Parking Locks</h3> <p>Most users need some means of securing one or more wheels to keep the chair from rolling down inclines or to provide stability during transfer to and from the chair. Two types of parking locks are available from the large wheel (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-07.jpg"><b>Fig. 7</b></a>): toggle and lever. Selection depends upon user preference.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-07.jpg"><strong>Figure 7. Two types of parking locks-left, toggle type; right, lever type. Variations of these two types of locks are available.</strong></a><br /> <p>Pin type locks are also available. These retain a caster in the trail position and are used to prevent swiveling during lateral transfer.</p> <h3>Cushions</h3> <p>The vast majority of paraplegics require, and can use successfully, seat cushions that are mass produced and are widely available at reasonable prices. A great many designs of seat cushions are available. Some have been developed by trial and error, the designs being based on what has proven to be acceptable to the inventor or his customers; other designs have a more scientific basis, but because the exact cause of decubitus ulcers is not known, precise criteria for design of wheelchair seating have not been established.<a></a> Although each of the cushion designs available has advantages and disadvantages, most of which are not clearly defined, selection of seat cushions for individual cases is seldom simple or straightforward.</p> <p>Commercially available cushions may be divided roughly into five categories, including "miscellaneous" or "other", based on material and design (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-08.jpg"><b>Fig. 8</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-08.jpg"><strong>Figure 8. Various types of seat cushions that are available.</strong></a> <ol> <li> <p>Foam</p> </li> <li> <p>Viscoelastic foam</p> </li> <li> <p>Gel</p> </li> <li> <p>Fluid</p> </li> <li> <p>Other</p> </li> </ol> <p><i>Foam Cushions</i></p> <p>Foam cushions generally use polyurethane or polyether foam, and are available in various configurations. The simplest are homogeneous rectangular blocks 2-4 inches thick; some are contoured; and others are composed of two or more layers of material of different densities, some of which may contain hollow spaces or cores in an attempt to distribute the load to specific areas.</p> <p><i>Viscoelastic Foam Cushions</i></p> <p>Viscoelastic foam is less resilient than ordinary foam.</p> <p><i>Gel Cushions</i></p> <p>Gel cushions consist of rather firm emulsion enclosed in a "non breathing" plastic casing.</p> <p><i>Fluid Flotation Cushions</i></p> <p>Water, air, or water-and-foam particles are used in a flexible, tailored plastic bag to provide distribution of forces. The overall effect varies with the amount of fluid introduced.</p> <p><i>Other Types</i></p> <p>Many other designs that combine several elements are available. Prominent among these are the ROHO, which uses a collection of air-filled tufts to distribute the loads and the VASIO (Veterans Administration Spinal Injury Orthosis), in which foams of two different densities are combined and contoured to meet the special needs of paraplegic patients.</p> <p>Each type and design has advantages and disadvantages, and, therefore, selection of the type most appropriate for individual patients is not easy. Until more is known, selection has to be made on a trial basis.</p> <h3>Sports Chairs</h3> <p>Since the introduction of wheelchair basketball shortly after World War II, a constant stream of modifications and refinements has been made to the basic wheelchair to meet the needs of wheelchair athletes. Development of the lightweight, high-performance, sports chair has led to racing among wheelchair users and has made playing tennis from wheelchairs practical and enjoyable. These chairs have also been found useful in non-competitive recreation, such as camping and mountain climbing. Much that has been learned in developing and using sports chairs has resulted in improved performance and quality of prescription wheelchairs, just as automobile racing has led to improvements in the family car. At the same time, many of the people who have been using conventional wheelchairs are now using sports chairs full-time.</p> <p>Like the basic prescription wheelchair, the sports chair (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-09.jpg"><b>Fig. 9</b></a>) has evolved through a series of refinements to where the general configurations of most chairs are strikingly similar. At least 20 manufacturers at this time offer one or more models. Most use 24 inch diameter wheels; some use 27 inch wheels. Weight varies from 16 to 38 pounds, due mainly to material selection and whether or not the chair can be folded. A number of designs incorporate provisions for folding; Others use wheels that can be disconnected (and connected) quickly without tools to make transportation easier.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-09.jpg"><strong>Figure 9. Three types of sports chairs. The one shown at the top is limited primarily for use in racing. The other two are more versatile.</strong></a><br /> <p>Nearly all use five inch diameter front castors, except one manufacturer that uses four inch wheels. Two make eight inch castors available as an option. Nearly all, if not all, have a feature that permits a choice of rear wheel axle position with respect to the frame (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-10.jpg"><b>Fig. 10</b></a>). Only a very few offer arm rests.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-10.jpg"><strong>Figure 10. Schematic showing adjustability often found in sports chairs that permit an optimum relationship between position of the user and the wheels.</strong></a><br /> <p>Many active wheelchair users prefer to use a sports type chair all the time, and in many instances options are offered that make regular use practical. Many models have adjustable features, and most manufacturers will provide a chair with dimensions to suit a given individual.</p> <p>A feature found on most sports chair, but not on other types, is the easy adjustability of wheelbase and seat height afforded by the positioning plate for the rear wheels. In many models, the position of the castor wheels can also be adjusted. Such adjustability, of course, permits the user to be seated in a position which puts the muscles in the upper limbs and shoulders in the optimum arrangements for maximum biomechanical efficiency.</p> <p>Because refinements and advances are being introduced so frequently, the periodical <i>SPORTS 'N' SPOKES</i>, published by the Paralyzed Veterans of America, has been devoting one issue each year to sports chairs and their specifications.<a></a></p> <h3>Summary</h3> <p>Because of increased competition and refinements brought about by the sports chair movement, paraplegics now have available high quality wheelchairs. No single chair design is apt to meet all the needs of each individual, but careful thought and attention to detail in prescription preparation can result in a chair that meets most of the needs of the paraplegic.</p> <p><b>References:</b></p> <ol> <li>Cochran, George Van B. and Vincent Palmieri, "Development of Test Methods for Evaluation of Wheelchair Cushions," <i>Bulletin of Prosthetics Research</i>, 10-22, 17:1:9-30, Spring 1980.</li> <li>Everest, H.A., et al., U.S. Patent No. 2,095.411, October 12, 1937.</li> <li><i>SPORTS 'N' SPOKES</i>, 5201 N. 19th Avenue, Suite 111, Phoenix, Arizona 85015.</li> <li>Grimby, Gunnar, "On the Energy Cost of Achieving Mobility," <i>Scand. J. Rehab. Med.</i>, Supplement 9, 1983, pp. 49-54.</li> <li>University of Alabama at Birmingham, Spinal Cord Injury Project, "Spinal Cord Injury - The Facts and Figures," 1986.</li> <li>Wilson, A. Bennett, Jr., <i>Wheelchairs: A Prescription Aid</i>, Rehabilitation Press, Charlottesville, VA, 1986.</li> </ol> <em><b>*A. Bennett Wilson, Jr. </b> A. Bennett Wilson, Jr. is an Associate Professor with the Department of Orthopedics and Rehabilitation at the University of Virginia, Charlotteville, Virginia 22908.<br /><br /><br /></em> Page Number(s) 82 - 90 Year 1987 Volume 11 Issue 2 Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-08.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-01.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Wheelchairs for Paraplegic Patients Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/5e9f050c02d96432d8f104ec812ace8c.pdf da0d38d9a804a332fd9a3207062a9f1a https://staging.drfop.org/files/original/08e07425408bf41c87dc2c93b224fb5b.jpg 5c092b58ef2060d68e7424b84d6116a0 https://staging.drfop.org/files/original/e346dec2bedf92a857e59abd1ffd7248.jpg 7ee5ff43fa419c57bc4fd8cc6391d463 https://staging.drfop.org/files/original/f61adfb1b17552120e234743993ec28c.jpg ab766cfcc2786236a2c9260ce284e2f4 https://staging.drfop.org/files/original/273c55454cc1bf885d5d972065422824.jpg 2bd9f6a2c4b4d4dc4605e3164b28a1a4 https://staging.drfop.org/files/original/d7748887e1fa845160bc8a5ed9a0b605.jpg a6a917a2af2d7d7b9c2aaf4fe33859dc https://staging.drfop.org/files/original/66af61cdb008228dfacfa6384bb43a35.jpg 4526ad7811f6fb0b5ab5e82c5898c111 https://staging.drfop.org/files/original/ec901e8f405550f48f40e16d73cb2668.jpg f6a4b8e029d8a483756ef3093ef5b526 https://staging.drfop.org/files/original/4f6d845321f89277e90d05be3717d8c6.jpg 1b032cda8b3d4109ce6eb11f5a7f1bff https://staging.drfop.org/files/original/8f7da8912d661f332b7e1a1bf78d597d.jpg 674e1d743a9075daacadf8b4dc82e328 https://staging.drfop.org/files/original/259e168640efa7a9e4790687b54c8fe3.jpg f2644041c4e2f5558269baa90c20d8ca https://staging.drfop.org/files/original/0e7f28c6e5f7b709866175e5ccdf4771.jpg a9c7feb31eff0f0a1e47b133085f51fb https://staging.drfop.org/files/original/117acbf788a7d3c1a7c6e8475739c1ed.jpg 415a50b0631ed70cc4f1c6e34ead3306 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_011.pdf Text Any textual data included in the document <h2>A Variable Volume Socket for Below-knee Prostheses</h2> <h5>A. Bennett Wilson, Jr.&nbsp;<a style="text-decoration: none;">*</a><br />C. Michael Schuch, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Robert O. Nitschke, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The benefits concerning control of edema by fitting the lower limb amputee as soon as the stitches are removed are well documented,<a></a> yet for a number of reasons, mostly economic, the majority of new amputees are not treated in this manner. As a result, most patients present for their first prosthesis with an edematous residual limb that can be expected to shrink even when it has been wrapped properly with an elastic bandage or with a shrinker sock. Proper management of these patients has usually required the fabrication of several provisional sockets in successively smaller sizes until the soft tissues have reached a point where no further reduction is to be expected. Besides the expense involved in this procedure, a truly proper fit occurs only for a very short period after each new provisional socket is provided, a condition which is bound to have an effect on the activity of the newly fitted patient. Thus, a socket that can be adjusted to accommodate the gradual change in residual limb volume is desirable.</p> <h3>History</h3> <p>Attempts to provide adjustable socket volume are found more commonly at the above-knee level.<a></a> The Irons, et al.<a></a> socket design has evolved to become available as a non-custom fitted, prefabricated socket system, manufactured and distributed by Orthomedics<a></a> and United States Manufacturing Company.<a></a> To quote Mooney,<a></a> a co-author of the paper by Irons, et al.,<a></a> "For the above-knee stump, the design constraints are simpler in that the residual limb usually presents no significant bony contours and adequate soft tissue covers all bony elements. On this basis, the fabrication of a lightweight above knee prosthesis with an adjustable socket is a relatively simple problem." Referring again to the Irons, et al.<a></a> study, Dr. Mooney7 states that, "a significantly higher percentage of amputees became functional users due to the availability of the adjustable above-knee prosthesis than would have been expected by previous experience if they had waited for the maturation time to be considered for a conventional socket. The average time to fitting with a conventional socket in the past was about six months. In this group, using earlier fit of adjustable sockets, which were also lightweight, a higher percentage of patients became functional users."</p> <p>The only volume adjustable below-knee socket system reported on to date is by Mooney, et al.<a></a> from the University of Texas at Dallas, who report early gratifying results with use of this system. However, it is an off-the-shelf item, which inherently presents fitting problems. As opposed to the above-knee limb, the below-knee limb requires more exacting contours of fit due to prominent bony contours, and relatively less soft tissue. In addition, the below-knee amputee often presents with adherent scar tissue in the suture areas. For these reasons, most will agree that a custom fit is mandatory at the below-knee level.</p> <p>An interesting fact can be noted in all of the designs cited: ease of volume adjustments were concentrated in the proximal aspect of the socket as opposed to the distal aspect, where the greatest reduction in volume occurs.</p> <h3>Goals And Design Criteria</h3> <p>After reviewing existing designs in which the volume of the socket can be adjusted, and considering the use of materials and techniques now available, a set of criteria was established for a custom fitted variable volume below-knee socket as follows: 1) the socket would be custom fitted to the individual patient; 2) existing prosthetic molding, modification, and fabrication techniques would be used as appropriate; 3) the volume would be controlled equally or selectively between proximal and distal parts of the residual limb; 4) normal prosthetic cosmesis would be possible and practical; and 5) the finished prosthesis would be light, but durable.</p> <p>The original, primary purpose of the project was to design a socket for use as a preparatory prosthesis, and thus avoid the need for several socket changes before stabilization occurs. However, it appears that the design that has resulted may also be very appropriate for use over extended periods where fluctuation in limb volume is difficult to control, or where the shear stresses normally encountered with present day socket designs present a problem.</p> <p>Because of the two-piece design (<a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-01.jpg"><b>Fig. 1</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-02.jpg"><b>Fig. 2</b></a>), it is possible to don and doff the prosthesis without subjecting the skin of the residual limb to shearing forces, and thus should be considered when it is desirable to avoid shear on the limb. Additionally, the two-piece construction should add a measure of suspension if this element is considered in the individual design.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-01.jpg"><strong>Figure 1. Exploded schematic view of the variable volume socket showing major components.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-02.jpg"><strong>Figure 2. Schematic showing relationship of the major components of the variable volume socket.</strong></a><br /> <p>We are confident that the concept is valid and useful. What follows here is, we hope, sufficient information for an experienced prosthetist to try the concept. The materials and dimensions given are those that have been found to work in our still limited experience, but are by no means considered to be the best.</p> <p>Our original method for controlling volume, by use of two conventional hose clamps, is described here, because we have yet to locate a commercially available adjustment buckle that is suitable. We made some progress in designing a buckle especially for this purpose, but have not pursued the idea since the hose clamps can be made to work satisfactorily. However, there is probably a place for a more convenient method of controlling the circumferential dimensions.</p> <h3>Casting And Modifying The Positive Model</h3> <p>As stated in the design criteria, this socket system is intended to make use of existing prosthetic molding, modification, and fabrication techniques. We recommend use of the casting procedure described by Fillauer<a></a> in which an impression of the anterior portion of the limb is made first, using plaster splints to capture the bony definition before enclosing the remainder of the residual limb with plaster. Model modification should be carried out in normal function. We also recommend the use of a transparent diagnostic socket and algination procedure as described by Schuch and Lucy,<a></a> before proceeding with pouring the final positive model and fabrication of the socket.</p> <p><i>Fabrication of the Socket</i></p> <ol> <li> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-03.jpg"><b>Step 1&nbsp;</b></a><br />Place the positive model in a vise horizontally with the anterior section facing up.</p> </li> <li> <p><strong><a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-04.jpg">Step 2&nbsp;&amp; 3</a></strong><br />Over the positive model, form a Pelite™ liner for the anterior half of the socket. After heating a proper size sheet of Pelite™, a piece of latex rubber can be used to form the Pelite™ around the cast model.</p> </li> <li> <p>Trim the Pelite™ liner so that it extends posteriorly slightly past the midline, dividing the anterior-posterior halves of the model. Skive all edges that will be inside the socket. Remove the Pelite™ liner from the cast in preparation for the next step.</p> </li> <li> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-05.jpg"><b>Steps 4 and 5</b></a><br />Rotate the model in the vise 180° so that the posterior surface is up.</p> </li> <li> <p>Using conventional drape molding techniques, vacuum form a piece of 1/8 inch polyethylene (or Surlyn®) around the model, posterior side up so the seam is on the anterior side.</p> </li> <li> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-06.jpg"><b>Step 6</b></a><br />Trim the polyethylene to form a posterior socket shell that extends anteriorly just past the midline and "underlaps" the Pelite™ anterior liner by about 3/8-1/2 inch. Again, skive all edges that will be inside the socket.</p> </li> <li> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-07.jpg"><b>Step 7</b></a><br />With the Pelite™ anterior liner and the polyethylene posterior shell in place on the model, pull a thin sheath of nylon over both to hold them in place.</p> </li> <li> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-08.jpg"><b>Step 8</b></a><br />On the posterior aspect of the model, glue a 1/4 inch diameter rope to form the cutout for the posterior volume control panel. Prepare for lamination in the usual manner. For use as a temporary design prosthesis, we use Otto Bock<a></a> modular endoskeletal components and laminate the 4R42 component (socket adaptor with pyramid and lamination anchor) directly into the socket.</p> </li> <li> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-09.jpg"><b>Step 9</b></a></p> <p>Before beginning the lamination procedure, cut two polyethylene strips 1/16 inch thick by 9/16 inch wide by the circumference, plus 1/2 inch of the cast model at the levels shown.</p> <p>The strips are placed in the lamination layup and are removed after the lamination sets up to form channels for the volume control straps. Layup for the lamination is as follows:</p> <blockquote> <p>1 layer of 1/2 oz. dacron felt<br />1 nylon stockinette<br />the 4R42 component (if used)<br />I.P.O.S.<a></a> glass matting over the lamination anchors of the 4R42 component and over the medial, lateral, and posterior aspects of the layup<br />1 nylon stockinette; the two polyethylene strips cut earlier are placed at the appropriate levels;<br />1 nylon stockinette<br />2 nyglass stockinettes; laminate with 80:20 mixtures of acrylic resin</p> </blockquote> </li> <li> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-10.jpg"><b>Steps 10, 11, and 12</b></a><br />When the laminate has set and cured, cut out the window over the rope and trim as shown.</p> </li> <li> <p>Using a pair of needle nose pliers, pull out the two polyethylene strips imbedded in the lamination. This leaves a clean, hidden track for guiding the pull of the control straps.</p> </li> <li> <p>Cut out an area about 1 1/2 inches along each control strap track in the anterior-lateral area of the socket, to allow for exposure of the adjustable part of the control strap.</p> </li> <li> <p>Make up control straps of 1/2 inch da-cron tape and two to three inches of the hose clamps.</p> </li> <li> <p>Put the socket system back on the cast model for determination of the initial volume setting. Insert the dacron straps through the tracks and speedy rivet the hose clamp section so that the hex head of the clamp is exposed in the slots cut in step 12 above (<a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-11.jpg"><b>Fig. 3</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-11.jpg"><strong>Figure 3. Photograph of laminated outer socket prior to mounting on adjustable leg. A foam block is shown here but this practice has been superceded by use of the Otto Bock 4R42 component which is laminated into the distal end of the outer socket.</strong></a></li> <li> <p>Attach the pylon and foot and align in the conventional way (<a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-12.jpg"><b>Fig. 4</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-12.jpg"><strong>Figure 4. Variable volume socket mounted on an adjustable leg.</strong></a></li> </ol> <h3>Clinical Experience</h3> <p>To date, seven variable volume below-knee sockets have been fitted on six carefully chosen amputees. Five of these patients were new amputees and the variable volume socket prosthesis was their first prosthesis. One of these five had an extremely edematous limb due to a recent infection, and required two successive variable volume sockets before being fitted with a definitive conventional P.T.B, prosthesis. The remaining patient was a young amputee, three years post-amputation, who was having difficulty maintaining consistency in limb volume. The variable volume socket proved to be very useful in managing this patient.</p> <p>Evaluation was basically simple and subjective. The clinic team discussed and recorded any problems that arose with the socket design and documented that atrophy was accommodated by the variable volume socket. In all cases, maintenance of socket fit was made possible by decreasing socket volume as atrophy of the residue limb took place. At no point was comfort compromised by a reduction of socket volume.</p> <p>In addition to the patients fitted at the University of Virginia; trial fittings were made by Mr. Nitschke in the courses of development at Leimkuehler, Inc. in Cleveland, Ohio, American Orthotic and Prosthetic Laboratory, Inc. of Columbus, Ohio, and Rochester Orthopedic Laboratories, Inc. in Rochester, NY where we were given much help and encouragement. In addition, Karl Fillauer, CPO of Fillauer Orthopedic, Inc. in Knoxville, Tennessee has fit two patients and Robert Gooch, CP and John Michael, CPO of Duke University have fit one patient, all of whom are currently being followed.</p> <h3>Summary And Conclusion</h3> <p>Rationale, design criteria, and fabrication techniques for an adjustable volume below-knee socket have been discussed and described. Successful fittings with the system have been noted. It is felt that this system can meet a need by providing new amputees with a durable, cosmetic, and reasonably long lasting preparatory prosthesis that accommodates the familiar problem of residual limb volume shrinkage.</p> <h3>Acknowledgments</h3> <p>This work was made possible by support from the Veterans Administration Rehabilitation Research and Development Service. We are also grateful for the help and encouragement provided by Messrs. Jon Leimkuehler, CPO, Peter Ockenfels, CPO, Karl Fillauer, CPO, Carlton Fillauer, CPO, Robert Klebba, Robert Gooch, CP, John Michael, CPO, and Dr. Frank Clippinger.</p> <p><b>References:</b></p> <ol> <li>Brownsey, ZZ; Fillauer, ZZ: "Temporary Prosthesis with Adjustable Socket," <i>Physical Therapy</i>, 47:12:December, 1967, pp. 1129-1131</li> <li>Fernie, Geoff, R. and Pamela J. Holiday, "Volume Fluctuations in the Residual Limbs of Lower Limb Amputees," <i>Archives of Physical Medicine and Rehabilitation</i>, 63:4:April, 1982, pp. 162-165.</li> <li>Fillauer, Carlton, "A Patella-Tendon-Bearing Socket with a Detachable Media Brim," <i>Orthotics and Prosthetics</i>, 25:4:December 1971, pp. 25</li> <li>Irons, G., V. Mooney, S. Putnam, M. Quigley, "A Lightweight Above Knee Prosthesis With an Adjustable Socket, <i>Orthotics and Prosthetics</i>, 31:1:March 1977, pp. 3-15.</li> <li>Malone, J. et al, "Rehabilitation for Lower Extremity Amputation," <i>Archives of Surgery</i>, 116:1:January 1981, pp. 93-98.</li> <li>Malone, J. et al., "Therapeutic and Economic Impact of a Moderate Amputation Program," <i>Annals of Surgery</i>, 189:6:June 1979, pp. 798-802.</li> <li>Mooney, V., B. McClellan, D. Cummings, P. Smith, "Early Fitting of the Below Knee Amputee," <i>Orthopedics</i>, 8:2:February 1985, pp. 199-202.</li> <li><a href="cpo/1986_03_101.asp">Schuch, C. Michael, and Tony Lucy, "Experience with the Use of Alginate in Transparent Diagnostic Below-Knee Sockets," <i>Clinical Prosthetics and Orthotics</i>, 10:3:Summer 1986, pp. 101-104.</a></li> <li>Orthomedics, Inc., 2950 East Imperial Highway, Brea, California 92621.</li> <li>Otto Bock Orthopedic Industry, Inc., 4130 Highway 55, Minneapolis, Minnesota 55422.</li> <li>United States Manufacturing Company, 180 North San Gabriel Blvd., Pasadena, California 91107.</li> <li>I.P.O.S., U.S.A., 155 Portage Road, Lewiston, New York 14092.</li> </ol> <b>*Robert O. Nitschke, C.P.O. </b> Robert Nitschke is a consultant and lives in Rochester, NY.<br /><b><br />*C. Michael Schuch, C.P.O. </b> Department of Orthopedics and Rehabilitation at the University of Virginia.<br /><b><br />*A. Bennett Wilson, Jr. </b> Department of Orthopedics and Rehabilitation at the University of Virginia.<br /> <div style="width: 400px;"><br /><br /></div> Page Number(s) 11 - 19 Year 1987 Volume 11 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-01.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-02.jpg Figure 3 STEP 1 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-03.jpg Figure 4 STEP 2 &3 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-04.jpg Figure 5 STEP 4&5 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-05.jpg Figure 6 STEP 6 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-06.jpg Figure 7 STEP 7 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-07.jpg Figure 8 STEP 8 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-08.jpg Figure 9 STEP 9 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-09.jpg Figure 10 STEP 10,11&12 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-10.jpg Figure 11 FIGURE 3 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-11.jpg Figure 12 FIGURE 4 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-12.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Variable Volume Socket for Below-knee Prostheses Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. * C. Michael Schuch, C.P.O. * Robert O. 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Bennett Wilson, Jr., B.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>Loss of limb has been a problem as long as man has been in existence. Even some prehistoric men must have survived crushing injuries resulting in amputation, and certainly some children were born with congenitally deformed limbs with effects equivalent to those of amputation. In 1958 the Smithsonian Institution reported the discovery of a skull dating back about 45,000 years of a person who, it was deduced, must have been an arm amputee, because of the way his teeth had been used to compensate for lack of limb. Leg amputees must have compensated partly for their loss by the use of crude crutches and, in some instances, by the use of peg legs fashioned from forked sticks or tree branches (<b>Fig. 1</b> and <b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Mosaic from the Cathedral of Lescar, France, depicts an amputee supported at the knee by a wooden pylon. Some authorities place this in the Gallo-Roman era. From Putti, V., Historic Artificial Limbs, 1930. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Pen drawing of a fragment of antique vase unearthed near Paris in 1862 which shows a figure whose missing limb is replaced by a pylon with a forked end. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The earliest known record of a prosthesis being used by man was made by the famous Greek historian, Herodotus. His classic "History," written about 484 B.C., contains the story of the Persian soldier, Hegistratus, who, when imprisoned in stocks by the enemy, escaped by cutting off part of his foot, and replaced it later with a wooden version.</p> <p>A number of ancient prostheses have been displayed in museums in various parts of the world. The oldest known is an artificial leg unearthed from a tomb in Capua in 1858, thought to have been made about 300 B.C., the period of the Samnite Wars. Constructed of copper and wood, the Capua leg was destroyed when the Museum of the Royal College of Surgeons was bombed during World War II. The Alt-Ruppin hand (<b>Fig. 3</b>), recovered along the Rhine River in 1863, and other artificial limbs of the 15th century are on display at the Stibbert Museum in Florence. Most of these ancient devices were the work of armorers. Made of iron, these early prostheses were used by knights to conceal loss of limbs as a result of battle, and a number of the warriors are reported to have returned successfully to their former occupation. Effective as they were for their intended use, these specialized devices could not have been of much use to any group other than the knights, and the civilian amputees for the most part must have had to rely upon the pylon and other makeshift prostheses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Alt-Ruppin Hand (Circa 1400). The thumb is rigid; the fingers move in pairs and are sprung by the buttons at the base of the palm; the wrist is hinged. Putti, V., Chir. d. org. di movimento, 1924-25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the use of ligatures was set forth by Hippocrates, the practice was lost during the Dark Ages, and surgeons during that period and for centuries after stopped bleeding by either crushing the stump or dipping it in boiling oil. When Ambroise Pare, a surgeon in the French Army, reintroduced the use of ligatures in 1529, a new era for amputation surgery and prostheses began. Armed with a more successful technique, surgeons were more willing to employ amputation as a lifesaving measure and, indeed, the rate of survival must have been much higher. The practice of amputation received another impetus with the introduction of the tourniquet by Morel in 1674, and removal of limbs is said to have become the most common surgical procedure in Europe. This in turn led to an increase in interest in artificial limbs. Pare, as well as contributing much in the way of surgical procedures, devised a number of limb designs for his patients. His leg (<b>Fig. 4</b>) for amputation through the thigh is the first known to employ articulated joints. Another surgeon, Verduin, introduced in 1696 the first known limb for below-knee amputees that permitted freedom of the knee joint (<b>Fig. 5</b>), in concept much like the thigh-corset type of below-knee limb still used by many today. Yet, for reasons unknown, the Verduin prosthesis dropped from sight until it was reintroduced by Serre in 1826 and. until recently, was the most popular type of below-knee prosthesis used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Artificial leg invented by Ambroise Pare (middle sixteenth century). From Pare, A, Oeuvres Completes, Paris, 1840. From the copy in the National Library of Medicine. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Verduin Leg (1696). From MacDonald, J., Am. J. Surg., 1905. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After Pare's above-knee prosthesis, which was constructed of heavy metals, the next real advance seems to be the use of wood, introduced in 1800 by James Potts of London. Consisting of a wooden shank and socket, a steel knee joint, and an articulated foot, the Potts invention (<b>Fig. 6</b>) was equipped with artificial tendons connecting the knee and the ankle, thereby coordinating toe lift with knee flexion. It was made famous partly because it was used by the Marquis of Anglesea after he lost a leg at the Battle of Waterloo. Thus it came to be known as the Anglesea leg. With some modifications the Anglesea leg was introduced into the United States in 1839. Many refinements to the original design were incorporated by American limb fitters and in time the wooden above-knee leg became known as the "American leg."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Anglesea Leg (1800). Below knee at left above knee at right. Knee, ankle, and foot are articulated. From Bigg, H. H.. Orthopraxy, 1877. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Civil War produced large numbers of amputees and consequently created a great interest in artificial limbs, no doubt inspired partly by the fact that the federal and state governments paid for limbs for amputees who had seen war service.</p> <p>J. E. Hanger, one of the first Southerners to lose a leg in the Civil War, replaced the cords in the so-called American leg with rubber bumpers about the ankle joint, a design used almost universally until rather recently. Many patents on artificial limbs were issued between the time of the Civil War and the turn of the century, but few of the designs seem to have had much lasting impact.</p> <p>During this period, with the availability of chloroform and ether as anesthetics, surgical procedures were greatly improved and more functional amputation stumps were produced by design rather than by fortuity.</p> <p>World War I stirred some interest in artificial limbs and amputation surgery but, because the American casualty list was relatively small, this interest soon waned and, because of the economic depression of the Thirties, some observers think, very little progress was made in the field of limb prosthetics between the two World Wars. Perhaps the most significant contributions were the doctrines set forth and emphasized by Haddan and Thomas, a prosthetist-surgeon team from Denver, that fit and alignment of the prosthesis were the most critical factors in the success of any limb and that much better end-results could be expected if prosthetists and physicians worked together.</p> <p>Early in 1945, the National Academy of Sciences, at the request of the Surgeon General of the Army, initiated a research program in prosthetics. The initial reaction of the research personnel was that the development of a few mechanical contrivances would solve the problem. However, it soon became evident that much more must be known about biomechanics and other matters before real progress could be made. Devices and techniques based on fundamental data have materially changed the practice of prosthetics during the past dozen years. However, the best conceivable prosthesis is but a poor substitute for a live limb of flesh and blood, and so the research program is still continuing. Fiscal support for research and development by some 20 laboratories is provided by the Veterans Administration, the Vocational Rehabilitation Administration, the National Institutes of Health, the Children's Bureau, the Army, and the Navy. The over-all program is coordinated by the Committee on Prosthetics Research and Development of the National Academy of Sciences-National Research Council.</p> <p>Soon after the close of World War II, the Artificial Limb Manufacturers Association, which had been formed during World War I, engaged the services of a professional staff to coordinate more effectively the efforts of individual prosthetists. Known today as the American Orthotics and Prosthetics Association, this organization consists of some 415 limb and brace shops, and plays a large part in keeping individual prosthetists and orthotists advised of the latest trends and developments in prosthetics and orthotics.</p> <p>In 1949, upon the recommendation of the Association, the American Board for Certification of Prosthetists and Orthotists was established to ensure that prosthetists and orthotists met certain standards of excellence, much in the manner that certain physicians' specialty associations are conducted. Examinations are held annually for those desiring to be certified. In addition to certifying individuals as being qualified to practice, the American Board for Certification approves individual shops, or facilities, as being satisfactory to serve the needs of amputees and other categories of the disabled requiring mechanical aids. Certified prosthetists wear badges and shops display the symbol of certification (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Symbol of certification by the American Board for Certification in Orthotics and Prosthetics. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The research program, with the cooperation of the prosthetists, has introduced a sufficient number of new devices and techniques to modify virtually every aspect of the practice of prosthetics. To reduce the time lag between research and widespread application, facilities have been established within the medical schools of three universities for short-term courses in special aspects of prosthetics. Courses are offered to each member of the prosthetics-clinic team-the physician, the therapist, and the prosthetist. Also, special courses are offered to vocational rehabilitation counselors and administrative personnel concerned with the welfare of amputees. Approximately 2,100 physicians, 1,900 therapists, and 1,400 prosthetists have been enrolled in these courses during the period 1953 through 1962.</p> <p>Prior to 1957 medical schools offered little in the way of training in prosthetics to doctors and therapists. To encourage the inclusion of prosthetics into medical and paramedical curricula, the National Academy of Sciences organized the Committee on Prosthetics Education and Information, and as a result of the efforts of this group many schools have adopted courses in prosthetics at both undergraduate and graduate levels.</p> <p>Today there are approximately 200 amputee-clinic teams in operation throughout the United States. Each state, with assistance from the Vocational Rehabilitation Administration, carries out programs that provide the devices and training required to return the amputee to gainful employment. The Children's Bureau, working through a number of states, has made it possible for child amputees to receive the benefit of the latest advances in prosthetics. The Veterans Administration provides all eligible veterans with artificial limbs. If the amputation is related to his military service, the beneficiary receives medical care and prostheses for the remainder of his life. The Public Health Service, through its hospitals, provides limbs and care to members of the Coast Guard and to qualified persons who have been engaged in the Maritime Service.</p> <p>In addition to these Government agencies that are concerned with the amputee, there are several hundred rehabilitation centers throughout the United States that assist amputees, especially those advanced in age, in obtaining the services needed for them to return to a more normal life.</p> <p>Thus, through the cooperative efforts of Government and private groups, considerable progress has been made in the practice of prosthetics and there is little need for an amputee to go without a prosthesis.</p> <h3>Reasons For Amputation</h3> <p>Amputation may be the result of an accident, or may be necessary as a lifesaving measure to arrest a disease. A small but significant percentage of individuals are born without a limb or limbs, or with defective limbs that require amputation or fitting (like that of an amputee).</p> <p>In some accidents a part or all of the limb may be completely removed; in other cases, the limb may be crushed to such an extent that it is impossible to restore sufficient blood supply necessary for healing. Sometimes broken bones cannot be made to heal, and amputation is necessary. Accidents that cause a disruption in the nervous system and paralysis in a limb may also be cause for amputation even though the limb itself is not injured. The object of amputation in such a case is to improve function by substituting an artificial limb for a completely useless though otherwise healthy member. Amputation of paralyzed limbs is not performed very often but has in some cases proven to be very beneficial. Accidents involving automobiles, farm machinery, and firearms seem to account for most traumatic amputations. Freezing, electrical burns, and power tools also account for many amputations.</p> <p>Diseases that may make amputation necessary fall into one of three main categories-vascular, or circulatory, disorders; cancer; and infection. The diseases that cause circulatory problems most often are arteriosclerosis, or hardening of the arteries, diabetes, and Buerger's disease. In these cases not enough blood circulates through the limb to permit body cells to replace themselves, and unless the limb, or part of it, is removed the patient cannot be expected to live very long. In nearly all these cases the leg is affected because it is the member of the body farthest from the heart and, in accordance with the principles of hydraulics, blood pressure in the leg is lower than in any other part of the bod}'. Vascular disorders are, of course, much more prevalent among older persons. Considerable research is being undertaken to determine the cause of vascular disorders so that amputation for these reasons may at least be reduced if not eliminated, but at the present time vascular disorders are the cause of a large number of lower-extremity amputations.</p> <p>In many cases amputation of part or all of a limb has arrested a malignant or cancerous condition. In view of present knowledge, the entire limb is usually removed. Malignancy may affect either the arms or legs. Much time and effort are being spent to develop cures for the various types of cancer.</p> <p>Since the introduction of antibiotic drugs, infection has been less and less the cause for amputation. Moreover, even though amputation may be necessary, control of the infection may allow the amputation to be performed at a lower level than would be the case otherwise.</p> <p>Recently, "thalidomide babies" have been given extensive press coverage; however, thalidomide is by no means the sole cause of congenital malformations. Absence of all or part of a limb at birth is not an uncommon occurrence. Many factors seem to be involved in such occurrences, but what these factors are is not clear. The most frequent case is absence of most of the left forearm, which occurs slightly more often in girls than in boys. However, all sorts of combinations occur, including complete absence of all four extremities. Sometimes intermediate parts such as the thigh or upper arm are missing but the other parts of the extremity are present, usually somewhat malformed. In such cases amputation may be indicated; however, even a weak, malformed part is sometimes worth preserving if sensation is present and the partial member is capable of controlling some part of the prosthesis. Extensive studies are being carried out to determine the reasons for congenital malformations.</p> <h3>Losses Incurred</h3> <p>Many of the limitations resulting from amputation are obvious; others less so. An amputation through the lower extremity makes standing and locomotion without the use of an artificial leg or crutches difficult and impracticable except for very short periods. Even when an artificial leg is used, the loss of joints and the surrounding tissues, and consequently loss of the ability to sense position, is felt keenly. The sense of touch of the absent portion is also lost, but in the case of the lower-extremity amputee this is not quite as important as it might seem because the varying pressure occurring between the stump and the socket indicates external loading. In the upper-extremity amputee, sense of touch is more important.</p> <p>Most lower-extremity amputees cannot bear the total weight of the body on the end of the stump, and other parts of the anatomy must be found for support.</p> <p>Muscles attached at each end to bones are responsible for movement of the arms and legs. Upon a signal from the nervous system muscle tissue will contract, thus producing a force which can move a bone about its joint (<b>Fig. 8</b>). Because muscle force can be produced only by contraction, each muscle group has an opposing muscle group so that movement in two directions can take place. This arrangement also permits a joint to be held stable in any one of a vast number of positions for relatively long periods of time. How much a muscle can contract is dependent upon its length, and the amount of force that can be generated is dependent upon its circumference.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Schematic drawing of muscular action on skeletal system. The motion shown here is flexion, or bending, of the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Muscles that activate the limbs must of course pass over at least one joint to provide a sort of pulley action; some pass over two. Thus, some muscles are known as one-joint muscles, others as twro-joint muscles. When muscles are severed completely, they can no longer transmit force to the bone and, when not used, wither away or atrophy. It will be seen later that these facts are very important in the rehabilitation of amputees.</p> <h3>Types of Amputation</h3> <p>Amputations are generally classified according to the level at which they are performed (<b>Fig. 9</b>). Some amputation levels are referred to by the name of the surgeon credited with developing the amputation technique used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Classification of amputation by level. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Lower-Extremity Amputations</h4> <p><i>Syme's Amputation</i></p> <p>Developed about 1842 by James Syme, a leading Scottish surgeon, the Syme amputation leaves the long bones of the shank (the tibia and fibula) virtually intact, only a small portion at the very end being removed (<b>Fig. 10</b>). The tissues of the heel, which are ideally suited to withstand high pressures, are preserved, and this, in combination with the long bones, usually permits the patient to bear the full weight of his body on the end of the stump. Because the amputation stump is nearly as long as the unaffected limb, a person with Syme's amputation can usually get about the house without a prosthesis even though normal foot and ankle action has been lost. Atrophy of the severed muscles that were formerly attached to bones in the foot to provide ankle action results in a stump with a bulbous end which, though not of the most pleasing appearance, is quite an advantage in holding the prosthesis in place. Since its introduction, Syme's operation has been looked upon with both favor and disfavor among surgeons. It seems to be the consensus now that "the Syme" should be performed in preference to amputation at a higher level if possible. In the case of most women, though, "the Syme" is undesirable because of the difficulty of providing a prosthesis that matches the shape of the other leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Excellent Syme stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Below-Knee Amputations</i></p> <p>Any amputation above the Syme level and below the knee joint is known as a below-knee amputation. Because circulatory troubles have often developed in long below-knee stumps, and because the muscles that activate the shank are attached at a level close to the knee joint, the below-knee amputation is usually performed at the junction of the upper and middle third sections (<b>Fig. 11</b>). Thus nearly full use of the knee is retained- an important factor in obtaining a gait of nearly normal appearance. However, it is rare for a below-knee amputee to bear a significant amount of weight on the end of the stump; thus the design of prostheses must provide for weight-bearing through other areas. Several types of surgical procedures have been employed to obtain weight-bearing through the end of the below-knee stump, but none has found widespread use.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical, well-formed, right below-knee stump. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Knee-Bearing Amputations</i></p> <p>Complete removal of the lower leg, or shank, is known as a knee disarticulation. When the operation is performed properly, the result is an efficient, though bulbous, stump (<b>Fig. 12</b>) capable of carrying the weight-bearing forces through the end. Unfortunately, the length causes some problems in providing an efficient prosthesis because the space used normally to house the mechanism needed to control the artificial shank properly is occupied by the end of the stump. Nevertheless, prostheses have been highly beneficial in knee-disarticulation cases. Development of adequate devices for obtaining control of the shank is currently under way, and such devices should be generally available in the near future.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Typical knee-disarticulation stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Several amputation techniques have been devised in an attempt to overcome the problems posed by the length and shape of the true knee-disarticulation stump. The Gritti-Stokes procedure entails placing the kneecap, or patella, directly over the end of the femur after it has been cut off about two inches above the end. When the operation is performed properly, excellent results are obtained, but extreme skill and expert postsurgical care are required. Variations of the Gritti-Stokes amputation have been introduced from time to time but have never been used widely.</p> <p><i>Above-Knee Amputations</i></p> <p>Amputations through the thigh are among the most common (<b>Fig. 13</b>). Total body weight cannot be taken through the end of the stump but can be accommodated through the ischium, that part of the pelvis upon which a person normally sits.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Typical, well-formed above-knee stump. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Hip Disarticulation and Hemipelvectomy</i></p> <p>A true hip disarticulation (<b>Fig. 14</b>) involves removal of the entire femur, but whenever feasible the surgeon leaves as much of the upper portion of the femur as possible in order to provide additional stabilization between the prosthesis and the wearer, even though no additional function can be expected over the true hip disarticulation. Both types of stump are provided with the same type of prosthesis. With slight modification the same type of prosthesis can be used by the hemipelvectomy patient, that is, when half of the pelvis has been removed. It is surprising how well hip-disarticulation and hemipelvectomy patients have been able to function when fitted with the newer type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Patient with true hip-disarticulation amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Upper-Extremity Amputations</h4> <p><i>Partial-Hand Amputations</i></p> <p>If sensation is present the surgeon will save any functional part of the hand in lieu of disarticulation at the wrist. Any method of obtaining some form of grasp, or prehension, is preferable to the best prosthesis. If the result is unsightly, the stump can be covered with a plastic glove, lifelike in appearance, for those occasions when the wearer is willing to sacrifice function for appearance. Many prosthetists have developed special appliances for partial-hand amputations that permit more function than any of the artificial hands and hooks yet devised and, at the same time, permit the patient to make full use of the sensation remaining in the stump. Such devices are usually individually designed and fitted.</p> <p><i>Wrist Disarticulation</i></p> <p>Removal of the hand at the wrist joint was once condemned because it was thought to be too difficult to fit so as to yield more function than a shorter forearm stump. However, with plastic sockets based on anatomical and physiological principles, the wrist-disarticulation case can now be fitted so that most of the pronation-supination of the forearm-an important function of the upper extremity-can be used. In the case of the wrist disarticulation (<b>Fig. 15</b>), nearly all the normal forearm pronation-supination is present. Range of pronation-supination decreases rapidly as length of stump decreases; when 60 per cent of the forearm is lost, no pronation-supination is possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. A good wrist-disarticulation stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Amputations Through the Forearm</i></p> <p>Amputations through the forearm are commonly referred to as below-elbow amputations and are classified as long, short, and very short, depending upon the length of stump (<b>Fig. 9</b>). Stumps longer than 55 per cent of total forearm length are considered long, between 35 and 55 per cent as short, and less than 35 per cent as very short.</p> <p>Long stumps retain the rotation function in proportion to length; long and short stumps without complications possess full range of elbow motion and full power about the elbow, but often very short stumps are limited in both power and motion about the elbow. Devices and techniques have been developed to make full use of all functions remaining in the stump.</p> <p><i>Disarticulation at the Elbow</i></p> <p>Disarticulation at the elbow consists of removal of the forearm, resulting in a slightly bulbous stump (<b>Fig. 16</b>) but usually one with good end-weight-bearing characteristics. The long bulbous end, while presenting some fitting problems, permits good stability between socket and stump, and thus allows use of nearly all the rotation normally present in the upper arm-a function much appreciated by the amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Amputation through the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Above-Elbow Amputation</i></p> <p>Any amputation through the upper arm is generally referred to as an above-elbow amputation (<b>Fig. 9</b>). In practice, stumps in which less than 30 per cent of the humerus remains are treated as shoulder-disarticulation cases; those with more than 90 per cent of the humerus remaining are fitted as elbow-disarticu-lation cases.</p> <p><i>Shoulder Disarticulation and Forequarter Amputation</i></p> <p>Removal of the entire arm is known as shoulder disarticulation but, whenever feasible, the surgeon will leave intact as much of the humerus as possible to provide stability between the stump and the socket (<b>Fig. 17</b>). When it becomes necessary to remove the clavicle and scapula, the operation is known as a forequarter, or interscapulothoracic, amputation. The very short above-elbow, the shoulder-disarticulation, and the forequarter cases are all provided with essentially the same type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. A true shoulder disarticulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Postsurgical Period</h3> <p>The period between the time of surgery and time of fitting the prosthesis is an important one if a good functional stump, and thus the most efficient use of a prosthesis, is to be obtained. The surgeon and others on his hospital staff will do everything possible to ensure the best results, but ideal results require the wholehearted cooperation of the patient.</p> <p>It is not unnatural for the patient to feel extremely depressed during the first few days after surgery, but after he becomes aware of the possibilities of recovery, the outlook becomes brighter, and he generally enters cooperatively into the rehabilitation phase.</p> <p>As soon as the stump has healed sufficiently, exercise of the stump is started in order to keep the muscles healthy and reduce the possibility of muscle contractures. Contractures can be prevented easily, but it is most difficult and sometimes impossible to correct them. At first exercises are administered by a therapist or nurse; later the patient is instructed concerning the type and amount of exercise that should be undertaken. The patient is also instructed in methods and amount of massage that should be given the stump to aid in the reduction of the stump size. Further, to aid shrinkage, cotton-elastic bandages are wrapped around the stump (<b>Fig. 18</b>) and worn continu- ously until a prosthesis is fitted. The bandage is removed and reapplied at regular intervals- four times during the day, and at bedtime. It is most important that a clean bandage is available for use each day.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Compression wrap for above-knee amputation. The wrap of elastic bandage aids in shrinking the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee is taught to apply the bandage unless it is physically impossible for him to do so, in which case some member of his family must be taught the proper method for use at home.</p> <p>To reduce the possibility of contractures, the lower-extremity stump must not be propped upon pillows. Wheel chairs should be used as little as possible; crutch walking is preferred, but the above-knee stump must not be allowed to rest on the crutch handle (<b>Fig. 19</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Actions to be avoided by lower-extremity amputees during the immediate postoperative period. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Phantom Sensation</h4> <p>After amputation the patient almost always has the sensation that the missing part is still present (<b>Fig. 20</b>). The exact cause of this is as yet unknown. The phantom sensation usually recedes to the point where it occurs only infrequently or disappears entirely, especially if a prosthesis is used. In a large percentage of cases, moderate pain may accompany the phantom sensation but, in general, this too eventually disappears entirely or occurs only infrequently. In a small percentage of cases severe phantom pain persists to the point where medical treatment is necessary.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. One form of the "phantom" sensation. Here the two toes seem to reside in the stump itself. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Time of Fitting</h4> <p>Surgeons increasingly have become aware that best results are obtained with artificial limbs when they are fitted as early as possible after surgery, that is, when pain and soreness have disappeared. This time will vary, depending upon type of amputation and condition of the patient. The earliest time is about six weeks after the operation. Below-knee stumps as a rule require a longer healing period than above-knee and upper-extremity stumps. An elderly patient whose legs have been amputated by reason of vascular insufficiency usually requires a longer healing period than an otherwise-healthy young person whose legs have been amputated as the result of an accident.</p> <h3>Prostheses for Various Types of Amputation</h3> <p>Much time and attention have been devoted to the development of mechanical components, such as knee and ankle units, for artificial limbs, yet by far the most important factors affecting the successful use of a prosthesis are the fit of the socket to the stump and the alignment of the various parts of the limb in relation to the stump and other parts of the body.</p> <p>Thus, though many parts of a prosthesis may be mass-produced, it is necessary for each limb to be assembled in correct alignment and fitted to the stump to meet the individual requirements of the intended user. To make and fit artificial limbs properly requires a complete understanding of anatomical and physiological principles and of mechanics; craftsmanship and artistic ability are also required.</p> <p>In general, an artificial limb should be as light as possible and still withstand the loads imposed upon it. In the United States willow and woods of similar characteristics have formed the basis of construction for more limbs than any other material, though aluminum, leather-and-steel combinations, and fibre have been used widely. Wood construction is still the type most used in the United States for above-knee prostheses, but plastic laminates similar to those so popular in small-boat construction are the materials of choice for virtually all other types of prostheses. Plastic laminates are light in weight, easy to keep clean, and do not absorb perspiration. They may be molded easily and rapidly over contours such as those found on a plaster model of a stump. Plastic laminates can be made extremely rigid or with any degree of flexibility required in artificial-limb construction. In some instances, especially in upper-extremity sockets, the fact that most plastic laminates do not permit water vapor to pass to the atmosphere has caused discomfort, but recently a porous type has been developed by the Army Medical Biomechanical Research Laboratory (formerly the Army Prosthetics Research Laboratory). Except experimentally, its use thus far has been restricted to artificial arms. Of course, most of the mechanical parts are made of steel or aluminum, depending upon their function.</p> <p>As in the case of the tailor making a suit, the first step in fabrication of a prosthesis is to take the necessary measurements for a good fit. If the socket is to be fabricated of a plastic laminate, an impression of the stump is made. Most often this is accomplished by wrapping the stump with a wet plaster-of-Paris bandage and allowing it to dry, as a physician does in applying a cast when a bone is broken (<b>Fig. 21</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Steps in the fabrication of a plastic prosthesis for a below-knee amputation. A, Taking the plaster cast of the stump; B, pouring plaster in the cast to obtain model of the stump; C, introducing plastic resin into fabric pulled over the model to form the plastic-laminate socket; D, the plastic-laminate socket mounted on an adjustable shank for walking trials; E, a wooden shank block inserted in place of the adjustable shank after proper alignment has been obtained; F, the prosthesis after the shank has been shaped. To reduce weight to a minimum the shank is hollowed out and the exterior covered with a plastic laminate. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast, or wrap, is removed from the stump and filled with a plaster-of-Paris solution to form an exact model of the stump which-after being modified to provide relief for any tender spots, to ensure that weight will be taken in the proper places, and to take full advantage of the remaining musculature- can be used for molding a plastic-laminate socket. Often a "check" socket of cloth impregnated with beeswax is made over the model and tried on the stump to determine the correctness of the modifications.</p> <p>For upper-extremity cases the socket is attached to the rest of the prosthesis and a harness is fabricated and installed for operation of the various parts of the artificial arm. For the lower-extremity case the socket is fastened temporarily to an adjustable, or temporary, leg for walking trials (<b>Fig. 22</b>). With this device, the prosthetist can easily adjust the alignment until both he and the amputee are satisfied that the optimum arrangement has been reached. A prosthesis can now be made incorporating the same alignment achieved with the adjustable leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Using the above-knee adjustable leg and alignment duplication jig. Top, Adjusting the adjustable leg during walking trials; Center, the socket and adjustable leg in the alignment duplication jig; Bottom, replacement of the adjustable leg with a permanent knee and shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>There are many kinds of artificial limbs available for each type of amputation, and much has been written concerning the necessity for prescribing limbs to meet the needs of each individual. This of course is true particularly in the case of persons in special or arduous occupations, or with certain medical problems, but actually limbs for a given type of amputation vary to only a small degree. Following are descriptions of the artificial limbs most commonly used in the United States today.</p> <h4>Lower-Extremity Prostheses</h4> <p><i>Prostheses for Syme's Amputation</i></p> <p>Perhaps the major reason Syme's amputation was held in such disfavor in some quarters was the difficulty in providing a comfortable, sufficiently strong prosthesis with a neat appearance. The short distance between the end of the stump and the floor made it extremely difficult to provide for ankle motion needed. Most Syrae prostheses were of leather reinforced with steel side bars resulting in an ungainly appearance (<b>Fig. 23</b>). Research workers at the Prosthetic Services Centre at the Department of Veterans Affairs of Canada were quick to realize that the use of the proper plastic laminate might solve many of the problems long associated with the Syme prosthesis. After a good deal of experimentation, the Canadians developed a model in 1955 which, with a few variations, is used almost universally in both Canada and the United States today (<b>Fig. 24</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Syme prosthesis with side bars mounted on medial and lateral aspects of the shank. This type of construction has been virtually replaced by plastic laminates. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. The Syme prosthesis adopted by the Canadian Department of Veterans Affairs. The posterior opening extends the length of the shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Necessary ankle action is provided by making the heel of the foot of sponge rubber. The socket is made entirely of a plastic laminate. A full-length cutout in the rear permits entry of the bulbous stump. When the cutout is replaced and held in place by straps, the bulbous stump holds the prosthesis in place. In the American version (<b>Fig. 25</b>), a window-type cutout is used on the side because calculations show that smaller stress concentrations are present with such an arrangement.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Two views of the Canadian-type Syme prosthesis as modified bj the Veterans Administration Prosthetics Center, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In those cases where, for poor surgery or other reasons, full body weight cannot be tolerated on the end of the stump, provisions can be made to transfer all or part of the load to the area just below the kneecap. When this procedure is necessary, it can be accomplished more easily by use of the window-type cutout.</p> <p><i>Prostheses for Below-Knee Amputations</i></p> <p>Until recently most below-knee amputees were fitted with wooden prostheses carved out by hand (<b>Fig. 26</b>). A good portion of the body weight was carried on a leather thigh corset, or lacer, attached to the shank and socket by means of steel hinges. The shape of corset and upper hinges also held the prosthesis to the stump. The distal, or lower, end of the socket was invariably left open. Other versions of this prosthesis used aluminum, fibre or molded leather, as the materials for construction of the shank and socket, but the basic principle was the same. Many thousands of below-knee amputees have gotten along well with this type of prosthesis, but there are many disadvantages. Because the human knee joint is not a simple, single-axis hinge joint, relative motion is bound to occur between the prosthesis and the stump and thigh during knee motion when single-jointed side hinges are used, resulting in some chafing and irritation. To date it has not been possible to devise a hinge to overcome this difficulty. Edema, or accumulation of body fluids, was often present at the lower end of the stump. Most of these prostheses were exceedingly heavy, especially those made of wood.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Below-knee prosthesis with wood socket-shank, thigh corset, and steel side bars. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In an attempt to overcome these difficulties, the Biomechanics Laboratory of the University of California, in 1958, designed what is known as the patellar-tendon-bearing (PTB) below-knee prosthesis (<b>Fig. 27</b>). In the PTB prosthesis no lacer and side hinges are used, all of the weight being taken through the stump by making the socket high enough to cover all the tendon below the patella, or kneecap. The patellar tendon is an unusually inelastic tissue which is not unduly affected by pressure. The sides of the socket are also made much higher than has usually been the practice in the past in order to give stability against side loads. The socket is made of molded plastic laminate that provides an intimate fit over the entire area of the socket, and is lined with a thin layer of sponge rubber and leather. Because it is rare for a below-knee stump to bear much pressure on its lower end, care is taken to see that only a very slight amount is present in that area. This feature has been a big factor in eliminating the edema problem in many instances. The PTB prosthesis is generally suspended by means of a simple cuff, or strap, around the thigh just above the kneecap, but sometimes a strap from the prosthesis to a belt around the waist is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Cutaway view of the patellar-tendon-bearing leg for below-knee amputees. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the socket has been made, it is installed on a special adjustable leg (<b>Fig. 28</b>) so that the prosthetist can try various alignment combinations with ease. When both prosthetist and patient are satisfied, the leg is completed uti- lizing the alignment determined with the adjustable unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Trial below-knee adjustable leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The shank recommended is of plastic laminate and the foot prescribed is usually the SACH (solid-ankle, cushion-heel) design but other types can be used.</p> <p>It is now general practice in many areas to prescribe the PTB prosthesis in most new cases and in many old ones, and if side hinges and a corset are indicated later, these can be added.</p> <p>Stumps as short as 2-1/2 in. have been fitted successfully with the PTB prosthesis.</p> <p>In special cases, such as extreme flexion contracture, the so-called kneeling-knee, or bent-knee, prosthesis may be indicated. The prosthesis used is similar to that used for the knee-disarticulation case.</p> <p><i>Prostheses for the Knee-Disarticulation and Other Knee-Bearing Cases</i></p> <p>Because of the bulbous shape of the true knee-disarticulation stump, it is not possible to use a wooden socket of the type used on the tapered above-knee stump. To allow entry of the bulbous end, a socket is molded of leather to conform to the stump and is provided with a lengthwise anterior cutout that can be laced to hold the socket in position (<b>Fig. 29</b>). Because of the length of the knee-disarticulation and supracondylar stump, it is not possible to install any of the present knee units designed for above-knee prostheses and, therefore, heavy-duty below-knee joints are generally used. Most prosthetists try to provide some control of the shank during the swing phase of walking by inserting nylon washers between the mating surfaces of the joint to provide friction and by using checkstraps. Better devices for control of the knee joint are being developed and should be available in the near future.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Typical knee-disarticulation prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for Above-Knee Cases</i></p> <p>The articulated above-knee leg is in effect a compound pendulum actuated by the thigh stump. If the knee joint is perfectly free to rotate when force is applied, the effects of inertia and gravity tend to make the shank rotate too far backward and slam into extension as it rotates forward, except at a very slow rate of walking. The method most used today to permit an increase in walking speed is the introduction of some restraint in the form of mechanical friction about the knee joint. The limitation imposed by constant mechanical friction is that for each setting there is only one speed that produces a natural-appearing gait. When restraint is provided in the form of hydraulic resistance, a much wider range of cadence can be obtained without introducing into the gait pattern awkward and unnatural motions.</p> <p>Throughout the past century much time and effort have been spent in providing an automatic brake or lock at the knee in order to provide stability during the stance phase and to reduce the possibility of stumbling. Stability during the stance phase can be obtained by aligning the leg so that the axis of the knee is behind the hip and ankle axes. For most above-knee amputees in good health, such an arrangement has been quite satisfactory, but an automatic knee brake is indicated for the weaker or infirm patients.</p> <p>The prosthesis prescribed most commonly today for the above-knee amputee consists of a carved wooden socket, a single-axis knee unit with constant but adjustable friction, a wooden shank, and a SACH foot. The shank and socket are reinforced with an outer layer of plastic laminate to reduce the amount of wood required and thus keep weight to an optimum.</p> <p>When an automatic brake is indicated, the Bock, the "Vari-Gait" 100, and the Mortensen knee units (<b>Fig. 30</b>) are the ones most generally used. All are actuated upon contact of the heel with the ground. The Bock and "Vari-Gait" units can be used with almost any type of foot, while a foot of special design is necessary when the Mortensen mechanism is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Some examples of weight-actuated knee units. A, Bock "Safety-knee"; B, Vari-Gait knee; C, Morten-sen leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The "Hydra-Cadence" above-knee leg (<b>Fig. 31</b>) was until recently the only unit available that provided hydraulic friction to control the shank during the swing phase of walking. In addition to this feature, incorporated in the Hydra-Cadence design is provision for coordinated motion between the ankle action and the knee action. After the knee has flexed 20 deg., the toe of the foot is lifted as the knee is flexed further, thus giving more clearance between the foot and the ground as the leg swings through. Other hydraulic units recently made available are the Regnell (a Swedish design) and the DuPaCo. Still others are in advanced stages of development.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. The Hydra-Cadence Leg without cosmetic cover. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A number of methods for suspending the above-knee leg are available. For younger, healthy patients, the suction socket (<b>Fig. 32</b>A) is generally the method of choice. In this design the socket is simply fitted tightly enough to retain sufficient negative pressure, or suction, between the stump and the bottom of the socket when the leg is off the ground. Special valves are used to control the amount of negative pressure created so as not to cause discomfort. No stump sock is worn with the suction socket. A major advantage of this type of suspension is the freedom of motion permitted the wearer, thus allowing the use of all the remaining musculature of the stump. Another important advantage is the decreased amount of piston action between stump and socket. Additional comfort is also obtained by elimination of all straps and belts.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Above-knee sockets and methods of suspension. A, Total-contact suction socket; B, above-knee leg with Silesian bandage for suspension; C, above-knee leg with pelvic belt for suspension. Most above-knee sockets have a quadrilateral-shaped upper portion as shown. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In some cases additional suspension is provided by adding a "Silesian Bandage," (<b>Fig. 32</b>B), a light belt attached to the socket in such a way that there is very little restriction to motion of the various parts of the body.</p> <p>Patients with weak stumps and most of those with very short stumps will require a pelvic belt connected to the socket by means of a "hip" joint (<b>Fig. 32</b>C). Because the connecting joint cannot be placed to coincide with the normal joint, certain motions are restricted. Pelvic-belt suspension is generally indicated for the older patient because of the problems encountered in donning the suction socket, especially that of bending over to remove the donning sock.</p> <p>Shoulder straps, at one time the standard method of suspending above-knee prostheses, are still sometimes indicated for the elderly patient.</p> <p>Prior to the introduction of the suction socket into the United States soon after the close of World War II, virtually all above-knee sockets had a conical-shaped interior and were known as plug fits, most of the weight being borne along the sides of the stump. Such a design does not permit the remaining musculature to perform to its full capabilities. In the development of the suction socket, a design known as the quadrilateral socket (<b>Fig. 32</b>) evolved, and now is virtually the standard for above-knee sockets regardless of the type of suspension used. When the pelvic belt or suspender straps are used, the socket is fitted somewhat looser than in the case of the suction socket, and the stump sock is generally worn to reduce skin irritation from the pumping action of the loose socket. Most of the body weight is taken on the ischium of the pelvis, that part which assumes the load when an individual is sitting.</p> <p>The quadrilateral socket, because of the method employed to permit full use of the remaining muscles, does not resemble the shape of the stump but, as the name implies, is more rectangular in shape. Until recently the standard method of fitting a quadrilateral socket called for no contact over the lower end of the stump, a hollow space being left in this area. Although this method was quite successful there remained a sufficient number of cases that persistently developed ulcers or edema over the end of the stump. Experiments involving the use of slight pressure over the stump-end led to the development of what is known as the plastic total-contact socket (<b>Fig. 32</b>A). As the name implies, the socket is in contact with the entire surface of the stump. The total-contact socket has helped to cure most of the problem cases and is now being used routinely in many areas.</p> <p>In fitting the above-knee prosthesis, the prosthetist carves the interior of the socket using measurements of the stump as a guide. When a satisfactory fit has been achieved the socket is usually mounted on an adjustable leg for alignment trial, after which the wooden shank and the knee are substituted for the adjustable unit and the leg is finished by applying a thin layer of plastic laminate over the shank and the thigh piece.</p> <p>In the case of the total-contact socket, the prosthetist obtains a plaster cast of the stump, usually with the aid of a special casting jig (<b>Fig. 33</b>), and thus obtains a model of the stump over which the plastic socket can be formed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Special jig developed by the Veterans Administration Prosthetics Center to facilitate casting above-knee stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for Hip-Disarticulation and Hemi-pelveclomy Cases</i></p> <p>A prosthesis (<b>Fig. 34</b>) developed by the Canadian Department of Veterans Affairs in 1954 and modified slightly through the years has become accepted as standard practice. In the Canadian design a plastic-laminate socket is used, and the "hip" joint is placed on the front surface in such a position that, when used with an elastic strap connecting the rear end of the socket to a point on the shank ahead of the femur, stability during standing and walking can be achieved without the use of a lock at the hip joint. The location of the hip joint in the Canadian design also facilitates sitting, a real problem in earlier designs.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Hip-disarticulation prosthesis, known as the Canadian-type because its principle was originally conceived by workers at the Department of Veterans Affairs of Canada. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A constant-friction knee unit is most often used with the hip-disarticulation prosthesis, but some prosthetists have reported successful use of hydraulic knee units.</p> <p>The hemipelvectomy patient is provided with the same type of prosthesis but the socket design is altered to allow for the loss of part of the pelvis.</p> <h4>Upper-Extremity Prostheses</h4> <p>The major role of the human arm is to place the hand where it can function and to transport objects held in the hand. The energy for operation of the hand substitute in upper-extremity prostheses is derived from relative motion between two parts of the body. Energy for operation of the elbow joint, when necessary, can be obtained in the same way. The stump, of course, is also a source of energy for control of the prosthesis in all except the shoulder-disarticulation and fore-quarter cases. Force and motion can be obtained through a cable connected between the device to be operated and a harness across the chest or shoulders.</p> <p><i>Hand Substitutes-Terminal Devices</i></p> <p>All upper-extremity prostheses for amputation at the wrist level and above have, in common, the problem of selection of the terminal device, a term applied to artificial hands and substitute devices such as hooks. In some areas of the world there is a tendency to supply the arm amputee with a number of devices, each designed for a specific task such as eating, shaving, hairgrooming, etc. In the United States such an approach has been considered too clumsy, and opinion has been that the terminal device should be designed so that most upper-extremity amputees can perform the activities of daily living with a single device, or at most with two devices.</p> <p>The so-called split hooks are much more functional than any artificial hand devised to date. The arm amputee must rely heavily upon visual cues in handling objects and the hook offers more visibility. The hook also offers more prehension facility, and can be more easily introduced into and withdrawn from pockets than a device in the form of a hand. Therefore, the hook is used in manual occupations and those avocations requiring manual dexterity. When extensive contact with the public is necessary and for social occasions, the hand is of course generally preferred. Many amputees have both types of devices, using each as the occasion warrants. Two basic types of mechanism have been developed for terminal-device operation- voluntary-opening and voluntary-closing. In the former, tension on the control cable opens the fingers against an elastic force; in the latter, tension in the control cable closes the fingers against an elastic force. Each type of mechanism has its advantages and disadvantages, neither being superior to the other when used in a wide range of activities. Both hands and hooks are available with either type of mechanism.</p> <p>The major types of terminal devices are shown in <b>Fig. 35</b> and <b>Fig. 36</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Voluntary-closing terminal devices. A, APRL-Sierra Hand; left, cutaway view showing mechanism; right, assembled hand without cosmetic glove; B, APRL-Sierra Hook. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Voluntary-opening terminal devices. The wide range of models offered by the D. W. Dorrance Company includes sizes and designs for all ages. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Wrist-Disarticulation Case</i></p> <p>One of the problems in fitting the wrist disarticulation in the past has been to keep the over-all length of the prosthesis commensurate with the normal arm. The development of very short wrist units, especially for wrist-disarticulation cases, has materially reduced this problem. However, these units are available in only the screw, or thread, type, and cannot be obtained in the bayonet type which lends itself to quick interchange of terminal devices.</p> <p>The socket for the wrist-disarticulation case need not extend the full length of the forearm and is fitted somewhat loosely at the upper, or proximal, end to permit the wrist to rotate. A simple figure-eight harness and Bowden cable are used to operate the terminal device <b>Fig. 37</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Typical methods of fitting below-elbow amputees with medium to long stumps. Above, the figure-eight, ring-type harness is most generally used Where possible flexible leather hinges and open biceps cuff or pad are used. When more stability between socket and stump is required, rigid (metal) hinges and closed cuffs can be used (inserts A and B). In insert C, fabric straps are used for suspension in lieu of a leather billet. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Long Below-Elbow Case</i></p> <p>The prosthesis for the long below-elbow case is essentially the same as that for the wrist-disarticulation patient except that the quick-disconnect wrist unit can be used when desired.</p> <p><i>Prostheses for the Short Below-Elbow Case</i></p> <p>The socket for the short below-elbow stump, where there is no residual rotation of the forearm, is usually fitted snugly to the entire slump, and often rigid hinges connecting the socket to a cuff about the upper arm are used to provide additional stability. Either the figure-eight harness or the chest-strap harness may be used, the latter being preferred when heavy-duty work is required since it tends to spread the loads involved in lifting over a broader area than is the case with the figure-eight design.</p> <p>A wrist-flexion unit, which permits the terminal device to be tilted in toward the body for more effective use, can be provided in the short below-elbow prosthesis but is seldom prescribed for unilateral cases.</p> <p><i>Prostheses for the Very Short Below-Elbow Case</i></p> <p>Often the very short below-elbow case cannot control the prosthesis of the short below-elbow type through the full range of motion, either because of a muscle contracture or because the stump is too short to provide the necessary leverage.</p> <p>When a contracture is present that limits the range of motion of the stump, a "split-socket" and "step-up" hinge may be used. With this arrangement of levers and gears, movement of the stump through one degree causes the prosthetic forearm to move through two degrees; thus, a stump that has only about half the normal range of motion can drive the forearm through the desired 135 deg. However, when the step-up hinge is used, twice the normal force is required. When the stump is incapable of supplying the force required, it can be assisted by employing the "dual-control" harness wherein force in the terminal-device control cable is diverted to help lift the forearm. When the elbow stump is very short or has a very limited range of motion, an elbow lock operated by stump motion is employed to obtain elbow function.</p> <p>Recently a number of prosthetists have reported success in fitting very short below-elbow cases with an arm which is bent to give a certain amount of preflexion. This type of fitting, which was developed in Munster, West Germany, eliminates the necessity for using the rather clumsy step-up hinges and split socket, thus providing improved prosthetic control without a disadvantageous force feedback. Furthermore, the harness is not necessary for suspension of the prosthesis. The maximum forearm flexion may be limited to about 100 deg., but this does not appear to be a significant disadvantage to unilateral amputees (<b>Fig. 38</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Comparison of split socket and Munster-type fitting of short below-elbow case. A, Split socket and step-up hinge provides 140 deg. of forearm flexion; B, Munster-type fitting permits less forearm flexion but enables the amputee to carry considerably greater weight with flexed prosthesis unsupported by harness. Courtesy New York University College of Engineering Prosthetic and Orthotic Research. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Elbow-Disarticulation Case</i></p> <p>Because of the length of the elbow-dis-articulation stump, the elbow-locking mechanism is installed on the outside of the socket. Otherwise the prosthesis and harnessing methods (<b>Fig. 39</b>) are identical to those applied to the above-elbow case.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Typical prosthesis for the elbow-disarticulation case. The chest-strap harness with shoulder saddle is shown here, but the above-elbow figure-eight is also used. See Figure 40. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Above-Elbow Case</i></p> <p>For the above-elbow prosthesis to operate efficiently, it is necessary that a lock be provided in the elbow joint, and it is, of course, preferable that the lock is engaged and disengaged without resorting to the use of the other hand or pressing the locking actuator against an external object such as a table or chair.</p> <p>Several elbow units that can be locked and unlocked alternately by the same motion are available. This action is usually accomplished by the relative motion between the prosthesis and the body when the shoulder is depressed slightly and the arm is extended somewhat. The motion required is so slight that with practice the amputee can accomplish the action without being noticed. These elbow units contain a turntable above the elbow axis that permits the forearm to be positioned with respect to the humerus, supplementing the normal rotation remaining in the upper arm and thus allowing the prosthesis to be used more easily close to the mid-line of the body.</p> <p>The elbow units described above are available with an adjustable coil spring to assist in flexing the elbow when this is desired. The flexion-assist device may be added or removed without affecting the other operating characteristics.</p> <p>The plastic socket of the above-elbow prosthesis covers the entire surface of the stump. The most popular harness used is the figure-eight dual-control design wherein the terminal-device control cable is also attached to a lever on the forearm so that, when the elbow is unlocked, tension in the control cable produces elbow flexion, and, when the elbow is locked, the control force is diverted to the terminal device (<b>Fig. 40</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. Typical prosthesis for the above-elbow case. The figure-eight harness is shown here but the chest-strap harness with shoulder saddle may also be used. See Fig. 39. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The chest-strap harness may also be used in the dual-control configuration.</p> <p><i>Prostheses for the Shoulder-Disarticulation and Forequarter Cases</i></p> <p>Because of the loss of the upper-arm motion as a source of energy for control and operation of the prosthesis, restoration of the most vital functions in the shoulder-disarticulation case presents a formidable problem; for many years a prosthesis was provided for this type of amputation only for the sake of appearance. In recent years, however, it has been possible to make available prostheses which provide a limited amount of function (<b>Fig. 41</b>). To date it has not been possible to devise a shoulder joint that can be activated from a harness, but a number of manually operated joints are available. Various harness designs have been employed but, because of the wide variation in the individual cases and the marginal amount of energy available, no standard pattern has developed, each design being made to take full advantage of the remaining potential of the particular patient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Typical prosthesis for the shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for Bilateral Upper-Extremity Amputees</i></p> <p>Except for the bilateral, shoulder-disarticu-lation case, fitting the bilateral case offers few problems not encountered with the unilateral case. The prostheses provided are generally the same as those prescribed for corresponding levels in unilateral cases. Artificial hands are rarely used by bilateral amputees because hooks afford so much more function. Many bilateral cases find that the wrist-flexion unit, at least on one side, is of value. The harness for each prosthesis may be separated, but it is the general practice to combine the two (<b>Fig. 42</b>). In addition to being neater, this arrangement makes the harness easier for the patient to don unassisted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Harness for the bilateral below-elbow/ above-elbow case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Some prosthetists have claimed success in fitting bilateral shoulder-disarticulation cases with two prostheses. Because of the lack of sufficient sources of energy for control, most cases of this type are provided with a single, functional prosthesis and a plastic cap over the opposite shoulder which provides an anchor for the harness and also fills this area to present a better appearance (<b>Fig. 43</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Special harness arrangement for the bilateral shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Learning to Use the Prosthesis</h3> <p>To derive maximum benefit from his prosthesis, the amputee must understand how it functions and learn the best means of controlling it. A patient may be of the opinion that he is getting along very well when, in reality, he could do much better. Use of the prosthesis can best be learned under the supervision of an instructor who has had special training.</p> <p>All amputees using an artificial limb for the first time will need some instruction. In some instances, when a prosthesis is replaced with one of a different design, special instruction will be required. The time required for training depends upon the complexity of the device and the physical condition and degree of coordination of the patient. The time required will vary from a few hours to several weeks. In many instances amputees themselves have become excellent trainers, but more often such training is given by physical or occupational therapists. Usually, physical therapists instruct lower-extremity patients and occupational therapists teach upper-extremity cases.</p> <p>During the period of instruction, the trainer is careful to observe any effects the use of the prosthesis has on the patient, especially at points where the prosthesis is in contact with the body. Any changes are reported immediately to the physician in charge.</p> <h4>Lower-Extremity Cases</h4> <p>One of the major goals in training the leg amputee is to enable him to walk as gracefully as possible. Training of the leg amputee is begun as soon as the clinic team is satisfied with fit and alignment, and preferably while the artificial leg is in an unfinished state, or "in the rough." Thus, should there be need for changes in alignment as training progresses, they can be made readily. Often training can be started on an adjustable leg.</p> <p>A patient with a Syme amputation needs a minimum of training. The average below-knee case will require somewhat more, though usually not extensive, unless other medical problems are present. The training required is usually quite extensive for patients who have lost the knee joint.</p> <p>The ability to balance oneself is the first prerequisite in learning to walk, and so it is balance that is taught first to the above-knee amputee. Two parallel railings are used to give the patient confidence and reduce the possibility of falling (<b>Fig. 44</b>). Balancing on both legs is practiced first, then on each leg. Walking in a straight line between the parallel bars is repeated until the patient no longer requires use of the hands for support. Walking in a straight line is practiced until the gait is even and smooth.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Above-knee patient being trained to walk by a physical therapist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a rhythmic gait has been accomplished, more difficult tasks are learned, such as pivoting, turning, negotiating stairs and ramps, and sitting on and arising from the floor.</p> <p>Most unilateral above-knee patients can use their prostheses quite well without the necessity for a cane. However, in the case of short, weak stumps it may be advisable to employ a cane for additional support and stability. If a cane is necessary, it should be selected to meet the needs of the patient, and it must be used properly if ungainly walking patterns are to be avoided. Canes with curved handles and made from a single piece of wood should be used. The shaft should not show any signs of buckling under the full load of the body weight, and should be just long enough so that the elbow is bent slightly when the bottom of the cane rests near the foot. The cane is used on the side opposite the amputation to help maintain balance but is not used to the extent that body weight is centered between the good leg and the cane (<b>Fig. 45</b>). Continued use of the cane in this manner usually results in a limp that is difficult to overcome. It has been found that, for bio-mechanical reasons, it is helpful for the amputee to carry a briefcase or purse on the side of the amputation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Above-knee patient being taught correct use of cane. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Training the Hip-Disarticulation Cases</i></p> <p>The training of hip-disarticulation cases follows much the same pattern as that for above-knee cases. With the advent of the Canadian-type prosthesis, the training procedure has been considerably simplified. Some special precautions must be taken to avoid stumbling while ascending stairs.</p> <p><i>Special Considerations for Bilateral Leg Cases</i></p> <p>As would be expected, bilateral-leg cases pose special problems in addition to those of the unilateral cases and, therefore, a good deal of time will usually be required in training. Patients with two good below-knee stumps will seldom require canes. Some bilateral above-knee amputees can get along without canes, but as a general rule at least one cane is required.</p> <h4>Upper-Extremity Cases</h4> <p>The first objective in the training program for upper-extremity amputees is to ensure that the patient can perform the activities encountered in daily living, such as eating, grooming, and toilet care. When this goal has been attained, attention is devoted to any special training that might be required in vocational pursuits (<b>Fig. 46</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Upper-extremity amputees performing vocational tasks. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Before the prosthesis is put to useful purposes, the patient is shown how the various mechanisms are controlled and is made to practice these motions until they can be performed in a graceful manner and without undue exertion. In general, the arm amputee soon becomes so adept in these procedures that they are carried out without conscious thought. During this period, the functioning of the prosthesis, especially of the harness and control cables, is watched carefully by the instructor and constantly rechecked to ensure maximum performance.</p> <p>Only when the patient has mastered use of the various controls is practice in the handling of objects and the performance of activities of daily living undertaken.</p> <h3>Care of the Stump</h3> <p>Even under the most ideal circumstances the amputation stump, when called upon to operate a prosthesis, is subjected to certain abnormal conditions which, if not compensated for, may lead to physical disorders which make the use of a prosthesis impossible.</p> <p>Lack of ventilation as a result of encasing the stump in a socket with impervious walls causes an accumulation of perspiration and other secretions of glands found in the skin. In addition to the solid matter in the secretions, bacteria will accumulate in the course of a day. Both the solid matter and bacteria can lead to infection, and the solid matter, though it may appear to be insignificant, may result in abrasions and the formation of cysts. For these reasons cleanliness of the stump and anything that comes in contact with it for any length of time is of the utmost importance, even when sockets of the newer porous plastic laminate are used.</p> <p>The stump, therefore, should be washed thoroughly each day, preferably just before retiring. A soap or detergent containing hexa-chlorophene, a bacteriostatic agent, is recommended, but strong disinfectants are to be avoided. To be fully effective, the bacteriostatic agent must be used daily. Some six or seven daily applications are necessary before full effectiveness is obtained, and any cessation of this routine lowers the agent's ability to combat the bacteria. A physician who is himself an amputee has suggested that after an amputee takes a bath, the stump should be dried first in order to minimize the risk of introducing infection to it by the towel.</p> <p>When the prosthesis is used without a stump sock, the stump should be thoroughly dry as moisture may cause swelling that will result in rubbing and irritation. For such cases, it is especially desirable for the stump to be cleansed in the evening.</p> <p>The stump sock should receive the same meticulous care as the stump. The socks should be changed daily and washed as soon as they are taken off. In this way the perspiration salts and other residue are easier to remove. A mild soap and warm water are used to keep shrinkage to a minimum. Woolite (a cold-water soap) and cold water in recent trials have given excellent results. A rubber ball inserted in the "toe" during the drying process ensures retention of shape.</p> <p>Elastic bandages should be washed daily in the same manner as stump socks, but should not be hung up to dry; rather they should be laid out on a flat surface away from excessive heat and out of the direct rays of the sun. Hanging places unnecessary stresses on the elastic threads, and heat and sunlight accelerate deterioration.</p> <p>It is of the utmost importance that any skin disorder of the stump-no matter how slight- receive prompt attention, because such disorders can rapidly worsen and become disabling. The amputee should see a physician for treatment. He should also see his pros-thetist; it may be that adjustment of the prosthesis will eliminate the cause of the disorder. In no case should iodine or any other strong disinfectant be used on the skin of the stump.</p> <p>Sometimes the skin of the stump is rubbed raw by socket friction. When this happens, the skin should be gently washed with a mild toilet soap. After the stump has been rinsed and dried, Bacitracin ointment, or some other mild antiseptic, should be applied, and the area covered with sterile gauze. The prosthesis should be completely dry before it is put on. If such abrasions occur frequently, the pros-thetist should be informed. If there is the slightest sign of infection, the amputee should see a physician.</p> <p>Small painless blisters should not be opened; they should be washed gently with a mild soap and left alone. Large, painful blisters should be treated by a physician.</p> <h4>Bandaging the Stump</h4> <p>The stump is usually kept wrapped in an elastic bandage from the time healing permits until the time the prosthesis is delivered. Also, bandaging is recommended when for some reason it is impracticable or impossible for the patient to wear his limb routinely. It is there- fore highly desirable for the amputee, or at least one member of his family, to be able to apply the bandages. Many amputees can wrap their stumps unaided and, indeed, prefer to do so. Others prefer and, in some instances, require the help of another person.</p> <p>Recommended methods for applying elastic bandages for below-knee, above-knee, below-elbow and above-elbow patients are shown in <b>Fig. 47</b>, <b>Fig. 48</b>, and <b>Fig. 49</b>, respectively. These illustrations first appeared in a booklet entitled "Industrial Amputee Rehabilitation," prepared by Dr. C. O). Bechtol under the sponsorship of Liberty Mutual Insurance Co. of Boston.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Recommended method of applying elastic bandage to the below-knee stump. The bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Recommended method of applying elastic bandage to the above-knee stump. The stump is kept in a relaxed position, and the bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Elastic bandages applied properly to upper-extremity stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Care of the Prosthesis</h3> <p>In addition to the care required in keeping the inside of the socket clean, which has been stressed, best results can be obtained only if the prosthesis is maintained in the best operating condition. Like all mechanical devices, artificial limbs can be expected to receive wear and be discarded for a new device, but the length of useful life can be extended materially if reasonable care is taken in its use. An example often quoted is that of two identical automobiles. The car given the maintenance recommended by the manufacturer and operated with care will outlast many times the vehicle given spotty maintenance and operated with disregard for the heavy stresses imposed. So it is with artificial limbs. Some amputees require a new prosthesis every few years, or even more often, while others who follow the manufacturer's instructions, apply preventive maintenance practices, and have minor problems corrected without delay, have received satisfactory service from their limbs for periods as long as twenty years.</p> <p>Manufacturers' instructions vary with the design of the device. They consist mainly of lubrication practices and should be followed closely. Too much lubricant can sometimes produce conditions as troublesome as excessive wear. Looseness of joints and fastenings should be corrected as soon as it is detected, for the wear rate increases rapidly under such a condition. Any cracks that appear in supporting structures should be reinforced immediately in order to avoid complete failure and the necessity for replacement. The foot should be examined weekly for signs of excessive wear.</p> <p>A point often overlooked by leg amputees, but nevertheless one of the factors affecting optimum use of the artificial limb, is the condition of the shoe. Badly worn or improper shoes can have adverse effects on the stability and gait of the wearer. This is a matter that requires especially close attention in the case of child amputees.</p> <p>Hooks and artificial hands should be treated with the same care that the normal hand is given. Because the sensation of feeling is absent in the terminal device, the upper-extremity amputee is all too prone to use hooks to pry and hammer and to handle hot objects that are deleterious to the hook materials. Hands with cosmetic gloves should be washed daily, and of course hot objects and staining materials should be avoided.</p> <h3>Special Considerations in Treatment of Child Amputees</h3> <p>Only a few years ago it was seldom that a child amputee was fitted with a prosthesis before school age and often not until much later. In recent years experience has shown that fitting at a much earlier age produces more effective results.</p> <p>If there are no complicating factors, children with arm amputations usually should be provided with a passive type of prosthesis soon after they are able to sit alone, which is generally at about six months of age. Certain gross two-handed activities are thus made possible, crawling is facilitated, the child becomes accustomed to using and wearing the prosthesis, and moves easily into using a body-operated prosthesis as his coordination develops soon after his second birthday.</p> <p>Lower-extremity child amputees should be fitted with prostheses as soon as they show signs of wanting to stand. The development of muscular coordination of child amputees is the same as for nonhandicapped children and, therefore, this phase may take place as early as eight months or as late as 20 or more months.</p> <p>Children, especially when fitted at an early age, almost always adapt readily to prostheses. As the child grows, the artificial limb seems to become a part of him in a manner seldom seen in adults (<b>Fig. 50</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Children with upper-extremity amputations performing two-handed activities. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Except for the very young, children's prostheses follow much the same design as those for the adult group. Special devices and techniques have been developed for initial fitting of infants and problem cases.</p> <p>Regardless of where the child amputee resides, or the extent of his parents' financial resources, he need not go without the treatment and prostheses required to make full use of his potentials. To ensure that such services are available, the Children's Bureau of the De-partment of Health, Education, and Welfare has assisted a number of states in establishing well-organized child-amputee clinics, and the facilities of these states are available to residents of states where such specialized services are not to be had. There is an agency in each slate that can advise the parents of the proper course of action.</p> <p>Most children can be treated on an outpatient basis, but for the more severely handicapped many of the clinics have facilities for in-patient treatment. The clinic team for children is often augmented by a pediatrician and a social worker, and sometimes by a psychologist.</p> <p>Training very young children is one of the most difficult problems of the clinic team. Although the learning ability of young children may be rapid, their attention span is of such short duration that extreme patience is required. Regardless of the ability of the therapist, successful results cannot be achieved without complete cooperation of the parents. The mental attitude of the parents is reflected in the child, and all too often children have rejected prostheses because the parents, consciously or subconsciously, could not accept the fact that a prosthesis was needed. Parents of children born with a missing or deformed limb often experience a sense of guilt, a feeling that only adds to an already difficult problem. The guilt feeling is unwarranted, inasmuch as the knowledge of the causes of congenital defects -and appropriate preventive measures- is very limited. The recent discovery of the effects of thalidomide suggests that other causes may be found.</p> <p>As a rule, lower-extremity amputees present fewer problems than the upper-extremity cases. It is natural for the child to walk, and almost invariably the lower-extremity patient adapts rather quickly. Parents, however, should keep close observation of the walking habits of the child, the condition of his stump, and the state of repair of his prosthesis, and above all they should present the child before the clinic at the recommended times. A gradual change in walking habit may indicate that the child has outgrown the prosthesis or that excessive wear of the prosthesis has taken place. Any unusual appearance of the stump should be reported to the physician immediately so that remedial steps may be taken, thereby avoiding more complicated medical problems at a later date. Children give a prosthesis more wear and tear than do adults and it is important that the prosthesis be examined carefully at regular intervals and needed repairs made as soon as possible-not only to ensure the safety of the child but to avoid the necessity for major repairs at a later date.</p> <p>Many upper-extremity child amputees adapt readily to artificial arms-some even want to sleep with the arm in place-but in many cases the child will need a great deal of encouragement before he will accept the device and make use of it. At first the unilateral amputee may feel that the prosthesis is a deterrent rather than an aid, but with the proper encouragement this feeling is reversed.</p> <p>Parents can help by continuing the training given in the clinics. From the beginning the artificial arm should be worn as much as possible. Young children should be given toys that require two hands for use and older children should be given household chores that require two-handed activities. In the latter case not only does the child learn to appreciate the usefulness of the prosthesis, but he also gains a feeling of being a useful member of the family and thus a better mental attitude is created.</p> <p>The child amputee should not be sheltered from the outside world but encouraged to associate with other children and, to the extent that he can, to take part in their activities. Of course there are certain limitations, but the number of activities that can be performed with presently available prostheses is amazing. It goes almost without saying that the child should receive no more special attention than is necessary, and should be made to perform the activities of daily living of which he is capable.</p> <p>It has been shown that it is preferable for the child amputee to attend a regular school rather than one for the handicapped. Most child amputees can and do take their place in society and the transition from school to work is much easier if they are not shown unnecessary special consideration. Nonhandicapped children soon accept the amputee and make little comment after the initial reaction.</p> <p>Here again the arm amputee is apt to be faced with the most problems. Some public school officials have hesitated to admit arm amputees wearing hooks for fear that the child may use them as weapons. This attitude is unrealistic. If such incidents have occurred, they are rare indeed. However, arm prostheses should be removed when the child is engaged in body-contact sports such as football.</p> <p>Cleanliness of the stump, prosthesis, and stump sock is just as important for children as for adults. The same procedures as those outlined on pages 35-36 are recommended.</p> <h3>Special Considerations in the Treatment of Elderly Patients</h3> <p>Persons who have had amputations during youth or middle age seldom encounter additional problems in wearing their prostheses as they become older. However, for those patients who have an amputation in later life many unusual problems are apt to be present. Most amputations in elderly patients are necessary because of circulatory problems, almost always affecting the lower extremity. For many years the wisdom of fitting such patients with prostheses was debatable, the thought being that the remaining leg, which in most cases was subject to the same circulatory problems as the one removed, would be overtaxed and thus the need for its removal would be hastened. Energy studies in recent years have shown that crutch-walking is more taxing than use of an artificial limb. Experience with rather large numbers of elderly leg amputees has shown that failure of the remaining leg has not been accelerated by use of a prosthesis, and stumps that have been fitted properly have not been troublesome. As a result more and more elderly patients are benefiting by the use of artificial limbs. A rule of thumb used in some clinics to decide whether or not to fit the elderly patient is that if he can master crutch-walking he should be fitted. This measure should be used with discretion because in some instances patients who could not meet the crutch-walking requirement have become successful wearers of prostheses.</p> <p>Most clinic teams feel that if the patient can use the prosthesis to make him somewhat independent around the house, the effort is fully warranted.</p> <p>Artificial legs for the older patients, as a rule, should be as light as possible. Except for the most active patients, only a small amount of friction is needed at the knee for control of the shank during the swing phase of walking because the gait is apt to be slow. Suction sockets are rarely indicated because of the effort required in donning them. A quadrilateral-shaped socket is used with one stump sock and a pelvic belt. Silesian bandages have been used successfully, allowing more freedom of motion and increased comfort.</p> <p>For the elderly below-knee cases, the patellar-tendon-bearing prosthesis is being used quite successfully.</p> <h3>Cineplasty</h3> <p>In 1896 the Italian surgeon, Vanghetti, conceived the idea of connecting the control mechanism of a prosthesis directly to a muscle. Several ideas involving the formation of a club-like end or a loop of tendon in the end of a stump muscle were tried out in Italy. Just prior to World War I the German surgeon, Sauerbruch, devised a method of producing a skin-lined tunnel through the belly of the muscle. A pin through the tunnel was attached to a control cable, and thus energy for operation of the prosthesis was transferred directly from a muscle group to the control mechanism. With refinements the Sauerbruch method is available for use today, but it must be used cautiously.</p> <p>Although tunnels have been tried in many muscle groups, the below-elbow amputee is the only type that can be said to benefit truly from the cineplasty procedure. A tunnel properly constructed through the biceps can supply power for operation of a hand or hook, and there need be no harnessing above the level of the tunnel. Thus, the patient is not restricted by a harness and the terminal device can be operated with the stump in any position. Training the tunneled muscle and care of the tunnel require a great deal of work by the patient; thus if the cineplasty procedure is to be successful the patient must be highly motivated.</p> <p>Some female below-elbow amputees have been highly pleased with results from a biceps tunnel, but as a rule cineplasty does not appeal to women.</p> <p>Cineplasty is not indicated for children. Sufficient energy is not available for proper operation of the prosthesis and the effects of growth on the tunnel are not known.</p> <p>Tunnels have been tried in the forearm muscles but the size of these muscles is such that the energy requirements for prosthesis operation are rarely met. While tunnels in the pectoral muscle are capable of developing great power, in the light of present knowledge the disadvantages tend to outweigh the advantages. It is extremely difficult to harness effectively the energy generated, and very little, if any, of the harness can be eliminated. It is true that an additional source of control can be created, but with the devices presently available little use can be made of this feature.</p> <p>No application for cineplasty has been found in lower-extremity amputation cases.</p> <p>Still another type of cineplasty procedure is the Krukenberg operation, whereby the two bones in the forearm stump are separated and lined with skin to produce a lobster-like claw. The result, though rather gruesome in appearance, permits the patient to grasp and handle objects without the necessity of a prosthesis. Because sensation is present, the Krukenberg procedure has been found to be most useful for blind bilateral amputees. Although prostheses can be used with Krukenberg stumps when appearance is a factor, the operation has found little favor in the United States.</p> <h3>Agencies That Assist Amputees</h3> <p>For several centuries at least, governments have traditionally cared for military personnel who received amputations in the course of their duties. But only in recent years, except in isolated cases, has the amputee in civilian life had much assistance in making a comeback. Today there are available services to meet the needs of every category of amputee. Aside from the humanitarian aspects of such programs, it has been found to be good business to return the amputee to productive employment and, in the case of some of the more debilitated, to provide them with devices and training to take care of themselves.</p> <p>The Armed Services provide limbs for mili- tary personnel who receive amputations while on active duty, and many of these cases are returned to active duty. After the patient has been discharged from military service, the Veterans Administration assumes responsibility for his medical care and prosthesis replacement for the remainder of his life. The U. S. Public Health Service, through its Marine Hospitals, cares for the prosthetics needs of members of the U. S. Maritime Service.</p> <p>Each state provides some sort of service for child amputees. If sufficient facilities are not available within a state, provisions can be made for treatment in one of the regional centers set up in a number of states with the help and encouragement of the Children's Bureau of the Department of Health, Education, and Welfare. With assistance from the Vocational Rehabilitation Administration of the Department of Health, Education, and Welfare, every state operates a vocational rehabilitation program designed to help the amputee return to gainful employment. Recently some of these programs have been extended to render assistance to housewives and the elderly as well.</p> <p>Private rehabilitation centers, almost universally nonprofit and sponsored largely by voluntary organizations, greatly augment the state and federal programs.</p> <p>Information concerning rehabilitation centers serving a particular area may be obtained from the Association of Rehabilitation Centers, Inc., 828 Davis Street, Evanston, Ill.</p> <p><b>References:</b></p> <ol> <li>Alldredge, R. H., <i>Amputations and prostheses</i>, Chapter 12 in <i>Christopher's Textbook of surgery</i>, 5th ed., W. B. Saunders Co., Philadelphia, 1949.</li> <li>American Academy of Orthopaedic Surgeons, <i>Orthopaedic appliances atlas</i>, vol. 2, Artificial Limbs, J. W. Edwards, Ann Arbor, Michigan, 1960.</li> <li>Batch, Joseph W., August W. Spittler and James G. McFaddin, <i>Advantages of the knee disarticulation over amputations through the thigh</i>, J. Bone and Joint Surg., Boston, 36A. :921-930, October 1954.</li> <li>Brunnstrom, Signe, <i>The lower extremity amputee</i>, in Bierman and Licht's <i>Physical medicine in general practice</i>, Hoeber-Harper, New York, 1952</li> <li>DeLorme, Thomas, Progressive resistive exercise, Appleton and Co., New York, 1951.</li> <li>Eisert, Otto and O. W. Tester, <i>Dynamic exercises for lower extremity amputees</i>, Arch. Phys. Med. and Rehab., 25:11, November 1954.</li> <li>Gillis, Leon, <i>Artificial limbs</i>, Pitman Medical Publishing Co., Ltd., London, 1957.</li> <li>Hitchcock, William E., <i>Notes on the diagnosis and treatment of above-knee fitting problems</i>, Prosthetics Education, Post-Graduate Medical School, New York University, New York, August 1957.</li> <li>Kerr, Donald and Signe Brunnstrom, <i>Training of the lower-extremity amputee</i>, ed. Charles C Thomas, Springfield, Ill., 1956.</li> <li>Klopsteg, Paul E., Philip D. Wilson, et al, <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>MacDonald, J., Jr., <i>History of artificial limbs</i>, Am. J. Surg., 19:76-80, 1905.</li> <li>Motis, G. M., <i>Final report on artificial arm and leg research and development</i>, Northrop Aircraft, Inc., Hawthorne, Calif., Final report to the Committee on Artificial Limbs, National Research Council, February 1951.</li> <li>Slocum, D. B., <i></i>An atlas of amputations, C. V. Mosby Co., St. Louis, 1949.</li> <li>University of California (Berkeley and San Fran- cisco), Biomechanics Laboratory, <i>Manual of below-knee prosthetics</i>, 1959.</li> <li>University of California (Los Angeles), Depart- ment of Engineering, <i>Manual of upper extremity prosthetics</i>, 2nd ed., W. R. Santschi, ed., 1958.</li> <li>University of California (Los Angeles), School of Medicine, Prosthetics Education Program, <i>Manual of above-knee prosthetics</i>, Miles H. Anderson and Raymond E. Sollars, eds., January 1, 1957.</li> <li>University of California Press (Berkeley and Los Angeles), <i>The limb-deficient child</i>, Berton B lakes-lee, ed., 1963.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr., B.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Technical Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Avenue, N.W., Washington, D.C. 20418</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Limb Prosthetics Today Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr., B.S.M.E. * https://staging.drfop.org/files/original/13483799eeef6de665c9bbb9af7b9faa.pdf c58980d044e592784ff92c261572cb70 https://staging.drfop.org/files/original/88328052220571e0fc20a864a6829964.jpg 66cafb6c0ae410559da88d3c6d548b21 https://staging.drfop.org/files/original/96e82ff7eea90594d484b9bd33e81c7e.jpg 1434282fa08d69ba185572ba4a1fcd1b https://staging.drfop.org/files/original/b6d5144215bb3dbbd723c4b8bb3a62a5.jpg e5382c2d9f7afecf74fe925fff7e28a5 https://staging.drfop.org/files/original/9cb7c3ebdffb95d6682116b73f94baa3.jpg 3208b240ca5b9271e98a68e4b09db6d0 https://staging.drfop.org/files/original/79695db2e584586503cc226686d16e5d.jpg 15434912daba69219d4e20745bd20a2a https://staging.drfop.org/files/original/32ad6c8f31a40cf8768910f1f71a1e86.jpg 9ad57bb3f90aece39e7c67bc4ef9a9e7 https://staging.drfop.org/files/original/2dd6ac18d6245c9d29236c6c620a12ad.jpg 6b452113afc75f8a732e203232711048 https://staging.drfop.org/files/original/5b0cbe7e09c8a178d30df13f69f31b97.jpg a90dab8ec34461f8015b8160e1c757a3 https://staging.drfop.org/files/original/aa411e9c0d94b09ee34d8dfe6cd61643.jpg fc2fc8ec437f8c653cbf5204e56de2b5 https://staging.drfop.org/files/original/edc114da52e28e0c0b6b7232ac00385e.jpg 724e3a1f505bb49024a7dfd947aeb382 https://staging.drfop.org/files/original/0c3ce7981d1ba2ffd57a31f9b99441cb.jpg 394e213d7b1c2193df215ac99c04fe37 https://staging.drfop.org/files/original/ad3b7233a6cabfff6c8399230b2a134d.jpg 4d44106fab8c1b1165d4b3fac0937598 https://staging.drfop.org/files/original/88fa3fd1d2928a71d8d8e0999736376b.jpg c2bea47e140174bc3875689af1a1b991 https://staging.drfop.org/files/original/ee51beb02fd85067cd1d579fac60ba28.jpg af3799f1f630e053b0fd5fe9480fb8bd https://staging.drfop.org/files/original/ac4030ee6c7df699fe7d75382c651bdf.jpg 7116e89a6c7eb72b5f55206c520ef96d https://staging.drfop.org/files/original/945bda9a12449fb3635d9974f819b027.jpg ba18513057ab53a915cf3129a30346a8 https://staging.drfop.org/files/original/739f04652820548143db4fa58b496a59.jpg 5030742e0bfdb6beb718ef64ecac8ea0 https://staging.drfop.org/files/original/1737d62016b57b8b2823cb05b2d0c4a0.jpg fd477e4cae07b389d7b5be19e0705ebc https://staging.drfop.org/files/original/3fd18dbb5eab5745097f327f368b2b8b.jpg 1f4f074ccae5fda0c472b769bf69f07a DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_01_001.pdf Year 1967 Volume 11 Issue 1 Page Number(s) 1 - 46 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1967_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Limb Prosthetics-1967</h2> <h5>A. Bennett Wilson, Jr., B.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p><i>Because of the large demand for reprints of </i>"Limb Prosthetics Today" <i>which originally appeared in the Autumn 1963 issue of ARTIFICIAL LIMBS, the article has been revised to reflect the numerous advances that have been introduced into limb prosthetics since 1963. To distinguish this revision from the original we have chosen the title </i>"Limb Prosthetics-1967."</p> <p>Loss of limb has been a problem as long as man has been in existence. Even some prehistoric men must have survived crushing injuries resulting in amputation, and certainly some children were born with congenitally deformed limbs with effects equivalent to those of amputation. In 1958 the Smithsonian Institution reported the discovery of a skull dating back about 45,000 years of a person who, it was deduced, must have been an arm amputee, because of the way his teeth had been used to compensate for lack of limb. Leg amputees must have compensated partly for their loss by the use of crude crutches and, in some instances, by the use of peg legs fashioned from forked sticks or tree branches (<b>Fig. 1</b> and <b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Mosaic from the Cathedral of Lescar, France, depicts an amputee supported at the knee by a wooden pylon. Some authorities place this in the Gallo-Roman era. From Putti, V., Historic Artificial Limbs, 1930. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Pen drawing of a fragment of antique vase unearthed near Paris in 1862 which shows a figure whose missing limb is replaced by a pylon with a forked end. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The earliest known record of a prosthesis being used by man was made by the famous Greek historian, Herodotus. His classic <i>"History" </i>written about 484 B.C., contains the story of the Persian soldier, Hegistratus, who, when imprisoned in stocks by the enemy, escaped by cutting off part of his foot, and replaced it later with a wooden version.</p> <p>A number of ancient prostheses have been displayed in museums in various parts of the world. The oldest known is an artificial leg unearthed from a tomb in Capua in 1858, thought to have been made about 300 B.C., the period of the Samnite Wars. Constructed of copper and wood, the Capua leg was destroyed when the Museum of the Royal College of Surgeons was bombed during World War II. The Alt-Ruppin hand (<b>Fig. 3</b>), recovered along the Rhine River in 1863, and other artificial limbs of the 15th century are on display at the Stib-bert Museum in Florence. Most of these ancient devices were the work of armorers. Made of iron, these early prostheses were used by knights to conceal loss of limbs as a result of battle, and a number of the warriors are reported to have returned successfully to their former occupation. Effective as they were for their intended use, these specialized devices could not have been of much use to any group other than the knights, and the civilian amputees for the most part must have had to rely upon the pylon and other makeshift prostheses. Although the use of ligatures was set forth by Hippocrates, the practice was lost during the Dark Ages, and surgeons during that period and for centuries after stopped bleeding by either crushing the stump or dipping it in boiling oil. When Ambroise Pare, a surgeon in the French Army, reintroduced the use of ligatures in 1529, a new era for amputation surgery and prostheses began. Armed with a more successful technique, surgeons were more willing to employ amputation as a lifesaving measure and, indeed, the rate of survival must have been much higher. The practice of amputation received another impetus with the introduction of the tourniquet by Morel in 1674, and removal of limbs is said to have become the most common surgical procedure in Europe. This in turn led to an increase in interest in artificial limbs. Pare, as well as contributing much in the way of surgical procedures, devised a number of limb designs for his patients. His leg (<b>Fig. 4</b>) for amputation through the thigh is the first known to employ articulated joints. Another surgeon, Verduin, introduced in 1696 the first known limb for below-knee amputees that permitted freedom of the knee joint (<b>Fig. 5</b>), in concept much like the thigh-corset type of below-knee limb still used by many today. Yet, for reasons unknown, the Verduin prosthesis dropped from sight until it was reintroduced by Serre in 1826 and, until recently, was the most popular type of below-knee prosthesis used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Alt-Ruppin Hand (circa 1400). The thumb is rigid; the fingers move in pairs and are sprung by the buttons at the base of the palm; the wrist is hinged. Putti, V., Chir. d. org. di movimento, 1924-25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Artificial leg invented by Ambroise Pare (middle sixteenth century). From Pare, A., Oeuvres Completes, Paris, 1840. From the copy in the National Library of Medicine. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Verduin Leg (1696). From MacDonald, J., Am. J. Surg., 1905. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After Pare's above-knee prosthesis, which was constructed of heavy metals, the next real advance seems to be the use of wood, introduced in 1800 by James Potts of London. Consisting of a wooden shank and socket, a steel knee joint, and an articulated foot, the Potts invention (<b>Fig. 6</b>) was equipped with artificial tendons connecting the knee and the ankle, thereby coordinating toe lift with knee flexion. It was made famous partly because it was used by the Marquis of Anglesea after he lost a leg at the Battle of Waterloo. Thus it came to be known as the Anglesea leg. With some modifications the Anglesea leg was introduced into the United States in 1839. Many refinements to the original design were incorporated by American limb fitters and in time the wooden above-knee leg became known as the "American leg."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Anglesea Leg (1800). Below knee at left, above knee at right. Knee, ankle, and foot are articulated. From Bigg, H. H., Orthopraxy, 1877. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Civil War produced large numbers of amputees and consequently created a great interest in artificial limbs, no doubt inspired partly by the fact that the federal and state governments paid for limbs for amputees who had seen war service.</p> <p>J. E. Hanger, one of the first Southerners to lose a leg in the Civil War, replaced the cords in the so-called American leg with rubber bumpers about the ankle joint, a design used almost universally until rather recently. Many patents on artificial limbs were issued between the time of the Civil War and the turn of the century, but few of the designs seem to have had much lasting impact.</p> <p>During this period, with the availability of chloroform and ether as anesthetics, surgical procedures were greatly improved and more functional amputation stumps were produced by design rather than by fortuity.</p> <p>World War I stirred some interest in artificial limbs and amputation surgery but, because the American casualty list was relatively small, this interest soon waned and, because of the economic depression of the Thirties, some observers think, very little progress was made in the field of limb prosthetics between the two World Wars. Perhaps the most significant contributions were the doctrines set forth and emphasized by Thomas and Haddan <i>, </i><a></a> a prosthetist-surgeon team from Denver, that fit and alignment of the prosthesis were the most critical factors in the success of any limb and that much better end results could be expected if prosthetists and physicians worked together.</p> <p>Early in 1945, the National Academy of Sciences, at the request of The Surgeon General of the Army, initiated a research program in prosthetics.<a></a> The initial reaction of the research personnel was that the development of a few mechanical contrivances would solve the problem. However, it soon became evident that much more must be known about biomechanics and other matters before real progress could be made <i><a></a>. </i>Devices and techniques based on fundamental data have materially changed the practice of prosthetics during the past 15 years. However, the best conceivable prosthesis is but a poor substitute for a live limb of flesh and blood, and so the research program is still continuing. Fiscal support for research and development by some 30 laboratories is provided by the Veterans Administration, the Vocational Rehabilitation Administration, the National Institutes of Health, the Children's Bureau, the Army, and the Navy. The overall program is coordinated by the Committee on Prosthetics Research and Development of the National Academy of Sciences-National Academy of Engineering.</p> <p>In England and Europe, research in artificial limbs was resumed after World War II at Queen Mary's Hospital, Roehampton, London, by the Ministry of Health, and a new program was initiated in West Germany by the government. Also, a program was started in Russia. The so-called "Thalidomide Tragedy" of 1959-1960 gave incentive for governments to support research, and now there are effective programs in Canada, Denmark, Holland, Scotland, and Sweden, and the studies in England and Germany have been greatly expanded. Under Public Law 480 the United States supports prosthetics research in India, Israel, Poland, and Yugoslavia.</p> <p>Soon after the close of World War II, the Artificial Limb Manufacturers Association, which had been formed during World War I, engaged the services of a professional staff to coordinate more effectively the efforts of individual prosthetists. Known today as the American Orthotics and Prosthetics Association,<a style="text-decoration:none;">*</a> this organization consists of some 500 limb and brace shops, and plays a large part in keeping individual prosthetists and ortho-tists advised of the latest trends and developments in prosthetics and orthotics.</p> <p>In 1949, upon the recommendation of the Association, the American Board for Certification in Orthotics and Prosthetics, Inc.,<a style="text-decoration:none;">*</a> was established to ensure that prosthetists and orthotists met certain standards of excellence, much in the manner that certain physicians' specialty associations are conducted. Examinations are held annually for those desiring to be certified. In addition to certifying individuals as being qualified to practice, the American Board for Certification approves individual shops, or facilities, as being satisfactory to serve the needs of amputees and other categories of the disabled requiring mechanical aids. Certified prosthetists wear badges and shops display the symbol of certification (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Symbol of certification by the American Board for Certification in Orthotics and Prosthetics, Inc. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The research program, with the cooperation of the prosthetists, has introduced a sufficient number of new devices and techniques to modify virtually every aspect of the practice of prosthetics. To reduce the time lag between research and widespread application, facilities have been established within the medical schools of three universities for short-term courses in special aspects of prosthetics. Courses are offered to each member of the prosthetics-clinic team-the physician, the therapist, and the prosthetist. Also, special courses are offered to vocational rehabilitation counselors and administrative personnel concerned with the welfare of amputees. Approximately 5,787 physicians, 3,962 therapists, and 2,000 prosthetists have been enrolled in these courses during the period 1953 through 1967.</p> <p>Prior to 1957 medical schools offered little in the way of training in prosthetics to doctors and therapists. To encourage the inclusion of prosthetics into medical and paramedical curricula, the National Academy of Sciences organized the Committee on Prosthetics Education and Information, and as a result of the efforts of this group many schools have adopted courses in prosthetics at both undergraduate and graduate levels.</p> <p>Today there are approximately 200 amputee-clinic teams in operation throughout the United States. Each state, with assistance from the Vocational Rehabilitation Administration, carries out programs that provide the devices and training required to return the amputee to gainful employment. The Children's Bureau, working through a number of states, has made it possible for child amputees to receive the benefit of the latest advances in prosthetics. The Veterans Administration provides all eligible veterans with artificial limbs. If the amputation is related to his military service, the beneficiary receives medical care and prostheses for the remainder of his life. The Public Health Service, through its hospitals, provides limbs and care to members of the Coast Guard and to qualified persons who have been engaged in the Maritime Service.</p> <p>In July 1965 the 89th Congress passed Public Law 89-97, the Medicare bill, which includes provision for artificial limbs at essentially no cost for persons 65 years of age and over. The bill also assists individual states in providing artificial limbs for persons who are medically indigent at any age. A number of states have enacted legislation to take advantage of the offer by the federal government.</p> <p>In addition to the government agencies that are concerned with the amputee, there are several hundred rehabilitation centers throughout the United States that assist amputees, especially those advanced in age, in obtaining the services needed for them to return to a more normal life.</p> <p>Thus, through the cooperative efforts of government and private groups, considerable progress has been made in the practice of prosthetics and there is little need for an amputee to go without a prosthesis.</p> <h3>Reasons For Amputation</h3> <p>Amputation may be the result of an accident, or may be necessary as a lifesaving measure to arrest a disease. A small but significant percentage of individuals are born without a limb or limbs, or with defective limbs that require amputation or fitting (like that of an amputee).</p> <p>In some accidents a part or all of the limb may be completely removed; in other cases, the limb may be crushed to such an extent that it is impossible to restore sufficient blood supply necessary for healing. Sometimes broken bones cannot be made to heal, and amputation is necessary. Accidents that cause a disruption in the nervous system and paralysis in a limb may also be cause for amputation even though the limb itself is not injured. The object of amputation in such a case is to improve function by substituting an artificial limb for a completely useless though otherwise healthy member. Amputation of paralyzed limbs is not performed very often but has in some cases proven to be very beneficial. Accidents involving automobiles, farm machinery, and firearms seem to account for most traumatic amputations. Freezing, electrical burns, and the misuse of power tools also account for many amputations.</p> <p>Improved medical and surgical procedures introduced in recent years have resulted in the preservation of many limbs that would have been amputated. Infection, once a cause of a high fraction of amputations, can usually be controlled by use of antibiotics. Newer methods of vessel and nerve suturing make it possible to save limbs that would have had to be amputated some years ago. Highly qualified surgical teams have demonstrated during the last few years that it is possible to replace a completely severed limb.</p> <p>Diseases that may make amputation necessary fall into one of three main categories: vascular, or circulatory, disorders; cancer; and infection. The diseases that cause circulatory problems most often are arteriosclerosis, or hardening of the arteries, diabetes, and Buerger's disease. In these cases not enough blood circulates through the limb to permit body cells to replace themselves, and unless the limb, or part of it, is removed the patient cannot be expected to live very long. In nearly all these cases the leg is affected because it is the member of the body farthest from the heart and, in accordance with the principles of hydraulics, blood pressure in the leg is lower than in any other part of the body. Vascular disorders are, of course, much more prevalent among older persons. Considerable research is being undertaken to determine the cause of vascular disorders so that amputation for these reasons may at least be reduced if not eliminated, but at the present time vascular disorders are the cause of a large number of lower-extremity amputations.</p> <p>In many cases amputation of part or all of a limb has arrested a malignant or cancerous condition. In view of present knowledge, the entire limb is usually removed. Malignancy may affect either the arms or legs. Much time and effort are being spent to develop cures for the various types of cancer.</p> <p>Since the introduction of antibiotic drugs, infection has been less and less the cause for amputation. Moreover, even though amputation may be necessary, control of the infection may allow the amputation to be performed at a lower level than would be the case otherwise.</p> <p>"Thalidomide babies" born between 1958 and 1961 have been given extensive press coverage; however, thalidomide is by no means the sole cause of congenital malformations. Absence of all or part of a limb at birth is not an uncommon occurrence. Many factors seem to be involved in such occurrences, but what these factors are is not clear. The most frequent case is absence of most of the left forearm, which occurs slightly more often in girls than in boys. However, all sorts of combinations occur, including complete absence of all four extremities. Sometimes intermediate parts such as the thigh or upper arm are missing but the other parts of the extremity are present, usually somewhat malformed. In such cases amputation may be indicated; however, even a weak, malformed part is sometimes worth preserving if sensation is present and the partial member is capable of controlling some part of the prosthesis. Extensive studies are being carried out to determine the reasons for congenital malformations.</p> <h3>Losses Incurred</h3> <p>Many of the limitations resulting from amputation are obvious; others less so. An amputation through the lower extremity makes standing and locomotion without the use of an artificial leg or crutches difficult and impracticable except for very short periods. Even when an artificial leg is used, the loss of joints and the surrounding tissues, and consequently loss of the ability to sense position, is felt keenly. The sense of touch of the absent portion is also lost, but in the case of the lower-extremity amputee this is not quite as important as it might seem because the varying pressure occurring between the stump and the socket indicates external loading. In the upper-extremity amputee, sense of touch is more important.</p> <p>Most lower-extremity amputees cannot bear the total weight of the body on the end of the stump, and other parts of the anatomy must be found for support.</p> <p>Muscles attached at each end to bones are responsible for movement of the arms and legs. Upon a signal from the nervous system muscle tissue will contract, thus producing a force which can move a bone about its joint (<b>Fig. 8</b>). Because muscle force can be produced only by contraction, each muscle group has an opposing muscle group so that movement in two directions can take place. This arrangement also permits a joint to be held stable in any one of a vast number of positions for relatively long periods of time. How much a muscle can contract is dependent upon its length, and the amount of force that can be generated is dependent upon its circumference.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Schematic drawing of muscular action on skeletal system. The motion shown here is flexion, or bending, of the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Muscles that activate the limbs must of course pass over at least one joint to provide a sort of pulley action; some pass over two. Thus, some muscles are known as one-joint muscles, others as two-joint muscles. When muscles are severed completely, they can no longer transmit force to the bone and, when not used, wither away or atrophy. It will be seen later that these facts are very important in the rehabilitation of amputees.</p> <h3>Types of Amputation</h3> <p>Amputations are generally classified according to the level at which they are performed (<b>Fig. 9</b>). Some amputation levels are referred to by the name of the surgeon credited with developing the amputation technique used. The general rule in selecting the site of amputation is to save all length that is medically possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Classification of amputation by level. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Lower-Extremity Amputations</h4> <p><i>Syme's Amputation</i></p> <p>Developed about 1842 by James Syme, a leading Scottish surgeon, the Syme amputation leaves the long bones of the shank (the tibia and fibula) virtually intact, only a small portion at the very end being removed (<b>Fig. 10</b>).<a></a> The tissues of the heel, which are ideally suited to withstand high pressures, are preserved, and this, in combination with the long bones, usually permits the patient to bear the full weight of his body on the end of the stump. Because the amputation stump is nearly as long as the unaffected limb, a person with Syme's amputation can usually get about the house without a prosthesis even though normal foot and ankle action has been lost. Atrophy of the severed muscles that were formerly attached to bones in the foot to provide ankle action results in a stump with a bulbous end which, though not of the most pleasing appearance, is quite an advantage in holding the prosthesis in place.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Excellent Syme stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since its introduction, Syme's operation has been looked upon with both favor and disfavor among surgeons. It seems to be the consensus now that "the Syme" should be performed in preference to amputation at a higher level if possible. In the case of most women, though, "the Syme" is undesirable because of the difficulty of providing a prosthesis that matches the shape of the other leg.</p> <p><i>Below-Knee Amputations</i></p> <p>Any amputation above the Syme level and below the knee joint is known as a below-knee amputation. Because circulatory troubles have often developed in long below-knee stumps, and because the muscles that activate the shank are attached at a level close to the knee joint, the below-knee amputation is usually performed at the junction of the upper and middle third sections (<b>Fig. 11</b>). Thus nearly full use of the knee is retained-an important factor in obtaining a gait of nearly normal appearance. However, it is rare for a below-knee amputee to bear a significant amount of weight on the end of the stump; thus the design of prostheses must provide for weight-bearing through other areas. Several types of surgical procedures have been employed to obtain weight-bearing through the end of the below-knee stump, but none has found widespread use.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical, well-formed, right below-knee stump. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Knee-Bearing Amputations</i></p> <p>Complete removal of the lower leg, or shank, is known as a knee disarticulation. When the operation is performed properly, the result is an efficient, though bulbous, stump (<b>Fig. 12</b>) capable of carrying the weight-bearing forces through the end. Unfortunately, the length causes some problems in providing an efficient prosthesis because the space used normally to house the mechanism needed to control the artificial shank properly is occupied by the end of the stump. Nevertheless, excellent prostheses can be provided the knee-disar-ticulation case.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Typical knee-disarticulation stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Several amputation techniques have been devised in an attempt to overcome the problems posed by the length and shape of the true knee-disarticulation stump. The Gritti-Stokes procedure entails placing the kneecap, or patella, directly over the end of the femur after it has been cut off about two inches above the end. When the operation is performed properly, excellent results are obtained, but extreme skill and expert postsurgical care are required. Variations of the Gritti-Stokes amputation have been introduced from time to time but have never been used widely.</p> <p><i>Above-Knee Amputations</i></p> <p>Amputations through the thigh are among the most common (<b>Fig. 13</b>). Because of the high pressures exerted on the soft tissues by the cut end of the bone, total body weight cannot be taken through the end of the stump but can be accommodated through the ischium, that part of the pelvis upon which a person normally sits.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Typical, well-formed above-knee stump-Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Hip Disarticulation and Hemipelvectomy</i></p> <p><i>A </i>true hip disarticulation (<b>Fig. 14</b>) involves removal of the entire femur, but whenever feasible the surgeon leaves as much of the upper portion of the femur as possible in order to provide additional stabilization between the prosthesis and the wearer, even though no additional function can be expected over the true hip disarticulation.<a></a> Both types of stump are provided with the same type of prosthesis. With slight modification the same type of prosthesis can be used by the hemipelvectomy patient, that is, when half of the pelvis has been removed. It is surprising how well hip-disarticulation and hemipelvectomy patients have been able to function when fitted with the newer type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Patient with true hip-disarticulation amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Upper-Extremity Amputations</h4> <p><i>Partial-Hand Amputations</i></p> <p>If sensation is present the surgeon will save any functional part of the hand in lieu of disarticulation at the wrist. Any method of obtaining some form of grasp, or prehension, is preferable to the best prosthesis. If the resuit is unsightly, the stump can be covered with a plastic glove, lifelike in appearance, for those occasions when the wearer is willing to sacrifice function for appearance. Many pros-thetists have developed special appliances for partial-hand amputations that permit more function than any of the artificial hands and hooks yet devised and, at the same time, permit the patient to make full use of the sensation remaining in the stump. Such devices are usually individually designed and fitted.</p> <p><i>Wrist Disarticulation</i></p> <p>Removal of the hand at the wrist joint was once condemned because it was thought to be too difficult to fit so as to yield more function than a shorter forearm stump. However, with plastic sockets based on anatomical and physiological principles, the wrist-disarticulation case can now be fitted so that most of the pronation-supination of the forearm-an important function of the upper extremity-can be used. In the case of the wrist disarticulation (<b>Fig. 15</b>), nearly all the normal forearm pronation-supination is present. Range of pronation-supination decreases rapidly as length of stump decreases; when 60 per cent of the forearm is lost, no pronation-supination is possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. A good wrist-disarticulation stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Amputations Through The Forearm</i></p> <p>Amputations through the forearm are commonly referred to as below-elbow amputations and are classified as long, short, and very short, depending upon the length of stump (<b>Fig. 9</b>). Stumps longer than 55 per cent of total forearm length are considered long, between 35 and 55 per cent as short, and less than 35 per cent as very short.</p> <p>Long stumps retain the rotation function in proportion to length; long and short stumps without complications possess full range of elbow motion and full power about the elbow, but often very short stumps are limited in both power and motion about the elbow. Devices and techniques have been developed to make full use of all functions remaining in the stump.</p> <p><i>Disarticulation At The Elbow</i></p> <p>Disarticulation at the elbow consists of removal of the forearm, resulting in a slightly bulbous stump (<b>Fig. 16</b>) but usually one with good end-weight-bearing characteristics. The long bulbous end, while presenting some fitting problems, permits good stability between socket and stump, and thus allows use of nearly all the rotation normally present in the upper arm-a function much appreciated by the amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Amputation through the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Above-Elbow Amputation</i></p> <p>Any amputation through the upper arm is generally referred to as an above-elbow amputation (<b>Fig. 9</b>). In practice, stumps in which less than 30 per cent of the humerus remains are treated as shoulder-disarticulation cases; those with more than 90 per cent of the humerus remaining are fitted as elbow-disar-ticulation cases.</p> <p><i>Shoulder Disarticulation And Forequarter Amputation</i></p> <p>Removal of the entire arm is known as shoulder disarticulation but, whenever feasible, the surgeon will leave intact as much of the humerus as possible to provide stability between the stump and the socket (<b>Fig. 17</b>). When it becomes necessary to remove the clavicle and scapula, the operation is known as a forequarter, or interscapulothoracic, amputation. The very short above-elbow, the shoulder-disarticulation, and the forequarter cases are all provided with essentially the same type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. A true shoulder disarticulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Postsurgical Period</h3> <p>The period between the time of surgery and time of fitting the prosthesis is an important one if a good functional stump, and thus the most efficient use of a prosthesis, is to be obtained. The surgeon and others on his hospital staff will do everything possible to ensure the best results, but ideal results require the wholehearted cooperation of the patient.</p> <p>It is not unnatural for the patient to feel extremely depressed during the first few days after surgery, but after he becomes aware of the possibilities of recovery, the outlook becomes brighter, and he generally enters cooperatively into the rehabilitation phase.</p> <p>It has been generally agreed through the years that the earlier a patient could be fitted the easier would be the rehabilitation process. However, until a few years ago, virtually no patients were provided with a prosthesis before six weeks after amputation, and such cases were rare, the average time probably being closer to four months.</p> <p>With the advent of improved cast-taking methods, and temporary legs in which alignment can be easily adjusted, Duke University, about 1960, began an experiment to determine the earliest practical time after surgery for providing amputees with limbs. By 1963 it had been shown clearly that it was not only practical but desirable to fit a temporary, but well-fitted, limb as soon as the sutures were removed some two to three weeks after surgery. In 1963 Dr. Marian Weiss of Poland, in an address in Copenhagen, reported success with fitting amputees immediately after surgery while the patient was still anesthetized, and beginning ambulation training the day after.<a></a>Dr. Weiss's work stimulated similar work in this country, notably at the University of California, San Francisco; the Oakland Naval Hospital; Prosthetics Research Study, Seattle, Washington; Duke University; the University of Miami; Marquette University; and New York University. Results with over 400 patients of all types have shown immediate postsurgical fitting of prostheses to be the method of choice when possible. Healing seems to be accelerated, postsurgical pain is greatly alleviated, contractures are prevented from developing, phantom pain seems to be virtually nonexistent, less psychological problems seem to ensue, and patients are returned to work or home at a much earlier date than seemed possible only a few years ago.</p> <p>The procedure consists essentially of providing a rigid plaster dressing over the stump which serves as a socket, and the use of an adjustable leg which can be removed and reinstalled easily (<b>Fig. 18</b>).<a></a> The cast-socket is left in place for 10 to 12 days during which ambulation is encouraged. At the end of this time the cast-socket is removed, the stitches are usually taken out, and a new cast-socket is provided immediately. The original prosthetic unit is replaced and realigned. The second cast-socket is left in place for eight to ten days at which time a new cast can be taken for the permanent, or definitive, prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Schematic cross section showing most of the elements of the application of a prosthesis to a below-knee amputee immediately after surgery. The suture line, silk dressing, and drain are not shown for the sake of clarity. View "A" is an enlarged schematic section of the cast socket, prosthetic unit attachment straps, stump sock, and fluffed gauze at the distal portion of the stump. The fluffed gauze does not extend beyond the area indicated. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Special courses in immediate postsurgical fitting and early fitting are being offered to qualified prosthetics clinic teams by Northwestern University, the University of California at Los Angeles, and New York University.</p> <h4>Contractures</h4> <p>When immediate postsurgical fitting is employed there is little opportunity for contractures to develop. When these procedures are not used, it is most important to avoid the development of muscle contractures. They can be prevented easily but it is most difficult, and sometimes impossible, to correct them. At first exercises are administered by a therapist or nurse; later the patient is instructed concerning the type and amount of exercise that should be undertaken. The patient is also instructed in methods and amount of massage that should be given the stump to aid in the reduction of the stump size. Further, to aid shrinkage, cotton-elastic bandages are wrapped around the stump (<b>Fig. 19</b>) and worn continuously until a prosthesis is fitted. The bandage is removed and reapplied at regular intervals- four times during the day, and at bedtime. It is most important that a clean bandage is available for use each day.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Compression wrap for above-knee amputation. The wrap of elastic bandage aids in shrinking the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee is taught to apply the bandage unless it is physically impossible for him to do so, in which case some member of his family must be taught the proper method for use at home.</p> <p>To reduce the possibility of contractures, the lower-extremity stump must not be propped upon pillows. Wheelchairs should be used as little as possible; crutch walking is preferred, but the above-knee stump must not be allowed to rest on the crutch handle (<b>Fig. 20</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Actions to be avoided by lower-extremity amputees during the immediate postoperative period. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Phantom Sensation</h4> <p>After amputation the patient almost always has the sensation that the missing part is still present. The exact cause of this is as yet unknown. The phantom sensation usually recedes to the point where it occurs only infrequently or disappears entirely, especially if a prosthesis is used. In a large percentage of cases, moderate pain may accompany the phantom sensation but, in general, this too eventually disappears entirely or occurs only infrequently. In a small percentage of cases severe phantom pain persists to the point where medical treatment is necessary.<a></a> </p> <h3>Prostheses for Various Types of Amputation</h3> <p>Much time and attention have been devoted to the development of mechanical components, such as knee and ankle units, for artificial limbs, yet by far the most important factors affecting the successful use of a prosthesis are the fit of the socket to the stump and the alignment of the various parts of the limb in relation to the stump and other parts of the body.</p> <p>Thus, though many parts of a prosthesis may be mass-produced, it is necessary for each limb to be assembled in correct alignment and fitted to the stump to meet the individual requirements of the intended user. To make and fit artificial limbs properly requires a complete understanding of anatomical and physiological principles and of mechanics; craftsmanship and artistic ability are also required.</p> <p>In general, an artificial limb should be as light as possible and still withstand the loads imposed upon it. In the United States willow and woods of similar characteristics have formed the basis of construction for more limbs than any other material, though aluminum, leather-and-steel combinations, and fibre have been used widely. Plastic laminates so popular in small-boat construction form the basis for construction of most artificial limbs. Some artificial legs are made of wood, and occasionally leather is used for sockets, but the trend is toward the plastic laminates. They are light in weight, easy to keep clean, and do not absorb perspiration. They may be molded easily and rapidly over contours such as those found on a plaster model of a stump. Plastic laminates can be made extremely rigid or with any degree of flexibility required in artificial-limb construction. In some instances, especially in upper-extremity sockets, the fact that most plastic laminates do not permit water vapor to pass to the atmosphere has caused discomfort, but recently a porous type has been developed by the Army Medical Biomechanical Research Laboratory (formerly the Army Prosthetics Research Laboratory). Except experimentally, its use thus far has been restricted to artificial arms. Of course, most of the mechanical parts are made of steel or aluminum, depending upon their function.</p> <p>As in the case of the tailor making a suit, the first step in fabrication of a prosthesis is to take the necessary measurements for a good fit. If the socket is to be fabricated of a plastic laminate, an impression of the stump is made. Most often this is accomplished by wrapping the stump with a wet plaster-of-Paris bandage and allowing it to dry, as a physician does in applying a cast when a bone is broken (<b>Fig. 21</b>). A number of devices have been introduced in recent years to aid the prosthetist in obtaining accurate casts rapidly <i><a></a>. </i>Most use an apparatus that permits the patient to absorb some of the weight-bearing load through the affected side while the cast is being formed (<b>Fig. 22</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Steps in the fabrication of a plastic prosthesis for a below-knee amputation. A, Taking the plaster cast of the stump; B, pouring plaster in the cast to obtain model of the stump; C, introducing plastic resin into fabric pulled over the model to form the plastic-laminate socket; D, the plastic-laminate socket mounted on an adjustable shank for walking trials; E, a wooden shank block inserted in place of the adjustable shank after proper alignment has been obtained; F, the prosthesis after the shank has been shaped. To reduce weight to a minimum the shank is hollowed out and the exterior covered with a plastic laminate. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Special jig developed by the Veterans Administraton Prosthetics Center to facilitate casting above-knee stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast, or wrap, is removed from the stump and filled with a plaster-of-Paris solution to form an exact model of the stump which-after being modified to provide relief for any tender spots, to ensure that weight will be taken in the proper places, and to take full advantage of the remaining musculature can be used for molding a plastic-laminate socket. Often a "check" socket of cloth impregnated with beeswax is made over the model and tried on the stump to determine the correctness of the modifications.</p> <p>For upper-extremity cases the socket is attached to the rest of the prosthesis and a harness is fabricated and installed for operation of the various parts of the artificial arm. For the lower-extremity case the socket is fastened temporarily to an adjustable, or temporary, leg for walking trials (<b>Fig. 23</b>). With this device, the prosthetist can easily adjust the alignment until both he and the amputee are satisfied that the optimum arrangement has been reached. A prosthesis can now be made incorporating the same alignment achieved with the adjustable leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Using the above-knee adjustable leg and alignment duplication jig. Top, Adjusting the adjustable leg during walking trials; Center, the socket and adjustable leg in the alignment duplication jig; Bottom, replacement of the adjustable leg with a permanent knee and shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An even more refined procedure uses the "Staros-Gardner" coupling (<b>Fig. 24</b>).<a></a> Not only is the need for the alignment jig eliminated but in the case of above-knee fittings the alignment adjustments can be made with the knee unit that is to be used permanently, an important factor when sophisticated knee units are used because the present adjustable leg is available with only a single-axis, constant-friction joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Adjustable coupling used for alignment of artificial legs. This unit was designed by the Veterans Administration Prosthetics Center and is suitable for below-knee as well as above-knee legs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>There are many kinds of artificial limbs available for each type of amputation, and much has been written concerning the necessity for prescribing limbs to meet the needs of each individual. This of course is true particularly in the case of persons in special or arduous occupations, or with certain medical problems, but actually limbs for a given type of amputation vary to only a small degree. Following are descriptions of the artificial limbs most commonly used in the United States today.</p> <h4>Lower-Extremity Prostheses</h4> <p><i>Prostheses For Syme's Amputation</i></p> <p>Perhaps the major reason Syme's amputation was held in such disfavor in some quarters was the difficulty in providing a comfortable, sufficiently strong prosthesis with a neat appearance. The short distance between the end of the stump and the floor made it extremely difficult to provide for ankle motion needed.</p> <p>Most Syme prostheses were of leather reinforced with steel side bars resulting in an ungainly appearance (<b>Fig. 25</b>). Research workers at the Prosthetic Services Centre at the Department of Veterans Affairs of Canada were quick to realize that the use of the proper plastic laminate might solve many of the problems long associated with the Syme prosthesis. After a good deal of experimentation, the Canadians developed a model in 1955 which, with a few variations, is used almost universally in both Canada and the United States today (<b>Fig. 26</b>)<a></a>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Syme prosthesis with side bars mounted on medial and lateral aspects of the shank. This type of construction has been virtually replaced by plastic laminates. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. The Syme prosthesis adopted by the Canadian Department of Veterans Affairs. The posterior opening extends the length of the shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Necessary ankle action is provided by making the heel of the foot of sponge rubber. The socket is made entirely of a plastic laminate. A full-length cutout in the rear permits entry of the bulbous stump. When the cutout is replaced and held in place by straps, the bulbous stump holds the prosthesis in place. In the American version (<b>Fig. 27</b>), a window-type cutout is used on the side because calculations show that smaller stress concentrations are present with such an arrangement.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Two views of the Canadian-type Syme prosthesis as modified by the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In those cases where, for poor surgery or other reasons, full body weight cannot be tolerated on the end of the stump, provisions can be made to transfer all or part of the load to the area just below the kneecap. When this procedure is necessary, it can be accomplished more easily by use of the window-type cutout.</p> <p><i>Prostheses For Below-Knee A mputations</i></p> <p>Until recently most below-knee amputees were fitted with wooden prostheses carved out by hand (<b>Fig. 28</b>). A good portion of the body weight was carried on a leather thigh corset, or lacer, attached to the shank and socket by-means of steel hinges. The shape of corset and upper hinges also held the prosthesis to the stump. The distal, or lower, end of the socket was invariably left open. Other versions of this prosthesis used aluminum, fibre or molded leather, as the materials for construction of the shank and socket, but the basic principle was the same. Many thousands of below-knee amputees have gotten along well with this type of prosthesis, but there are many disadvantages. Because the human knee joint is not a simple, single-axis hinge joint, relative motion is bound to occur between the prosthesis and the stump and thigh during knee motion when single-jointed side hinges are used, resulting in some chafing and irritation. To date it has not been possible to devise a hinge to overcome this difficulty. Edema, or accumulation of body fluids, was often present at the lower end of the stump. Most of these prostheses were exceedingly heavy, especially those made of wood.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Below-knee prosthesis with wood socket-shank, thigh corset, and steel side bars. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In an attempt to overcome these difficulties, the Biomechanics Laboratory of the University of California, in 1958, designed what is known as the patellar-tendon-bearing (PTB) below-knee prosthesis (<b>Fig. 29</b>). In the PTB prosthesis no lacer and side hinges are used, all of the weight being taken through the stump by making the socket high enough to cover all the tendon below the patella, or kneecap.<a></a> The patellar tendon is an unusually inelastic tissue which is not unduly affected by pressure. The sides of the socket are also made much higher than has usually been the practice in the past in order to give stability against side loads. The socket is made of molded plastic laminate that provides an intimate fit over the entire area of the socket, and is lined with a thin layer of sponge rubber and leather. Because it is rare for a below-knee stump to bear much pressure on its lower end, care is taken to see that only a very slight amount is present in that area. This feature has been a big factor in eliminating the edema problem in many instances. The PTB prosthesis is generally suspended by means of a simple cuff, or strap, around the thigh just above the kneecap, but sometimes a strap from the prosthesis to a belt around the waist is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Cutaway view of the patellar-tendon-bear-ing leg for below-knee amputees. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the socket has been made, it is installed on a special adjustable leg (<b>Fig. 30</b>) so that the prosthetist can try various alignment combinations with ease. When both prosthetist and patient are satisfied, the leg is completed utilizing the alignment determined with the adjustable unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Trial below -knee adjustable leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The shank recommended is of plastic laminate and the foot prescribed is usually the SACH (solid-ankle, cushion-heel) design but other types can be used.</p> <p>It is now general practice in many areas to prescribe the PTB prosthesis in most new cases and in many old ones, and if side hinges and a corset are indicated later, these can be added.</p> <p>Stumps as short as two and one-half inches have been fitted successfully with the PTB prosthesis.</p> <p>In special cases, such as extreme flexion contracture, the so-called kneeling-knee, or bent-knee, prosthesis may be indicated. The prosthesis used is similar to that used for the knee-disarticulation case.</p> <p>Several simplified adjustable shanks have been made available recently expressly for use in the immediate postsurgical fitting technique (<b>Fig. 31</b>). Straps are provided for lamination into the plaster cast-socket. Provisions are incorporated for adjustability in all planes. The shank and foot can be connected to and disconnected from the socket easily and quickly. Although these units were designed for temporary use, they are sturdy enough for use on a permanent basis. A natural appearance can be obtained by using plastic cosmetic covers.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Prosthetic unit designed especially for fitting below-knee cases immediately after surgery. The stainless steel straps are laminated into the plaster socket. All parts below the top plate are easily removed without affecting alignment. A sach foot is normally used with this device. Although designed for temporary use, this device can form part of a "permanent" prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Knee-Disarticulation And Other Knee-Bearing Cases</i></p> <p>Because of the bulbous shape of the true knee-disarticulation stump, it is not possible to use a wooden socket of the type used on the tapered above-knee stump. To allow entry of the bulbous end, a socket is molded of leather to conform to the stump and is provided with a lengthwise anterior cutout that can be laced to hold the socket in position (<b>Fig. 32</b>). The length of the knee-disarticulation and supracondylar stump makes it difficult to install any of the present knee units designed for above-knee prostheses and, therefore, heavy-duty below-knee joints are generally used. Most prosthetists try to provide some control of the shank during the swing phase of walking by inserting nylon washers between the mating surfaces of the joint to provide friction and by using checkstraps. Some prosthetists have installed commercially available piston-type hydraulic swing-phase control units, but this requires extreme care to achieve the proper result.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Typical knee-disarticulation prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For Above-Knee Cases</i></p> <p>The articulated above-knee leg is in effect a compound pendulum actuated by the thigh stump. If the knee joint is perfectly free to rotate when force is applied, the effects of inertia and gravity tend to make the shank rotate too far backward and slam into extension as it rotates forward, except at a very slow rate of walking. The method most used today to permit an increase in walking speed is the introduction of some restraint in the form of mechanical friction about the knee joint. The limitation imposed by constant mechanical friction is that for each setting there is only one speed that produces a natural-appearing gait. When restraint is provided in the form of hydraulic resistance, a much wider range of cadence can be obtained without introducing into the gait pattern awkward and unnatural motions.</p> <p>In recent years a number of hydraulic units have been made available for control of the shank during the swing phase. Among them are the DuPaCo, the Henschke-Mauch Model <i>"B" </i>(<b>Fig. 33</b>), and the Hydra-Knee. These units are all of the piston-cylinder-type, provide for swing-phase control only, and are designed so that they can be incorporated into the more conventional leg structures. The Hydra-Cadence leg (<b>Fig. 34</b>), a complete knee-shin-foot unit, in addition to providing swing-phase control hydraulically, uses the hydraulic system to control ankle action in concert with knee motion. After the knee is flexed 20 deg., the toe of the foot is lifted as the knee is flexed further, thereby giving more clearance between the foot and the floor as the leg swings through.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. The Henschke-Mauch "HYDRAULIK" set-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. The Hydra-Cadence Leg without cosmetic cover. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Throughout the past century much time and effort have been spent in providing an automatic brake or lock at the knee in order to provide stability during the stance phase and to reduce the possibility of stumbling. Stability during the stance phase can be obtained by aligning the leg so that the axis of the knee is behind the hip and ankle axes. For most above-knee amputees in good health, such an arrangement has been quite satisfactory, but an automatic knee brake is indicated for the weaker or infirm patients.</p> <p>When an automatic brake is indicated, the Bock, the "Vari-Gait" 100, and the Mortensen knee units (<b>Fig. 35</b>) are the ones most generally used. All are actuated upon contact of the heel with the ground. The Bock and "Vari-Gait" units can be used with almost any type of foot, while a foot of special design is necessary when the Mortensen mechanism is used. A promising stance-phase control unit currently being evaluated is the Henschke-Mauch Model "A" hydraulic unit. The Model "A" unit contains the same swing-phase control device as the Model "B" and provides a braking action about the knee when there is a tendency to buckle. The braking action is brought about by the attitude of a pendulum which in turn is controlled by the inertia forces in the shank. The Model "A" and Model "B" units are interchangeable.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Some examples of weight-actuated knee units. A, Bock "Safety-knee"; B, Vari-Gait knee; C, Mortensen leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A number of methods for suspending the above-knee leg are available. For younger, healthy patients, the suction socket (<b>Fig. 36</b>A) has generally been the method of choice. In this design the socket is simply fitted tightly enough to retain sufficient negative pressure, or suction, between the stump and the bottom of the socket when the leg is off the ground. Special air valves are used to control the amount of negative pressure created so as not to cause discomfort. No stump sock is worn with the suction socket. A major advantage of this type of suspension is the freedom of motion permitted the wearer, thus allowing the use of all the remaining musculature of the stump. Another important advantage is the decreased amount of piston action between stump and socket. Additional comfort is also obtained by elimination of all straps and belts.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Above-knee sockets and methods of suspension. A, Total-contact suction socket; B, above-knee leg with Silesian bandage for suspension; C, above-knee leg with pelvic belt for suspension. Most above-knee sockets have a quadrilateral-shaped upper portion as shown. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In some cases additional suspension is provided by adding a "Silesian Bandage," (<b>Fig. 36</b>B),a light belt attached to the socket in such a way that there is very little restriction of motion of the various parts of the body.</p> <p>Patients with weak stumps and most of those with very short stumps will require a pelvic belt connected to the socket by means of a "hip" joint (<b>Fig. 36</b>C). Because the connecting joint cannot be placed to coincide with the normal joint, certain motions are restricted. Pelvic-belt suspension is generally indicated for the older patient because of the problems encountered in donning the suction socket, especially that of bending over to remove the donning sock.</p> <p>Shoulder straps, at one time the standard method of suspending above-knee prostheses, are still sometimes indicated for the elderly patient.</p> <p>Prior to the introduction of the suction socket into the United States soon after the close of World War II, virtually all above-knee sockets had a conical-shaped interior and were known as plug fits, most of the weight being borne along the sides of the stump. Such a design does not permit the remaining musculature to perform to its full capabilities. In the development of the suction socket, a design known as the quadrilateral socket (<b>Fig. 36</b>) evolved, and now is virtually the standard for above-knee sockets regardless of the type of suspension used. When the pelvic belt or suspender straps are used, the socket is fitted somewhat looser than in the case of the suction socket, and the stump sock is generally worn to reduce skin irritation from the pumping action of the loose socket. Most of the body weight is taken on the ischium of the pelvis, that part which assumes the load when an individual is sitting.</p> <p>The quadrilateral socket, because of the method employed to permit full use of the remaining muscles, does not resemble the shape of the stump but, as the name implies, is more rectangular in shape. Until recently the standard method of fitting a quadrilateral socket called for no contact over the lower end of the stump, a hollow space being left in this area. Although this method was quite successful there remained a sufficient number of cases that persistently developed ulcers or edema over the end of the stump. Experiments involving the use of slight pressure over the stump-end led to the development of what is known as the plastic total-contact socket.<a></a></p> <p>(<b>Fig. 36</b>A). As the name implies, the socket is in contact with the entire surface of the stump. In taking some pressure over the end of the stump, the pressure on the ischium area is reduced, thereby providing more comfort to the patient. It also appears that the pressure over the end of the stump helps circulation and improves proprioception. Today the total-contact socket is the method of choice for use by above-knee amputees.</p> <p>In fitting the wooden above-knee prosthesis, the prosthetist carves the interior of the socket using measurements of the stump as a guide. When a satisfactory fit has been achieved the socket is usually mounted on an adjustable leg for alignment trial, after which the wooden shank and the knee are substituted for the adjustable unit and the leg is finished by applying a thin layer of plastic laminate over the shank and the thigh piece.</p> <p>In the case of the total-contact socket, the prosthetist obtains a plaster cast of the stump, usually with the aid of a special casting jig (<b>Fig. 22</b>), and thus obtains a model of the stump over which the plastic socket can be formed.</p> <p>Special adjustable pylon-type legs (<b>Fig. 37</b> and <b>Fig. 38</b>) are available for fitting immediately after surgery, or use as a temporary leg. Provisions are made for all necessary adjustments, and a manually operated knee lock is provided for use by infirm patients.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Prosthetic unit designed especially for fitting above-knee cases immediately after surgery. The same principles used in the below-knee device (Fig. 31.) are incorporated. In addition, mechanical friction about the "knee" axis and a mechanical "knee" lock are provided. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Prosthetic unit designed especially for fitting above-knee cases immediately after surgery. This is essentially the same unit shown in Fig. 37. except that hydraulic resistance instead of mechanical friction is provided about the knee joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For Hip-Disarticulation And Hemi-pelveclomy Cases</i></p> <p>A prosthesis (<b>Fig. 39</b>) developed by the Canadian Department of Veterans Affairs in 1954 and modified slightly through the years has become accepted as standard practice. In the Canadian design a plastic-laminate socket is used, and the "hip" joint is placed on the front surface in such a position that, when used with an elastic strap connecting the rear end of the socket to a point on the shank ahead of the femur, stability during standing and walking can be achieved without the use of a lock at the hip joint. The location of the hip joint in the Canadian design also facilitates sitting, a real problem in earlier designs.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Hip-disarticulation prosthesis, known as the Canadian-type because its principle was originally conceived by workers at the Department of Veterans Affairs of Canada. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A constant-friction knee unit is most often used with the hip-disarticulation prosthesis, but some prosthetists have reported successful use of hydraulic knee units.</p> <p>The hemipelvectomy patient is provided with the same type of prosthesis but the socket design is altered to allow for the loss of part of the pelvis.</p> <h4>Upper-Extremity Prostheses<a></a></h4> <p>The major role of the human arm is to place the hand where it can function and to transport objects held in the hand. The energy for operation of the hand substitute in upper-extremity prostheses is derived from relative motion between two parts of the body. Energy for operation of the elbow joint, when necessary, can be obtained in the same way. The stump, of course, is also a source of energy for control of the prosthesis in all except the shoulder-disarticulation and forequarter cases. Force and motion can be obtained through a cable connected between the device to be operated and a harness across the chest or shoulders.</p> <p>In recent years artificial arms powered by electricity have received considerable publicity. An artificial hand powered by electricity and controlled by electrical signals from muscles has been developed in Russia for below-elbow amputees. Versions of the Russian design are available in England and Canada. Similar devices have also been developed in Austria and Italy. However, the below-elbow patient, of all the types of upper-extremity amputees, is the least handicapped and therefore less in need of sophisticated devices. The devices are expensive and in their present state of development seem to offer no real advantage over the simpler conventional devices. The real need is for patients with amputations above the elbow and higher. Efforts to develop useful externally powered arms, both electrical and pneumatic, are being made in both the United States and abroad, especially in reference to severely handicapped children <a></a>.</p> <p><i>Hand Substitutes - Terminal Devices</i></p> <p>All upper-extremity prostheses for amputation at the wrist level and above have, in common, the problem of selection of the terminal device, a term applied to artificial hands and substitute devices such as hooks. In some areas of the world there is a tendency to supply the arm amputee with a number of devices, each designed for a specific task such as eating, shaving, hairgrooming, etc. In the United States such an approach has been considered too clumsy, and opinion has been that the terminal device should be designed so that most upper-extremity amputees can perform the activities of daily living with a single device, or at most with two devices.</p> <p>The so-called split hooks are much more functional than any artificial hand devised to date. The arm amputee must rely heavily upon visual cues in handling objects and the hook offers more visibility. The hook also offers more prehension facility, and can be more easily introduced into and withdrawn from pockets than a device in the form of a hand. Therefore, the hook is used in manual occupations and those avocations requiring manual dexterity. When extensive contact with the public is necessary and for social occasions, the hand is of course generally preferred. Many amputees have both types of devices, using each as the occasion warrants.</p> <p>Two basic types of mechanism have been developed for terminal-device operation-voluntary-opening and voluntary-closing. In the former, tension on the control cable opens the fingers against an elastic force; in the latter, tension in the control cable closes the fingers against an elastic force. Each type of mechanism has its advantages and disadvantages, neither being superior to the other when used in a wide range of activities. Both hands and hooks are available with either type of mechanism.</p> <p>The major types of terminal devices are shown in <b>Fig. 40</b> and <b>Fig. 41</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. Voluntary-closing terminal devices. A, APRL-Sierra Hand; left, cutaway view showing mechanism; right, assembled hand without cosmetic glove; B, APRL-Sierra Hook. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Voluntary-opening terminal devices. The wide range of models offered by the D. W. Dor-rance Company includes sizes and designs for all ages. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Wrist-Disarticulation Case</i></p> <p>One of the problems in fitting the wrist disarticulation in the past has been to keep the overall length of the prosthesis commensurate with the normal arm. The development of very short wrist units, especially for wrist-disarticulation cases, has materially reduced this problem. However, these units are available in only the screw, or thread, type, and cannot be obtained in the bayonet type which lends itself to quick interchange of terminal devices.</p> <p>The socket for the wrist-disarticulation case need not extend the full length of the forearm and is fitted somewhat loosely at the upper, or proximal, end to permit the wrist to rotate. A simple figure-eight harness and Bowden cable are used to operate the terminal device <b>Fig. 42</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Typical methods of fitting below-elbow amputees with medium to long stumps. Above, the figure-8, ring-type harness is most generally used. Where possible flexible leather hinges and open biceps cuff or pad are used. When more stability between socket and stump is required, rigid (metal) hinges and closed cuffs can be used (inserts A and B). In insert C, fabric straps are used for suspension in lieu of a leather billet. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Long Below-Elbow Case</i></p> <p>The prosthesis for the long below-elbow case is essentially the same as that for the wrist-disarticulation patient except that the quick-disconnect wrist unit can be used when desired.</p> <p><i>Prostheses For The Short Below-Elbow Case</i></p> <p>The socket for the short below-elbow stump, where there is no residual rotation of the forearm, is usually fitted snugly to the entire stump, and often rigid hinges connecting the socket to a cuff about the upper arm are used to provide additional stability. Either the figure-eight harness or the chest-strap harness may be used, the latter being preferred when heavy-duty work is required since it tends to spread the loads involved in lifting over a broader area than is the case with the figure-eight design.</p> <p>A wrist-flexion unit, which permits the terminal device to be tilted in toward the body for more effective use, can be provided in the short below-elbow prosthesis but is seldom prescribed for unilateral cases.</p> <p><i>Prostheses For The Very Short Below-Elbow Case</i></p> <p>Often the very short below-elbow case cannot control the prosthesis of the short below-elbow type through the full range of motion, either because of a muscle contracture or because the stump is too short to provide the necessary leverage.</p> <p>When a contracture is present that limits the range of motion of the stump, a "split-socket" and "step-up" hinge may be used. With this arrangement of levers and gears, movement of the stump through one degree causes the prosthetic forearm to move through two degrees; thus, a stump that has only about half the normal range of motion can drive the forearm through the desired 135 deg. However, when the step-up hinge is used, twice the normal force is required. When the stump is incapable of supplying the force required, it can be assisted by employing the "dual-control" harness wherein force in the terminal-device control cable is diverted to help lift the forearm. When the elbow stump is very short or has a very limited range of motion, an elbow lock operated by stump motion is employed to obtain elbow function.</p> <p>Recently a number of prosthetists have reported success in fitting very short below-elbow cases with an arm which is bent to give a certain amount of prerlexion. This type of fitting, which was developed in Munster, West Germany, eliminates the necessity for using the rather clumsy step-up hinges and split socket, thus providing improved prosthetic control without a disadvantageous force feedback. Furthermore, the harness is not necessary for suspension of the prosthesis. The maximum forearm flexion may be limited to about 100 deg., but this does not appear to be a significant disadvantage to unilateral amputees (<b>Fig. 43</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Comparison of split socket and Munster-type fitting of short below-elbow case. A, Split socket and step-up hinge provides 140 deg. of forearm flexion; B, Munster-type fitting permits less forearm flexion but enables the amputee to carry considerably greater weight with flexed prosthesis unsupported by harness. Courtesy New York University College of Engineering Prosthetic and Orthotic Research. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Elbow-Disarticulation Case</i></p> <p>Because of the length of the elbow-disarticulation stump, the elbow-locking mechanism is installed on the outside of the socket. Otherwise the prosthesis and harnessing methods (<b>Fig. 44</b>) are identical to those applied to the above-elbow case.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Typical prosthesis for the elbow-disarticulation case. The chest-strap harness with shoulder saddle is shown here, but the above-elbow figure-eight is also used. See Figure 45. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Above-Elbow Case</i></p> <p>For the above-elbow prosthesis to operate efficiently, it is necessary that a lock be provided in the elbow joint, and it is, of course, preferable that the lock is engaged and disengaged without resorting to the use of the other hand or pressing the locking actuator against an external object such as a table or chair.</p> <p>Several elbow units that can be locked and unlocked alternately by the same motion are available. This action is usually accomplished by the relative motion between the prosthesis and the body when the shoulder is depressed slightly and the arm is extended somewhat. The motion required is so slight that with practice the amputee can accomplish the action without being noticed. These elbow units contain a turntable above the elbow axis that permits the forearm to be positioned with respect to the humerus, supplementing the normal rotation remaining in the upper arm and thus allowing the prosthesis to be used more easily close to the mid-line of the body.</p> <p>The elbow units described above are available with an adjustable coil spring to assist in flexing the elbow when this is desired. The flexion-assist device may be added or removed without affecting the other operating characteristics.</p> <p>The plastic socket of the above-elbow prosthesis covers the entire surface of the stump. The most popular harness used is the figureeight dual-control design wherein the terminal-device control cable is also attached to a lever on the forearm so that, when the elbow is unlocked, tension in the control cable produces elbow flexion, and, when the elbow is locked, the control force is diverted to the terminal device (<b>Fig. 45</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Typical prosthesis for the above-elbow case. The figure-8 harness is shown here but the chest-strap harness with shoulder saddle may also be used. See Fig. 44. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The chest-strap harness may also be used in the dual-control configuration.</p> <p><i>Prostheses for the Shoulder-Disarticulation and Forequarter Cases</i></p> <p>Because of the loss of the upper-arm motion as a source of energy for control and operation of the prosthesis, restoration of the most vital functions in the shoulder-disarticulation case presents a formidable problem; for many years a prosthesis was provided for this type of amputation only for the sake of appearance. In recent years, however, it has been possible to make available prostheses which provide a limited amount of function (<b>Fig. 46</b>). To date it has not been possible to devise a shoulder joint that can be activated from a harness, but a number of manually operated joints are available. Various harness designs have been employed but, because of the wide variation in the individual cases and the marginal amount of energy available, no standard pattern has developed, each design being made to take full advantage of the remaining potential of the particular patient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Typical prosthesis for the shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For Bilateral Upper-Extremity Amputees</i></p> <p>Except for the bilateral, shoulder-disarticulation case, fitting the bilateral case offers few problems not encountered with the unilateral case. The prostheses provided are generally the same as those prescribed for corresponding levels in unilateral cases. Artificial hands are rarely used by bilateral amputees because hooks afford so much more function. Many bilateral cases find that the wrist-flexion unit, at least on one side, is of value. The harness for each prosthesis may be separated, but it is the general practice to combine the two (<b>Fig. 47</b>). In addition to being neater, this arrangement makes the harness easier for the patient to don unassisted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Harness for the bilateral below-elbow/ above-elbow case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Some prosthetists have claimed success in fitting bilateral shoulder-disarticulation cases with two prostheses. Because of the lack of sufficient sources of energy for control, most cases of this type are provided with a single, functional prosthesis and a plastic cap over the opposite shoulder which provides an anchor for the harness and also fills this area to present a better appearance (<b>Fig. 48</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Special harness arrangement for the bilateral shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Learning to Use the Prosthesis</h3> <p>To derive maximum benefit from his prosthesis, the amputee must understand how it functions and learn the best means of controlling it. A patient may be of the opinion that he is getting along very well when, in reality, he could do much better. Use of the prosthesis can best be learned under the supervision of an instructor who has had special training.</p> <p>All amputees using an artificial limb for the first time will need some instruction. In some instances, when a prosthesis is replaced with one of a different design, special instruction will be required. The time required for training depends upon the complexity of the device and the physical condition and degree of coordination of the patient. The time required will vary from a few hours to several weeks. In many instances amputees themselves have become excellent trainers, but more often such training is given by physical or occupational therapists. Usually, physical therapists instruct lower-extremity patients and occupational therapists teach upper-extremity cases.</p> <p>During the period of instruction, the trainer is careful to observe any effects the use of the prosthesis has on the patient, especially at points where the prosthesis is in contact with the body. Any changes are reported immediately to the physician in charge.</p> <h4>Lower-Extremity Cases</h4> <p>One of the major goals in training the leg amputee<a></a> is to enable him to walk as gracefully as possible. Training is begun as soon as the amputee is provided with a comfortable prosthesis. In the case of immediate postsurgical fitting,<a></a> training is begun usually on the day following surgery and an adjustable leg is used. There is a growing tendency to train lower-extremity amputees on legs with adjustable features even though they have not been fitted immediately after surgery. Some other goals of training are to teach the patient proper methods of donning the prosthesis, caring for the stump, arising after a fall, and use of canes and crutches when necessary. The type of training will, of course, depend upon the level of amputation.</p> <p>A patient with a Syme amputation needs a minimum of training. The average below-knee case will require somewhat more, though usually not extensive, unless other medical problems are present. The training required is usually quite extensive for patients who have lost the knee joint.</p> <p>The ability to balance oneself is the first prerequisite in learning to walk, and so it is balance that is taught first to the above-knee amputee. Two parallel railings are used to give the patient confidence and reduce the possibility of falling (<b>Fig. 49</b>). Balancing on both legs is practiced first, then on each leg. Walking in a straight line between the parallel bars is repeated until the patient no longer requires use of the hands for support. Walking in a straight line is practiced until the gait is even and smooth.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Above-knee patient being trained to walk by a physical therapist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a rhythmic gait has been accomplished, more difficult tasks are learned, such as pivoting, turning, negotiating stairs and ramps, and sitting on and arising from the floor.</p> <p>Most unilateral above-knee patients can use their prostheses quite well without the necessity for a cane. However, in the case of short, weak stumps it may be advisable to employ a cane for additional support and stability. If a cane is necessary, it should be selected to meet the needs of the patient, and it must be used properly if ungainly walking patterns are to be avoided. Canes with curved handles and made from a single piece of wood should be used. The shaft should not show any signs of buckling under the full load of the body weight, and should be just long enough so that the elbow is bent slightly when the bottom of the cane rests near the foot. The cane is used on the side opposite the amputation to help maintain balance but is not used to the extent that body weight is centered between the good leg and the cane (<b>Fig. 50</b>). Continued use of the cane in this manner usually results in a limp that is difficult to overcome. It has been found that, for biomechan-ical reasons, it is helpful for the amputee to carry a briefcase or purse on the side of the amputation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Above-knee patient being taught correct use of cane. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Training The Hip-Disarticulation Cases</i></p> <p>The training of hip-disarticulation cases follows much the same pattern as that for above-knee cases. With the advent of the Canadian-type prosthesis, the training procedure has been considerably simplified. Some special precautions must be taken to avoid stumbling while ascending stairs.</p> <p><i>Special Considerations For Bilateral Leg Cases</i></p> <p>As would be expected, bilateral-leg cases pose special problems in addition to those of the unilateral cases and, therefore, a good deal of time will usually be required in training. Patients with two good below-knee stumps will seldom require canes. Some bilateral above-knee amputees can get along without canes, but as a general rule at least one cane is required.</p> <h4>Upper-Extremity Cases</h4> <p>The first objective in the training program for upper-extremity amputees is to ensure that the patient can perform the activities encountered in daily living, such as eating, grooming, and toilet care. When this goal has been attained, attention is devoted to any special training that might be required in vocational pursuits (<b>Fig. 51</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. Upper-extremity amputees performing vocational tasks. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Before the prosthesis is put to useful purposes, the patient is shown how the various mechanisms are controlled and is made to practice these motions until they can be performed in a graceful manner and without undue exertion. In general, the arm amputee soon becomes so adept in these, procedures that they are carried out without conscious thought. During this period, the functioning of the prosthesis, especially of the harness and control cables, is watched carefully by the instructor and constantly rechecked to ensure maximum performance.</p> <p>Only when the patient has mastered use of the various controls is practice in the handling of objects and the performance of activities of daily living undertaken.</p> <h3>Care of the Stump</h3> <p>Even under the most ideal circumstances the amputation stump, when called upon to operate a prosthesis, is subjected to certain abnormal conditions which, if not compensated for, may lead to physical disorders which make the use of a prosthesis impossible.</p> <p>Lack of ventilation as a result of encasing the stump in a socket with impervious walls causes an accumulation of perspiration and other secretions of glands found in the skin. In addition to the solid matter in the secretions, bacteria will accumulate in the course of a day. Both the solid matter and bacteria can lead to infection, and the solid matter, though it may appear to be insignificant, may result in abrasions and the formation of cysts. For these reasons cleanliness of the stump and anything that comes in contact with it for any length of time is of the utmost importance, even when sockets of the newer porous plastic laminate are used.</p> <p>The stump, therefore, should be washed thoroughly each day, preferably just before retiring. A soap or detergent containing hexa-chlorophene, a bacteriostatic agent, is recommended, but strong disinfectants are to be avoided. To be fully effective, the bacteriostatic agent must be used daily. Some six or seven daily applications are necessary before full effectiveness is obtained, and any cessation of this routine lowers the agent's ability to combat the bacteria. A physician who is himself an amputee has suggested that after an amputee takes a bath, the stump should be dried first in order to minimize the risk of introducing infection to it by the towel.</p> <p>When the prosthesis is used without a stump sock, the stump should be thoroughly dry as moisture may cause swelling that will result in rubbing and irritation. For such cases, it is especially desirable for the stump to be cleansed in the evening.</p> <p>The stump sock should receive the same meticulous care as the stump. The socks should be changed daily and washed as soon as they are taken off. In this way the perspiration salts and other residue are easier to remove. A mild soap and warm water are used to keep shrinkage to a minimum. Woolite (a cold-water soap) and cold water in recent trials have given excellent results. A rubber ball inserted in the "toe" during the drying process ensures retention of shape.</p> <p>Elastic bandages should be washed daily in the same manner as stump socks, but should not be hung up to dry; rather they should be laid out on a flat surface away from excessive heat and out of the direct rays of the sun. Hanging places unnecessary stresses on the elastic threads, and heat and sunlight accelerate deterioration.</p> <p>It is of the utmost importance that any skin disorder of the stump-no matter how slight- receive prompt attention, because such disorders can rapidly worsen and become disabling. The amputee should see a physician for treatment. He should also see his pros-thetist; it may be that adjustment of the prosthesis will eliminate the cause of the disorder. In no case should iodine or any other strong disinfectant be used on the skin of the stump.</p> <p>Sometimes the skin of the stump is rubbed raw by socket friction. When this happens, the skin should be gently washed with a mild toilet soap. After the stump has been rinsed and dried, Bacitracin ointment, or some other mild antiseptic, should be applied, and the area covered with sterile gauze. The prosthesis should be completely dry before it is put on. If such abrasions occur frequently, the pros-thetist should be informed. If there is the slightest sign of infection, the amputee should see a physician.</p> <p>Small painless blisters should not be opened; they should be washed gently with a mild soap and left alone. Large, painful blisters should be treated by a physician.</p> <h4>Bandaging The Stump</h4> <p>The stump is usually kept wrapped in an elastic bandage from the time healing permits until the time the prosthesis is delivered. Also, bandaging is recommended when for some reason it is impracticable or impossible for the patient to wear his limb routinely. It is therefore highly desirable for the amputee, or at least one member of his family, to be able to apply the bandages. Many amputees can wrap their stumps unaided and, indeed, prefer to do so. Others prefer and, in some instances, require the help of another person.</p> <p>Recommended methods for applying elastic bandages for below-knee, above-knee, below-elbow and above-elbow patients are shown in <b>Fig. 52</b>, <b>Fig. 53</b>, and <b>Fig. 54</b>, respectively. These illustrations first appeared in a booklet entitled "Industrial Amputee Rehabilitation," prepared by Dr. C. O. Bechtol under the sponsorship of Liberty Mutual Insurance Co. of Boston.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 52. Recommended method of applying elastic bandage to the below-knee stump. The bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 53. Recommended method of applying elastic bandage to the above-knee stump. The stump is kept in a relaxed position, and the bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 54. Elastic bandages applied properly to upper-extremity stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Care of the Prosthesis</h3> <p>In addition to the care required in keeping the inside of the socket clean, which has been stressed, best results can be obtained only if the prosthesis is maintained in the best operating condition. Like all mechanical devices, artificial limbs can be expected to receive wear and be discarded for a new device, but the length of useful life can be extended materially if reasonable care is taken in its use. An example often quoted is that of two identical automobiles. The car given the maintenance recommended by the manufacturer and operated with care will outlast many times the vehicle given spotty maintenance and operated with disregard for the heavy stresses imposed. So it is with artificial limbs. Some amputees require a new prosthesis every few years, or even more often, while others who follow the manufacturer's instructions, apply preventive maintenance practices, and have minor problems corrected without delay, have received satisfactory service from their limbs for periods as long as twenty years.</p> <p>Manufacturers' instructions vary with the design of the device. They consist mainly of lubrication practices and should be followed closely. Too much lubricant can sometimes produce conditions as troublesome as excessive wear. Looseness of joints and fastenings should be corrected as soon as it is detected, for the wear rate increases rapidly under such a condition. Any cracks that appear in supporting structures should be reinforced immediately in order to avoid complete failure and the necessity for replacement. The foot should be examined weekly for signs of excessive wear.</p> <p>A point often overlooked by leg amputees, but nevertheless one of the factors affecting optimum use of the artificial limb, is the condition of the shoe. Badly worn or improper shoes can alter alignment and therefore have adverse effects on the stability and gait of the wearer. This is a matter that requires especially close attention in the case of child amputees.</p> <p>Hooks and artificial hands should be treated with the same care that the normal hand is given. Because the sensation of feeling is absent in the terminal device, the upper-extremity amputee is all too prone to use hooks to pry and hammer and to handle hot objects that are deleterious to the hook materials. Hands with cosmetic gloves should be washed daily, and of course hot objects and staining materials should be avoided.</p> <h3>Special Considerations in Treatment of Child Amputees <a></a></h3> <p>Only a few years ago it was seldom that a child amputee was fitted with a prosthesis before school age and often not until much later. In recent years experience has shown that fitting at a much earlier age produces more effective results.</p> <p>If there are no complicating factors, children with arm amputations usually should be provided with a passive type of prosthesis soon after they are able to sit alone, which is generally at about six months of age. Certain gross two-handed activities are thus made possible, crawling is facilitated, the child becomes accustomed to using and wearing the prosthesis, and moves easily into using a body-operated prosthesis as his coordination develops soon after his second birthday.</p> <p>Lower-extremity child amputees should be fitted with prostheses as soon as they show signs of wanting to stand. The development of muscular coordination of child amputees is the same as for nonhandicapped children and, therefore, this phase may take place as early as eight months or as late as 20 or more months.</p> <p>Children, especially when fitted at an early age, almost always adapt readily to prostheses. As the child grows, the artificial limb seems to become a part of him in a manner seldom seen in adults (<b>Fig. 55</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 55. Children with upper-extremity amputations performing two-handed activities. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Except for the very young, children's prostheses follow much the same design as those for the adult group. Special devices and techniques have been developed for initial fitting of infants and problem cases.</p> <p>Regardless of where the child amputee resides, or the extent of his parents' financial resources, he need not go without the treatment and prostheses required to make full use of his potentials. To ensure that such services are available, the Children's Bureau of the Department of Health, Education, and Welfare has assisted a number of states in establishing well-organized child-amputee clinics, and the facilities of these states are available to residents of states where such specialized services are not to be had. There is an agency in each state that can advise the parents of the proper course of action.</p> <p>Most children can be treated on an outpatient basis, but for the more severely handicapped many of the clinics have facilities for in-patient treatment. The clinic team for children is often augmented by a pediatrician and a social worker, and sometimes by a psychologist.</p> <p>Training very young children is one of the most difficult problems of the clinic team. Although the learning ability of young children may be rapid, their attention span is of such short duration that extreme patience is required. Regardless of the ability of the therapist, successful results cannot be achieved without complete cooperation of the parents. The mental attitude of the parents is reflected in the child, and all too often children have rejected prostheses because the parents, consciously or subconsciously, could not accept the fact that a prosthesis was needed. Parents of children born with a missing or deformed limb often experience a sense of guilt, a feeling that only adds to an already difficult problem. The guilt feeling is unwarranted, inasmuch as the knowledge of the causes of congenital defects-and appropriate preventive measures- is very limited. The recent discovery of the effects of thalidomide suggests that other causes may be found.</p> <p>As a rule, lower-extremity amputees present fewer problems than the upper-extremity cases.</p> <p>It is natural for the child to walk, and almost invariably the lower-extremity patient adapts rather quickly. Parents, however, should keep close observation of the walking habits of the child, the condition of his stump, and the state of repair of his prosthesis, and above all they should present the child before the clinic at the recommended times. A gradual change in walking habit may indicate that the child has outgrown the prosthesis or that excessive wear of the prosthesis has taken place. Any unusual appearance of the stump should be reported to the physician immediately so that remedial steps may be taken, thereby avoiding more complicated medical problems at a later date. Children give a prosthesis more wear and tear than do adults and it is important that the prosthesis be examined carefully at regular intervals and needed repairs made as soon as possible-not only to ensure the safety of the child but to avoid the necessity for major repairs at a later date.</p> <p>Many upper-extremity child amputees adapt readily to artificial arms-some even want to sleep with the arm in place-but in many cases the child will need a great deal of encouragement before he will accept the device and make use of it. At first the unilateral amputee may feel that the prosthesis is a deterrent rather than an aid, but with the proper encouragement this feeling is reversed.</p> <p>Parents can help by continuing the training given in the clinics. From the beginning the artificial arm should be worn as much as possible. Young children should be given toys that require two hands for use and older children should be given household chores that require two-handed activities. In the latter case not only does the child learn to appreciate the usefulness of the prosthesis, but he also gains a feeling of being a useful member of the family and thus a better mental attitude is created.</p> <p>The child amputee should not be sheltered from the outside world but encouraged to associate with other children and, to the extent that he can, to take part in their activities. Of course there are certain limitations, but the number of activities that can be performed with presently available prostheses is amazing. It goes almost without saying that the child should receive no more special attention than is necessary, and should be made to perform the activities of daily living of which he is capable.</p> <p>It has been shown that it is preferable for the child amputee to attend a regular school rather than one for the handicapped. Most child amputees can and do take their place in society and the transition from school to work is much easier if they are not shown unnecessary special consideration. Nonhandicapped children soon accept the amputee and make little comment after the initial reaction.</p> <p>Here again the arm amputee is apt to be faced with the most problems. Some public school officials have hesitated to admit arm amputees wearing hooks for fear that the child may use them as weapons. This attitude is unrealistic. If such incidents have occurred, they are rare indeed. However, arm prostheses should be removed when the child is engaged in body-contact sports such as football.</p> <p>Cleanliness of the stump, prosthesis, and stump sock is just as important for children as for adults. The same procedures as those outlined on pages 37-39 are recommended.</p> <h3>Special Considerations in the Treatment of Elderly Patients</h3> <p>Persons who have had amputations during youth or middle age seldom encounter additional problems in wearing their prostheses as they become older. However, for those patients who have an amputation in later life many unusual problems are apt to be present. Most amputations in elderly patients are necessary because of circulatory problems, almost always affecting the lower extremity. For many years the wisdom of fitting such patients with prostheses was debatable, the thought being that the remaining leg, which in most cases was subject to the same circulatory problems as the one removed, would be overtaxed and thus the need for its removal would be hastened. Energy studies in recent years have shown that crutch-walking is more taxing than use of an artificial limb. Experience with rather large numbers of elderly leg amputees has shown that failure of the remaining leg has not been accelerated by use of a prosthesis, and stumps that have been fitted properly have not been troublesome. As a result more and more elderly patients are benefiting by the use of artificial limbs. A rule of thumb used in some clinics to decide whether or not to fit the elderly patient is that if he can master crutch-walking he should be fitted. This measure should be used with discretion because in some instances patients who could not meet the crutch-walking requirement have become successful wearers of prostheses.</p> <p>The patient should be fitted as soon as possible, to avoid such complications as the development of contractures. The availability of adjustable pylon-type legs and the use of plaster or plastic sockets now makes early fitting practical, and this approach is being adopted by more and more centers. Many geriatric patients have benefited from the immediate postsurgical fitting procedures.</p> <p>Most clinic teams feel that if the patient can use the prosthesis to make him somewhat independent around the house, the effort is fully warranted.</p> <p>Artificial legs for the older patients, as a rule, should be as light as possible. Except for the most active patients, only a small amount of friction is needed at the knee for control of the shank during the swing phase of walking because the gait is apt to be slow. Suction sockets are rarely indicated because of the effort required in donning them. A quadrilateral-shaped socket is used with one stump sock and a pelvic belt. Silesian bandages have been used successfully, allowing more freedom of motion and increased comfort.</p> <p>For the elderly below-knee cases, the patellar-tendon-bearing prosthesis is being used quite successfully.</p> <h3>Cineplasty <a></a></h3> <p>In 1896 the Italian surgeon, Vanghetti, conceived the idea of connecting the control mechanism of a prosthesis directly to a muscle. Several ideas involving the formation of a club-like end or a loop of tendon in the end of a stump muscle were tried out in Italy. Just prior to World War I the German surgeon, Sauerbruch, devised a method of producing a skin-lined tunnel through the belly of the muscle. A pin through the tunnel was attached to a control cable, and thus energy for operation of the prosthesis was transferred directly from a muscle group to the control mechanism. With refinements the Sauerbruch method is available for use today, but it must be used cautiously.</p> <p>Although tunnels have been tried in many muscle groups, the below-elbow amputee is the only type that can be said to benefit truly from the cineplasty procedure. A tunnel properly constructed through the biceps can supply power for operation of a hand or hook, and there need be no harnessing above the level of the tunnel. Thus, the patient is not restricted by a harness and the terminal device can be operated with the stump in any position. Training the tunneled muscle and care of the tunnel require a great deal of work by the patient; thus if the cineplasty procedure is to be successful the patient must be highly motivated.</p> <p>Some female below-elbow amputees have been highly pleased with results from a biceps tunnel, but as a rule cineplasty does not appeal to women.</p> <p>Cineplasty is not indicated for children. Sufficient energy is not available for proper operation of the prosthesis and the effects of growth on the tunnel are not known.</p> <p>Tunnels have been tried in the forearm muscles but the size of these muscles is such that the energy requirements for prosthesis operation are rarely met. While tunnels in the pectoral muscle are capable of developing great power, in the light of present knowledge the disadvantages tend to outweigh the advantages. It is extremely difficult to harness effectively the energy generated, and very little, if any, of the harness can be eliminated. It is true that an additional source of control can be created, but with the devices presently available little use can be made of this feature.</p> <p>No application for cineplasty has been found in lower-extremity amputation cases.</p> <p>Still another type of cineplasty procedure is the Krukenberg operation, whereby the two bones in the forearm stump are separated and lined with skin to produce a lobster-like claw. The result, though rather gruesome in appearance, permits the patient to grasp and handle objects without the necessity of a prosthesis.</p> <p>Because sensation is present, the Krukenberg procedure has been found to be most useful for blind bilateral amputees. Although prostheses can be used with Krukenberg stumps when appearance is a factor, the operation has found little favor in the United States.</p> <h4>Agencies That Assist Amputees</h4> <p>For several centuries at least, governments have traditionally cared for military personnel who received amputations in the course of their duties. But only in recent years, except in isolated cases, has the amputee in civilian life had much assistance in making a comeback. Today there are available services to meet the needs of every category of amputee. Aside from the humanitarian aspects of such programs, it has been found to be good business to return the amputee to productive employment and, in the case of some of the more debilitated, to provide them with devices and training to take care of themselves.</p> <p>The Armed Services provide limbs for military personnel who receive amputations while on active duty, and many of these cases are returned to active duty. After the patient has been discharged from military service, the Veterans Administration assumes responsibility for his medical care and prosthesis replacement for the remainder of his life. The U.S. Public Health Service, through its Marine Hospitals, cares for the prosthetics needs of members of the U.S. Maritime Service.</p> <p>Each state provides some sort of service for child amputees. If sufficient facilities are not available within a state, provisions can be made for treatment in one of the regional centers set up in a number of states with the help and encouragement of the Children's Bureau of the Department of Health, Education, and Welfare. With assistance from the Vocational Rehabilitation Administration of the Department of Health, Education, and Welfare, every state operates a vocational rehabilitation program designed to help the amputee return to gainful employment. Some of these programs render assistance to housewives and the elderly as well.</p> <p>Private rehabilitation centers, almost universally nonprofit and sponsored largely by voluntary organizations, greatly augment the state and federal programs.</p> <p>Information concerning rehabilitation centers serving a particular area may be obtained from the Association of Rehabilitation Centers, 828 Davis Street, Evanston, Ill. 60201.</p> <p><b>References:</b></p> <ol> <li>Artificial Limbs, Autumn 1957.</li> <li>Artificial Limbs, April 1961.</li> <li>Artificial Limbs, June 1962.</li> <li>Bechtol, Charles O., and George T. Aitken, <i>Cineplasty</i>, Chap. 12 in <i>Orthopaedic appliances atlas</i>, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>Blakeslee, Berton, <i>The limb-deficient child</i>, University of California Press, 1963.</li> <li>Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., <i>Immediate postsurgical prosthetics in the management of lower-extremity amputees</i>, Prosthetic and Sensory Aids Service, Veterans Administration, 1967.</li> <li>Committee on Artificial Limbs, National Research Council, Washington, D.C., <i>Terminal research reports on artificial limbs</i>, covering the period from 1 April 1945 through 30 June 1947.</li> <li>Feinstein, Bertram, James C. Luce, and John N. K. Langton, <i>The influence of phantom limbs</i>, Chap. 4 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Foort, J., <i>Adjustable-brim fitting of the total-contact above-knee socket</i>, Biomechanics Laboratory, University of California (Berkeley and San Francisco), No. 50, March 1963.</li> <li>Foort, James, <i>The patellar-tendon-bearing prosthesis for below-knee amputees</i>, a review of technique and criteria, Artificial Limbs, Spring 1965.</li> <li>Hampton, Fred, <i>Suspension casting for below-knee, above-knee, and Syme's amputations</i>, Artificial Limbs, Autumn 1966.</li> <li>Klopsteg, P. E., <i>The functions and activities of the Committee on Artificial Limbs of the National Research Council</i>, J. Bone and Joint Surg., 29: 538-540, 1947.</li> <li>National Academy of Sciences-National Research Council, <i>The control of external power in upper-extremity rehabilitation</i>, Publication 1352, 1966.</li> <li>Sarmiento, Augusto, R. E. Gilmer, and A. Finnieston, <i>A new surgical-prosthetic approach to Syme's amputation, a preliminary report</i>, Artificial Limbs, Spring 1966.</li> <li>Staros, Anthony, <i>Dynamic alignment of artificial limbs with the adjustable coupling</i>, Artificial Limbs, Spring 1963.</li> <li>Taylor, Craig L., <i>Control design and prosthetic adaptations to biceps and pectoral cineplasty</i>, Chap. 12 in <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Thomas, Atha, and Chester C. <i>Haddan, Amputa- tion prosthesis</i>, Lippincott, Philadelphia, Pa., 1945.</li> <li>Vultee, Frederick E., <i>Physical treatment and training of amputees</i>, Chap. 7 in <i>Orthopaedic appliances atlas</i>, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>Weiss, Marian, <i>The prosthesis on the operating table from the neurophysiological point of view</i>, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bechtol, Charles O., and George T. Aitken, Cineplasty, Chap. 12 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton, The limb-deficient child, University of California Press, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Immediate postsurgical prosthetics in the management of lower-extremity amputees, Prosthetic and Sensory Aids Service, Veterans Administration, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Vultee, Frederick E., Physical treatment and training of amputees, Chap. 7 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">National Academy of Sciences-National Research Council, The control of external power in upper-extremity rehabilitation, Publication 1352, 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chap. 12 in Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California (Berkeley and San Francisco), No. 50, March 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Artificial Limbs, June 1962.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Foort, James, The patellar-tendon-bearing prosthesis for below-knee amputees, a review of technique and criteria, Artificial Limbs, Spring 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Artificial Limbs, April 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Staros, Anthony, Dynamic alignment of artificial limbs with the adjustable coupling, Artificial Limbs, Spring 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Hampton, Fred, Suspension casting for below-knee, above-knee, and Syme's amputations, Artificial Limbs, Autumn 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chap. 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Immediate postsurgical prosthetics in the management of lower-extremity amputees, Prosthetic and Sensory Aids Service, Veterans Administration, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Weiss, Marian, The prosthesis on the operating table from the neurophysiological point of view, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Artificial Limbs, Autumn 1957.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Artificial Limbs, April 1961.</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, R. E. Gilmer, and A. Finnieston, A new surgical-prosthetic approach to Syme's amputation, a preliminary report, Artificial Limbs, Spring 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Suite 130, 919-18th St., N.W., Washington, D.C. 20006.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Suite 130, 919-18th St., N.W., Washington, D.C. 20006.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Klopsteg, P. E., The functions and activities of the Committee on Artificial Limbs of the National Research Council, J. Bone and Joint Surg., 29: 538-540, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Committee on Artificial Limbs, National Research Council, Washington, D.C., Terminal research reports on artificial limbs, covering the period from 1 April 1945 through 30 June 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Thomas, Atha, and Chester C. Haddan, Amputa- tion prosthesis, Lippincott, Philadelphia, Pa., 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr., B.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Avenue, N.W., Washington, D.C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-12.jpg Figure 3 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-23.jpg Figure 4 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-34.jpg Figure 5 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-45.jpg Figure 6 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-52.jpg Figure 7 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-53.jpg Figure 8 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-54.jpg Figure 9 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-55.jpg Figure 10 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-02.jpg Figure 11 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-03.jpg Figure 12 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-04.jpg Figure 13 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-05.jpg Figure 14 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-06.jpg Figure 15 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-07.jpg Figure 16 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-08.jpg Figure 17 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-09.jpg Figure 18 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-10.jpg Figure 19 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-11.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 Limb Prosthetics-1967 Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr., B.S.M.E. * https://staging.drfop.org/files/original/43d2e80bb7287060417ad2e656a4a222.pdf 1e835407f00822f0f13ceb8823bc60bb https://staging.drfop.org/files/original/4883a90da6034c4c1b32440d97b3755d.jpg 6be8ba96a52feee7928cfa58d70a9cb1 https://staging.drfop.org/files/original/30087b0ad704d400a5301996e194aa1b.jpg 03b421194ff589844bf70b4d3b6137c3 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_01_047.pdf Year 1967 Volume 11 Issue 1 Page Number(s) 47 - 50 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1967_01_047.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_01_047.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>New Concepts in the Management of Lower-Extremity Amputees</h2> <h5>A. Bennett Wilson, Jr., B.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>For many years the acceptable practice in management of lower-extremity amputation after wound closure consisted of the application of a reinforced gauze dressing and the confinement of the patient to bed until the wound was healed. Fitting of a prosthesis was seldom attempted until edema was reduced to a more or less stable point by means of elastic bandages which had to be removed and reapplied at regular intervals during the day. Elaborate precautions had to be taken so that muscle contractures would not occur. With this method of treatment it was rare for a patient to be fitted less than six weeks after surgery, most patients requiring a much longer period.<a></a></p> <p>The reluctance to fit patients before the stump was "stabilized" was, in a large part, due to the need for one or more socket replacements shortly after the initial fitting. A number of physicians advocated the use of temporary prostheses usually consisting of a plaster-of-Paris socket and a peg leg to hasten stabilization of the stump, but this practice never became widespread, probably because no adequate documentation was made of the various series that were reported, and many physicians realized that it was extremely difficult to obtain adequate fit and alignment with the techniques existing then.</p> <p>The introduction of the patellar-tendon-bearing socket, total-contact sockets, new stump-casting techniques, adjustable legs, and plastic-laminate sockets led the Department of Orthopaedic Surgery, Duke University, to embark on a study to determine the earliest practical time for fitting. The project has demonstrated clearly that successful application of prostheses can be made as soon as it is safe to remove the sutures.</p> <p>In the late fifties Berlemont of France <a></a> began providing patients with leg prostheses immediately upon completion of surgery and initiating ambulation training the following day. Berlemont's technique was modified somewhat by Weiss of Poland <a></a>, who brought it to the attention of Americans in a lecture given at the Sixth International Prosthetics Course in Copenhagen in July 1963. A tour of the United States by Weiss later that year, sponsored by the Vocational Rehabilitation Administration and the Committee on Prosthetics Research and Development, stimulated sufficient interest at the University of California, San Francisco, and the U.S. Naval Hospital, Oakland, for these groups to experiment with the concepts reported by Weiss.</p> <p>Initial results led the Veterans Administration to support an experimental program proposed by the Prosthetics Research Study of Seattle, Washington. Other groups, notably Duke University, the University of Miami, Marquette University, and a group in New York City centered around the Hospital for Joint Diseases, became interested and embarked on modest experimental programs.</p> <p>Because there was not available any written or visual material covering European experience, each group approached the problem along somewhat different lines. From time to time through the efforts of the Committee on Prosthetics Research and Development and the University Council on Orthotic-Prosthetic Education, these groups were brought together for the purpose of exchanging ideas and coordinating the efforts of all involved. Meanwhile, the Vocational Rehabilitation Administration made it possible for a number of the research teams to visit Weiss. Experience with more than 400 cases has now been accumulated.</p> <p>At its meeting January 20, 1967, which was preceded by a conference of research teams involved in immediate postsurgical fitting, UCOPE decided to offer courses in the technique to qualified teams.</p> <p>The basic technique consists of the application of a nonadherent silk mesh dressing and fluffed gauze over the wound and a sterile stump sock and plaster-of-Paris cast (which is also the socket for the prosthesis) over the stump (<b>Fig. 1</b>). To the socket is attached an adjustable pylon-type prosthesis suitable for the level of amputation. Provisions are made for easy removal and reattachment of the prosthetic unit to prevent the prosthesis from being wrapped in the bedclothes and causing undue stresses on the stump. A drain is usually used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. An example of immediate postsurgical fitting of prosthesis to a below-knee amputee. Note the waist-belt suspension, the cast-socket carried above the knee, the pylon, and the foot. See also Figure 18 in Limb Prosthetics-1967, the preceding article in this issue. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient is encouraged to stand <i>between parallel bars or with the aid of a "walker" </i>about 24 hours after surgery if there are no physical or medical contraindications. The amount of weight-bearing and ambulation is increased daily and the patient is graduated to crutches, to canes, and to unaided walking as his physical condition permits. The drain is removed 48 hours after surgery, and the cast-socket is kept in place until time for removal of the stitches- some 10 to 14 days after surgery.</p> <p>A new cast-socket is applied immediately, and the pylon-type prosthesis is replaced. The second cast is removed 8 to 10 days later when it is generally possible to make a cast for fabrication of a plastic socket.</p> <p>The advantages of treating patients in this manner are a reduction in the formation of edema, a reduction in the incidence of pain, elimination of the formation of contraction, decreased hospitalization time, and less time lost from work. The technique appears to permit improved wound healing, and a number of investigators feel that in cases of amputations because of vascular disorders many more knee joints may be preserved than when conventional methods of treatment are used. In one series of a hundred cases, the average time between surgery and delivery of the "permanent" prosthesis was 28 days. The shortest time was 17 days <a></a>. <b>Fig. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Progress of 80-year-old patient whose leg was amputated because of vascular disease and diabetes. A, First day postoperative; B, seventh day postoperative; C, seventeenth day postoperative; D, twenty-sixth day postoperative. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Patients of all types and all ages have been treated successfully by fitting prostheses immediately after surgery. However, success depends upon many factors, and the technique should not be undertaken unless the team has a thorough understanding of proven methods. For this reason, courses are being offered at Northwestern University, the University of California, Los Angeles, and New York University.</p> <p>In spite of the success achieved by the research teams and others that have been trained by them, it is not clear why certain of the advantages accrue, and to what degree the various factors that enter into success are critical. Continued research is expected to answer these questions.</p> <p><b>References:</b></p> <ol> <li>Alldredge, Rufus H., The principles of amputation surgery, Chap. 10 in Orthopaedic Appliances Atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>Berlemont, M., Notre experience de l'appareillage precoce des ampules des membres inferieurs aux Etablissements Helio-Marins de Berck, Annales de Medecine Physique, Tome IV, No. 4, Oct.-Nov.-Dec, 1961.</li> <li>Berlemont, M., L'appareillage des amputes des membres inferieurs sur le table d''operations, paper given at the International Congress of Physical Medicine, Paris, 1964.</li> <li>Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Management of lower-extremity amputees using immediate postsurgical fitting techniques, Prosthetic and Sensory Aids Service, U.S. Veterans Administration, 1967.</li> <li>Weiss, Marian, The prosthesis on the operating table from the neurophysiologies point of view, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Management of lower-extremity amputees using immediate postsurgical fitting techniques, Prosthetic and Sensory Aids Service, U.S. Veterans Administration, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Weiss, Marian, The prosthesis on the operating table from the neurophysiologies point of view, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Berlemont, M., Notre experience de l'appareillage precoce des ampules des membres inferieurs aux Etablissements Helio-Marins de Berck, Annales de Medecine Physique, Tome IV, No. 4, Oct.-Nov.-Dec, 1961.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Berlemont, M., L'appareillage des amputes des membres inferieurs sur le table d''operations, paper given at the International Congress of Physical Medicine, Paris, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., The principles of amputation surgery, Chap. 10 in Orthopaedic Appliances Atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr., B.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development. National Academy of Sciences-National Research Council, 2101 Constitution Ave., N.W., Washington, D.C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1967_01_047/1967_01_047-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1967_01_047/1967_01_047-2.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource New Concepts in the Management of Lower-Extremity Amputees Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr., B.S.M.E. * https://staging.drfop.org/files/original/c1dcd8002daf073f875a014ab93e6d77.pdf 9f6846fc84195173da86b474bf524650 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_04_003.pdf Text Any textual data included in the document <h2>Hydraulics and Above-Knee Prosthetics</h2> <h5>A. Bennett Wilson, Jr., B.S.M.E. <a style="text-decoration: none;">*</a></h5> <p>Some of the highlights in the history of the use of hydraulic systems in artificial legs might be useful in understanding the present status and influencing the future application of hydraulic principles in lower-limb prosthetics.</p> <p>One of the prime objectives of the designers of artificial legs for above-knee amputees is control of the knee joint, and, thus, the shank to provide the amputee with the means to stand and walk safely, efficiently, and gracefully. Sporadically since 1918, and possibly before, hydraulic principles were proposed as a means for locking or braking the knee to enhance safety, but none of these ideas seem to have reached a practical stage until after World War II.</p> <p>When the National Academy of Sciences (NAS) initiated a research program in limb prosthetics in 1945 at the request of the Surgeon General of the Army, surveys of amputees indicated that the above-knee amputees felt that their greatest need was a knee lock that would prevent stumbling. This "finding" prompted a number of designs in the United States that used hydraulic systems to provide knee locking or braking on demand. Concurrently, a team in Germany, Ulrich Henschke, a physician, and Hans Mauch, an engineer, developed a leg prototype that used a hydraulic lock activated by motion of the abdominal wall. After Dr. Henschke and Mr. Mauch moved to the United States at the invitation of the United States Air Force, they were encouraged by their host to continue development of their design, and they became active in the NAS Artificial Limb Program.</p> <p>During the 1940's, Mr. Jack Stewart, an AK amputee and inventor, devised, to meet his own needs, an above knee leg which used a hydraulic system to not only provide knee locking, but also to provide shock absorption at the heel, co-ordinated motion between knee and ankle joints, and adjustability of the height of the heel. Swing phase control was provided by hydraulic fluid being forced through a single orifice, a serendipitous sort of circumstance.</p> <p>About 1951, leaders in the research program came to the conclusion, based on data developed at the University of California, that perhaps, more important than control in the stance phase, is control during the swing phase. Mr. Mauch was requested to give high priority to the design of a mechanism that would provide control of the knee during swing phase so that the amputee could vary cadence without changing the friction control setting. At about the same time, it was recognized that the characteristics of a fluid flowing through an orifice had the possibility of providing automatically the change in resistance to knee flexion and extension needed to compensate for changes in the walking cadence.</p> <p>Using many of the same parts designed for the stance-control system as well as data provided by the University of California Biomechanics Laboratory concerning knee movements during swing phase, Mr. Mauch produced a unit with a number of orifices arranged to provide changes in resistance to rotation at the knee corresponding to the "normal." This design, known as the Model "B," after some years of testing and field use, was combined with the stance-control system to produce the Model "A," which when modified was marketed as the Henschke-Mauch S'n'S (Swing and Stance) knee unit. During the development of the Henchke-Mauch units several less complex hydraulic and pneumatic units were also developed by others and marketed commercially with some degree of success.</p> <p>During the early 1950's 18 units of the Stewart design known as the Stewart-Vickers Hydraulic Leg were evaluated by a team at New York University, who found good amputee acceptance, and recommended that the locking feature be eliminated since the cost could be reduced appreciably and the test subjects didn't seem to make use of that feature. This recommendation was followed by Mr. Stewart, who a short while later sold all rights to U.S. Manufacturing Co., who manufactured and marketed it as the Hydra-Cadence Leg. The Hydra-Cadence Leg has been a commercial success, but in spite of a great deal of experience, no one can be sure of the relative importance of its many features.</p> <p>The development of hydraulic mechanisms for artificial legs has been plagued by leakage and breakage, which is only natural in an effort that tries to arrive at the optimum compromise between cost, weight, and function. Whether or not this optimum has been achieved is not yet known. We do know, however, that active above-knee and hip-disarticulation amputees appreciate the swing-phase control function afforded by hydraulic mechanisms and that the present day costs are not prohibitive for a substantial number of amputees. No definitive studies have been made that would delineate the efforts of the various factors and features involved, singly or in combination. With the availability of 4-channel 24-hour physiological surveillance systems and other sophisticated instrumentation, such studies seem to be quite feasible now and certainly should be considered.</p> <p>For at least thirty years the need for voluntary control of the knee joint has been recognized, but until the advent of the microcomputer it was difficult to conceive of a practical method to accomplish this. When microcomputers became available, the first reaction of some designers was simply to add the microcomputer to present hydraulic systems, but these efforts failed most probably because the systems available were not designed for control by computer. At any rate, it would seem that the weight alone of present systems would make voluntary control impractical, and thus any project in this area should begin anew.</p> <p>At present, very little work seems to be going on in the area of voluntary control systems. Some work at the Massachusetts Institute of Technology has been reported for nearly a decade. More recently, the REC at Moss Rehabilitation Hospital started a project where pattern recognition techniques are used to obtain subconscious control of a knee mechanism by EMG signals about the hip joint, which shows a good deal of promise.</p> <p>Perhaps what we need most at this point is more information concerning the contribution of each variable, such as swing-phase control, stance-phase control, ankle action, weight, and weight distribution, singly and in combination, for designers of the next generation of above-knee legs. With the technology now available to us, this appears to be possible as well as practical.</p> <em><b>*A. Bennett Wilson, Jr., B.S.M.E. </b>Assistant Director, Rehabilitation Research and Training Center Dept. of Orthopaedics and Rehabilitation University of Virginia Medical Center Charlottesville, Virginia 22908.<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 3 - 4 Year 1983 Volume 7 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Hydraulics and Above-Knee Prosthetics Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr., B.S.M.E. * https://staging.drfop.org/files/original/aee975bd01e173cadb6bd332d9927ed3.pdf d866aabd179e97ad8f259caadfd4f46d https://staging.drfop.org/files/original/cf7e5a1c10865c7a2f6801745802706f.jpg bfb079830381162d6ce2c95f6c3db913 https://staging.drfop.org/files/original/80177bdc2c6d01dcef1002642392393f.jpg b72fa1e2bc643d38e868474976fab946 https://staging.drfop.org/files/original/d61fadd50e79b7203cb643df570abb42.jpg 50e9ab54ca359ad9fdd2b19c36f7ff32 https://staging.drfop.org/files/original/cabb1a4acfdfba520a78a7dc281f59b0.jpg e6d1577d5fee57ef9520df78f3a2e50d https://staging.drfop.org/files/original/fa7e073d9826e1cc48df65128f65c987.jpg 4e64810dc51607824b7edfab6b000dba https://staging.drfop.org/files/original/cb3215048cf3a11c179f71432884353b.jpg 08d1ecaf1034507e7ae1bb4edb00e1dd https://staging.drfop.org/files/original/8cbb68c28d3f97aca81a578e0068b1b6.jpg 160e3c6521c277fc6bbfc22fb411ad60 https://staging.drfop.org/files/original/ed88f8904d06fe0b726da88a744ab157.jpg f6e276d8e77f1ef1a8b4164aea967c37 https://staging.drfop.org/files/original/499b2d14df818927c677e6ab81294bf3.jpg 8832e1d454749fcb34de722dc4763cd4 https://staging.drfop.org/files/original/f0db8d36bc5ab95237bdaf8b3f0774ad.jpg 00a77b4c33e9d587ebfb6657f4b2f634 https://staging.drfop.org/files/original/ffa5c106a3a94dc6f3ffba57275d427b.jpg 505850a92d9a616c370f7071f20a4962 https://staging.drfop.org/files/original/26a9bc87b04573a87b50af221f53a172.jpg 26d44ea9c02e9b1e215d3cc9777cbbe7 https://staging.drfop.org/files/original/83d1441b01dcdb73ab0174906f56b719.jpg f27a354f95c023f556c00e45b7da38c5 https://staging.drfop.org/files/original/f811aafb32502cadbb7ea0672580e37a.jpg 033ffb96764b132c3b786e618d38b8da https://staging.drfop.org/files/original/68652caa9997d995b4fa091cbbaff9f0.jpg fcf7b1acefad733dab4306d7139d21fc https://staging.drfop.org/files/original/6f10c8ec7cab2b8734bacc6b74dacf84.jpg e11fd3ddf35479f9b8a871e27886d182 https://staging.drfop.org/files/original/d8a9c69caa7a722e6c26cc46a47ca86f.jpg b59874d90b7c956ebbbb4b223045572b https://staging.drfop.org/files/original/78f9d8d11382034703a6765a230cd321.jpg 99cc18ad6bf2cc161fd7ec5e42b8b512 https://staging.drfop.org/files/original/557e4cce203fd0edcfa199807c18deef.jpg 6148afe4dbedeaeeeaefae592b2154bd DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_02_001.pdf Year 1968 Volume 12 Issue 2 Page Number(s) 1 - 27 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Recent Advances in Above-Knee Prosthetics</h2> <h5>A. Bennett Wilson, JR.. B.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>During the past few years, many innovations have been introduced into the practice of above-knee prosthetics. Most of the literature on the new practices has been provided by the innovators, and therefore the reports and articles on the subject generally are limited to a single approach. It is the purpose of this article to survey past and present practices and to set forth, as accurately as possible, a perspective of procedures and devices available today for the management of the above-knee amputee.</p> <p>Amputation through the thigh results in distinct functional losses. The obvious ones are loss of support by the long bones and loss of joints, resulting in inability to stand and move extensively from place to place. In addition, the appearance of the patient becomes altered from the "normal" in both static and dynamic conditions.</p> <p>Lost support and mobility can be replaced to some extent by the use of a wheelchair or crutches or both, but it has been shown that use of an articulated prosthesis is the most effective means of compensating for these losses. An amputee with a functional prosthesis can negotiate stairs, ramps, and other obstacles and, therefore, can move through areas that would be impracticable if not impossible for a wheelchair. Crutches, properly used, offer a great deal of facility of movement but require the use of considerably more energy than a well-fitted and -aligned above-knee prosthesis, or even a peg leg. <a></a> Also, when crutches are used the hands are not free during ambulation. Another argument for the use of a functional prosthesis is that a fairly normal appearance can be achieved.</p> <p>The basic functional prosthesis for the above-knee amputee consists of a socket, a knee unit, a shank, and a foot-ankle unit. In cases where it is not deemed advisable to keep the socket in place by air pressure (suction socket), suspension must be provided by a belt about the pelvic area or by a shoulder harness.</p> <p>Not so many years ago it was common practice for the prosthetist to make in his shop nearly every part for a prosthesis from basic materials such as wood, steel, and leather. This practice was time-consuming and wasteful. To eliminate as much manual work as possible, the prosthetist today designs and fabricates the socket from basic materials to fit each patient individually, but uses prefabricated components, which he purchases from manufacturers, for the rest of the prosthesis. <a></a></p> <h3>Sockets</h3> <p> Until the introduction of the suction socket in the late 1940's. <a></a> it was common practice to provide the above-knee amputee with a so-called plug-fit socket suspended by a pelvic band connected to the socket by a metal "hip" joint (<b>Fig. 1</b>) <a></a> The plug fit did not provide for a very adequate distribution of forces between stump and socket. There was a tendency for the formation of an adductor roll, and the stability provided between stump and socket left much to be desired. The pelvic belt was heavy. The "hip" joint restricted motion essentially to flexion and extension, and was subject to frequent breakage. Most of the sockets were carved from willow wood and reinforced with rawhide, although sockets formed from aluminum sheet were not uncommon.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical prosthesis for above-knee amputees during the 1940's. Note pelvic band, mechanical "hip joint," carved wooden socket with a "plug fit," and pelvic-control knee joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The primary purpose of the suction socket (<b>Fig. 2</b>) was to provide increased function and comfort by eliminating the mechanical hip joint and pelvic belt. Pressures between the stump and socket were distributed over wider areas; stability and, therefore, control were improved materially. A socket of the quadrilateral shape <a></a> became standard whether or not suction was used for suspension. The waist belt and Silesian bandage were introduced as more comfortable suspension methods to supplant the pelvic belt and hip joint in some cases. Willow wood remained the material of choice, but plastic laminate (usually nylon stockinet impregnated with a polyester resin) replaced rawhide as a reinforcement material.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. An early version of the suction-socket prosthesis <i>(right), </i>shown in comparison to the so-called conventional above-knee prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Experience with problem cases, with the early versions of the suction socket in which a certain amount of air space is left below the distal end of the stump, led the University of California, Berkeley, to develop the modification now known as the total-contact above-knee socket (<b>Fig. 3</b>).<a></a> In a certain number of cases, edema developed in spite of most careful fitting with the "open-end" socket. It was found that the edema could be eliminated by providing a small amount of counter-pressure over the distal end. It was also found that the entire stump must be in contact with the socket in order to keep the circulatory system in balance. The introduction of counterpressure also reduced the unit pressures at the proximal region of the stump, and the contact over the end of the stump seemed to enhance proprioception.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. An above-knee prosthesis with a quadrilateral, total-contact socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To provide a well-fitting total-contact socket of wood requires a great deal of skill and is quite time-consuming compared with the use of plastic laminates. Plastic laminates, which had proven so useful in the fabrication and fitting of upper-extremity and below-knee prostheses, had not been used for above-knee sockets because of the difficulty encountered in obtaining an adequate cast for preparation of the positive model needed for molding the laminate. A few highly skilled prosthetists had been known to produce adequately formed casts using only their hands, but this achievement was exceptional. To solve this problem, several devices were developed so that casts of above-knee stumps that required a minimum amount of modification could be achieved.</p> <p>The UC-Berkeley device (<b>Fig. 4</b>) <a></a> uses a series of adjustable brims with which the cast is taken under weight-bearing conditions; the Veterans Administration Prosthetics Center device uses a three-part universal jig for holding the stump in position, also under weight-bearing conditions (<b>Fig. 5</b>); <a></a> the New York University casting fixture is a portable device that holds the cast in position but does not require the patient to be in a weight-bearing position (<b>Fig. 6</b>); <a></a> and Northwestern University has developed a modification of the UC-Berkeley technique in which a cast sock is used to suspend the stump and thus assist in forming the desired contours (<b>Fig. 7</b>). <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The fixture for the "brim-fitting" technique developed at the University of California Biomechanics Laboratory (San Francisco and Berkeley). Adjustable, easily interchangeable brims are available in a complete range of sizes. The view on the right shows attitude of patient in fixture; right leg is not shown for clarity. See <b>Fig. 7</b> for still another view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The fixture for casting the impression of an above-knee stump developed at the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Anterior view of the New York University casting brim in use. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. A method, developed at Northwestern University, which uses the University of California casting fixture. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The object of each of these tools is exactly the same: to provide a cast of the above-knee stump that requires the least modification for the fabrication of a well-fitting, quadrilateral, total-contact socket. Each has its advantages and disadvantages. None is superior to the others in all aspects, and selection is based on the personal preferences of the prosthetist. Many facilities have two or even all three devices available for use as circumstances dictate.</p> <h4>Fitting And Alignment</h4> <p> The basic rationale of alignment as set forth by Radcliffe <a></a> in the early 1950's is essentially unchanged, although proper use of some of the hydraulic knee units demands some variations.</p> <p>In order to make it easier for the prosthetist to achieve optimum alignment, the University of California, Berkeley, developed the adjustable leg (<b>Fig. 8</b>) and alignment duplication jig (<b>Fig. 9</b>). <a></a> Dynamic alignment is obtained during amputee ambulation with the adjustable pylon, and the alignment obtained is transferred to the finished prosthesis during fabrication by use of the alignment duplication jig. This procedure proved to be highly satisfactory for use with single-axis, constant-mechanical-friction knee joints, since the adjustable leg also contained this type of joint. Because the functions of the Hydra-Cadence leg demanded that it be aligned somewhat differently, the STAROS-GARDNER coupling (<b>Fig. 10</b>) was designed. <a></a> When placed between the top of the knee block and the thigh piece or socket, the Staros-Gardner coupling provides all the adjustments permitted by the adjustable leg except mediolateral placement of the foot with respect to the knee axis, an adjustment not often used and, then, only to provide better cosmetic appearance. A technique was developed so that when final alignment was achieved a wooden block could be substituted for the coupling, thereby eliminating the need for the alignment duplication jig.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The adjustable above-knee leg developed by the University of California Biomechanics Laboratory (San Francisco and Berkeley). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The alignment duplication jig developed by the University of California Biomechanics Laboratory (San Francisco and Berkeley) to be used in conjunction with the adjustable leg shown in <b>Fig. 8</b>. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Staros-Gardner coupling being used to achieve alignment in an above-knee prosthesis. When the desired alignment has been achieved the coupling is replaced with a section of wood. A technique has been developed so that alignment can be maintained without need for the alignment duplication jig. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Components</h3> <p> Components for above-knee prostheses can be obtained from central manufacturers in a number of ways. The most common approach is to purchase "knee-shin set-ups" and foot-ankle units, and to connect these to each other and to the socket in the alignment best suited for the individual patient. The knee-shin set-up usually consists of a wooden knee block, the proximal portion of a hollow wooden shank, and a knee control mechanism (<b>Fig. 11</b>). Excess wood is provided so that the knee and shin can be individually contoured, and in the finished prosthesis the entire unit is reinforced structurally by the application of a plastic laminate over the exterior. Complete wooden set-ups are available, but are seldom used. However, when coordinated motion between knee and ankle is incorporated in the prosthesis, as in the Hydra-Cadence unit, a complete set-up is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical knee-shin wood set-up. <i>Courtesy U.S. Manufacturing Co.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A number of temporary, or preparatory prostheses, popularly known as "pylons," are available (<b>Fig. 12</b>). Usually these devices are used with an ordinary foot-ankle unit which can be incorporated into the final or definitive prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. "Pylons" for above-knee amputations. <i>Left, </i>U.S. Manufacturing Co.; <i>Center, </i>A. J. Hosmer Corp. unit based on the UCB adjustable leg; <i>Right, </i>VAPC unit designed to accommodate a variety of knee-control devices. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Knee Units</h3> <p> Probably no other component of artificial limbs has received as much attention from designers and "gadgeteers" as the knee joint. Several hundred patents have been issued for knee designs, and many types have been produced and offered to the public, but relatively few designs have been used widely.</p> <p>The primary functions of a knee unit for above-knee prostheses are control of the leg during standing and the stance phase of walking, and control of the shank during the swing phase of walking.</p> <p><i>Swing-Phase Control</i></p> <p>The articulated above-knee prosthesis functions as a compound pendulum. As the thigh stump is brought forward during the latter stages of stance phase, the knee begins to flex and the foot is lifted from the ground because of the effects of inertia. The force propelling the shank acts more or less horizontally through the knee joint, while the center of gravity of the shank is well below this level; thus a moment is created, resulting in rotation of the shank about the knee joint in a backward direction (<b>Fig. 13</b>). <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Forces developed during rotation of the shank about the knee joint during forward swing of the thigh. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The less friction there is in the joint, the higher will be the rise of the heel for any given acceleration. Therefore, when a nearly frictionless joint is used, the amputee must use very short steps at a low cadence, so that the shank and foot will return to the proper fully extended position to support him as stance phase is begun. If friction, or some other form of resistance, is introduced, rise of the heel is restrained and shank motion toward full extension is retarded, so that longer steps at higher cadences are possible. When the amount of friction is constant, only one best speed is available to the patient. To overcome this limitation, designers have turned to hydraulic and pneumatic devices to obtain desirable resistance.</p> <p>To guide the design of swing-phase control units, the University of California has plotted knee moments against time for the ideal prosthesis during swing phase (<b>Fig. 14</b>). <a></a> This diagram is based on data accumulated from four normal young males, allowances being made for weight and weight distribution between normal and artificial limbs. The values, of course, will change as cadence is varied and as the height and weight distribution are changed. However, the general pattern should not change.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Knee-moment pattern required for natural swing of an artificial leg. This curve was developed by the University of California Biomechanics Laboratory based on data collected during the study of human locomotion. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Constant Friction (Mechanical)</i></p> <p>Constant friction in a way is a misnomer, because the amount of friction or restraint can be controlled or set, but does not vary in accordance with the needs of the amputee during a given cycle. The amount of friction can be controlled in a number of ways, the most common being the application of a braking surface to the peripheral area of the knee bolt (<b>Fig. 15</b>). The typical knee-moment diagram for a constant-friction knee unit is shown in <b>Fig. 16</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. One type of constant-friction single-axis knee joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Knee-moment patterns of various swing-phase units in comparison with the ideal curve of <b>Fig. 14</b>. Data were taken at the Veterans Administration Prosthetics Center. The knee units were adjusted for intermediate resistance, and were subjected to 43 cycles per min. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Intermittent Friction</i></p> <p>To more closely approximate the ideal knee-moment diagram, several designs have been made to vary the amount of mechanical friction applied at predetermined points during the swing phase. The Northwestern University Intermittent-Friction Knee Unit (<b>Fig. 17</b>) is one such device that is available commercially. Mechanical friction is provided by pressure between three disks mounted concentrically with the long axis of the knee bolt. The resistance offered by each individual disk is brought into play at varying intervals during the swing phase. The knee-moment diagram of the Northwestern University unit is shown in <b>Fig. 16</b>. The unit is available in a wood set-up, and is delivered with three disks installed. Two additional disks of different configurations are provided for interchange with the regular disks, so that the pattern of resistance about the knee can be changed to suit the amputee on an individualized basis. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Intermittent-Friction Knee Unit developed at Northwestern University, installed in a wood set-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Hydraulic Swing-Phase Control Units</i></p> <p>Because the resistance offered by an orifice to the flow of a fluid increases at a greater rate than the increase in velocity of the fluid, hydraulic systems are ideally suited for control of the shank during swing phase. Thus, heel rise and terminal deceleration can be controlled automatically over a wide range of cadences, giving the amputee much more flexibility in speed of ambulation. <a></a> The value to be obtained by applying these principles has been recognized for many years, but a good deal of engineering was required to develop units that met the exacting demands of limb prosthetics. <a></a></p> <p>The Henschke-Mauch Model "B" unit (<b>Fig. 18</b>) is a very sophisticated device available in a wood set-up to make its use compatible with standard components and practices. A number of orifices are so incorporated into the cylinder wall that the moving piston successively blocks off escape of the fluid and thus varies the resistance throughout the swing phase in order to approximate the ideal moment curve (<b>Fig. 16</b>). Resistance to flexion and to extension may be adjusted independently of each other by the wearer.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. The Henschke-Mauch "Hydraulik" Knee Unit. <i>Left, </i>Unit installed in a wood set-up; <i>Right, </i>cross-section of the Model "B" (Swing-Phase) Unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In a clinical evaluation program conducted by the Veterans Administration, involving more than 30 test subjects, the results were overwhelmingly in favor of the Henschke-Mauch unit in comparison with mechanical friction devices previously worn by the amputees in the study. <a></a></p> <p>The ability to vary gait easily and a reduction in effort required and fatigue produced were the advantages most frequently cited. The last two advantages are particularly noteworthy, since the experimental prostheses were heavier than the prostheses worn previously.</p> <p>The DuPaCo "Hermes" Knee (<b>Fig. 19</b>) is quite similar in design and function to the Henschke-Mauch Model "B" unit and is also available in a wood set-up. Resistance to flexion and to extension may be adjusted independently of each other by the amputee. A clinical study of the DuPaCo knee by the Veterans Administration resulted in very positive reactions, strikingly similar to those obtained in the study with the Henschke-Mauch Model "B" unit. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. DuPaCo "Hermes" Hydraulic Swing-Phase Control Unit mounted in a wood set-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Unlike the Henschke-Mauch and DuPaCo units, the "Hydra-Cadence" hydraulic leg (<b>Fig. 20</b>) is an integrated system incorporating some ankle control as well as swing-phase control. This system is available only in a metal frame, with a specially designed foot-ankle assembly. For appearance, the metal frame that constitutes the shank is covered with a cosmetic cover of a relatively thin, semirigid plastic cast to resemble an average normal shank. The swing-phase unit is a relatively simple piston type and does not offer quite as precise control of function as the more sophisticated units. In addition to control of the shank during swing phase, resistance to plantar flexion is controlled hy-draulically, and motion between the ankle and knee are coordinated so that dorsi-flexion of the ankle takes place after the knee has been flexed 20 deg. The object of the coordinated motion feature was to provide additional toe clearance during the swing phase, but unfortunately the motion does not take place at the time when it is needed most. Nevertheless, as in many other instances, the side effects are highly useful. One advantage of coordinated motion appreciated by amputees is that during sitting dorsiflexion of the foot allows the wearer to draw his artificial foot comfortably under his knee, thus keeping it out of the way when he is seated in a theater or bus. In clinical tests conducted by the Veterans Administration, the overwhelming majority of test subjects preferred the "Hydra-Cadence" unit to their conventional limbs. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. "Hydra-Cadence" Artificial Leg with cosmetic cover removed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The swing-phase control system of the "Hydra-Cadence" unit is offered in a wood set-up or separately for use in a pylon as the "Hydra-Knee" (<b>Fig. 21</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. "Hydra-Knee" installed in a wood set-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the problems of leakage and high maintenance costs have been overcome to a point where hydraulic devices are practical, pneumatic systems also have appeal since manufacturing costs should be materially lower. Pneumatic systems are not apt to produce a knee-moment curve as smooth as those obtained with hydraulic units, but many feel that they offer an excellent compromise suitable for many amputees.</p> <p>One such device nearly ready for commercial distribution is the University of California Pneumatic Swing-Phase Unit. <a></a> Like the Henschke-Mauch and DuPaCo units, the UCB device consists essentially of a moving piston in a cylinder (<b>Fig. 22</b>). It will be available initially in a pylon-type shank and wooden knee block.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Pneumatic Swing-Control Unit developed at the Biomechanics Laboratory, University of California (San Francisco and Berkeley). <i>Left, </i>Cutaway view; <i>Center, </i>complete unit; <i>Right, </i>pylon and cosmetic cover designed especially for the pneumatic unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Stance-phase Units</h3> <p>Increased understanding of fitting and alignment has alleviated many of the former problems of stability control of the leg during stance phase, especially for those patients with relatively strong stumps. Nevertheless, there appears to be a real need for knee units that provide assurance against buckling yet do not interfere with other functions of the leg. The increase in the number of "geriatric" patients in recent years has tended to highlight this need. Patents have been granted for many ways of stabilizing the knee, but few have been found practical. Doubtless the most widespread stance-phase control device in use today is the Otto Bock knee (<b>Fig. 23</b>). Purely mechanical in action, the Bock knee provides resistance to flexion by a friction braking action effected by weight-bearing. When weight is placed on the prosthesis, the knee block moves slightly toward the shank to engage a "V"-type brake. Swing-phase control consists of constant friction and a spring-biased extensor mechanism.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. The Otto Bock Safety Knee Unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Henschke-Mauch Model "A" unit (<b>Fig. 24</b>), currently in an advanced experimental stage, consists essentially of the Model "B" unit (<b>Fig. 18</b>) with provisions for stance-phase control added. Braking of the knee joint is controlled by the complex interaction of a pendulum and a counterweight suspended in hydraulic fluid. <a></a> The braking action is brought into play whenever required to arrest buckling action, and is removed only by the prolonged hyperextension moment typical of late stance phase, so theoretically there should be a smoother transition between stance phase and swing phase than that provided by other units. Moreover, for special tasks, the amputee can set the knee either in "freewheeling" or almost fully locked position.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Henschke-Mauch "Hydraulik" Model "A" (Swing and Stance Control) Unit. <i>1, </i>Cylinder; <i>2. </i>piston; <i>3, </i>piston rod; <i>4, </i>hydraulic fluid; 5<i>, </i>accumulator piston; <i>6, </i>dashpot; 7, dashpot piston; <i>8, </i>control bushing; <i>9, </i>swing adjustment screw; <i>10 </i>and <i>11</i>. check valves; <i>12 </i>and <i>13. </i>channels: <i>14, </i>pendulum; <i>15, </i>valve; <i>16, </i>counterweight; <i>17, </i>spring; <i>18, </i>stance adjustment screw; <i>19, </i>selector switch. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A clinical evaluation by the Veterans Administration involving 50 units has nearly been completed. It is expected that the Henschke-Mauch Model "A" unit will be available for general use in the near future.</p> <h3>Foot-ankle Units</h3> <p> Many attempts have been made to develop foot-ankle units that offer more than the minimum function required, which is controlled plantar flexion. Through the years several designs have been manufactured and made available, but none has found widespread use, usually because the maintenance requirements of the units have outweighed any functional gain they offered. Thus, today, nearly every artificial leg (except the "Hydra-Cadence") incorporates either a SACH (solid-ankle cushion-heel) foot (<b>Fig. 25</b>) or a so-called conventional foot (<b>Fig. 26</b>). Both designs provide controlled resistance to plantar flexion, firm resistance to dorsi-flexion, and limited toe motion, but little else. Resistance to plantar flexion can be adjusted more easily in the conventional foot by introducing rubber bumpers of different densities. The absence of parts in the SACH foot which rotate or rub and its resistance to moisture make its use attractive. Since its introduction in 1958, the design of the SACH foot has been refined in a number of ways. Initially the SACH foot was made by laminating layers of foam rubber around a wooden keel. Later, techniques for molding the rubber were developed and most units are manufactured in this manner. However, the laminated type is available for special applications where shaping to unusual sizes and configurations is required.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. The SACH (solid-ankle, cushion-heel) Foot. <i>Upper, </i>Laminated type; <i>Lower, </i>molded type. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Cross-section of a typical "conventional" foot-ankle unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Very recently, a special SACH foot has been made available by Kingsley Manufacturing Co. for use in immediate postsurgical fitting procedures (<b>Fig. 27</b>). This version has a flat, wide sole designed for use without a shoe while the patient is in the hospital. This permits equal leg length when the natural foot of the patient is bare or is covered simply with a sock or slipper. It is also about 20 per cent lighter than the conventional SACH foot, and resistance to toe break is less.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Special SACH foot for use in immediate postsurgical fitting procedures. <i>Courtesy Kingsley Manufacturing Co.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Veterans Administration Prosthetics Center is responsible for updating the specifications for the SACH foot, and makes periodic checks of mass-produced units on a random basis.</p> <p>At the present time, development of a more functional foot-ankle unit using hydraulic principles is under way.</p> <table> <tbody><tr><td> <h3><i>Definitions</i></h3></td> </tr> <tr><td> <p><i>Preparatory Prosthesis</i></p> </td> </tr> <tr><td> <p>A cosmetically unfinished functional replacement for an amputated extremity, fitted and aligned in accordance with sound biomechanical principles, which is worn for a limited period of time to expedite prosthetic wear and use and to aid in the evaluation of amputee adjustment.</p> </td> </tr> <tr><td> <p><i>Pylon</i></p> </td> </tr> <tr><td> <p>A rigid supporting member, usually tubular, that is attached to the socket or knee unit of a prosthesis. The lower end of the pylon should be connected to a foot-ankle assembly.</p> </td> </tr> <tr><td> <p><i>Rigid Dressing</i></p> </td> </tr> <tr><td> <p>A plaster stump wrap, usually applied in the operating or recovery room immediately following operation, for the purpose of controlling edema and pain. It is preferably shaped in accordance with the basic patellar-tendon-bearing (PTB) or quadrilateral designs, but is not necessarily so.</p> </td> </tr> <tr><td> <p><i>Immediate Postsurgical Prosthetic Fitting</i></p> </td> </tr> <tr><td> <p>A procedure wherein a functional socket, designed for weight bearing and walking, is fitted to the patient immediately after operation in the operating or recovery room, or at some time prior to removal of sutures. As distinct from the rigid dressing, referred to above, this socket should be shaped in accordance with the basic PTB or quadrilateral design; it incorporates provision for easy attachment and detachment of a pylon and foot-ankle assembly.</p> </td> </tr> <tr><td> <p><i>Early Prosthetic Fitting</i></p> </td> </tr> <tr><td> <p>A procedure wherein a preparatory prosthesis, as defined above, is provided for the amputee immediately following removal of sutures.</p> </td> </tr> <tr><td> <p><i>Permanent Prosthesis</i></p> </td> </tr> <tr><td> <p>A replacement for a missing limb, which meets accepted checkout standards for comfort, fit, alignment, function, appearance, and durability.</p> </td> </tr> </tbody></table> <h3>Pylons</h3> <p> Recently a number of devices known as pylons have been developed to meet the requirements imposed by immediate and early postsurgical fitting, namely, functional devices that contain built-in alignment features but are light enough for use throughout the day. Also, devices used in fitting immediately postoperatively should be easily removable from the socket so that the device may be disconnected when the patient is sleeping. Provision for locking the knee joint manually is desirable for use with infirm patients.</p> <p>The Hosmer Above-Knee Temporary Leg (<b>Fig. 28</b>) is a modification of the adjustable leg originally designed by the University of California Biomechanics Laboratory for alignment adjustment during walking trials.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. The Hosmer Above-Knee Temporary Leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The U.S. Manufacturing Co. above-knee constant-friction pylon (<b>Fig. 29</b>) is simple, is light in weight, and provides all adjustments necessary in aligning a leg. However, the wedge disks used to change the adduction-abduction and flexion-extension attitudes of the socket require compensatory adjustments to maintain position in one while the other is changed. Hence some degree of skill in using this unit is required.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. The U.S. Manufacturing Co. Above-Knee Constant-Friction Pylon. The expanded metal straps at the top are provided for use with plaster-of-Paris sockets. <i>Courtesy U.S. Manufacturing Co.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The U.S. Manufacturing Co. also provides an above-knee temporary prosthesis with the "Hydra-Knee" unit installed (<b>Fig. 30</b>). Alignment adjustment is provided in the same manner as in the above-knee unit shown in <b>Fig. 29</b>. Cosmetic covers similar to those used with "Hydra-Cadence" units are available.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. The Hydra-Knee Pylon. <i>Courtesy U.S. Manufacturing Co.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To provide for independent adjustment in the adduction-abduction and flexion-extension planes, the Veterans Administration Prosthetics Center designed a unit (<b>Fig. 31</b>) in which threaded "disks" are used to provide a wedging action between two conical surfaces placed apex to apex. This device is incorporated in the VAPC "Standard" above-knee pylon which permits the interchange of several knee mechanisms including various constant friction knees, the DuPaCo swing-control unit, both of the Henschke-Mauch knee units, and the UCB pneumatic device. This very desirable interchangeability feature permits the patient to try out a number of swing-control devices at a minimum cost.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Pylon developed at the Veterans Administration Prosthetics Center. This unit will accommodate a number of different standard mechanisms for control of the knee. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is feasible and practical to use any of these prostheses for indefinite periods. Thus, changes in alignment can be made if they are needed. A comparison of the major features and characteristics of the various pylons is given in <b>Table 1</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Use of the Prosthetics Research Study (Seattle) casting fixture to form socket in fitting above-knee case with prosthesis immediately after operation. <i>Courtesy Prosthetics Research Study, Seattle, Wash.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Time of Fitting</h3> <p> From time to time through the years, a few clinicians have argued for fitting new amputees with temporary or "training" limbs, either for acceleration of the rehabilitation process or to evaluate the patient's potential for use of a prosthesis if there is doubt about his ability to use one. No one argued against this approach provided the temporary limb was properly fitted and aligned. However, when fitting was done before the stump had stabilized the frequent socket changes that were necessary resulted in high costs. If poorly fitted and aligned prostheses were used, more harm than good could result.</p> <p>The introduction of improved casting methods, improved fabrication techniques, and adjustable pylons led the Orthopaedic Department at Duke University to conduct a series of experiments, beginning about 1960, in which it was demonstrated that it is feasible and, indeed, desirable to fit amputees as soon as the wound has healed. <a></a> In 1963, several groups in the United States began experimenting with the concept of fitting the patient immediately after operation and allowing some degree of ambulation very soon thereafter, a technique that had achieved some success in a rather crude way in France and Poland.<a></a></p> <p>By 1967 the technique had been developed in sufficient detail at the Prosthetics Research Study, Seattle, Washington, and experience with experimental cases was such that it seemed warranted to offer special courses in the Prosthetics Education Program in immediate postsurgical fitting of prostheses. The technique applies to all levels of lower-extremity amputation. Experience has shown that the formation of edema is materially reduced, postoperative pain is reduced, development of contractures is avoided, stump bandaging is unnecessary, and the general well-being of the patient is better than when he is treated in the conventional manner. The procedure obviously reduces both time of hospitalization and time required for rehabilitation, and it is appropriate for use in virtually all types of cases except where an open amputation is indicated. More time is required by the surgeon and prosthetist in the management of the patient during the first two weeks, but substantial savings are effected in the over-all treatment program.</p> <p>For the above-knee case, immediate postsurgical fitting consists essentially of providing the patient with a quadrilateral total-contact socket of plaster-of-Paris bandage (<b>Fig. 32</b>) and an easily detachable functional pylon, allowing him to begin weight-bearing about 24 hours after amputation (<b>Fig. 33</b>). No special surgical techniques are needed. Myoplasty, consisting of some method to ensure reattachment of the cut muscles about the thigh, is recommended in any case. <a></a> The cast-socket is left in place for 8 to 12 days, at which time the sutures can usually be removed. A new cast socket is applied immediately and is kept in place until measurements and a cast can be made for the definitive prosthesis, usually 10 to 12 days later. If some other condition precludes the patient from walking, a rigid dressing of plaster of Paris should be used, rather than conventional dressings, to keep formation of edema to a minimum and thus provide a stump that will cause the pros-thetist less trouble.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Above-knee amputation patient fitted with a prosthesis immediately after amputation. <i>Courtesy Prosthetics Research Study, Seattle, Wash.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Immediate postsurgical fitting and early fitting have been very successful in the hands of competent surgeon-prosthetist teams, and are routine procedures in many centers today. Research in this area is continuing in order to refine the methods still further.</p> <h3>Above-Knee Prosthetics for Children</h3> <p> Amputation in children can be classified as either acquired or congenital. The acquired amputation is the result of trauma or of disease, usually a malignant tumor. The congenital type is the result of a malformation occurring during embryonic development.</p> <p>Management of the acquired amputation in children is essentially the same as that for the adult. Because wounds in children tend to heal faster than they do in adults, immediate postsurgical fitting and early fitting techniques are most appropriate. Usually care must be taken to keep the child patient from being too active. The quadrilateral, total-contact, plastic, suction socket is nearly always indicated. A Silesian bandage may be used, but is usually not needed. For patients below the age of puberty, the only knee unit available is the constant-friction type. SACH and conventional feet are available in sizes suitable for children of all ages.</p> <p>Children with congenital malformations of the lower extremities usually offer a greater challenge. Many times the stump and proximal anatomy are abnormal in structure, and these features must be taken into account in design of the socket and suspension. For guidelines and suggestions for treatment of unusual and bizarre cases, the reader is referred to <i>The Limb-Deficient Child</i>. <a></a></p> <p>For the high, bilateral above-knee case where conventional above-knee or knee-disarticulation prostheses are not suitable, <i>i.e., </i>the patient is unable to use crutches, the use of the swivel walker is recommended (<b>Fig. 34</b> and <b>Fig. 35</b>). <a></a> Designed at the Ontario Crippled Children's Centre for use by patients with severe involvement of all four limbs, the swivel walker has met with success wherever it has been used. Motion is effected by displacement of the center of gravity of the body. Although movement is restricted to smooth, level surfaces, the swivel walker offers an effective means of mobility, and the psychological benefits to be gained from it are quite rewarding.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Principle of the "Swivel Walker" developed at the Ontario Crippled Children's Centre, Toronto, Canada, for very high, bilateral, lower-extremity cases. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. The OCCC swivel walker with articulated joints that permit a sitting position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Above-Knee Prosthetics for Geriatric Cases</h3> <p> At one time it was an almost universal rule to amputate through the thigh in cases of peripheral vascular disease when limb ablation was indicated. However, since it has been shown that many knee joints can be saved in spite of what appear to be overwhelming odds, the ratio of above-knee to below-knee amputations is decreasing. Unfortunately, however, there will always be a certain number of above-knee cases.</p> <p>Immediate postsurgical and early fitting practices should be used whenever possible. Proper use of these procedures reduces the mortality rate drastically and permits the fitting of definitive prostheses considered impossible, or at least impractical, only a few years ago. The use of provisional prostheses permits the clinic team to determine, without question, whether or not a definitive prosthesis is indicated. The VAPC "Standard" AK Pylon permits experimentation with several hydraulic units as well as with mechanical friction knee control.</p> <p>In spite of the many useful innovations that have been introduced into the practice of above-knee prosthetics through the years, there is still room for further improvement. Among the developments needed are more foolproof methods of obtaining optimum fit and alignment. Sockets that can be adjusted to meet the constantly changing cyclical demands of the amputee are certainly desirable and possible. Indeed, it might be feasible to provide a socket that is adjusted automatically to meet the needs of the patient constantly throughout the day. In any event, studies of the effect of pressure on human tissues must lead eventually to a better application of limb prostheses.</p> <p>Needed also are methods for fitting and fabrication of limbs in even less time than is presently required. Materials that can be formed at temperatures safe to human tissues are now becoming available, and it is hoped that a useful socket can be molded over the stump, eliminating the need for plaster of Paris in taking impressions and making models of the stump. Such a technique, when used with adjustable pylons that are cheap enough and light enough to leave as the "permanent" prosthesis, should permit fast, economical service.</p> <p>Concurrently with studies designed to point the way to more functional prostheses and more efficient service, a number of surgeons are studying and trying to devise methods for providing more functional stumps. In recent years the techniques of amputation have taken on more significance in the minds of surgeons and, consequently, prosthetists have been seeing stumps that are more functional than has been the case in the past. Further research and a continuation of educational programs should result in even more improvement.</p> <h3>Acknowledgment</h3> <p>Special appreciation is due the Prosthetic and Sensory Aids Service of the Veterans Administration for providing nearly all of the illustrations for this article.</p> <p><b>References:</b></p> <ol> <li>Anderson, M. H., J. J. Bray, and C. A. Hennessy,<i>The construction and fitting of lower-extremity prostheses</i>, Chap. 6 in Orthopaedicappliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 263-312.</li> <li>Bard, Gregory, and H. J. Ralston, <i>The measurment of energy expenditure during ambulation, with special reference to evaluation of assistive devices</i>, Arch. Phys. Med., 40:415-420, October 1959.</li> <li>Blakeslee, Berton, ed.,<i>The limb-deficient child</i>, University of California Press, Berkeley and San Francisco, 1963.</li> <li>Burgess, E. M., J. E. Traub, and A. B. Wilson, Jr., <i>Immediate postsurgical prosthetics in the management of lower extremity amputees</i>, Veterans Administration, Washington, D.C., 1967.</li> <li>Foort, J.,<i> Adjustable-brim fitting of the total-contact above-knee socket</i>, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 50, March 1963.</li> <li>Foort, J., and N. C. Johnson, <i>Edema in lower-extremity amputees</i>, Biomechanics Laboratory, University of California, San Francisco and Berkeley, 1962.</li> <li>Golbranson, F. L., Charles Asbelle, and Donald Strand,<i> Immediate postsurgical fitting and early ambulation</i>, Clin. Orth., 56:119-131, 1968.</li> <li>Goldner, J. Leonard, Frank W. Clippinger, Jr., and Bert R. Titus, <i>Use of temporary plaster or plastic pylons preparatory to fitting a permanent above knee or below knee prosthesis</i>, Final Report of Project 1363 to (U.S.)</li> <li>Vocational Rehabilitation Administration by Duke University Medical Center, Durham, N.C., 1967. 9. Haddan, Chester C, and Atha Thomas,<i> Status of the above-knee suction socket in the United States</i>, Artif. Limbs, 1:2:29-39, May 1954.</li> <li>Hampton, Fred, <i>Suspension casting for below-knee, above-knee, and Syme's amputations</i>, Artif. Limbs, 10:2:5-26, Autumn 1966.</li> <li>Hanger, H. B.,<i>Above-knee socket shape and clinical considerations</i>, Committee on Pros-thetic-Orthotic Education, National Research Council, August 1964.</li> <li>Kay, Hector W., K. A. Cody, and H. E. Kramer, <i>Total contact above-knee socket studies</i>, Prosthetic and Orthotic Studies, Research Division, NYU School of Engineering and Science, June 1966.</li> <li>Lewis, Earl A., <i>Fluid controlled knee mechanisms, clinical considerations</i>, Bull. Pros. Res., 10:3:24-56, Spring 1965.</li> <li>Motloch, W. M., and Jane Elliott, <i>Fitting and training children with swivel walkers</i>, Artif. Limbs, 10:2:27-38, Autumn 1966.</li> <li>Murphy, E. F., <i>The swing phase of walking with above-knee prostheses</i>, Bull. Pros. Res., 10:1:5-39, Spring 1964.</li> <li>Murphy, Eugene F., <i>Lower-extremity components</i>, Chap. 5 in <i>Orthopaedic appliances atlas</i>, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 129-261.</li> <li>Radcliffe, C. W., <i>Functional considerations in the fitting of above-knee prostheses</i>, Artif. Limbs, 2:1:35-60, January 1955.</li> <li>Radcliffe, C. W.,<i> Biomechanical design of an improved leg prosthesis</i>, Biomechanics Laboratory, University of California, Berkeley, Ser. 11, Issue 33, October 1957.</li> <li>Radcliffe, C. W., and H. J. Ralston, <i>Performance characteristics of fluid-controlled prosthetic knee mechanisms</i>, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 49, February 1963.</li> <li>Staros, Anthony, <i>Dynamic alignment of artificial legs with the adjustable coupling</i>, Artif. Limbs, 7:1:31-43, Spring 1963.</li> <li>Staros, Anthony, and Eugene F. Murphy, <i>Properties of fluid flow applied to above-knee prostheses</i>, Bull. Pros. Res., 10:1:40-65, Spring 1964.</li> <li>Staros, Anthony, and Edward Peizer, <i>Northwestern University intermittent mechanical friction system (disk-type)</i>, Artif. Limbs, 9:1:45-52, Spring 1965.</li> <li>Thomas, Atha, and C. C. Haddan, <i>Amputation prosthesis</i>, Lippincott, Philadelphia, Pa., 1945.</li> <li>Veterans Administration, Prosthetic and Sensory Aids Service, <i>Clinical application study of the Hydra-cadence above-knee prosthesis</i>, TR-2, Nov. 1, 1963.</li> <li>Veterans Administration, Prosthetic and Sensory Aids Service, <i>Clinical application study of the Henschke-Mauch "Hydraulik" swing control system</i>, TR-3, Dec. 1, 1964.</li> <li>Veterans Administration, Prosthetic and Sensory Aids Service, <i>Clinical application study of the DuPaCo "Hermes" hydraulic control unit</i>, TR-4, Jan. 4,1965.</li> <li>Wilson, A. Bennett, Jr., <i>New concepts in the management of lower-extremity amputees</i>, Artif. Limbs, 11:1:47-50, Spring 1967.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Motloch, W. M., and Jane Elliott, Fitting and training children with swivel walkers, Artif. Limbs, 10:2:27-38, Autumn 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Blakeslee, Berton, ed.,The limb-deficient child, University of California Press, Berkeley and San Francisco, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Burgess, E. M., J. E. Traub, and A. B. Wilson, Jr., Immediate postsurgical prosthetics in the management of lower extremity amputees, Veterans Administration, Washington, D.C., 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Burgess, E. M., J. E. Traub, and A. B. Wilson, Jr., Immediate postsurgical prosthetics in the management of lower extremity amputees, Veterans Administration, Washington, D.C., 1967.</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Golbranson, F. L., Charles Asbelle, and Donald Strand, Immediate postsurgical fitting and early ambulation, Clin. Orth., 56:119-131, 1968.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., New concepts in the management of lower-extremity amputees, Artif. Limbs, 11:1:47-50, Spring 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Goldner, J. Leonard, Frank W. Clippinger, Jr., and Bert R. Titus, Use of temporary plaster or plastic pylons preparatory to fitting a permanent above knee or below knee prosthesis, Final Report of Project 1363 to (U.S.)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Murphy, Eugene F., Lower-extremity components, Chap. 5 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 129-261.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Murphy, E. F., The swing phase of walking with above-knee prostheses, Bull. Pros. Res., 10:1:5-39, Spring 1964.</td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Staros, Anthony, and Eugene F. Murphy, Properties of fluid flow applied to above-knee prostheses, Bull. Pros. Res., 10:1:40-65, Spring 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Veterans Administration, Prosthetic and Sensory Aids Service, Clinical application study of the Hydra-cadence above-knee prosthesis, TR-2, Nov. 1, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Veterans Administration, Prosthetic and Sensory Aids Service, Clinical application study of the DuPaCo 'Hermes' hydraulic control unit, TR-4, Jan. 4,1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Veterans Administration, Prosthetic and Sensory Aids Service, Clinical application study of the Henschke-Mauch 'Hydraulik' swing control system, TR-3, Dec. 1, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Lewis, Earl A., Fluid controlled knee mechanisms, clinical considerations, Bull. Pros. Res., 10:3:24-56, Spring 1965.</td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Staros, Anthony, and Eugene F. Murphy, Properties of fluid flow applied to above-knee prostheses, Bull. Pros. Res., 10:1:40-65, Spring 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and H. J. Ralston, Performance characteristics of fluid-controlled prosthetic knee mechanisms, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 49, February 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Staros, Anthony, and Edward Peizer, Northwestern University intermittent mechanical friction system (disk-type), Artif. Limbs, 9:1:45-52, Spring 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Biomechanical design of an improved leg prosthesis, Biomechanics Laboratory, University of California, Berkeley, Ser. 11, Issue 33, October 1957.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Biomechanical design of an improved leg prosthesis, Biomechanics Laboratory, University of California, Berkeley, Ser. 11, Issue 33, October 1957.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Murphy, E. F., The swing phase of walking with above-knee prostheses, Bull. Pros. Res., 10:1:5-39, Spring 1964.</td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Murphy, Eugene F., Lower-extremity components, Chap. 5 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 129-261.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Staros, Anthony, Dynamic alignment of artificial legs with the adjustable coupling, Artif. Limbs, 7:1:31-43, Spring 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Staros, Anthony, Dynamic alignment of artificial legs with the adjustable coupling, Artif. Limbs, 7:1:31-43, Spring 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Functional considerations in the fitting of above-knee prostheses, Artif. Limbs, 2:1:35-60, January 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Hampton, Fred, Suspension casting for below-knee, above-knee, and Syme's amputations, Artif. Limbs, 10:2:5-26, Autumn 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Kay, Hector W., K. A. Cody, and H. E. Kramer, Total contact above-knee socket studies, Prosthetic and Orthotic Studies, Research Division, NYU School of Engineering and Science, June 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Kay, Hector W., K. A. Cody, and H. E. Kramer, Total contact above-knee socket studies, Prosthetic and Orthotic Studies, Research Division, NYU School of Engineering and Science, June 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 50, March 1963.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Kay, Hector W., K. A. Cody, and H. E. Kramer, Total contact above-knee socket studies, Prosthetic and Orthotic Studies, Research Division, NYU School of Engineering and Science, June 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 50, March 1963.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Foort, J., and N. C. Johnson, Edema in lower-extremity amputees, Biomechanics Laboratory, University of California, San Francisco and Berkeley, 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Hanger, H. B.,Above-knee socket shape and clinical considerations, Committee on Pros-thetic-Orthotic Education, National Research Council, August 1964.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Functional considerations in the fitting of above-knee prostheses, Artif. Limbs, 2:1:35-60, January 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Thomas, Atha, and C. C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, Pa., 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Vocational Rehabilitation Administration by Duke University Medical Center, Durham, N.C., 1967. 9. Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United States, Artif. Limbs, 1:2:29-39, May 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Anderson, M. H., J. J. Bray, and C. A. Hennessy,The construction and fitting of lower-extremity prostheses, Chap. 6 in Orthopaedicappliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 263-312.</td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Murphy, Eugene F., Lower-extremity components, Chap. 5 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 129-261.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bard, Gregory, and H. J. Ralston, The measurment of energy expenditure during ambulation, with special reference to evaluation of assistive devices, Arch. Phys. Med., 40:415-420, October 1959.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and H. J. Ralston, Performance characteristics of fluid-controlled prosthetic knee mechanisms, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 49, February 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, JR.. B.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Research Council, 2101 Constitution Ave., N.W., Washington, D.C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Recent Advances in Above-Knee Prosthetics Creator An entity primarily responsible for making the resource A. Bennett Wilson, JR.. B.S.M.E. * https://staging.drfop.org/files/original/99ea32a0e2c94d4c7589431c1ce25157.pdf 2e7fbc0fa2eb0306b0ca796e5ddda33f https://staging.drfop.org/files/original/db98a4319f901a5df31650f9d7aaafee.jpg 0fa803d29cb641dc7320e3d9a863936f https://staging.drfop.org/files/original/64d9411b67eb520fc954e715926b9298.jpg 726bcec99286d9cecafabb7eb8dc978d https://staging.drfop.org/files/original/16c6695c898c94d3672358c548efdb97.jpg 79d67a4e4d9d172c26b6a84ae56bf6d9 https://staging.drfop.org/files/original/52576dcdb3ac9adc947bf94d02d02a39.jpg ea6217584377d64348133ea09815076b https://staging.drfop.org/files/original/58f2050e89cae296d63c129ffca2499c.jpg e164595194dd9613126ebed26bc18d6f https://staging.drfop.org/files/original/e2bcd7e4954572b656575f76c6af042f.jpg a1cd131317ea4a80a7ff5fa68bb4b971 https://staging.drfop.org/files/original/ab3796e5b9f95a10bab6a6a4709fa759.jpg 929d3223aba1e1b2a7483eeebec5b0cd https://staging.drfop.org/files/original/c6047dac85ad7f0f42b9c09184f5c29b.jpg 65c71a86ab2789401328078e47ef9466 https://staging.drfop.org/files/original/ecf16ce9b6a02f16a28b7068eae7fa6a.jpg bfd62cca40c1d6ea9aa12468949eb70a https://staging.drfop.org/files/original/f517f80846ccc5574405da3e9e1627c2.jpg fde37795ae610a1848e2baff68929c95 https://staging.drfop.org/files/original/f762ec99d412e60f2d8d35ce9d55db87.jpg e26a637f131da62ed04ac2a515036959 https://staging.drfop.org/files/original/b166d882aab8ca9bff2a7ca99b8d8045.jpg 5dfee50cca7846001283b3b9c216796f https://staging.drfop.org/files/original/d6e1c536ddb7878b64b3bb95f1c31c0f.jpg c09e884e976731eb2d27af842c9614ad https://staging.drfop.org/files/original/c751d02f21559b315e9457299166cfeb.jpg 8d9e303bb98ad2f59b8056e9ffca5dca DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_02_001.pdf Year 1970 Volume 14 Issue 2 Page Number(s) 1 - 18 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Prosthetics and Orthotics Program</h2> <h5>A. Bennett Wilson. Jr. <a style="text-decoration:none;">*</a><br /></h5> <p> Early in 1945, at the request of the Surgeon General of the Army, the National Research Council sponsored a conference of surgeons, engineers, physicists, and prosthetists to consider the feasibility of effecting improvements in artificial limbs<a></a>. Conclusions that emerged from the conference were that virtually no organized research of significance had been conducted in the field of limb prosthetics, and that application of technology already in existence should produce improved devices. </p> <p> Organization of Research Program</p> <p>Subsequently, at the request of the surgeon general, the NRC established the Committee on Prosthetic Devices (later the Committee on Artificial Limbs) to organize a research program<a></a>. (The members of the Committee on Prosthetic Devices were: Paul E. Klopsteg, Ph.D., Chairman; Harold R. Conn, M.D.; Roy D. McClure, M.D.; Robert R. McMath, D.Sc; Mieth Maeser; Paul B. Magnuson, M.D.; Edmond M. Wagner; and Philip D. Wilson, M.D. Consultants: Robert S. Allen and Charles F. Kettering.) Subcontracts were entered into with sixteen universities, industrial laboratories, and foundations: </p> <ul> <li>Adel Precision Products Corp., Burbank, Calif. </li><li>Armour Research Foundation, Chicago, Ill. </li><li>C. C. Bradley and Sons, Inc., Syracuse, N.Y. (Catranis, Inc.) </li><li> Goodyear Tire and Rubber Co., Akron, Ohio </li><li>A. J. Hosmer Corp., Los Angeles, Calif. </li><li>International Business Machines Corp., Endicott, N.Y. </li><li> Mellon Institute of Industrial Research, Pittsburgh, Pa. </li> <li> National Research and Manufacturing Co., San Diego, Calif. </li> <li> Northrop Aircraft, Inc., Hawthorne, Calif. </li> <li> Northwestern University, Evanston, Ill. </li> <li> Research Institute Foundation, Detroit, Mich. </li> <li> Sierra Engineering Co., Sierra Madre, Calif. </li> <li> United States Plywood Corp., New Rochelle, N.Y. </li> <li> University of California, Berkeley and San Francisco, and Los Angeles </li> <li> Vard, Inc., Pasadena, Calif. </li> </ul> <p> Funds were initially supplied by the Office of Scientific Research and Development. With the impending disestablishment of OSRD shortly after World War II, the Office of the Surgeon General of the Army for a short time assumed fiscal responsibility for the program. Then, for fiscal year 1947, the Army and the Veterans Administration shared the support. The Army, the Navy, and the Veterans Administration cooperated by establishing laboratories within their own organizations. </p> <p> In some laboratories, development of components and application of new materials was begun, but it soon became clear to the committee that more knowledge of the patients' requirements was needed if significant progress was to be made. This in turn required a more detailed knowledge of the biomechanics of human extremities, and thus projects in this area were started. Also, anthropometric data were obtained with the idea of selecting rationally a series of standard sizes of components. </p> <p> The activities of the various groups were initially coordinated by the Committee on Artificial Limbs, and considerable progress was made during the first two years. By the spring of 1947, the committee felt that it had completed its task of establishing an organized program and suggested that contracts between the government and the research laboratories be made directly, and that the committee be reconstituted as an advisory group to the sponsoring agency. At that time, the majority of service-connected amputees had been discharged from the armed forces, and their medical care had become the responsibility of the Veterans Administration. Therefore, new contracts were effected between the VA and those laboratories in which promising developments were identifiable (1947: Catranis, Inc.; Northrop Aircraft, Inc.; University of California, Berkeley and San Francisco, and Los Angeles; 1948: New York University.) At the request of the VA, the NRC established the Advisory Committee on Artificial Limbs to continue the coordination and the correlation of the program. The Army, the Navy, and the VA continued to operate their own laboratories. </p> <p> The general feeling at the beginning of the program was that the solution to the problem of providing better prostheses lay in developing new devices, and rapid advances were made by applying new materials and fabrication methods. It was apparent, however, that fit, suspension, and control were at least as important as components were in the successful use of an artificial limb, and perhaps even more so. Letters of inquiry were sent by the committee early in its history to all known limb manufacturers, and one of the first subcontracts was made with the Research Institute Foundation, a laboratory operated by the Orthopedic Appliance and Limb Manufacturers Association. </p> <p> In the spring of 1946, arrangements were made with certain prosthetists to fit experimental suction-socket above-knee limbs, with cooperation from local surgeons and assistance from the committee staff. Studies to establish the principles of socket configuration, fitting, and alignment were initiated as supplements to the existing projects. Both fitting and harnessing of artificial arms were studied at other projects. </p> <h4> Public Law 729 </h4> <p> In 1948, the Eightieth Congress, recognizing the need for continuity in a program of this kind, passed Public Law 729, which authorized the expenditure of $1,000,000 annually for research in limb prosthetics and sensory aids (amended by P.L. 85-56, Eighty-fifth Congress, to remove the $1,000,000 limitation). The Veterans Administration was designated as the appropriate agency for the administration of the funds, and the Administrator of Veterans Affairs was authorized and encouraged to make the results of the proposed program widely available, so that all disabled persons might benefit. </p> <h4> Suction-Socket "Schools" </h4> <p> By October 1948, experience in a number of experimental settings indicated that the suction socket provided significant advantages over other methods of fitting and suspension for above-knee amputations, and that the technique should be released for general use. Because of the many factors which enter into the successful application of the suction socket, however, the publication of a teaching manual was not considered sufficient to ensure success. Therefore, with the assistance of the Orthopedic Appliance and Limb Manufacturers Association (now the American Orthotic and Prosthetic Association) and a distinguished group of surgeons, the NRC organized a series of regional workshops to teach surgeons and prosthetists the proper application of the suction socket. The University of California at Berkeley was assigned the initial responsibility for this program. The regional workshops were continued under VA auspices with cooperation of OALMA through 1952, by which time it was felt that the suction-socket technique had become established. During the entire program, approximately forty workshops were held. </p> <h4> Prosthetics Education Program </h4> <p> Through the findings of the UCLA case study and other endeavors, a considerable body of knowledge in upper-extremity prosthetics had been accumulated by 1952. Hence, the development was undertaken of a medium through which knowledge about the greatly improved devices and techniques that were available could be disseminated throughout the nation. Since the new developments involved the use of plastic laminates for all upper-extremity amputation levels, the time required for thorough instruction in fabrication of prostheses ruled out the use of regional teaching sessions. The Veterans Administration therefore financed the organization and operation of the Prosthetics Education Program at the University of California at Los Angeles. Following a pilot school in 1952 for teams from the Chicago area, participation in the UCLA cources was ultimately extended to surgeons, physicians, occupational and physical therapists, and prosthetists from all over the United States. Prosthetists attended for six weeks; they were joined by the therapists for the last two weeks, and by the physicians and surgeons for the final week, during which these disciplines worked together as a clinic team. </p> <p> The upper-extremity courses proved to be extremely popular and very successful. During the initial, intensive phase of the program (1953-55), 12 courses were conducted. As a result of these efforts, personnel constituting 75 specialized amputee clinics, and representing 30 states and the District of Columbia, were trained. Twenty-eight of these clinics were held at Veterans Administration installations, while 47 were at other public and private institutions. Concomitant with the upper-extremity education program, the VA funded a nationwide field study, conducted by New York University, to assess the value not only of specific devices but also of the treatment program taught at the schools. This study gathered much useful information and also served to reinforce the instructional material. </p> <p> This combined education-research program not only served to introduce new improved concepts in the management of upper-extremity amputees, but also was a tremendous stimulus to the formation of amputee clinics and clinic teams throughout the nation. Today, more than 400 amputee clinics staffed with trained personnel are in operation in the United States. This treatment concept has also spread to other countries throughout the world. </p> <p> The education program at UCLA proved to be so successful that the VA sponsored the establishment of a similar education program at New York University in 1956 to meet the needs of clinic personnel. Subsequently, the Vocational Rehabilitation Administration funded an additional prosthetics school at Northwestern University in 1959. As new devices and techniques emerged from the research program, additional courses were developed at all three schools, so that today every aspect of amputee management is covered. </p> <h4> Present Program Organization</h4> <p> By 1953, the Advisory Committee on Artificial Limbs recognized that child amputees had special problems, and began to work with the Michigan Crippled Children Commission to determine what might be done to solve some of these problems. The Children's Bureau supported the establishment of several research centers, and in 1955 the committee created the Subcommittee on Child Prosthetics Problems. </p> <p> From the beginning, the committee had felt that much of the experience gained in research in limb prosthetics was applicable to the field of orthopedic bracing, but it recognized that problems in orthotics were even more complex. Therefore, work was initially concentrated on prosthetics. About 1960, the Committee on Prosthetics Research and Development took steps to assist in the development of improved orthotic devices and techniques. At the present time, an active program in orthotics, supplementary and complementary to the prosthetics program, is under way. </p> <p> In 1966, at the request of the Veterans Administration, CPRD formed the Subcommittee on Sensory Aids to advise the VA concerning its research program in that area. The subcommittee also serves the Social and Rehabilitation Service in the same capacity. </p> <p> Prior to 1954, most of the research, development, and education activities in prosthetics and orthotics in the United States were supported by the Veterans Administration. In 1954, Congress enacted the Vocational Rehabilitation Act, which for the first time authorized the Office of Vocational Rehabilitation (later the Vocational Rehabilitation Administration and now the Social and Rehabilitation Service of the Department of Health, Education, and Welfare) to support research and education in rehabilitation. The prosthetics and orthotics research and education programs of the VRA were initiated gradually, beginning in 1955-a significant milestone being the assumption of the fiscal responsibility for the three prosthetics schools. </p> <p> Today the Veterans Administration, the Social and Rehabilitation Service, the Maternal and Child Health Service, and, to a limited extent, the National Institutes of Health, all support extramural research in these fields. The VA, the Army, and the Navy also operate research and development laboratories as part of their respective organizational endeavors. </p> <p> The VA, SRS, and MCHS support the Committee on Prosthetics Research and Development, which is responsible for correlating the various research projects and for advising the interested governmental agencies on matters related to prosthetics and orthotics. The VA and SRS also support the Committee on Prosthetic-Orthotic Education of the Division of Medical Sciences, National Academy of Sciences—National Research Council. CPOE's activities are directed toward the stimulation of educational programs for medical and paramedical personnel. </p> <p> Laboratories supported by the VA, SRS, MCHS, the Army, and the Navy, and their areas of interest, are listed at the end of this article. </p> <h4> Accomplishments </h4> <p> As a result of the research program, virtually every aspect of the management of amputees has been changed and improved. A similar program has now been initiated in orthotics, with the findings of the prosthetics program already strongly influencing research and clinical practice in orthotics. </p> <h4> Fundamental Studies </h4> <p> The fundamental studies supported originally by the VA, supplemented later by support from SRS and NIH mainly at the University of California at Berkeley and at Los Angeles<a></a>, have widely increased our knowledge about human locomotion, phantom pain, the functions of the upper extremities, the properties of voluntary muscle, and energy consumption. These studies not only have provided the basis for most of the new designs that have emerged from the research program but also have proven to be a stimulus to others to investigate the basic principles underlying the neuromuscular system. It is anticipated that fundamental studies will continue to contribute to the total research effort. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical force-plate results for a normal subject during level walking, illustrative of the information obtained in fundamental studies. (From Klopsteg, Wilson, et at., "Human Limbs and Their Substitutes,'' p. 453.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Fitting, Alignment, and Harnessing Techniques </h4> <p> Prior to the research program, it was the general surgical practice to amputate at certain specified levels, referred to as "sites of election." Most lower-extremity amputations resulted either in below-knee stumps that were six inches or shorter, or, in the case of above-knee amputations, in stumps no longer than two-thirds the length of the original thigh. Similar circumstances prevailed for upper-extremity amputations. The primary reason for these surgical practices was the lack of satisfactory techniques for fitting the longer stumps, especially those involving disarticulation, despite the fact that, in most cases, the longer the stump, the more functional it is. Improved techniques have now been developed for fitting stumps at all levels, and surgeons have been encouraged to save all length medically feasible. <b>Fig. 2</b>,<b>Fig. 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Force-length measurement of a biceps tunnel. (From "Human Limbs and Their Substitutes," p. 328.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Total-tension I, passive P, and developed-tension ? curves for flexor muscles of the human forearm. (From "Human Limbs and Their Substitutes," p. 328.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> New approaches to alignment based on biomechanics have been established for most amputation levels. New devices to aid in achieving optimum alignment have been devised and made available commercially. Descriptions of the new alignment principles, techniques, and instruments have been widely published, and their application is stressed in the Prosthetics Education Program. <b>Fig. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. A quadrilateral, total-contact socket developed for above-knee amputees under the program at University of California, Los Angeles. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> As an outcome of biomechanical analyses, new lower-extremity socket designs have been developed for all levels of amputation. The new socket designs have revolutionized fitting practices not only in the United States but also throughout the world. <b>Fig. 5</b>,<b>Fig. 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The figure-eight, ring-type harness for below-elbow amputees developed at Northwestern University. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The prosthesis for a Syme's amputation developed by the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> New harnessing techniques for upper-extremity prostheses, also based on biomechanical analyses, have been developed and made available for general use. </p> <p> Not only have the new fitting, alignment, and harnessing techniques provided the patient with increased function and comfort, but they also are easier for the prosthetist to apply than the older methods. <b>Fig. 7</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The casting jig for above-knee stumps developed by the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Among the more significant techniques developed under the program are: the plastic Syme prosthesis, the patellar-tendon-bearing below-knee prosthesis and its variations, the quadrilateral total-contact above-knee socket (with or without suction suspension), the Canadian-type hip-disarticulation and hemipelvectomy prostheses, and various plastic-socket designs for upper-extremity amputations. </p> <h4> Devices </h4> <p> A large number of mechanical components have been developed to provide additional or improved functions. While most of the designs have involved individual components, each was planned in relation to the total prosthesis. Hence, these new items can be used in various combinations to meet the needs of each individual patient. Noteworthy examples among the components developed through the research program are: the harness-operated elbow lock, the APRL voluntary-closing hand and hook, the Northrop 2-load hook, voluntary-opening hand sizes 1-5, the SACH foot, the Henschke-Mauch "Hydraulik" knee units, the Hosmer-DuPaCo "Hermes" unit, and the UCB pneumatic knee unit. <b>Fig. 8</b>,<b>Fig. 9</b>,<b>Fig. 10</b>,<b>Fig. 11</b><b>Fig. 12</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The Henschke-Mauch "Hydraulik" knee unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The APRL-Sierra Model 44C artificial hand (without glove). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. The Northrop Model C elbow unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The Multiplex above-knee pylon-type prosthesis. Various knee-control devices are interchangeable when this unit is used. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. A below-knee prosthesis fabricated of synthetic balata, with a cosmetic cover, developed by the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Clinic-Team Concept </h4> <p> As a planned objective of the VA research program, the clinic-team concept was introduced and encouraged as the preferred method of amputee management. The results achieved have fully established the validity of this concept in providing superior service to the amputee and in promoting more successful use of prostheses. Today, utilization of the amputee clinic team is standard practice in the VA, and many state agencies have followed the lead of the VA by insisting that their patients be treated by a clinic team. Moreover, as a result of the VA experience, the Children's Bureau has encouraged the establishment of more than twenty specialized clinics throughout the United States to serve child amputees. <b>Fig. 13</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Steps in the clinic-team procedure. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Specifications and Checkout Procedures</h4> <p> In the course of the research program, specifications for manufactured components have been developed. The Veterans Administration Prosthetics Center in New York City regularly checks components against the specifications in order to insure that quality is being maintained. This procedure not only insures the provision of safe, durable devices to veterans, but also helps to keep the quality of the devices used by others at a high level. </p> <p> Procedures designed to assure that the total prosthesis is adequately constructed, fitted, and aligned have been developed for the use of clinic teams. These "checkout" procedures are modified as new devices and techniques become available, and have been of great assistance in raising the quality of amputee management. </p> <h4> Reduction in Rehabilitation Time </h4> <p> As a result of the introduction of immediate postoperative fitting procedures<a></a>and early fitting procedures, a substantial reduction in the time between amputation and return to home and job has been effected. The use of a rigid dressing immediately after amputation also helps to reduce edema and pain. </p> <p> At one time it was the rule in many hospitals, once the decision was made to remove part of a limb because of peripheral vascular disease, to amputate through the thigh because of the better blood supply in that region. Various studies have shown, however, that the knee joints in peripheral vascular cases can, with judicious care, be saved. As a result of these studies, rehabilitation time for many geriatric cases has been reduced even further. Indeed, the probability of rehabilitation itself can be markedly increased. </p> <h4> Reduction in Costs </h4> <p> The Veterans Administration has shown that, because of improved devices and procedures for fitting and aligning prostheses, artificial limbs were lasting twice as long in 1968 as they were in 1948. Although the average cost of artificial limbs increased 116.5% during that period, the increased "life" reduced the cost per year per eligible amputee veteran to about the same as it was in 1948.<a></a> </p> <p> In addition to an effective reduction in the cost of the devices, repair, maintenance, and clinic visits were also reduced substantially. There has been no discernible increase in the number of prosthetists in the United States over the past 20 years, yet the number of patients being served has increased considerably during that period, owing to the increase in the general population and to an increase in the number of amputations because of peripheral vascular disease in a population surviving to greater ages. </p> <h4> Dissemination of Information </h4> <p> <i>Prosthetics Education Program</i> </p> <p> The Prosthetics Education Programs originally established by the VA for training its clinic teams have proven to be extremely successful. The short-term courses have made possible the rapid and effective introduction to clinic teams of the new devices and techniques developed by the research program. </p> <p> Since the Prosthetics Education Program was organized in 1953, over 15,000 students have attended the courses offered by the three participating schools-New York University, Northwestern University, and the University of California at Los Angeles. </p> <p> <i>Degree and Associate in Arts Programs</i> </p> <p> Historically, the provision of educational opportunities in a given discipline has tended to create a demand for further education. This phenomenon has also been true of prosthetists and ortho-tists, and has led to the establishment of longer-term courses at several institutions. <b>Fig. 14</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. A typical laboratory scene in prosthetics-orthotics education. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> New York University undertook the most ambitious venture by establishing, in 1964, a four-year curriculum in prosthetics and orthotics leading to the Bachelor of Science degree. Two-year courses leading to the degree of Associate in Arts in prosthetics were begun at Chicago City Junior College (1965) and Cerritos College (1964). </p> <p> These expanding educational endeavors, plus numerous additional offerings such as the certificate course at UCLA and the technicians course at Delgado College, have raised the standard of prosthetics- orthotics practice at all levels, and have exerted a steady upward pressure on the requirements for certification. </p> <p> <i>Publications</i> </p> <p> From the beginning of the research program, it has been the policy of the sponsoring agencies to make new information available as it is developed to those concerned with the welfare of the amputee. This program, which has involved both periodic and special reports,<a></a> was financed initially by the Veterans Administration. SRS and the MCHS have since added their support. </p> <p> <i>Artificial Limbs, </i>a semiannual journal, was created in 1953 to provide a vehicle for dissemination of timely information, primarily to clinic-team personnel. Publication and distribution of the journal is the responsibility of the Committee on Prosthetics Research and Development, and it is mailed gratis to more than 4300 physicians, surgeons, therapists, pros-thetists, and research personnel. </p> <p> In 1961, the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development inaugurated the publication of the <i>Inter-Clinic Information Bulletin, </i>a monthly bulletin which serves as a vehicle for the exchange of information between child amputee clinics. The material for each issue is provided on a regularly scheduled basis by the 29 clinics affiliated with the SCPP's cooperative research program. More than 2500 copies of the ICIB are distributed gratis each month to interested individuals and institutions in the United States and abroad. </p> <p> In 1964, the Prosthetic and Sensory Aids Service of the VA began publication of its own semiannual journal, the <i>Bulletin of Prosthetics Research, </i>which is designed primarily to meet the needs of PSAS and covers a wide range of topics. It is available from the Superintendent of Documents of the U.S. Government Printing Office. Typically, some 2300 copies of each issue are sold, in addition to an official distribution of 3500 copies. </p> <p> In 1954, <i>Human Limbs and Their Substitutes<a></a>, </i>published by McGraw-Hill Book Company, was prepared principally from manuscripts developed by research personnel supported by the VA, and with the collaboration of the Office of the Surgeon General of the Army. This book was essentially a report on the results of the research program up to that time, and contains much basic information. Four thousand copies were printed, and the book had been out of print after 1960 until it was reprinted by the Hafner Publishing Company in 1968. </p> <p> Reports of special conferences organized by the Committee on Prosthetics Research and Development have been prepared in order to provide information useful to others as well as to those attending the meeting.<a></a> </p> <p><b>References:</b></p> <ol> <li>Burgess, Ernest M., Robert L. Romano, and Joseph H. Zettl, <i>The management of lower-extremity amputations, </i>TR 10-6, Prosthetic and Sensory Aids Service, Veterans Administration, August 1969. </li> <li>Committee on Artificial Limbs, National Research Council, <i>Terminal research reports on artificial limbs covering the period from 1 April 1945 through 30 June 1947 </i>(to the Office of the Surgeon General of the Army and the U.S. Veterans Administration).</li> <li>Committee on Prosthetics Research and Development, Selected bibliography on limb prosthetics, <i>Artif. Limbs, </i>12:2:42-48, Autumn 1968. </li> <li>Klopsteg, Paul E., Philip D. Wilson, et al., <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954. (Reprint edition, Hafner, 1968) </li> <li>Talley, William H., Prosthetics research-a cost reduction program, an editorial, <i>Bull. Pros. Res. </i>10-10, Fall 1968. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs, </i>Report to the Committee on Artificial Limbs, National Research Council, 1947, two volumes. </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Selected bibliography on limb prosthetics, Artif. Limbs, 12:2:42-48, Autumn 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., Human limbs and their substitutes, McGraw-Hill, New York, 1954. (Reprint edition, Hafner, 1968) </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Selected bibliography on limb prosthetics, Artif. Limbs, 12:2:42-48, Autumn 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Talley, William H., Prosthetics research-a cost reduction program, an editorial, Bull. Pros. Res. 10-10, Fall 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Robert L. Romano, and Joseph H. Zettl, The management of lower-extremity amputations, TR 10-6, Prosthetic and Sensory Aids Service, Veterans Administration, August 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Fundamental studies of human locomotion and other information relating to design of artificial limbs, Report to the Committee on Artificial Limbs, National Research Council, 1947, two volumes. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Committee on Artificial Limbs, National Research Council, Terminal research reports on artificial limbs covering the period from 1 April 1945 through 30 June 1947 (to the Office of the Surgeon General of the Army and the U.S. Veterans Administration).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Committee on Artificial Limbs, National Research Council, Terminal research reports on artificial limbs covering the period from 1 April 1945 through 30 June 1947 (to the Office of the Surgeon General of the Army and the U.S. Veterans Administration).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson. Jr. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-14.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Prosthetics and Orthotics Program Creator An entity primarily responsible for making the resource A. Bennett Wilson. Jr. * https://staging.drfop.org/files/original/c4f7c87a6d3b45eaeeb780028322aac3.pdf 2f3019f3a58522e9c6c9ef279008e662 https://staging.drfop.org/files/original/e3fa45ed04f25031b0eae1b1ae3563f7.jpg 1d480fe476876e4ae28210d460878f00 https://staging.drfop.org/files/original/8d9753f4b6b5322d836534694564a736.jpg 18e2d169d78ebf6f59e41dce49306715 https://staging.drfop.org/files/original/ba2d5caaf2bb5a526891c65720e02f75.jpg 4c419b14d2f5c2e8b85e998eec950f1e https://staging.drfop.org/files/original/1bb426ed68464888794dcdf4a783cf53.jpg d1da7506184096c8d68116798a87facd https://staging.drfop.org/files/original/1c12f7dc0e21d73986874eddb77e705e.jpg 6f0727ef350636789bc9df62f3eccbf4 https://staging.drfop.org/files/original/00d157335a62ec44dbfdf98f9c624906.jpg f4e81019aca87bb8e609ca049e7db794 https://staging.drfop.org/files/original/5e53449d0db91f56ed12371c0939588b.jpg 38d62fb95c884d54aa066fc874713827 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_02_101.pdf Text Any textual data included in the document <h2>The Cast Off Valve: An Improved Method for Removing and Retaining Above Knee Casts and Prosthetic Sockets</h2> <h5>Albert F. Rappoport, M.A., CP.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>The fabrication of a prosthesis continues to be a labor intensive process. The advent of prefabricated components, together with the use of central fabrication, has allowed many prosthe-tists to utilize their time more effectively. Time saving devices have always been welcomed by the prosthetic practitioner, especially when the quality of work is not compromised.</p> <p>Removal of an above-knee socket from a plaster model is a common procedure in most prosthetic facilities. There are several methods for removing the socket from the cast. These methods will be addressed later in the text and the problems of each discussed. The most improved method is the Cast Off Valve (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-1.jpg"><b>Fig. 1</b></a>). The Cast Off Valve uses compressed air, linking it directly to the above-knee socket (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-2.jpg"><b>Fig. 2</b></a>). The female coupling of the air hose is attached to the male connector of the Cast Off Valve (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-3.jpg"><b>Fig. 3</b></a>). The Cast Off Valve is then threaded into the suction valve housing of the above-knee socket. This method saves manpower, time, and energy by allowing removal of the socket from the cast in a matter of seconds. It is also effective in the duplication of any definitive above-knee suction socket. The concept is credited in its design to Judd Lundt, B.S.A.E., Assistant Director at UCLA's Prosthetic Education Program.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-1.jpg"><strong>Figure 1. The Cast Off Valve.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-2.jpg"><strong>Figure 2. Female couple of air hose to male connector on Cast Off Valve.</strong></a><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-3.jpg">Figure 3. Cast Off Valve attached to female air hose coupling.</a><br /></strong><br /> <h3>Methods Of Removing Socket From Cast</h3> <p>Several methods have been used, with varying degrees of success, in removing an above-knee socket from a plaster model. The oldest method involves breaking the plaster out of the socket with a cold chisel and hammer, or air chisel. This is a labor intensive process which is still practiced by many prosthetists (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-4.jpg"><b>Fig. 4</b></a>). This process is not always necessary to facilitate the removal of a definitive socket.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-4.jpg"><strong>Figure 4. Age old method of removing socket by breaking out plaster by hand.</strong></a><br /> <h3>Bivalving</h3> <p>Many times, the prosthetist would like to save the plaster model for further modification or reference. One approach to saving the model is to bivalve the socket with a cast saw (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-5.jpg"><b>Fig. 5</b></a>). Once the socket has been bivalved, the cast can be touched up with minor plastic additions and used again. After the socket is bivalved, it cannot be reused. This process is not only time consuming, but can be eliminated in many circumstances.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-5.jpg">Figure 5. Bivalving socket to retain cast.</a><br /></strong><br /> <h3>Compressed Air</h3> <p>The use of compressed air is by far the most popular method. It saves labor, time, sockets, and casts. A newly formed check socket or laminated socket may be easily blown off using an air gun. The newly fabricated socket must be trimmed just proximal to the desired trim line. A hole must then be drilled at the distal end of the socket to correspond in size to the tip of the air gun (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-6.jpg"><b>Fig. 6</b></a>). One person holds the air gun with compressed air in the hole at the distal end of the socket, while the other person gently taps, trying not to fracture the socket, at the proximal brim. This is continued until the air is forced through the socket and assists in forcing the socket off the cast. Some radical socket shapes may prevent the ease of this technique, in which case it may be helpful to attempt this procedure while the socket is still warm or to refer back to the previously mentioned methods. The compressed air technique is an effective way to remove the socket from the cast without damaging either one. Two drawbacks to this method are: 1) it requires two persons to remove the socket, and 2) it is possible for air to leak through the hole where the air gun is held at the socket's distal end.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-6.jpg"><strong>Figure 6. Removing socket from cast using compressed air. This two-person operation requires one person to use air gun to direct air through hole in bottom of socket and second person to tap proximal socket.<br /></strong></a><br /> <h3>Cast Off Valve</h3> <p>The use of the Cast Off Valve can improve the effectiveness of the compressed air method (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-7.jpg"><b>Fig. 7</b></a>). This improved technique can be employed whenever a valve housing is used in either a laminated socket or clear check socket. The Cast Off Valve is designed to fit the valve housing and link the air hose coupling directly to the socket. This approach allows a stronger air pressure to be obtained and little chance for air leakage. The use of this method requires only one person, freeing the hands of a second person who holds the air gun in the hole (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-6.jpg"><b>Fig. 6</b></a>). First, the proximal brim of the socket should be trimmed with a cast saw. Once the Cast Off Valve is installed, the air hose can then be connected and the socket will blow off without any further effort. One may need to gently tap the proximal brim with a piece of wood dowling and hammer to assist the removal. (Note: certain radical socket shapes may prevent the use of this method.) In summary, the Cast Off Valve requires only one person to remove a socket from the cast with a minimum amount of effort, reduction of time and improved results over methods previously discussed.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-7.jpg">Figure 7. The Cast Off Valve is threaded into valve housing and air hose is connected to blow socket off with minimum effort and maximum results.</a><br /></strong><br /> <h3>Socket Duplication</h3> <p>The Cast Off Valve also is excellent when an above-knee suction socket is to be duplicated from a definitive limb. No longer is an alginate impression or use of duplicating foam necessary. The patient's socket should be filled with plaster and a holding pipe inserted once the plaster has set. The valve housing must be cleared of any material so the Cast Off Valve can be inserted. The air hose coupling can then be hooked up and the socket is blown off in a matter of seconds. The socket is duplicated exactly in plaster and ready for lamination or check socket fabrication.</p> <h3>Summary</h3> <p>The Cast Off Valve has been well accepted and tested clinically with great success for the past two years by the staff at UCLA's Prosthetic Education Program and Prosthetic-Or-thotic Laboratory. The UCLA prosthetic staff has found this device to be valuable, in many cases, in removing an above-knee socket in both quadrilateral and CAT-CAM designs. This method allows the cast to remain undamaged for further reference and can be useful when duplicating a definitive socket. When working with an appropriately shaped cast, the Cast Off Valve allows the removal of the socket from the cast with improved results from the previously aforementioned methods.</p> <h3>Acknowledgments</h3> <p>This work is supported by VA Contract #633P-1667 Rehabilitation Research &amp; Developmental Funds. Special thanks to Shirley M. Forsgren for the photography on this article and to Diane I. Lyons for preparation of the manuscript. Special thanks also to Dr. Ernest M. Burgress for his continued support in the research and development of advancing prosthetics. Thanks to Christopher Hoyt, CP, David Litig, CP, Mark Yamaka, CP, Richard Boryk, CPO, and Kenneth Neal, O/P Technician for their clinical evaluation of the cast-off valve at UCLA's Prosthetic-Orthotic Laboratory.</p> <p><em><b>*Albert F. Rappoport, M.A., CP. </b> Albert F. Rappoport, M.A., CP., is Chief of Research Prosthetics with the Prosthetics Research Study, 1102 Columbia Street, Room 409, Seattle, Washington 98104, (206) 622-7717. He is formerly Senior Prosthetist-Orthotist at UCLA's Prosthetic-Orthotic Laboratory in Los Angeles, California.<br /><br /><br /></em></p> <br /> <div style="width: 400px;"></div> Page Number(s) 101 - 105 Year 1987 Volume 11 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-6.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 7 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-7.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 The Cast Off Valve: An Improved Method for Removing and Retaining Above Knee Casts and Prosthetic Sockets Creator An entity primarily responsible for making the resource Albert F. Rappoport, M.A., CP. * https://staging.drfop.org/files/original/bd8676bd2ae282b639f2399c6de321e3.pdf ffb53e28db8f2fc150a90906e09d5a19 https://staging.drfop.org/files/original/b5b98ec26d73edf01c22777a6f4f5372.jpg 2970dc2423a7e01f1bb92f8ceb1a1354 https://staging.drfop.org/files/original/bb57324218f589f3d313b6eacad77646.jpg 39967dc29d987500fb2008de8d00e469 https://staging.drfop.org/files/original/9f4e8fe4f15db8a5f8ba4d01ee1a70be.jpg 27a0ccb1ddc4f295ced948da5496ca58 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_173.pdf Text Any textual data included in the document <h2>Below-Knee Waterproof Sports Prosthesis with Joints and Corset</h2> <h5>Alfred W. Lehneis, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>This article is concerned with the development of a waterproof below-knee prosthesis with knee joints and corset, utilizing the supracondylar/suprapatellar (SC/SP) suspension socket. A case report is described below.</p> <p>The patient had a below-knee amputation due to traumatic injury with a resultant amputation length of the tibia of approximately 1" (<a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-1.jpg"><b>Fig. 1</b></a>). This patient currently wears a PTB type socket with leather thigh corset, polycen-tric joints and an SC/SP suspension socket, thus, no auxilliary suspension was necessary (<a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-2.jpg"><b>Fig. 2</b></a>). He was doing well with this design in all activities of daily living, but desired a waterproof prosthesis for boating.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-1.jpg"><strong>Figure 1. Length of tibia is approximately 1".</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-2.jpg"><strong>Figure 2. Patient currently wears a PTB type socket with a leather thigh corset.</strong></a><br /> <p>In developing the waterproof design, the following components were utilized: Kingsley beachcomber foot, Otto Bock polycentric stainless steel knee joints, and a corset fabricated from 4mm Subortholen thermoplastic. Closures were 1" dacron straps with virgin nylon buckle closures used on scoliosis type body jackets.</p> <p>The fitting and fabrication of the prosthesis was as follows: the patient was casted (including the thigh) and the cast modified, using standard procedures for SC/SP suspension, an insert was fabricated from Pelite™, and the socket was fabricated with acrylic resin and carbon/glass reinforcements, especially at the side bar attachment sites.</p> <p>After fabrication of the socket, the socket was foamed up and set-up on a Staros-Gardner coupling and aligned atop the beachcomber foot. The bars were then attached directly to the socket (not over the foam build-up), and the area over the bars filled with fiberglass/resin putty. The thigh bars were contoured to the modified cast, over which the Subortholen thermoplastic had been molded and attached to the corset. The patient was then fitted and aligned in the usual manner, but while wearing topsider type boating shoes.</p> <p>After optimum alignment was achieved, the Staros/Gardener coupling was transferred out. This can be accomplished on a horizontal transfer device. The prosthesis was then shaped to the patient's tracing and measurements and reduced to accommodate the lamination thickness. The sole of the foot is then removed and a woman's nylon is pulled over the entire prosthesis, followed by the PVA sleeve. A lamination of one carbon-glass and two nylons without pigment is performed. After the lamination is set, the laminated shell is split longitudinally on the posterior aspect (<a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.jpg"><b>Fig. 3</b></a>), taken off the prosthesis, and taped back together to retain its shape.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.jpg"><strong>Figure 3. The laminated shell is split longitudinally on the posterior aspect.</strong></a><br /> <p>The shaped portion of the prosthesis is cut to allow for a 3" ankle block and the socket is cut at the base. The foam between the ankle and socket is now eliminated (<a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.jpg"><b>Fig. 3</b></a>). The foam ankle block and the foam at the base of the socket can be sealed with a resin-silica mix to prevent water penetration.</p> <p>The laminated shell should be sealed with tape on the outside, and the seam should be sealed on the inside with Siegelharz. The socket and ankle block can then be bonded to the laminated shell. Once this is set, the outer shell should be sanded for a second lamination, and approximately 1" of the proximal socket and distal ankle block perimeter should be exposed (<a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.jpg"><b>Fig. 3</b></a>).</p> <p>The prosthesis is then filled with sand through the hole at the bottom of the ankle block. The hole is then sealed with play dough. Lay-up of the prosthesis consists of six alternating layers of nylon and nyglass. Two pieces of polypropylene with 120° arcs (<a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.jpg"><b>Fig. 3</b></a>) should be placed between the joints and the socket after the first two layers to allow attachment of the joint clevis after lamination. These pieces are removed after lamination. The foot drain hole is then reopened to release the sand. A second 1/2" hole should be drilled posterior and distal to the socket end to allow air to enter and escape the inner hollow of the leg. This allows water to enter and escape the foot drain hole and prevent bouyancy of the prosthesis.</p> <p>The thermoplastic corset is finished with a polyethylene tongue and dacron strap closures as described earlier. When assembling the prosthesis, bonding of the foot should be as recommended by Kingsley, Mfg. or using Devcon two-part epoxy.</p> <h3>Acknowledgments</h3> <p>The author gratefully acknowledges the technical contribution of Roger Losee, CO., and Robert Wilson, M.S., for the illustration in <a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.jpg"><b>Fig. 3</b>.</a></p> <p><em><b>*Alfred W. Lehneis, CP. </b> Alfred W. Lehneis, CP., is with Lehneis Orthotics and Prosthetics Associates in Roslyn, New York.</em></p> Page Number(s) 173 - 175 Year 1987 Volume 11 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 3 http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Below-Knee Waterproof Sports Prosthesis with Joints and Corset Creator An entity primarily responsible for making the resource Alfred W. Lehneis, CP. * https://staging.drfop.org/files/original/ba789f483ace72e6c0f63c6846e6c081.pdf 519c0ffb1b60b8ec2558c4682b78c1b1 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_04_005.pdf Text Any textual data included in the document <h2>Basic Changes in Lower Limb Prosthetics</h2> <h5>Alvin L. Muilenburg, C.P.O.&nbsp;</h5> <p>After several years of very little change in above knee amputee fitting, we now have a <i>C.P.O.</i> issue with four papers on current advanced clinical practice in lower limb prosthetics. Some of these advances can be brought into use without too much difficulty while others require much more training and careful follow-up.</p> <p>The techniques that involve materials and fabrication are usually not too difficult to try, but changes in these techniques can give us problems that we didn't expectand require extra caution during initial use.</p> <p>Alterations of socket shape to adapt to more difficult amputations or congenital deficiencies is something where we also look for improvements. Papers that are written giving experience and suggestions on how to solve these problems give us help that is needed in our day to day fitting. This usually does not alter our basic method of alignment and cast model alterations.</p> <p>The discussions concerning basic changes in socket shape and alignment cause us much more concern by whatever name they may be given. There is a new way to fit an AK amputation, that is certain. I cannot question the results; patient acceptance has been proven.</p> <p>New information, however, does not always come easily. These new methods have been brought to the public view only through a considerable amount of publicity, which then stimulates us to get more information. Traditionally, information and results have been passed on from one prosthetist to the other; usually by visiting the developers and exchanging new ideas.</p> <p>Educational institutions have provided a valuable learning ground. U.C.L.A. had a one week course in March and a few seminars have been held elsewhere. However, many details on how to teach the new methods have created controversy. We must support our educational institutions and help them to determine what should be taught.</p> <p>I believe we need a working group of a few prosthetists who are already involved in the new methods to develop guidelines for teaching. Perhaps the Academy could organize this. Clinical evaluation programs have been discussed but communication between prosthetists involved seems to have adequately covered that area.</p> <p>I want to express my appreciation to the publishers in this issue for all the work that has been done. Having this information published enables us to sort it out and make better decisions on improving our own care of the AK amputees.</p> Page Number(s) 5 - 5 Year 1985 Volume 9 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Basic Changes in Lower Limb Prosthetics Creator An entity primarily responsible for making the resource Alvin L. Muilenburg, C.P.O.  https://staging.drfop.org/files/original/596f5df1b45e5408aef2d2e48e214ce0.pdf 89788688822cc599a338f475aef91c26 https://staging.drfop.org/files/original/557b90124720a7da30c19930ed30060d.jpg 9d2990c77123a6377d72a6b73da5ddd1 https://staging.drfop.org/files/original/7f2ea2a39e9b4dc64c65b4067f43bef1.jpg 6533d942da6c283ee8488e49fbe0c9cd https://staging.drfop.org/files/original/ac090bbd79cd145e52cb323e58c729c5.jpg dc2fb43cee750c93112f0affc4206428 https://staging.drfop.org/files/original/ccee007808b1dde739c36d5b00a84e55.jpg ca28e413c0c22d65eae31d5c57c751e0 https://staging.drfop.org/files/original/42d540eb5f7d243a2ca53cb4bf06d76e.jpg b70baead32291e81c86a0750b9e4a4b3 https://staging.drfop.org/files/original/2ef9ffb0acc6dbf9ca7315d0af0b65e0.png 68b444d713762deb48fee990e6b67351 https://staging.drfop.org/files/original/d13990334d94f8492f71d5cfd1dbbd52.png d823f6dba920fa93bfa85d199b314ec6 https://staging.drfop.org/files/original/c715bcdfcce079d9e580963d051d2093.png bb37d520b9116d9fec4491ee5cbe2f09 https://staging.drfop.org/files/original/5bb4495a35e6ed75542b508319864f8c.png 86e9e1f85b2b7cf997340d8727376efe https://staging.drfop.org/files/original/05bf1a813e6795e969c67bfdf70beb0f.png a40d28845357c57383853d91eff35f12 https://staging.drfop.org/files/original/32b9476d17d9fdde664b335970aa3fe5.png a60199a7436285575bd5b6846f9edf04 https://staging.drfop.org/files/original/d09c868f1688a0ecaf1d9c45b742c1e6.png aea7141fd41b96043e2bf8c7e583b38d https://staging.drfop.org/files/original/453f7876178baebff0b7b7e77820263e.png 2215c16b82603b81bd349d1814c50193 https://staging.drfop.org/files/original/11dff246699d89e686eaade91a2ea9bb.png 3828c0ac5b26e697a16be78c5dd19ca0 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_01_008.pdf Text Any textual data included in the document <h2>The Biomechanics of the Foot</h2> <h5>André Bähler&nbsp;<a style="text-decoration: none;">*</a></h5> <p>"The human foot is one of nature's works of art and as such, it has not yet been fully recognized and explained. It will require a deal of scientific investigation before this structure is fully understood."</p> <p>These words of the old master of orthopaedics, Georg Hohmann, from his book "Fuss und Bein" are still applicable today. Thirty years later, the biomechanics of the foot have still not been completely explained, and there are many questions yet unanswered.</p> <p>The many, more or less articulated connections of the foot allow a variety of changes which make it difficult to understand the movement as a homogeneous process. Too many factors can only be qualified, but not quantified.</p> <p>Nor may we forget the reciprocal influence of the position of the foot, knee, and hip joints. Each change in the position of one of these joints automatically involves a change in the position of the other two joints.</p> <p>For example, in the upright position, the neck of the femur forms a posteriorly open angle of approximately 20 degrees. This is determined by the anatomical factors in relation to the frontal plane of the body. The direction of the axis of the hip joint corresponds fairly accurately to the connection inner-malleolus/ outer-malleolus, which have an exterior rotation of approximately 20 to 30 degrees in relation to the frontal plane. Consequently, there is a conformity between the ankle axis and the hip axis.</p> <p>In the upright position, the knee is practically locked due to the automatic rotation, so the position of this axis is of minor importance. When walking, the pelvis rotates approximately 20 degrees forward. As the lower leg also rotates inwardly in relation to the upper leg during flexion, the ankle axis rotates inwardly and the foot takes up a straight position in the swing phase.</p> <h3>Characteristics Of The Foot</h3> <p>The foot has the characteristics of a triple axial joint which allows it to assume any position. The three main axes of movement converge in the talus area (<a href="staging.drfop.org/files/original/557b90124720a7da30c19930ed30060d.jpg"><b>Fig. 1</b></a>). Particularly during rotational movements to adapt the foot to an uneven surface, all the joints are involved to some extent; nevertheless, the ankle joint, although formed as a hinge joint, forms the main joint for locomotion.</p> <p>According to Kapandji, the foot can be compared architectonically to a vault, which is supported by three arches. Other authors criticize this vault-concept on the basis that it is too static. However, the vault-structure is very meaningful as an aid to analyzing the foot in general (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-02.jpg"><b>Fig. 2</b></a>). The arrow shows the direction and position of the main weight, which is first taken by the calcaneus (A) and then transferred to the forefoot: inside on metatarsal I (B) and outside on metatarsal V (C). The front transversal vault can also be understood as a supporting construction: on the one side the two corner stones (metatarsal I and metatarsal V) and on the other side, the transverse vault (metatarsal II, III, and IV). This construction enables the forefoot to take a great amount of weight and at the same time allows the foot to adapt to uneven surfaces.</p> <p>Furthermore, it can be seen that when the feet are put together, the position of both cal-canei can be regarded as a vault structure. The position of the calcaneus together with a slight valgus position serves to stabilize the body, particularly during the walking motion of the leg (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-03.jpg"><b>Fig. 3</b></a>).</p> <h3>The Joints</h3> <p>The joints themselves pose some problems. Let us take for example the development of the inclination of the trochlea of the talus, and the distal tibial epiphyseal cartilage to the longitudinal axis of the lower leg in the frontal plane as described by Lanz Wachsmuth.</p> <p>Left in the infant and right in a two year old (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-04.jpg"><b>Fig. 4</b></a>), it can be seen that the axes of the ankle joint and the talocalcaneonavicular joint and that of the epiphyseal cartilage are developing. In the 12 year old, left, and in the adult, right, the axis becomes horizontal during normal growth process, stabilizing the support system of the foot (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-05.jpg"><b>Fig. 5</b></a>). The changes in the various process-, movement-, and development-axes of the ankle during the development of the child are probably one reason for the controversial views over the biomechanics of the foot.</p> <p>Biomechanically we are interested in the joints, and in particular, those used when walking.</p> <p><i>The Ankle Joint</i></p> <p>The ankle joint (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-06.jpg"><b>Fig. 6</b></a>) is of particular importance, because in at least one direction it secures a movement without which it would be impossible to walk. This joint could also be described as a hinge joint with a diagonal axis of rotation, which allows a movement of about 20 degrees up and down. This inclination of the ankle joint certainly contributes to stability when carrying weight and can only be fully understood when considered in connection with the talocalcaneonavicular joint.</p> <p><i>The Talo-Calcaneonavicular Joint</i></p> <p>The movement of the talocalcaneonavicular joint is decidedly more difficult to understand. Whereas the axis of the ankle joint can easily be defined, the axis of the talocalcaneonavicular joint is drawn obliquely from lateral posterior to medial anterior. It is surprising that both articular surfaces of the talocalcaneonavicular joint are congruent only in the mid-position. An incongruence develops between the two articular surfaces by both eversion and inversion. This incongruence cannot be maintained for long periods when carrying weight.</p> <p>The ankle joint and the talocalcaneonavicular joint must be regarded as a functional unit. The possible movements of these two joints can be compared to a spheroid joint which can be moved freely within its range of motion: flexion, supination, pronation, abduction and adduction which in some respects corresponds to a rotation.</p> <p><i>Chopart's Joint</i></p> <p>The talocalcaneonavicular joint, comprising the talus and the navicular, and the joint which is formed from the calcaneus and the cuboid, together all form a sort of working unit. These two joints comprise Chopart's joint which allows a rotational movement of the fore-foot.</p> <p><i>Lisfranc's Joint</i></p> <p>The Lisfranc joint is a collective joint where the three cuneiform bones and the cuboid bone on the one side, and the five metatarsal bones on the other side, are united to form an articular connection. The small deflectionary movement can be described as in an obliquely situated hinge exhibiting dorsal and plantarflexion.</p> <p>The Chopart and the Lisfranc joints are connected by taut ligaments so that there is hardly any friction between them. They serve primarily to give elasticity to the foot during pressure and allow it to adapt better to uneven surfaces.</p> <p><i>The Transversal Anterior Vault of the Foot</i></p> <p>From metatarsal I to metatarsal V, the metatarsal bones form an oblique arch (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-07.jpg"><b>Fig. 7</b></a>). This arch tends to drop due to excessive pressure, which can partly be attributed to walking on level ground. This "even" walking, which always puts pressure on the same points of the foot, leads to over-exertion of the individual metatarsal heads.</p> <p><i>The Toe Joints</i></p> <p>The toe joints are limited spheroid joints. That is, they are capable of sideways movement within certain limits, but are primarily intended as hinge joints with movement upwards and downwards.</p> <h3>The Ligaments</h3> <p>It is known that the structure of the foot is held together with muscles and ligaments. These ligaments are so constructed as to be able to withstand the extreme pressures exerted on the foot (long jump and high jump).</p> <h3>The Muscles</h3> <p>Long and short muscles hold and move the foot. If one of the muscles gives way, it is immediately visible from the gait how important the interaction of each muscle group is for locomotion. However, descriptive anatomy is not the theme here and so a further discussion of this aspect must be omitted.</p> <h3>The Mechanics Of Depression Of The Foot</h3> <p>Experience has shown that not every valgus of the calcaneus results in an equivalent drop of the longitudinal vault.</p> <p>The talipes valgoplanus is a collective term for different inadequacies which arise when the foot is under pressure. These can be classified according to different characteristics: (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-08.jpg"><b>Fig. 8</b></a>)</p> <ol> <li> <p>The pronation position of the calcaneus;</p> </li> <li> <p>Inward rotation of the ankle joint;</p> </li> <li> <p>A forward and inward drop of the talus;</p> </li> <li> <p>Abduction of the fore-foot; and</p> </li> <li> <p>Supination, i.e., a turning upwards of the first metatarsal.</p> </li> </ol> <p>These five basic characteristics of the talipes valgoplanus lead to a variety of outward manifestations, which must be taken into consideration when deciding on a course of action. This wide variety is one reason why the kinematics of the foot eludes an exact biomechanical and mathematical analysis.</p> <p>When pressure is applied in valgoplanus, the calcaneum gives way but the fore-foot remains flat on the ground, regardless of the extent of the flexion. Congenital and ischaemic valgoplanus are exceptions to this but they are not included in the discussion here (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-09.jpg"><b>Fig. 9</b></a>).</p> <p>Between the calcaneus, rear-, and fore-foot there is a distortion or rotation. If pressure is removed from the foot, the calcaneus falls into a vertical position, but the fore-foot then rotates to the same degree. Consequently the position of the rear-foot relative to the fore-foot remains a constant deformity (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-10.jpg"><b>Fig. 10</b></a>).</p> <p>What then is the role of the shoe in the standing position and swing-phase? In the standing position, more pressure is exerted medially on the rear part of the shoe (the counter and the heel), depending on the extent of the valgoplanus. However, the front of the shoe remains flat on the ground regardless of the extent of the deformity.</p> <p>In the swing-phase, the distortion between the fore- and rear-foot influences the alignment of the shoe. If the heel is too big or badly fitting, the fore-foot dictates the position of the shoe and as a result there is an unwanted deflection of the heel of the shoe from the heel of the foot.</p> <p>This means that the heel-strike is lateral and as pressure is exerted, it then turns inwards and adapts to the surface whereby it has returned to the original standing position. The distortion between the fore- and rear-foot, combined with an inadequate heel counter, produces a potential risk of injury. A stone on an inclined surface can easily lead to a strained joint (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-11.jpg"><b>Fig. 11</b></a>). This phenomenon is particularly significant for sportsmen and joggers who train in open country. After suffering such strains, the fear of further injury can hinder training.</p> <h3>Deformity Of The Fore-Foot (Talipes Transversoplanus)</h3> <p>During growth, there is a slight biomechanical change in the lateral metatarsal arch. The first metatarsal rotates pronatorally and this leads to a greater arching in adults.</p> <p>Congenital ligament or tissue weakness can cause this lateral arch to flatten under pressure and so result in a broadening of the fore-foot. Here, the length of the various metatarsal bones compared to the different patterns of pressure exerted on the fore-foot is of significant importance. Depending on the type of foot, the first or second metatarsal will be under greater pressure depending on which is the longer of the two. Instability between the fore- and rear-foot can also result if the inclination between metatarsal one and metatarsal five is too great. This type of foot tends to tilt sideways during the propulsion process of walking.</p> <p>In the case of the high-arched foot, the angle between the metatarsal and the ground increases, resulting in a greater load to the individual metatarsal heads.</p> <h3>The Shoe</h3> <p>From a biomechanical point of view, the shoe plays a significant part in the process of walking and standing. The height of the heel as well as the thickness of the sole greatly influence the conveyance of the weight and consequently influence locomotion itself. This sphere of influence must be duly considered, particularly in cases of static deformity. A build-up of the shoe, i.e., constructing a rocker bottom must be compensated for at the heel, otherwise the relationship between the heel-height and sole-thickness in the front of the shoe will be disturbed, thus having a negative effect on the roll-over process (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-12.jpg"><b>Fig. 12</b></a>).</p> <h3>Cushion-Heel</h3> <p>The attachment of a cushion-heel also changes the roll-over process in that it acts as a shock absorber at heel strike and at the same time increases the roll-over (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-13.jpg"><b>Fig. 13</b></a>).</p> <h3>Heel-To-Toe-Roll For The Whole Sole</h3> <p>A heel-to-toe roll sole can be attached to the shoe to protect the ankle joint and Chopart's joint. Measured radially from the knee, this allows a complete roll of the foot (<a href="http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-14.jpg"><b>Fig. 14</b></a>).</p> <h3>The Use Of Insoles</h3> <p>The insole and the shoe must form a unit with the level ground. Whether the foot is neutral, in pronation or supination, is of no significance.</p> <p>When insoles are made of solid material, their length and shape are important. It is of particular importance with handicapped patients that the insoles are kept somewhat longer in order to reduce the risk of tilting sideways. This pronatory support, especially in the forefoot region, gives the patient a feeling of security.</p> <p>The correction of the talipes valgus should be differentiated from the correction of the talipes varus. With talipes valgus, the rear of the foot should be supinated and the fore-foot pronated in order to achieve a rotation of the foot. With talipes varus, this is not possible. Here, the whole foot must be pronated, i.e., the rear- and fore-foot must be included in an homogenous correction.<br /><br /><em><b>*André Bähler </b>André Bähler is an Orthotist/Prosthetist from Zurich, Switzerland.</em></p> <p><b>References:</b></p> <ol> <li>G. Hohmann, <i>Fuss und Bein</i>, ihre Erkrankungen und deren Behandlung, Verlag von J.F. Bergmann 1951.</li> <li>J. Lang, W. Wachsmuth, <i>Praktische Anatomie</i>, Bein und Statik, Springer-Verlag AG.</li> <li>I.A. Kapandji, <i>The Physiology of the Joints</i>, Churchill Livingstone.</li> </ol> Page Number(s) 8 - 14 Year 1986 Volume 10 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_01_008/1986_01_008-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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Title A name given to the resource The Biomechanics of the Foot Creator An entity primarily responsible for making the resource André Bähler *