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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_04_009.pdf Text Any textual data included in the document <h2>Normal Shape-Normal Alignment (NSNA) Above-Knee Prosthesis</h2> <h5>Ivan A. Long, CP. <a style="text-decoration: none;">*</a></h5> On March 13, 1974, I saw the first x-ray of an amputee standing with his prosthesis, equal weight on both feet, heels 2" apart and toes 3" apart. (See <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-01.jpg">Fig. 1</a>. Notice the two zippers on the boots.) After seeing the amputated femur in such abduction, I realized that the quadrilateral socket and standard alignment procedures were not adequate for an above-knee limb. In December 1975, Orthotics and Prosthetics, the journal of the American Orthotic and Prosthetic Association, published my article, "Allowing Normal Adduction of Femur in Above-Knee Amputations." <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-01.jpg">Figure 1. X-ray of standing patient showing relative abduction of amputated femur as compared to normal side.</a> On February 2 and 3, 1981, I presented a demonstration and the booklet "Fabricating the 'Long's Line' Above-Knee Prosthesis" at Sabolich, Inc. in Oklahoma City. Shortly thereafter, news of a CAT-CAM socket available through Sabolich was announced. For the last 11 years, I have been fabricating only above-knee limbs and all have "Long's Line." The following article is presented so that prosthetists can provide the above-knee amputee with a limb that has a comfortable socket and alignment that allows him to walk in a normal fashion without drawing attention. Recently, it has been decided to call this work "Normal Shape-Normal Alignment" (NSNA) above knee prosthesis. <h3>What Is Wrong With Our Present A/K Prostheses?</h3> Most above-knee amputees walk with a wide base and a lurch to the amputated side. Only 100 percent concentration can change that pattern. We looked at 100 x-rays of above-knee amputees standing in their prostheses and found 92 out of 100 to have a difference in angle of the femur. In 91 to 92, the difference was towards abduction. (In this article, the angle of the sound femur is considered normal and movement away from the midline will be called abduction.) Most amputees would have to cross their legs to put the amputated femur in normal position while wearing the standard quadrilateral socket made all over the United States. Abduction was caused by the quadrilateral socket being entirely too large in the M-L dimension and too tight in the A-P. The ischium sits on top of the seat at best and a couple of inches above it in most fittings. The x-rays show the lateral wall to be several inches away from the femur except at the most distal point. When the femur exerts force against the lateral wall in weight bearing, the quadrilateral socket moves laterally immediately, because the ischium has no effect on stopping this shift. With the more narrow socket and increased A-P, the ischium is inside the socket, preventing lateral shifting of the socket during weight bearing. To insure proper angle of the femur, the distal femur is brought directly under the head of the femur. This allows hip musculature to work in a normal fashion. The narrow socket with a well shaped lateral wall will support this angle, and the ischium will secure the socket from shifting laterally, which destroys femoral support. Balance is dramatically improved when the foot is placed directly under the head of the femur rather than under the ischium. The amputee will immediately bring his feet closer together when he starts to walk, as opposed to a widened position when the foot is placed under the ischium. Long's Line is a straight line from the head of the femur (located approximately at the center of a narrow socket), through the distal femur, and down to the center of the heel. This line is not always vertical because it constantly shifts when changing from a standing position to a walking position. In order to support the femur, it is necessary to narrow the M-L dimension of the socket. The resulting greater A-P allows muscular function which is not possible with the crowded effect of a narrow A-P. <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-02.jpg">Table I</a> is used as a guide in establishing the width of the finished positive model. The figures were taken from approximately 500 sockets made in this facility, and may of these sockets have now been worn eight years. Very few, if any, sockets have been replaced because of shrinkage. Many sockets have been replaced as muscles return to normal and the thigh takes on its original shape and size increases. Most of the increase in size will take place in the A-P dimension, with very little change in M-L. Increasing the M-L dimension by anything more than 1/4" will result in a lateral gap at the top of the socket. <h3>Technique</h3> Thigh is measured as to length and circumference as high as possible and every two inches. Taking a cast: Take two pieces of 6" wide cotton stockinette, 32" long. Cut 17" into each piece and sew together to make undergarment for casting (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-03.jpg">Fig. 2</a>). Measure length of thigh and sew one leg of garment to fit thigh. Cut small holes in front and back of top of garment and insert cord to tie up over amputee's shoulder to help hold garment securely in place. With a snug fitting undergarment on the patient, and with the seam as near center as possible, the prosthetist will work from the side and completely circle the pelvis above the trochanter with a single wrap of 4" non-elastic plaster bandage. Pull it snug, for this wrap is to prevent downward slippage of the cast as more wraps of plaster are applied around the thigh. Work quickly so your finger can be placed around the ischium to mark its location and proper depth of cast before the plaster sets. This spot will be used to measure length to floor, pelvis level. The hand should be held to indicate the medial and posterior surfaces of ischium. Do not push forward of ischium. Ask the amputee to bring his knees together as tightly as possible and to extend his thigh to tighten the hamstrings. Hold this position until the plaster sets. Now place a vertical mark on lateral surface, with muscles tightened in extension (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-04.jpg">Fig. 3</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-03.jpg">Figure 2. Casting garment.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-04.jpg">Figure 3. Lateral view of cast ready to pour.</a> Tear the single wrap of plaster than encircles the pelvis. The cast will drop away. Immediately check depth of cast and location of ischium. Prepare cast for filling by adding duct tape around top to make top level. Pipe must be parallel with lateral mark, and tipped to medial to approximate Long's Line angle (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-05.jpg">Fig. 4</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-05.jpg">Figure 4. Anterior view of cast.</a> Now pour the cast full of plaster and let it set. When the plaster bandage and stockinette are peeled away, we now have a grossly oversided model (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-06.jpg">Fig. 5</a> and <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-07.jpg">Fig. 6</a>) that must be reduced in size. Practically all the reduction will take place on the lateral wall. <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-06.jpg">Figure 5. Posterior view of unaltered model.</a> <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-07.jpg">Figure 6. Lateral view of unaltered model.</a> Referring to <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-02.jpg">Table I</a>, the socket M-L will be 4.5" for a 19", 0 circumference level measurement of the amputee. <h3>Socket Modification</h3> <ol> <li> Lateral wall is to be shaped to give support over a wide area, and particularly the lateral posterior aspect of socket. </li> <li> The medial wall will be lower than seat level, and the cast will be the guide as to how low (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-08.jpg">Fig. 7</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-08.jpg">Figure 7. Medial view of modified model.</a></li> <li> Depth of the socket will be the same as measured length of the thigh. </li> <li> The seat will be at right angle to Long's Line. </li> <li> Long's Line is drawn from center of M-L (see chart) to center of distal femur (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg">Fig. 8</a>). (Distal femur will be very close to lateral surface, probably covered only by skin.) <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg">Figure 8. Posterior view of modified model.</a></li> <li> Top 1" of medial wall will flare outward at 45° (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg">Fig. 9</a>, point Y). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg">Figure 9. Anterior view showing relationship of medial brim (point X) to ischium and of lateral wall (point Y) to greater trochanter.</a></li> <li> Lateral wall is higher than usual. Do go above the trochanter (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg">Fig. 9</a>, point Y). </li> <li> Seat need not be wide, but sharp edges must be avoided (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-11.jpg">Fig. 10</a>). The ischium will bear on flare of socket, both medial and posterior. <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-11.jpg">Figure 10. Lateral view.</a></li> <li> Do not worry about the socket touching the greater trochanter. Take the cast down as though the trochanter does not exist. Practically all sockets gap in this area. In order to achieve the desired M-L, many casts will be reduced 2" or more (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-13.jpg">Fig. 11</a>, <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-12.jpg">Table II</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-13.jpg">Figure 11. Proximal view of socket and socket pattern for thigh measuring 19". Actual measurement of the pattern is 18".</a></li> <li> Many sockets require fill added distally on medial side, only because I failed to remove enough material in this area when modifying the model. </li> <li> Laminate socket using two layers of 1 oz. dacron felt plus extra felt around top. </li> <li> Remove socket from cast and trim excess plastic. </li> <li> Mark the center of the lateral wall at seat level for TKA. TKA should be parallel to lateral cast mark lines (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg">Fig. 12</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg">Figure 12. Lateral view of bench aligned prosthesis.</a></li> <li> Mark Long's Line on posterior of socket (Center of M-L through distal femur) (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg">Fig. 13</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg">Figure 13. Posterior view of bench aligned prosthesis.</a></li> <li> When using a standard wood set-up, knee bolt should be 4° higher on lateral side when Long's Line is vertical. Long's Line will thus not be in center, but towards lateral side. </li> <li> Mount socket on set-up so that lines are straight (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg">Fig. 12</a> and <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg">Fig. 13</a>) and medial wall checks out for height. </li> <li> Install valve and walk amputee. </li> </ol> DO NOT change the alignment. Allow the amputee to take a few steps and watch the foot come in to a narrow base normal gait pattern. Notice level knee bolt while walking. DO expect the amputee to have much more difficulty in readjusting to his old prosthesis. He will need to widen his base and may experience vertigo at first due to lack of support and extreme inward location of the foot. To finish shaping of the thigh, material is added to the knee block to widen the knee block in front of medial joint. This must not limit full extension (<a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-16.jpg">Fig. 14</a>). <a href="http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-16.jpg">Figure 14. Anterior view of prosthesis following completion of shaping.</a> *Ivan A. Long, CP. Ivan Long, CP., is President of Polycadence, 6080 West 55th Place, Arvada, California 80002. Page Number(s) 9 - 14 Year 1985 Volume 9 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-02.jpg THIS IS TABLE I Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-03.jpg THIS IS FIGURE 2 Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-04.jpg THIS IS FIGURE 3 Figure 5 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-05.jpg THIS IS FIGURE 4 Figure 6 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-06.jpg THIS IS FIGURE 5 Figure 7 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-07.jpg THIS IS FIGURE 6 Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 16 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-16.jpg THIS IS FIGURE 14 Figure 8 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-08.jpg THIS IS FIGURE 7 Figure 9 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-09.jpg THIS IS FIGURE 8 Figure 10 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-10.jpg THIS IS FIGURE 9 Figure 11 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-11.jpg THIS IS FIGURE 10 Figure 12 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-13.jpg THIS IS FIGURE 11 Figure 13 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-12.jpg THIS IS TABLE II Figure 14 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg THIS IS FIGURE 12 Figure 15 http://www.oandplibrary.org/cpo/images/1985_04_009/1985_04_009-14.jpg THIS IS FIGURE 13 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 Normal Shape-Normal Alignment (NSNA) Above-Knee Prosthesis Creator An entity primarily responsible for making the resource Ivan A. Long, CP. * Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. Contact Name/Title Operations Director Freddie Ossimbe: operations@onestepafrica.org Countries Served Uganda, Rwanda, Burundi, South Sudan, DR Congo, Zambia Email contact@onestepafrica.org Organization Type Including ID and tax status Non-profit Services Provided One Step Africa seeks to ensure prosthetic limbs and other physical attributes can be delivered to any community in Eastern Africa, regardless of how far they may be from the nearest large urban centre. Need I Financial Assistance Need II Volunteers: Prosthetists, Orthotists, Therapists Need III Materials, Components, and Equipment: New, Disassembled, Equipment, Used, Medical Supplies URL http://www.onestepafrica.org/ Mission Through innovative approaches to local logistics and supply chain distribution, One Step Africa seeks to ensure prosthetic limbs and other physical attributes can be delivered to any community in Eastern Africa, regardless of how far they may be from the nearest large urban centre. Continued work either independantly or alongside other organisations based in the area will strive to deliver the necessary skilled professionals and training needs into these remote communities, to ensure that prosthetic healthcare can be an option for anyone and everyone regardless of where they happen to live. It is our goal to drive towards reducing the gap between basic prosthetic healthcare in the developed and developing worlds. Volunteer Contact Fundraising & Volunteer Co-ordinator Johnson Komokesh: fundraising@onestepafrica.org Patient Contact Clinic Manager Dr. Mathieu Delacroix: clinic@onestepafrica.org 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 One Step Africa Description An account of the resource The East African Prosthetics Network https://staging.drfop.org/files/original/ade32438fe78cc76b9983a4b8b03a966.pdf 24729f77c1e834d976420985feac692f https://staging.drfop.org/files/original/d92a7eff2668b5c4ae4ad1304d095fa8.jpg 835435b1ece19459b1ac8d1a17c66508 https://staging.drfop.org/files/original/b5aae5c48c7c5d7cb3451ea33d46ca35.jpg 7f2c8261672b992d5e23edec9c77f155 https://staging.drfop.org/files/original/c23813c8338bfd0e458ded21a75e5f4e.jpg 0f0b8b3e72dd2046648a7cd419c0d7a3 https://staging.drfop.org/files/original/05f26b792282c85b48f580e1eae102ec.jpg 99d0cf43ee5a531ada3afac54450494f https://staging.drfop.org/files/original/ce9fd6c6b75b551158c3744e94f094b7.jpg 73c12aa3dbf0a65f1f4fa64ac9dd6213 https://staging.drfop.org/files/original/07ee80f09471576171407de72fa75dd5.jpg 4f76e5e9d6715c10b86b5cb853ec87a4 https://staging.drfop.org/files/original/97a5dc6f83c442defa0fe8ace990f196.jpg e8575a35f4234f2cacbfae587bae4e43 https://staging.drfop.org/files/original/97b8c915a4b3c287a6f6d8da7f49a69a.jpg cbc601a2e8329c86d4569281990ed01c https://staging.drfop.org/files/original/06006f97bc193b21a924aebb7cc5e327.jpg 90544b8e8968a5c9e75adc9c7dca2a85 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_01_027.pdf Year 1965 Volume 13 Issue 1 Page Number(s) 27 - 34 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_01_027.pdf"></a></td> <td></td> <td><a href="al/pdf/1965_01_027.pdf">View as PDF</a></td> </tr> <tr> <td>with original layout</td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Orthopaedic Shoes for Bilateral Partial Foot Amputations</h2> <h5>Anthony Staros, M.S.M.E. <a style="text-decoration:none;">*</a> Edward Peizer, Ph.D. <a style="text-decoration:none;">*</a> </h5> Most physicians and competent orthotists recommend the use of orthopaedic shoes in cases requiring shoe modifications or braces. However, in practice, the term "orthopaedic" is loosely applied to a variety of shoes of widely different cost, construction, function, durability, and appearance. Orthopaedic shoes are distinguished from stock or nonorthopaedic shoes by a steel shank, a long, high, reinforced counter and internal corrections; prescribed modifications are incorporated as elements of the shoe construction rather than added externally. These are clear differences, and the superiority of orthopaedic shoes is generally recognized. Although related, there are two vastly different types of shoes labeled "orthopaedic." One is the kind of shoe described above, which is usually referred to as the custom orthopaedic shoe; the other is the stock orthopaedic shoe. The latter usually contains a steel shank, and in certain instances it also includes a long medial counter and Thomas heel. At this point, however, the similarity to custom orthopaedic shoes ends. Additional corrections which are prescribed must be added externally. They do not include the reinforcement required to prevent "breaking" of the sole at undesirable points and to prevent lateral bulging of the uppers. Despite these disadvantages, stock orthopaedic shoes are frequently prescribed or selected by patients. Cost is probably a significant if not decisive factor since typical costs for stock orthopaedic shoes average half or less than half the cost of custom orthopaedic shoes. On analysis, however, cost differences tend to narrow, as the useful life of custom orthopaedic shoes is longer. In our opinion, the functional and cosmetic advantages of custom orthopaedic shoes far outweigh the cost differential. Apart from considerations of cost, stock orthopaedic shoes may be selected because the appearance to the untutored eye of a new pair seems adequate, and because the patient may seem initially to walk in much the same manner when wearing equally new custom orthopaedic and stock orthopaedic shoes. Not immediately apparent are the quick deterioration and shorter life of the stock orthopaedic shoe and the functional value of the custom orthopaedic shoe. Because of adaptive measures employed by the patient to overcome deficiencies in the stock shoe and to present a normal appearing gait, the external appearance of the gait pattern with the custom shoe may not always be superior. Adjustments made by the patient to adapt himself to the shoes are revealed in the interaction of forces between the foot and the ground during the stance phase of walking. It is primarily to these forces that the wearer of custom shoes reacts when expressing a preference for the function of one shoe over another, even though improvements by a reduction in gait deviations may go undetected during visual observation. A recent experience illustrates these points. A young man with congenital deformities of the feet, for whom orthopaedic shoes had been prescribed, was tested in our laboratory. (He also had congenital deformities of the hands.) He was considered an excellent subject for this type of analysis because of the remarkable adaptations he had made to his deformities. Despite their severity, he was an extremely adept walker with a nearly normal gait whether he wore shoes or not. We believed that his high adaptability would tend to mask, to an unusual extent, any gross differences in his gait and that, therefore, detectable differences could be attributed to the function offered by the shoe. <h3>The Subject</h3> The subject for this study was a 19-year-old congenital amputee with partial hands and feet (Fig. 1). At the initial examination he was wearing previously prescribed stock orthopaedic shoes with steel shanks as the only special feature. Added externally were sole and heel extensions (Fig. 2). After approximately 12 months of wear a severe break in the tarsal region of the right shoe and another, though less severe, of the left shoe were exhibited. The lateral walls of both shoes bulged excessively, resulting in permanent deformation and reduction of support. The short steel shank protruded through the sole at a point corresponding to the break, and the wear of the soles revealed a pattern of little or no support anterior to the shank which terminated at a point corresponding to the tarsometatarsal joint line (Fig. 3). <table> <tbody><tr> <td> <table> <tbody><tr> <td> Fig. 1. Congenital bilateral amputations with absence of tarsals in the right foot and presence of tarsals in the left. A, Lateral view; B, frontal view. </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> Fig. 2. Stock shoes showing deformation after 12 months' wear. A, B, Externally added heel and sole extensions can be seen. </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> Fig. 3. Stock shoes showing: A, break in tarsal region; B, uncosmetic external corrections; C, protruding short steel shank and a wear pattern indicative of lack of support in the metatarsal and toe areas. </td> </tr> </tbody></table> </td> </tr> </tbody></table> He was fitted at a commercial establishment with a prescription for custom orthopaedic shoes recommended by the Veterans Administration Prosthetics Center (Fig. 4). These shoes were specially reinforced with long, flat steel springs and steel shanks installed between inner and outer soles to increase the resistance to dorsiflexion after mid-stance and to shift the "toe break" further forward. They also featured stiff, high, long counters and a wider heel base with a reversed Thomas heel on the right shoe to increase lateral support. An inside cork extension was prescribed to accommodate leg shortening. After four months of use the wear pattern of the soles indicated that the patient was receiving support; that is, resistance to dorsiflexion or "shoe break" extended all the way out to the toe (Fig. 4B). <table> <tbody><tr> <td> <table> <tbody><tr> <td> Fig. 4. Custom shoes after four months' wear showing: A, cosmetic advantage; B, reversed Thomas heel and an even wear pattern indicative of support provided over entire surface. </td> </tr> </tbody></table> </td> </tr> </tbody></table> <h3>Procedures</h3> To record the gait performance of the patient as completely as possible, several methods were employed. Thirty-five mm. motion pictures were taken in both the anteroposterior and the mediolateral planes as the patient walked with his old shoes and with his new shoes. Similarly, cyclographic recordings were made of angular and linear displacements at the hip, knee, and ankle. Force plates were used to record the ground reaction forces during stance phase. Finally the patient's opinions were recorded. <h3>Results</h3> A motion-picture analysis showed that the subject walked very well with both stock and custom orthopaedic shoes. He was able to make small but significant compensations in his body alignment and in the timing of his movements with the result that the total body center of gravity maintained a smooth translatory path. In general, the more detailed cyclographic recordings clearly demonstrated a remarkable ability on the part of the patient to maintain a reasonably normal gait pattern despite differences in functional losses between right and left leg and substantial differences in the height and functional character of the shoes. As shown in Fig. 5 and Fig. 6, displacement patterns-that is, the motions of the hip, knee, and ankle in space-were essentially similar with both stock and custom shoes. The consistently higher elevation of each of the major joints with the custom shoe was due simply to differences in the elevation of the shoes. <table> <tbody><tr> <td> <table> <tbody><tr> <td> Fig. 5. Horizontal displacement of targeted points on the subject's right lower extremity during ambulation, </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> Fig. 6. Horizontal displacement of targeted points on the subject's left lower extremity during ambulation. </td> </tr> </tbody></table> </td> </tr> </tbody></table> Although knee-flexion patterns with custom and stock orthopaedic shoes were generally similar, flexion of the left knee during the early stance phase was reduced substantially with the custom shoes (Fig. 7). This was attributed to the increased support provided by the custom shoes in the tarsometatarsal region with a consequent reduction of the "drop off" on the right leg during late stance. As a result of the excessive "drop off" due to the "break" of the stock orthopaedic shoes, the hip remained at a lower elevation than it would otherwise have attained. The lower hip elevation necessitated additional compensatory flexion of the left knee by the patient in order to walk in a reasonably symmetrical manner. Reducing the "drop off" maintained the hip at a higher elevation and made this additional knee flexion unnecessary. <table> <tbody><tr> <td> <table> <tbody><tr> <td> Fig. 7. </td> </tr> </tbody></table> </td> </tr> </tbody></table> A computation of the actual forces applied to the ground was made by resolving both vertical and horizontal force components. Indicated in the following tabulation are the peak forces applied to the ground during the period of heel contact to foot flat and between the instant of heel off and push off in two trial runs with the stock shoes and in two trial runs with the custom shoes. (Table 1) <table> <tbody><tr> <td> <table> <tbody><tr> <td> </td> </tr> </tbody></table> </td> </tr> </tbody></table> As the patient weighed 196 lb., it may be seen that the differences between the first and second peaks were substantially lowered on the right foot and somewhat less diminished on the left foot when the custom shoes were worn, demonstrating a more nearly equal application of forces to the ground. These differences were due primarily to his ability to maintain higher fractions of his body weight on the supporting foot after heel off. Fig. 8 graphically illustrates, for comparative purposes, the average peak magnitudes of the axial load during heel contact to foot flat, and during heel off to push off. The most significant effect on gait of the custom shoes was to diminish the magnitude of the force with which the heel was initially applied to the ground and to increase the force applied to the ground during the portion of stance corresponding to the period between heel off and push off. Although the absolute values of these changes are small, they had highly significant effects in reducing the patient's adaptive efforts and in reducing shoe wear. As might be expected in the complete absence of plantar-flexion in the right foot, the effects were greater on the right side. <table> <tbody><tr> <td> <table> <tbody><tr> <td> Fig. 8. </td> </tr> </tbody></table> </td> </tr> </tbody></table> <h3>Subject's Opinion</h3> The subject stated unequivocally that the custom orthopaedic shoes were far superior to the stock shoes that he had previously worn. They were more comfortable, they provided better support, and the inside buildup was more cosmetically desirable. The subject wore the custom shoes home and refused to take the stock shoes with him, discarding them on the spot. <h3>Summary</h3> There is very little question in our minds of the superiority of custom orthopaedic shoes over stock orthopaedic shoes. Even in the case described in this article when, at first glance, the need might be considered minimal, clear advantages were provided. On this functional basis alone preference should go to custom orthopaedic shoes. Further study of the life expectancy of custom and stock orthopaedic shoes should serve to clarify objectively where real economy in this matter lies. <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;">Edward Peizer, Ph.D. </td></tr><tr><td class="clsTextSmall">Chief, Bioengineering Research Service, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York, N. Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;">Anthony Staros, M.S.M.E. </td></tr><tr><td class="clsTextSmall">Director, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York, N. Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_01_027/spring65-27.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_01_027/spring65-28.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_01_027/spring65-29.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_01_027/spring65-30.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_01_027/spring65-31.jpg Figure 6 http://www.oandplibrary.org/al/images/1965_01_027/spring65-32.jpg Figure 7 http://www.oandplibrary.org/al/images/1965_01_027/spring65-33.jpg Figure 8 http://www.oandplibrary.org/al/images/1965_01_027/spring65-99.jpg Figure 9 http://www.oandplibrary.org/al/images/1965_01_027/spring65-34.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 Orthopaedic Shoes for Bilateral Partial Foot Amputations Creator An entity primarily responsible for making the resource Anthony Staros, M.S.M.E. * Edward Peizer, Ph.D. * https://staging.drfop.org/files/original/c9f248aba5f777b90137fc5f653684ca.pdf f8b086eeef728c09345c4e2f59e8dd7e https://staging.drfop.org/files/original/c065f49a310f10a589f0a327d3e553c5.jpg 186d2ba85e30b71c039fa0154657cdce https://staging.drfop.org/files/original/bff051b61f6196998c950cf38167980c.jpg f771a9bfcf3050739cc85923b4f49d6f https://staging.drfop.org/files/original/d9d6a4e0ab4404f5bbe8bc6f1cc09fd1.jpg 1f970c7584285f498d6bf17c65c6f630 https://staging.drfop.org/files/original/febaffd06b576a9e62a93e9a0b40cd51.jpg 6acd7a71a2979ec382b0556569e30af1 https://staging.drfop.org/files/original/2bfcdb6e9deb8c4cf2472673f5174ef5.jpg 89553677fd4b9ef73da3014c83f7f72e https://staging.drfop.org/files/original/3e612a67d3f33d4c3dda57bb05207afc.jpg 23c4714870273c39c3ba99be300cd7c5 https://staging.drfop.org/files/original/8e70952489609f15226daf7eab16de3f.jpg 14e82719d1cbe0351948564744c75375 https://staging.drfop.org/files/original/1376f07c00973223d41d772b54427ee4.jpg 01ff296c026fd5f2d7c9b038490105b2 https://staging.drfop.org/files/original/0613d64bd48e27b9c797a6d197e3e2fc.jpg 106950e908dfdc134018cf1c8ecc0bf6 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_02_074.pdf Text Any textual data included in the document <h2>Orthopedic Walkers: Effect on Plantar Pressures</h2> <h5>James A. Birke, P.T., M.S. <a style="text-decoration: none;">*</a> Deborah A. Nawoczenski, P.T., M.Ed. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> Short leg (SLW) and patellar tendon bearing walkers (PTBW) are orthotic appliances<a style="text-decoration: none;">*</a> which have been recently designed as alternative devices to traditional plaster cast immobilization. The indications for use of lower leg walkers include severe ankle sprains, and ankle and foot fractures. Orthopedic walkers are convenient to use, lightweight, and removable to perform joint range of motion or inspect the extremity. Short leg walkers have been shown to be as effective as walking casts in healing stable ankle fractures, and patients treated with short leg walkers have shown significantly less edema, tenderness, and joint stiffness after six weeks of immobilization.<a></a> The authors feel that orthopedic walkers may also prove to be a beneficial alternative to traditional management of neuropathic fractures and plantar ulcerations, which are commonly seen in diabetes mellitus and Hansen's disease. Neuropathic foot lesions are the result of abnormal or repetitive stress.<a></a> Treatment techniques for neuropathic foot conditions should be effective in reducing pressure and shear stress. Traditional methods of treating neuropathic foot lesions include walking casts, fixed ankle braces, and PTB braces.<a></a> Plaster walking casts and PTB braces have been shown to significantly reduce pressure on the plantar surface of the foot during walking.<a></a> The total contact walking cast is considered effective in reducing pressure on the foot by redistributing forces on the plantar surface of the foot and lower leg. Several features of PTB orthoses shown to be important in achieving maximal weight bearing reduction on the foot include a rigid closure PTB shell, a heel-shoe clearance of 3/8" to 1", a fixed ankle joint, and a rocker sole.<a></a> Orthopedic walkers incorporate these same design features to varying degrees which has generated our interest in studying their effectiveness in reducing pressure on the foot. The SLW has a fixed ankle joint, rocker sole, and a polyurethane liner which is snugly secured to the leg with Velcro® closures (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-1.jpg">Fig. 1</a>). The PTBW incorporates all the features of the SLW, as well as a non-custom molded, semi-rigid polyethylene PTB shell (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-2.jpg">Fig. 2</a>). <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-1.jpg">Figure 1. Short Leg Walker.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-2.jpg">Figure 2. Patellar Tendon Bearing Walker.</a> The effectiveness of the SLW or PTBW in reducing pressure or shear stress on the foot has not previously been studied. The potential value of these devices in managing the neuropathic foot may be evaluated by their effectiveness in reducing pressure and shear stress. Currently, there are unreliable methods for measuring shear stress. However, shear is directly related to the perpendicular forces acting on the foot. Pressure equals the perpendicular forces per unit area. Pressure transducers provide a repeatable measurement of relative pressure inside footwear when the material interfacing with the transducers is controlled.<a></a> <h3>Purpose</h3> The purpose of this study was to determine the effectiveness of SLW and PTBW in reducing the pressure distribution on the normal foot during walking. <h3>Method</h3> Ten subjects (6 male and 4 female) without a history of foot pathology participated in this study. Capacitive pressure transducers<a style="text-decoration: none;">*</a> 2mm thick and 1.5cm in diameter were taped to the first metatarsal head (MTH), third MTH, fifth MTH, and plantar heel of the right foot of each subject (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-3.jpg">Fig. 3</a>). The foot was covered with a thin cotton stockinette which remained undisturbed during the study. Transducers were calibrated according to the manufacturer's instructions prior to testing each subject. Pressure recordings were made using a four-channel capacitive impedance bridge amplifier<a style="text-decoration: none;">*</a> and oscillographic recorder<a style="text-decoration: none;">*</a> while subjects walked in a cast shoe (CS-1) (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-4.jpg">Fig. 4</a>), short leg walker (SLW), patella tendon bearing walker (PTBW), and again in a cast shoe (CS-2). All the walking devices were fabricated by the same manufacturer.<a style="text-decoration: none;">*</a> The cast shoe was identical to the foot component of both the SLW and PTBW, utilizing identical rocker out-ersoles and 2.4mm polyurethane material insoles. SLW and PTBW were applied to the leg with a 3/8" heel-shoe clearance. Subjects walked a distance of 100 meters for each treatment condition. The testing order of treatments SLW, PTBW, and CS-2 was randomly assigned to eliminate systematic error. <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-3.jpg">Figure 3. Pressure transducer placement on selected areas of the foot.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-4.jpg">Figure 4. Cast Shoe.</a> Relative pressure was measured in millimeters of peak to peak chart deflection for 24 steps for each treatment condition. The middle distance of each run was used for analysis in order to eliminate pressure variations due to the acceleration and deceleration phases of each trial. Percent pressure change relative to CS-1 was calculated for treatments SLW, PTBW, and CS-2. Means and standard deviations were computed for treatments at each transducer site. An analysis of variance for repeated measures was used to determine whether treatment differences were significant within each site. Duncan's test was used for post-hoc analysis of means. A significance level of 0.05 was used for comparisons. <h3>Results and Discussion</h3> An analysis of variance (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-5.jpg">Table I</a>) for mean percent reduction in pressure was highly significant at all sites tested (<a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-6.jpg">Fig. 5</a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-7.jpg">Fig. 6</a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-8.jpg">Fig. 7</a>, and <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-9.jpg">Fig. 8</a>). Duncan's test was performed to establish which treatments differed. Significant differences were found between the percent reduction in pressure walking in SLW and PTBW as compared to the CS-2 at all sites. No difference was found between SLW and PTBW at any site. The percent pressure reduction using the walker devices was comparable at all the sites tested. <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-5.jpg">Table I. Analysis of Variance of Percent Pressure Reduction.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-6.jpg">Figure 5. Percent pressure reduction at the first metatarsal head (1 MTH) walking in cast shoe-2 (CS-2), short leg walker (SLW) and patellar tendon bearing walker (PTBW) compared to walking in cast shoe-1.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-7.jpg">Figure 6. Percent pressure reduction at the third metatarsal head (3 MTH) walking in cast shoe-2 (CS-2), short leg walker (SLW) and patellar tendon bearing walker (PTBW) compared to walking to in cast shoe-1.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-8.jpg">Figure 7. Percent pressure reduction at the fifth metatarsal head (5 MTH) walking in cast shoe-2 (CS-2), short leg walker (SLW) and patellar tendon bearing walker (PTBW) compared to walking in cast shoe-1.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-9.jpg">Figure 8. Percent pressure reduction at the heel walking in cast shoe-2 (CS-2), short leg walker (SLW) and patellar tendon bearing walker (PTBW) compared to walking in cast shoe-1.</a> This study demonstrated the effectiveness of the short leg and patellar tendon bearing walkers as compared to the cast shoe in reducing plantar pressure on the foot. Since all the devices in this study had the same sole design and insole materials, treatment differences must be attributable to proximal orthotic components including the polyurethane liner, fixed ankle uprights, and Velcro® closures. The SLW and PTBW differed only by the polyethylene, non-custom molded patellar tendon cuff. Since no treatment difference was seen between these devices, the PTBW cuff design must not have been effective. However, in follow-up, single subject trials, we were not able to change walking pressures by redesigning the PTBW cuff using polyethylene or plaster custom molded PTB cuffs. An alternative conclusion is that the SLW design alone optimally reduced plantar pressure by the fixed ankle joint and uprights snugly supporting the lower leg and calf. In this study, orthopedic walkers were equally effective in reducing pressure at all sites tested on the foot. In previous studies, casts were shown to reduce pressure more effectively in the forefoot than the heel, and PTB orthotics reduced pressure more effectively in the heel than the forefoot.<a></a> Based on the results of this study, othopedic walkers may be effective devices in the reduction of plantar foot pressure in patients with neuropathic conditions of the foot. There is no evidence to show that the PTBW will be more effective than the SLW. Further study utilizing a patient population is recommended. <h3>Conclusions</h3> Within the scope of this study, it is possible to conclude the following: (1) SLW and PTBW orthopaedic walkers are effective in reducing pressure at the first MTH, third MTH, fifth MTH and heel in normal subjects during walking, and (2) there is no difference in pressure distribution between the SLW and PTBW during walking. References: <ol> <li>Anderson, J.G., "Treatment and Prevention of Plantar Ulcers," Leprosy Review, 35, 1964, pp. 251-258.</li> <li>Birke, J.A. and D.S. Sims, "Walking Casts: Effect on Plantar Foot Pressures," Journal of Rehabilitation Research and Developement, 22:3, July, 1985, pp. 18-22.</li> <li>Brand, P.W., "The Insensitive Foot," Editor M.H. Jahss, Disorders of the Foot, Vol. II, W.B. Saunders, 1982, p. 1266.</li> <li>Cterctecko, G.C., M. Dhanendran, W.S. Hutton, and L.P. LeQuesne, "Vertical Forces Acting on the Foot of Diabetic Patients with Neuropathic Ulceration," British Journal of Surgery, 68, 1981, pp. 609-614.</li> <li>Coleman, W.S., P.W. Brand, and J.A. Birke, "The Total Contact Cast: A Therapy for Plantar Ulceration of the Insensitive Foot," Journal of the American Pediatric Medical Association, 74:11, November, 1984, pp. 548-552.</li> <li>Enna, CD., P.W. Brand, J.K. Reed, and D. Welch, "The Orthotic Care of the Denervated Foot in Hansen's Disease," Orthotics and Prosthetics, 30:1, March, 1976, pp. 33-39.</li> <li>Gristina, A.G., A.L.W. Thompson, N. Kester, W. Walsh, and J.A. Gristina, "Treatment of Neuropathic Conditions of the Foot and Ankle with a Patellar-Tendon-Bearing Brace," Archives of Physical Medicine and Rehabilitation, 54, December, 1973, pp. 562-564.</li> <li>Hall, O.C. and P.W. Brand, "The Etiology of the Neuropathic Plantar Ulcer," Journal of the American Pediatric Medical Association, 69:3, March, 1979, pp. 173-177.</li> <li>Helm, P.A., S.C. Walker, and G. Pullium, "Total Contact Casting in Diabetic Patients with Neuropathic Foot Ulcerations," Archives of Physical Medicine and Rehabilitation, 65, 1984, pp. 691-693.</li> <li>Lang-Stevenson, A.I., W. Sharrard, R.P. Betts, and T. Duckworth, "Neuropathic Ulcers of the Foot," Journal of Bone and Joint Surgery, (British) 67B, 1985, pp. 438-442.</li> <li>Lehmann, J.F., CG. Warren, D.R. Pemberton, B.C. Simons, and B.J. DeLateur, "Load-bearing Function of Patellar Tendon Bearing Braces of Various Designs," Archives of Physical and Medical Rehabilitation, 52, August, 1971, pp. 366-370.</li> <li>Patterson, R.P., and S.V. Fisher, "The Accuracy of Electrical Transducers for the Measurement of Pressure Applied to the Skin," IEEE Transactions on Biomedical Engineering, 26:8, August, 1979, pp. 450-456.</li> <li>Polakoff, D.R., S.M. Pearce, D.P. Grogan, and W.Z. Burkhead, "The Orthotic Treatment of Stable Ankle Fractures," Orthopedics, 7, 1984, pp. 1712-1715.</li> <li>Pollard, J.P., and L.P. LeQuesne, "Method of Healing Diabetic Forefoot Ulcers," British Medical Journal, 286, February, 1983, pp. 436-437.</li> <li>Pollard, J.P., L.P. LeQuesne, and J.W. Tappin, "Forces Under the Foot," Journal of Biomedical Engineering, 5, 1983, pp. 37-40.</li> <li>Sabato, S., Z. Yosipovitch, A. Simkin, and J. Sheskin, "Plantar Trophic Ulcers in Patients with Leprosy," International Orthopedics, 6, 1982, pp. 203-208.</li> <li>Soderberg, G., "Follow-up of Application of Plaster-of-Paris Casts for Noninfected Plantar Ulcers in Field Conditions," Leprosy Review, 41, 1970, pp. 184-190.</li> </ol> Footnote 3D Orthopedics, Inc., 10520 Olympic Drive, Dallas, Texas 75220. Footnote Gulton TR-400a, Gulton Industries, Inc., East Greenwich, Rhode Island. Footnote Hercules Orthoflex Data System, Allegany Ballistics Lab, Cumberland, Maryland. Footnote Hercules Orthoflex Data System, Allegany Ballistics Lab, Cumberland, Maryland. *Deborah A. Nawoczenski, P.T., M.Ed. Deborah A. Nawoczenski, P.T., M.Ed., is Assistant Professor at the Department of Physical Therapy for the College of Allied Health Professions at Temple University, Philadelphia, Pennsylvania 19140. *James A. Birke, P.T., M.S. James A. Birke, P.T., M.S., is Chief of the Physical Therapy Department at G.W. Long Hansen's Disease Center, Carville, Louisiana 70721. Page Number(s) 74 - 80 Year 1988 Volume 12 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-4.jpg Figure 5 TABLE I http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 FIGURE 5 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-6.jpg Figure 7 FIGURE 6 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-7.jpg Figure 8 FIGURE 7 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-8.jpg Figure 9 FIGURE 8 http://www.oandplibrary.org/cpo/images/1988_02_074/1988_02_074-9.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Orthopedic Walkers: Effect on Plantar Pressures Creator An entity primarily responsible for making the resource James A. Birke, P.T., M.S. * Deborah A. Nawoczenski, P.T., M.Ed. * https://staging.drfop.org/files/original/8a9d698b5aa9a88b1d78cca1010c8eea.pdf 19dc4e493a77c65d2001e424e6222098 https://staging.drfop.org/files/original/99962c094bd59683119343ed583b5ef4.jpg 39cc66fe8bd0fa42c218e04d12f792fa https://staging.drfop.org/files/original/5f782331cf98ead70319d472a0b9cb1f.jpg 342634e484594f8c0b6ec6fe1e681ed9 https://staging.drfop.org/files/original/0418850e6c8e9edf99ef13541eb7a5ae.jpg a24f4347ad26657b24aa89700949a9fc https://staging.drfop.org/files/original/8722aae75627f1d176b8d9a189158028.jpg e972a1cac03927a2aafa9101a7ca1f5c https://staging.drfop.org/files/original/e8bde8acef8665150fa610cabe02ddbd.jpg bdd02cd537217663f89754a8cbf9e89e https://staging.drfop.org/files/original/bdccea442ad3ab930b10461937bd5371.jpg be9a619d33b72a6e85e028985e907098 https://staging.drfop.org/files/original/e625aaa21e9345136d836397f35f4a25.jpg a7924af794fc40802662208fcc8abc16 https://staging.drfop.org/files/original/eb1591fd71b8878004fe4d6b6c82f8e8.jpg f673166d26b71b65d9dc04bd19d51530 https://staging.drfop.org/files/original/35e4a19292bc235080a381e346afc9df.jpg 2d9d56f7b3531d006b2ab2c40616d544 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_02_003.pdf Text Any textual data included in the document <h2>Orthotic Correction of Blount's Disease</h2> <h5>Terry J. Supan, C.P.O. <a style="text-decoration: none;">*</a> John M. Mazur, M.D. <a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> Infantile tibia vara is the result of abnormal growth in the proximal tibial epiphyseal late of the tibial plate. Blount<a></a> first identified the condition as osteochondrosis deformans tibialis in 1937. Clinically, tibia vara presents itself as a severe bowing of the proximal tibia, without the associated bowing of the tibial shaft or the femur, which is evident in physiological bowleg. On radiological examination of the child with tibia vara, a beaking of the medial aspect of the tibia metaphysis is noted. In 1964, Langenskiold and Riska<a></a> developed a grading system for chronologically staging the development of Blount's disease. Mitchell, et al.<a></a> advocated the use of the epiphyseal metaphyseal angle (E-M angle) as a simple quantitative measurement for Blount's disease in 1980. This method is useful to determine the severity of the disease and monitor treatment. Historically, the use of orthotic management in the correction of Blount's disease has not proven to be as successful as hoped. The lack of correction and increased laxity of the joint capsule of the knee have been the main reasons for not continuing with orthotic management. To this point, the treatment of choice for individuals with Stage IV or an E-M angle of greater than 30° has mandated that the child undergo one of several types of tibial osteotomies. Because of the high incidence of complications<a></a> and the recurrence of the condition, the authors felt that a new orthotic approach should be investigated. The result of that investigation has been the development of a knee-ankle-foot orthosis. This orthosis has successfully been used in seven cases of Blount's disease. <h3>Orthotic Design</h3> Previous orthoses used in the treatment of Blount's disease have been either a KAFO with a medial side bar only, or a KAFO with bilateral side bars. The medial side bar KAFO incorporated a varus corrective knee pad. The bilateral side bar orthosis is essentially a passive device to maintain the existing condition and to prevent it from getting worse. Neither system has proven to be completely successful in the treatment of Blount's disease. The design criteria established for the development of the knee-ankle-foot orthosis consists of the following: <ul> <li> The design must correct the varus deformity of the tibia. </li> <li> The medial joint capsule should not be distributed by the orthosis. </li> <li> Forces should be applied directly to the tibia and not the full length of the limb. </li> </ul> Because the patient is a growing child, it must be adjustable for growth as well as easily cleaned by the parents. The knee-ankle-foot orthosis which the authors have developed has met all of these criteria. Stress to the medial joint capsule was prevented by using an inversion of the supracondylar suspension technique used for below knee prostheses.<a></a> By having a medial thigh section extend beyond the joint space to the area of the medial tibial condyle, we were able to reduce the possibilities of applying stress to the joint space itself (<a href="/files/original/99962c094bd59683119343ed583b5ef4.jpg">Fig. 1</a>). <a href="/files/original/99962c094bd59683119343ed583b5ef4.jpg">Figure 1</a>. Bilateral KAFO's for Blounts with stainless steel medial side bar, thermoplastic femural section, and elastic tibial strap. Femural section protects the knee joint while the elastic applies maximum force to the apex of the tibial curve. A dynamic system was used to apply corrective forces to the tibia. The use of an elastic material to provide dynamic forces has been well documented.<a></a> A six-inch wide elastic gusset material with velcro closures provided an adjustable and continuously applied force to the tibia (<a href="/files/original/5f782331cf98ead70319d472a0b9cb1f.jpg">Fig. 2</a>). The maximum force applied to the limb with the elastic material is at the apex of the curve (<a href="/files/original/99962c094bd59683119343ed583b5ef4.jpg">Fig. 1</a>). This allows the maximum amount of correction with minimum amount of force. The velcro allows easy removal for laundering. All orthoses are provided with two sets of elastic straps. <a href="/files/original/5f782331cf98ead70319d472a0b9cb1f.jpg">Figure 2</a>. Cross section of leg and orthosis at mid-tibial level. The relationship of the sidebar, elastic, velcro, and limb are shown. The orthosis needed to be strong and adjustable because these children are growing and extremely active. The side bars are made of stainless steel which overlap for growth adjustment only between the knee and ankle (<a href="/files/original/99962c094bd59683119343ed583b5ef4.jpg">Fig. 1</a>). The knee-ankle-foot orthosis was not made adjustable proximal to this area in order to maintain the tibial extension of the thigh piece in its proper relationship to the tibial condyle. The patient's foot is maintained in a high top shoe which is attached to the medial side bar by means of a free ankle stirrup. <h3>Prescription Criteria</h3> The E-M angle is used to determine whether the patient meets the criteria for orthotic management of the Blount's disease. The E-M angle is measured on an anterior/posterior x-ray of the knee. To construct this angle, a line is first drawn through two points on the base of the proximal tibial epiphysis, selecting the first point at the base of the normal lateral side of the epiphysis and the second medial point as far away from the lateral side as possible, but at the base of the normal non-depressed epiphysis. Next, determine the midpoint at the base of the epiphyseal center, then draw a second or metaphyseal line from the medial tip of the metaphyseal peak to the midpoint of the epiphyseal center (<a href="/files/original/0418850e6c8e9edf99ef13541eb7a5ae.jpg">Fig. 3</a>). If this E-M angle is equal to or greater than 20°, then orthotic intervention is recommended. Mitchell et al. determined that the mean E-M angle for normal children was 3°-11°. Orthotic management is maintained for a minimum of nine months and at such time as the E-M angle is less than 15°. If the child is over eight years of age, orthotic correction will not be achieved. Based on our experience, orthotic management in stages I through III tibia vara can be effectively corrected with orthotic management. Aggressive treatment is necessary to achieve these results. Stages IV and V Blount's Disease and children over eight years of age need surgical treatment. <a href="/files/original/0418850e6c8e9edf99ef13541eb7a5ae.jpg">Figure 3</a>. Method of measuring the E-M angle. <h3>Case Study</h3> A white male, age 3, was presented at the orthotic clinic by his parents because of bowing of his right lower extremity (<a href="/files/original/8722aae75627f1d176b8d9a189158028.jpg">Fig. 4</a>). Clinical examination showed bilateral tibia vara. Bilateral standing AP radiograms were obtained. The E-M angle determined on these radiograms was 20° bilaterally (<a href="/files/original/e8bde8acef8665150fa610cabe02ddbd.jpg">Fig. 5</a>). The child was fitted with the bilateral KAFO's (<a href="/files/original/bdccea442ad3ab930b10461937bd5371.jpg">Fig. 6A</a>) and a new set of standing AP radiograms was obtained which showed no difference in the E-M angle at that time (<a href="/files/original/bdccea442ad3ab930b10461937bd5371.jpg">Fig. 6B</a>). <a href="/files/original/8722aae75627f1d176b8d9a189158028.jpg">Figure 4.</a> Clincal appearance of B.D. at age 3 with bilateral Blounts Disease. <a href="/files/original/e8bde8acef8665150fa610cabe02ddbd.jpg">Figure 5</a>. Standing A/P radiograms show E-M angles of 20° bilaterally. <a href="/files/original/bdccea442ad3ab930b10461937bd5371.jpg">Figures 6A (top) and 6B (bottom).</a> B.D. fitted with bilateral KAFO's. X-rays show no change at time of fitting. For the next six months, B.D. wore his bilateral KAFO's 23 hours a day with the knee joints in the locked position during weight bearing. After one week's wearing time, the patient no longer objected to wearing the devices and adapted his lifestyle accordingly. No restrictions were placed on the child concerning his daily activities. At his six-month checkup, new radiograms, both in and out of the KAFO's, were obtained. The E-M angle at that time was determined to be 15° bilaterally. Clinically, the child appears to have less bowing of his tibia as well. It was determined at that time that the side bars needed to be lengthened, which was done. It was decided that the parents could then allow the child to use the orthoses in the unlocked position during the daytime, but to return to the locked position at night. Because of growth of the child's feet, a shoe change was necessary. At nine months, the patient was again presented to the clinic. Once again the orthoses were lengthened (<a href="/files/original/e625aaa21e9345136d836397f35f4a25.jpg">Fig. 7</a>). New standing AP radiograms were also obtained, showing no significant alterations from the previous exam at six months (<a href="/files/original/eb1591fd71b8878004fe4d6b6c82f8e8.jpg">Fig. 8</a>). Day use of the KAFO was discontinued. <a href="/files/original/e625aaa21e9345136d836397f35f4a25.jpg">Figure 7.</a> Sidebars were lengthened twice during the treatment period. One shoe transfer was also completed. <a href="/files/original/eb1591fd71b8878004fe4d6b6c82f8e8.jpg">Figure 8.</a> Radiogram taken after 9 months of treatment show an E/M angle of less than 15° as well as less bowing of the tibial shaft. The patient returned for a twelve-month evaluation. No significant changes had occurred clinically in the patient's extremities (<a href="/files/original/35e4a19292bc235080a381e346afc9df.jpg">Fig. 9</a>), thus use of the orthoses was discontinued. <a href="/files/original/35e4a19292bc235080a381e346afc9df.jpg">Figure 9</a>. Orthotic treatment discontinued after 12 months. Clinical examination shows normal lower limbs. <h3>Summary</h3> This successful use of orthotic management in the early stages of Blount's disease has been proven at Southern Illinois University School of Medicine. An orthosis was designed to specifically meet the established criteria of correcting the tibial deformity, reducing the stress on the medial joint capsule, and allowing adjustability for growth. The device has been used in seven cases of tibia vara with excellent results in all cases. The E-M angle of the affected tibias have been reduced to less than 15°. Aggressive treatment in the early stages of Blount's disease will reduce the necessity of tibial osteotomies with their significant level of complications. References: <ol> <li>Blount, W.P., "Tibia vara osteochondrosis deformans tibia," J. Bone Joint Surg., 19, 1-29, 1937.</li> <li>Langenskiold, A.N., Riska, E.B., "Tibia vara osteochondrosis deformans tibia: a survey of seventy-one cases," J. Bone Joint Surg., 46-A, 1405-1420, 1964.</li> <li>Mitchell, E.I., Chung, S.M.K., Dask, M.M., Greg, J.R., "A new radiographic grading system for Blount s disease," Orthopaedic Review, Vol. 9, No. 9, 27-33, 1980.</li> <li>Steel, H.H., Sandral, R.E., Sullivan, P.D., "Applications of tibial osteotomy in children for genu varum or val gum," J. Bone Joint Surg., 53-A, 1629-1635, 1971.</li> <li>Marschael, K., Nitschke, R., "Principles of the patellar tendon supracondylar prostheses," Orthopaedic Appl. Journal, Vol. 21, No. 1, 33-38.</li> <li>Clancy, J., Landseth. R.E., "A dynamic orthotic system to assist pelvic extension: A preliminary report," Orthotics and Prosthetics, Vol. 29, No. 1, 3-9, March, 1975.</li> </ol> *John M. Mazur, M.D. John M. Mazur, M.D., Associate Professor, Department of Surgery, Division of Orthopaedics and Rehabilitation, Southern Illinois University School of Medicine. *Terry J. Supan, C.P.O. Terry Supan, C.P.O., Instructor, Department of Surgery; Director, Orthotic/Prosthetic Service, Southern Illinois University School of Medicine, Room 102, 707 North Rutledge Street, Springfield, Illinois 62702. <div style="width: 400px;"></div> Page Number(s) 3 - 7 Year 1985 Volume 9 Issue 2 Figure 3 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-06.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-09.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-02.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_02_003/1985_02_003-07.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Orthotic Correction of Blount's Disease Creator An entity primarily responsible for making the resource Terry J. Supan, C.P.O. * John M. Mazur, M.D. * https://staging.drfop.org/files/original/876ff6602d787cd8bb538c115168499b.pdf 4970b9dd38fb5c1f19b5d27c89c60acc Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_04_012.pdf Text Any textual data included in the document <h2>Orthotic Maintenance Program for the Myodysplastic Child</h2> <h5>Terry J. Supan, C.P.O. <a style="text-decoration: none;">*</a></h5> The faculty of the Southern Illinois University School of Medicine has been actively involved in a comprehensive, multidisciplinary approach to the management of the myelodysplasia child. Since the establishment of the orthotic clinic in July of 1982, a systematic approach to the orthotic-physical therapy needs has proven successful in providing a higher degree of function and fewer complications for these patients. The purpose of this article is to inform the reader of the appropriate orthotic involvement and the high degree of orthotic maintenance which is necessary for this type of patient. By describing the experiences of Southern Illinois University School of Medicine, it is hoped that the reader will gain a more realistic understanding of the orthotist's role in this situation. The types of orthoses run the full gambit from a simple UCB foot orthosis to a complex reciprocal gait orthosis. A consistency with these patients is that as children they develop at a normal rate. A second point with these children is the fact that without orthotic management, effective ambulation would not be possible. Higher levels of lesion necessitate a greater amount of orthotic management. When you combine an intimate fitting plastic orthosis with growth, you can understand the necessity for continuous maintenance and adjustments of their orthotic devices. A regular system of return visits is necessary. The relationship of the myodysplastic child to the orthotist is similar to that of a patient to their general practitioner. They are seen on a routine basis, unlike the medical specialists who only see a patient a limited number of times. This should be kept in mind if an orthotist is considering the possibilities of becoming involved in myodysplastic patient management. An orthotist involved with a clinical practice of scoliosis can associate the nature of their spinal practice with the ambulatory myelominengocele practice that we have developed at SIU School of Medicine. The repetition of clinic visits is very similar to that involved with scoliosis. However, there is an increase of time involvement with the child to make growth adjustments and maintain proper fitting plastic orthoses necessitated by the insensate skin in these children. If a CTLSO is improperly adjusted, it may affect the outcome of the scoliosis treatment, but it will not effect the activities of daily living of the individual. An improperly fitting RGO severely decreases function. Orthopaedic involvement with the myodysplastic child starts within the child's first few days of life. There is a high incidence of associated scoliosis, kyphosis, hip dysplasia and clubfoot deformities. Therefore, the infant must be continuously monitored. If any of these conditions exist, early orthotic intervention may be used effectively. Maintenance devices such as the Pavlik harnesses, thermoplastic TLSOs, and serial casting for clubfeet have all been used effectively. When the child reaches nine months of age, plans for ambulation are considered. If a resistant clubfoot exists, it is dealt with by surgical intervention at this time. A one stage Turco<a></a> procedure is accomplished with post surgical maintenance in an ankle-foot orthosis.<a></a> During this time period, if a dysplastic hip is also prevalent, bilateral molded knee orthoses connected with a spreader bar to maintain the hip in abduction and internal rotation are used. Since the ninth month is the milestone period for standing in the normal child, use of a parapodium<a></a> is considered. Because of the growth spurts which normally occur during this same time period, consistent monitoring of applied devices is necessary. The ankle-foot orthoses must not impinge on either the calcaneous, navicular or metatarsal heads. Proper knee and hip locations in both the knee orthoses and the parapodium must be checked. Children in these devices should return to the clinic or the orthotist every three months. Since the development of the reciprocal gait orthoses,<a></a> children with a thoracic level mye-lominengocele are now candidates for ambulation. This is only possible with aggressive orthopaedic and physical therapy management. Full range of motion of the paralyzed extremities and prevention of flexion contractures of the hip, knee, and ankle is necessary if effective use of the reciprocal gait orthosis is expected. If a dislocated hip exists unilaterally, which would impede the function of the orthosis, surgical intervention would be necessary prior to use of the RGO. Our experience has shown that twenty-four months of cognitive development is the ideal time frame for training of the reciprocal gait orthosis and fitting thereof. Prior to this milestone, communication with the child and the necessity of multiple adjustments to the orthosis limits the effectiveness of the RGO. Once it is determined that a child is a candidate for reciprocal gait ambulation, an extensive physical therapy program is initiated to improve upper extremity strength and increase standing balance. When the child is initially fitted with an orthosis, it is left in the adjustable state as recommended by the development team at Louisiana State University. Extensive post-fitting physical therapy is necessary. During the first week of physical therapy the orthotist repeatedly checks the device so that optimum orthotic ambulation can be achieved. Subtle adjustments of the cable housing length and hip joint locations can mean a difference between an ambulator and a nonambulator. After one month's use of the reciprocal gait orthosis, the correct location of the hip joints and cable should become evident. At that time the hip joints and knee joints can be attached on a more permanent basis. Because of the necessity of numerous adjustments on a growing child, screws instead of rivets are used. High strength Loctite® is used to prevent loosening of the screws. The child returns to the orthotic clinic one month after permanent attachment of the side bars to the RGO. Subsequent to that visit the child is seen every two months for the first five months. Thereafter return visits are decreased to four times a year. The physical therapy routine also diminishes as independence in use of assistance devices is decreased. Initially the child is seen on a daily basis for two weeks. Thereafter, a weekly therapy program is established. As the child progresses from parallel bars, to walker, to forearm crutches, it is no longer necessary to maintain a continuing outpatient physical therapy treatment. Parents and teachers have successfully been taught to monitor the fit of the devices and the ambulatory status of the patient. Periodic physical therapy evaluation for gait deviation prevention is all that is necessary. Growth adjustments and routine maintenance of both the reciprocal gait orthosis and parapodium are accomplished at approximately four month intervals. The use of the pop rivets on the parapodium, make it a relatively easy task to increase the distance between the floor and knee and hip centers. Increases up to one inch between each joint center can be accomplished before the tubular structures of the parapodium must be replaced. Since children are removed from the parapodium at age two, it is only necessary to maintain one size in stock. Because of the presence of static hip and knee joints in the parapodium, the exact alignment of anatomical/mechanical joint centers is not critical for standing. However, if the joint assemblies are extremely malaligned, they will cause impingement during seating. Because of the relative newness of the program, the first child fitted with the RGO has not had to have a replacement of any major component of the orthosis. However, since we are approaching the twenty-month time period, it appears that future replacement of the plastic sections of the KAFOs will be necessary. A review of the adjustments made for growth indicates that the first length corrections were between the knee centers and the ankles. Subsequent growth adjustments were made between the hips and the knees to improve seating comfort. Seating discomfort seems to be the first indicator of improper positioning of the hip joints. Maintenance of the devices have included replacement of Velcro® straps because of wear, replacement of the anterior cable due to breakage at the point of connection between the cable and connector to the hip joint, and the replacement of two thrust bearings in one hip joint. One child also has had the metal pelvic band increased in diameter secondary to pelvic growth. Although the metal pelvic band makes the orthosis heavier and cannot be as form-fitted as the thermoplastic pelvic section, it does have allowance for pelvic widening. In cases of pelvic obliquity, lumbar scoliosis, or lumbar kyphosis, a thermoplastic pelvic section is mandatory. There have been no increases in the maintenance of the thermoplastic versus the metal pelvic band. Because of longitudinal growth between the calcaneous and the malleoli, several of the children needed adjustments in the malleoli area of the ankle-foot section of the orthosis. This is accomplished by localized heating and expansion of the carbon inserts and the polypropylene material. Care should be taken not to overheat the materials. Initial assessment of the ambulatory program for thoracic level myelominengocele children at SIU has been favorable. All parties concerned-the clinic team, the parents, the funding agencies and the children themselves- seem to have accepted the program quite readily. Objective data cannot be determined on such a short range program. Only until such time as multiple years of experience has been gained in several centers will the determination of the cost/benefit ratio prove the worthiness of this program. Subjectively, however, the children seem to be much better off than they would be otherwise. In our own program, four children with spina bifida are in the pre-parapodium stage (younger than nine months). Seven children are in the preambulatory, parapodium stage of growth development. Two children are awaiting fitting of their orthoses pending authorization from state funding agencies. Eight children have been fitted with the reciprocal gait orthoses with wearing time ranging from twenty months to one month duration. Each of these children are followed on a three-month basis by the clinic team with subsequent visits to the orthotist for adjustments. No major deformities or pressure sores have developed on the children who are in the program during this time period. Urinary tract infections and stress fractures have been reduced in the patients fitted with the reciprocal gait orthoses, although every child in the program has had at least one long bone stress fracture prior to being fitted with the reciprocal gait orthoses. In summary, we have shown at SIU School of Medicine that a comprehensive team approach to myelomeningocele should include a program of ambulation for the thoracic level myodysplastic child. With a routine return visit program and follow-up adjustments on the orthotic devices, no major complications have arisen in the system. The use of pop rivets on the parapo-diums, and screws for attachment of side bars on the reciprocal gait orthoses, have contributed to the ready availability of adjustments to the devices. Although there are increases in time constraints involved in dealing with this severe level of disability, the program has subjectively proven to all concerned that this present technique for spina bifida management has proven successful. <h3>Acknowledgments</h3> The author wishes to thank Roy Douglas, C.R, and Carlton Filiauer, C.P.O., for their development of the RGO, and to acknowledge Barbara Sullivan, R.P.T., and John M. Mazur, M.D., for their assistance in the development of our program at Southern Illinois University School of Medicine. The assistance of Melenie Boiser in preparing the manuscript for this article is also acknowledged. References: <ol> <li>Turco, D.J., "Resistant congenital clubfoot (1979), A one-stage posterior medial release with internal fixation: a folio wup report of 15 year experience." Journal of Bone and Joint Surgery, 61A:805- 814.</li> <li>Supan, T.S., Mazur, J.M., and Johnson, B.S., "Postsurgical Orthotic Management of Resistant Clubfoot," 1984, AAOP National Seminar, Orlando, Florida, to be submitted for publication.</li> <li><a href="http://www.oandplibrary.org/al/1971_02_036.asp">Motlock, W., "The parapodium: an orthotic device for neuromuscular disorders." Artificial Limbs, 15, 13-17, 1971.</a></li> <li>Larson, Paul and Douglas, Roy, L.S.U. Reciprocating Gait Orthosis, Durr-Fillauer Medical, Inc., Chattanooga, TN, 25, 1983.</li> <li>Yngve, David, Douglas, Roy, and Roberts, John, "The Cable-Type Reciprocator's Gait Orthosis in Myelomeningocele," Developmental Medicine and Child Neurology, 25:116-117, 1983.</li> </ol> <div style="width: 400px;">*Terry J. Supan, C.P.O. Instructor, Division of Orthopaedics and Rehabilitation, Prosthetic/Orthotic Services, Dept. of Surgery, Southern Illinois University, School of Medicine, P.O. Box 39265, Springfield, Illinois 62708. </div> <div style="width: 400px;"></div> Page Number(s) 12 - 14 Year 1984 Volume 8 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Orthotic Maintenance Program for the Myodysplastic Child Creator An entity primarily responsible for making the resource Terry J. Supan, C.P.O. * https://staging.drfop.org/files/original/e2c61c59f3027ddb38ee4b0cad58918d.pdf 4858353a3eb0b95867caf9f1b1f0c2c5 https://staging.drfop.org/files/original/72d955fc50fde2bd2b5b4b1b61fa890d.jpg d1cb7af36eaa7f8d6fd1559e80442210 https://staging.drfop.org/files/original/2e7f596162524cefe76991581bbe8944.jpg c34932f2a3cf4306da2927cccbfd11f7 https://staging.drfop.org/files/original/6c08f5085c2f2e75abf1441c0fa75629.jpg 0da2cfe04fc70164f72489961e1c2d0e https://staging.drfop.org/files/original/6fc1780773a623d6bb12e14f72ae0de1.jpg 3f220ea36778d047dc8b3721a0987cc5 https://staging.drfop.org/files/original/5121ad2531312a946139f0f9fa81398c.jpg 20a8db15337befcfaebf9f8aa41d2bfc https://staging.drfop.org/files/original/7c209157d86272c7ca4678ada3e56a6d.jpg a2425d95830f7f8591ade9da25680e2a https://staging.drfop.org/files/original/37f4302ab2b2754b3775add6ca724672.jpg 77078b8c21f4ee471eeb1c731d3709c6 https://staging.drfop.org/files/original/49e03ca05a09b28f85c4d5ec8471ad81.jpg 8b088903d6682e433d8281cdb98047f7 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_02_051.pdf Text Any textual data included in the document <h2>Orthotic Management of the Arthritic Foot</h2> <h5>C. Michael Schuch, C.P.O. <a style="text-decoration: none;">*</a></h5> With ever increasing public exposure, orthotists are being requested more frequently to confront new challenges caused by physical disability. In the spectrum of orthotic protocols, management of the arthritic foot and ankle is a relatively new challenge. During the past five years, the Department of Orthopaedics and Rehabilitation, the Division of Rheumatology, and the Division of Prosthetics and Orthotics, all of the University of Virginia Medical Center, have comprised an Arthritis Rehabilitation Research and Training Center, providing a regional referral center for arthritis patients. Orthotic services for these patients have concentrated on the foot and the ankle, and this population of patients has been substantial enough to permit the development of a consistently successful protocol of management. The intent of this paper is to review the skeletal anatomy of the ankle and foot, discuss the types of arthritis and their relative pathophysiology and clinical manifestations, and finally to present our protocol for management of the various problems presented by the arthritic foot and ankle. <h3>Review of Ankle-Foot Anatomy</h3> The skeleton of the foot consists of three groups of bones: tarsal bones, metatarsal bones, and phalanges. The tarsal bones are further divided into two groups, the first group consisting of the talus and the calcaneus, together forming the hindfoot. The talus, which is the only bone to articulate with the tibia and the fibula, acts as a rocker by which the foot as a unit can be dorsiflexed and plantarflexed at the hinge of the ankle joint. In stance, the talus receives the entire weight of the lower limb; half this weight is transmitted forward to the bones forming the arch of the foot, and half of the weight is transmitted downward to the heel or calcaneous. The calcaneus, or os calcis, is the bone of the heel. It supports the talus, withstands shock as the heel strikes the ground, and transfers forward the portion of body weight it receives from the talus. The second group of tarsals consists of the five bones anterior to the talus and the calcaneus. The navicular, cuboid, and three cuneiforms increase flexibility of the foot, particularly in its twisting movements. These bones form the longitudinal arch of the foot, and are referred to collectively as the midfoot. The five metatarsal bones lie anterior to and articulate with the second group of tarsal bones described above. Each metatarsal consists of a base, a shaft, and a head, in respective order from proximal to distal. The distal-most bones of the foot are the five phalanges, which extend from the five metatarsals and form the bones of the toes. The metatarsals and the phalanges form the forefoot. The foot has three arches: the medial, lateral, and transverse. The normal medial arch rises through the calcaneous to the head of the talus, and from this high point it descends forward through the navicular, cuneiforms, and first three metatarsal heads. The lateral arch, which is lower than the medial, extends from the calcaneus to its high point at the cuboid, and down through the fourth and fifth metatarsals. The transverse arch rises across the width of the foot between the medial and lateral borders, primarily under the metatarsal shafts. The junctions of these various groups of bones form the joints that allow the functional motions of the ankle and foot to occur. The talocrural (ankle) joint consists of the medial and lateral malleoli and the trochlear surface of the talus. This joint permits the motion of plantar-flexion and dorsiflexion. The subtalar (talocal-caneal) joint is formed by the articulation of the talus and the calcaneus, and permits the heel to share in inversion and eversion. The transverse tarsal (midtarsal) joint is not an anatomic entity, but an important functional grouping of two joints which occur anterior to the talus. These two joints, the talocalcaneonavicular and the calcaneocuboid, permit much of the inversions version of the foot. The other tarsal joints, tarsometatarsal joints, and distal joints aid in flexibility of the foot from heel strike through mid-stance, and help the foot form a rigid lever during toe-off, or the propulsion part of the gait cycle. Each of the joints of the ankle and foot, including the joints between the sesamoids and the first metatarsal are lined with synovium so that when inflammatory conditions that affect the synovium are present, the foot and ankle may show dramatic changes clinically, radio-graphically, and pathologically. <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-1.jpg">Figure 1. View of patient's feet afflicted with rheumatoid arthritis. Note, hallux valgus, claw toes, depressed longitudinal arch, and pronation or eversion at the subtalar joint.</a> <h3>Types and Pathophysiology of Arthritis</h3> While there are a half dozen or more differing types of arthritis,<a></a> we will limit our discussion to the types that have a tendency to involve the foot and ankle. The most commonly seen and most debilitating form of arthritis is rheumatoid arthritis. Rheumatoid Arthritis Rheumatoid arthritis is an inflammatory condition of unknown etiology that primarily affects the synovial lining of joints, tendons, and bursae. Secondarily, it may cause destruction to cartilage, bone, ligaments, and other soft tissue. Most people with rheumatoid arthritis have some degree of foot and/or ankle involvement.<a></a> The joints of the feet are initially involved more often than the joints of the hands.<a></a> Vaino showed that more than 88% of adults and 69% of children with rheumatoid arthritis have involvement of the feet during some phase of the disease.<a></a> Guerra states that the earliest sign of rheumatoid arthritis is congestion of the synovial membranes with edema.<a></a> As the synovial inflammatory tissue and fluid within the joint accumulate, there is swelling of the soft tissue, and decreased range of motion of the joint. The inflamed synovium adjacent to the marginal bare areas causes destruction of bone, resulting in bony erosion at the margins. Because the inflamed synovium, known as the pannus, also proliferates, expansion occurs over the cartilage and destroys the cartilage through enzymatic action, producing symmetrical joint space narrowing. The pannus may also penetrate the unprotected bare bone and cause destruction of the cartilage from the marrow side. The reactive hyperemia, part of the inflammatory process, is implicated in the periarticular osteoporosis and the discontinuity of the subchondral bony plate.<a></a> Joint destruction and deformities occur and become fixed as the weakened support structure of the ankle and foot gives way to the normal mechanical stresses placed upon it; changes in alignment of joints allow muscles, tendons, and ligaments that cross the joints to exert different forces, and stiffness and pain in the joints prevent mobility.<a></a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-2.jpg">Figure 2. Schematic view showing the effects of claw toes with subluxed MTP joints, resulting in metatarsal head prominences on the plantar surfaces of the foot.</a> Clinical manifestations can include all joints of the ankle-foot, collectively or individually. Ankle involvement in rheumatoid arthritis is not as common as involvement of other joints of the foot.<a></a> The clinical picture of ankle involvement is less dramatic than with the other joints, with swelling, stiffness, decreased range of motion, and pain being the indicators. Unlike the ankle, the hindfoot is often affected early in rheumatoid arthritis. The most common deformity of the hindfoot is pes plano-valgus, or more simply, valgus of the hindfoot and flattening of the longitudinal arches.<a></a> The midfoot-tarsal joints develop inflammatory changes that contribute to the pes planovalgus deformity of the hindfoot and midfoot.<a></a> In time, each of the tarsal bones seem to be equally involved, causing loss of pronation-supination and malleability of the foot in general. The forefoot shows marked abnormalities on clinical and radiologic examination. The altered forces created by hindfoot and midfoot deformities act with the inflammatory process, affecting the metatarsal-phalangeal (MTP) joints and proximal interphalangeal (PIP) joints to give the typical findings of hallux valgus, claw toes, subluxation and depression of the metatarsal-phalangeal joints, abduction of the forefoot, and splay foot. Involvement here as in other parts of the foot is symmetric and increases with disease duration.<a></a> Osteoarthritis The next most commonly seen type of arthritis to cause foot problems is osteoarthritis, or degenerative joint disease. This form of arthritis is not a systemic inflammatory disease; rather it is a disease that is secondary to the wear and tear phenomena on joints. Disruption of the cartilagenous matrix occurs as a result of enzymatic action. Large weight-bearing joints of the body are particularly prone to dysfunction. The ankle joint and the first MTP joint seem most susceptible, with weight bearing, trauma, and footwear having all been implicated as causative agents. Radiologic examination reveals asymmetric narrowing of the joint space, the areas of stress demonstrating less interosseous space.<a></a> Other Arthritis Types The arthritis patient population requiring foot orthotic management primarily falls into one of the above two categories of diagnosis. However, occasions will arise necessitating foot and or ankle management for patients with other arthritic diagnoses. The seronegative arthridities are ankylosing spondylitis, Reiter's syndrome and its variants, and psoriatic arthritis. Two additional types of arthritis that may affect the foot and/or ankle are gout and systemic lupus erythematosis. While differing in pathophysiology from rheumatoid arthritis and osteoarthritis enough to warrant separate diagnostic classification, the clinical manifestations of the ankle and foot are similar. <h3>Orthotic Designs and Indications</h3> As in all orthotic management, the scope of the problem dictates the complexity of the orthosis. We have been pleased with the simplicity of the decision making process that has been developed at the University of Virginia. Sophisticated evaluation processes are not necessary; patient communication concerning location of pain and routine physical examination of ankle-foot abnormalities are sufficient. Observation of gait irregularities usually reinforce communication/physical examination findings. Orthotic management conveniently falls into two levels of complexity: foot orthoses (FO's) and ankle-foot orthoses (AFO's). Foot Orthoses The objectives of foot orthoses for arthritic patients include, (1) maintainence and support of existing arches of the foot; (2) re-establishment of fallen arches when flexibility permits; (3) provision of inversion-eversion balance or stability; (4) distribution of weight bearing pressures; and (5) provision of soft tissue supplement. The clinical picture requiring this level of orthotic management can range from mild longitudinal arch depression with callous formation under the metatarsal heads to severe loss of the longitudinal arches, medial drift of the talocalcaneonavicular joint complex, subluxation of MTP joints with depressed and protruding metatarsal heads, hallux valgus, and claw deformities of the phalanges. Traditional foot orthoses for this type of clinical picture have been Plastizote® inserts, molded directly to the patient's foot. However, Plastizote® is not durable; it packs down quickly with wear. The more severe the deformity, the quicker the material loses its integrity and ability to meet the objectives of foot orthoses as described above. Occasionally, arthritic patients have presented or reported being fit with rigid foot orthoses, fabricated of Nyloplex (Rohadur), usually provided by podiatrists. While this material selection and orthotic design are ideal for many cases, we have found it to be highly unsuccessful with arthritic patients to the point that we consider rigid foot orthotics contraindicated for this patient population. Our experience has shown that this type of orthosis lacks the flexibility and soft tissue supplement necessary to promote acceptance by patients with arthritis. The choice of materials and design for arthritic foot orthoses at the University of Virginia has been PVC-Pelite™ foot orthoses, molded over positive models of the patient's foot or feet. <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-3.jpg">Figure 3. View showing left foot impression taken in foam foot impression block. Note "X" identifying metatarsal head prominence.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-4.jpg">Figure 4. Foot impression filled with molding plaster forming a positive model of the patient's foot.</a> Description of Technique Negative impressions of the patient's feet are obtained using any of the commercially available foam impression blocks. This impression is taken with the patient seated, to capture the shape of the existing arches at their maximum height, free of weight-bearing loads. Care should be taken to balance inversion-eversion as the foot is pressed into the foam. Positive models are obtained in the conventional manner by pouring molding plaster into the impression forms. Modification of the positive model is necessary to meet the objectives of foot orthoses for arthritic patients as discussed above. The longitudinal arch is increased mildly, especially posteriorly, as proposed by Carlson, et al., in their technique for modification of the UCB foot orthosis.<a></a> This modification meets the objectives of maintenance and support of existing arches, provision of eversion or valgus stability, and distribution of weight bearing forces. The metatarsal or transverse arch modification is perhaps most important, and the degree of this modification in terms of size and depth parallels the severity of MTP subluxation and metatarsal head depression. It is frequently greater than 1/2" in depth. The shape of this modification should simulate that of prefabricated rubber metatarsal pads, which are commercially available in varying sizes and depths. Proper placement of this modification is critical; when an existing transverse arch can be identified, it should be exaggerated. If there is no identifiable transverse arch, the modification for this arch in the positive model falls under the metatarsal shafts, with the dome or apex of the plaster removal just posterior to the metatarsal heads, and the proximal edges blending gradually into the longitudinal arches. This modification provides support to uplift the depressed metatarsal heads and reduce trauma at the push-off phase of the gait cycle. It also meets the objectives of maintenance and support of existing arches in some cases, re-establishment of fallen arches in other cases, and better distribution of weight-bearing loads. The final modification to the positive model includes adding plaster to the plantar aspect of the PIP joints of the phalanges, which aids in providing a smooth transition from the MTP to the phalangeal area of the foot orthosis. The positive model is now complete and ready for molding of the base material, PVC Pelite™, which is available in 4' square sheets, 1/8" thick. PVC Pelite™ is ideal for foot orthoses because: (1) the PVC laminate (vinyl covering) assists the Pelite™ in maintaining its desired shape after heat molding; (2) the PVC laminate provides strength and durability, decreasing and even eliminating incidences of the Pelite™ packing down, and (3) the PVC laminate consists of closed cells and is waterproof, which makes it easy to clean and discourages the growth of bacteria and fungus. The size of the PVC Pelite™ sheet to be molded over the positive model is determined by closely tracing the positive model onto the PVC Pelite™ and allowing extra material to cover the longitudinal arch and extra material beyond the phalanges. Care should be taken to closely trace the lateral and posterior aspects of the positive model, because excess material here makes molding or vacuum forming more difficult, frequently resulting in bunching or folding of the material and, thus, an unacceptable orthosis. Heating the PVC Pelite™ sheet can take place in an oven, an electric skillet, or with a heat gun. The vinyl covering of PVC Pelite™ should not be subjected to high heat or heated directly since it can delaminate under these conditions and develop bubbles or blisters. When sufficiently pliable and moldable from the heat, the PVC Pelite™ sheet is molded in place over the plantar surface of the positive model using any of the following techniques: <ol> <li> Wrapping the PVC Pelite™ in place around the positive model with an elastic bandage. </li> <li> Vacuum formed in place using a vacuum hose placed inside a small airtight plastic bag. </li> <li> Vacuum formed in place using a commercially available foot orthosis vacuum-forming machine. </li> </ol> <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-5.jpg">Figure 5. Positive models of patient's feet, plantar surface facing up. Note identification of transverse (metatarsal) arch and prominent metatarsal heads.</a> <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-6.jpg">Figure 6. Molded PVC-Pelite™ foot orthosis, with longitudinal and metatarsal arch support.</a> Once the PVC Pelite™ is molded in place and cooled sufficiently for the molded shape to be maintained, a sheet of 1/2" thick medium density Pelite™ is cut to fill the transverse and longitudinal arch areas as a single piece. (To save time we have these precut in large numbers to a single large size that can be trimmed to fit a given positive mold.) This piece of 1/2" medium density Pelite™ is heated to a moldable state using oven, skillet, or heat gun, and is then molded or vacuum formed in place as was the PVC Pelite™. When sufficiently cooled, it is glued in place using Polyadhesive and sanded to a feather edge so that it will blend with the PVC Pelite™. Additional modifications to this PVC Pelite™ foot orthosis design may include either of the following: <ol> <li> For increased soft tissue supplement and shock absorption, 1/8" PPT can be glued to the bottom surface of the PVC Pelite™ foot orthosis. </li> <li> For maximum soft tissue supplement in cases of severe metatarsal head protrusion, nylon lined 1/8" PPT may be glued on top of PVC Pelite™ foot orthosis. </li> </ol> Either modification will require greater depth within the patient's shoes. With or without the above modifications, final shaping and fitting are done to the patient and his shoes. An additional point worthy of mention: soft tissue supplement, weight bearing pressure distribution, metatarsal head pain relief, and other plantar surface objectives can be attained with this foot orthosis system regardless of shoe integrity. However, when the objective is control of the inversion-eversion (varus-valgus) balance in the foot, or maintenance, support, or re-establishment of the longitudinal arch, the shoes become an adjunct to the foot orthosis and thus must have a firm heel counter with good integrity along the medial aspect of the longitudinal arch. <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-7.jpg">Figure 7. Rheumatoid arthritis patient wearing right molded, rigid copolymer AFO and left molded, weight-bearing, bivalve, rigid AFO.</a> Ankle Foot Orthoses Although somewhat rare compared to the numbers of patients we have encountered requiring foot orthotic management, there are those arthritics with severe enough involvement to warrant a higher level orthosis. The typical picture requiring AFO management is pain, swelling, and decreased range of motion located in the ankle (talocrural) joint, with frequent moderate to severe pes planus and subtalar (talocalcaneal) erosion. Although rheumatoid arthritis patients dominate this type of patient population, it is not unusual for patients with osteoarthritis to present at this level. Again, severity of involvement dictates the complexity of the orthosis. We have used two types or designs of AFO's in our management of these kinds of problems: rigid, molded plastic AFO's and bivalved, weight bearing, rigid, molded plastic AFO's (also known as PTB AFO's or axial load resist AFO's.) The distinction between the two is quite simple. When pain in the ankle or subtalar joint is due to the forces of walking or movement, i.e. if the normal movements of the ankle-subtalar complex in the course of walking causes or increases pain, yet standing stationary is comfortable and pain-free, the only need is elimination of motion which can be provided by a rigid, molded AFO. When pain is experienced in both standing and ambulation, the goals are to redistribute weight-bearing loads by reducing the amount of weight to be borne through the diseased ankle-foot complex and to eliminate range of motion. These objectives can be met with a bivalved, weight-bearing, rigid, molded AFO. As standard AFO's are commonplace items in any orthotic practice, detailed discussion in this context serves no purpose. However, the need for rigidity should be emphasized. The lower vertical trimlines need to be anterior to the malleoli, and carbon composite inserts can be used if necessary. Our chosen design for bivalved, weight bearing, rigid, molded AFO's is that described by Wilson, Stills, and Pritham<a></a> with the addition of a higher posterior trimline in the popliteal area, similar to that in a below-knee prosthesis. The reduction in the range of knee flexion as a result of this higher posterior trim is a minor sacrifice for a major gain in reduction in pain. We purposely try to avoid the use of the term PTB orthosis because of its erroneous weight-bearing implications. The patella tendon is identified by mild modification of the positive model in this anatomical region, similar to but much less aggressive than in a so called "PTB" prothesis. However, there is little concentrated weight-bearing in this area; the goal of weight-bearing is equal distribution throughout the entire part of the lower leg contained within the orthosis. Perhaps the most accurate prosthetic acronym describing the weight-bearing goals of the bivalved, weight-bearing, rigid, molded AFO, is the "total surface bearing" concept. In the case of an intact lower limb as is encountered in orthotics, modification of the term "to maximum surface bearing" seems appropriate. None of our patients requiring rigid AFO's has required SACH (solid-ankle cushion-heel) and rocker sole shoe modifications. We do recommend the use of shoes with soft soles constructed of Vibram® or crepe. <h3>Shoes for Arthritic Patients</h3> Proper shoes are a vital component of orthotic management of the arthritic foot. As was stated earlier, some foot orthotic objectives can be attained with shoes of poor quality or integrity. However, properly designed and fitted shoes can only enhance the best designed and fabricated foot or ankle-foot orthoses. Our large arthritic patient population at the University of Virginia has allowed us to recommend and fit a wide variety of accommodative shoes. As we gained experience, it became apparent that we could rely on a minimum inventory of shoe types or designs. I refrain from the use of the descriptor "style" because there may be several "styles" available within a shoe design category. The categories of "design" that I refer to could be listed and described as follows: <ol> <li> Thermo adjustable shoes </li> <li> Extra depth shoes </li> <li> Running shoes. </li> </ol> Thermo Adjustable Shoes <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-8.jpg">Figure 8. View of various shoes useful in the management of patients with arthritis affecting the feet and ankles.</a> This shoe type or design is made primarily of Dermaplast®, which is a heat shrinkable Plastizote®. Known as Apex Ambulators®, there are two styles available: #1201, the simplest and most accommodative, and #1273, a more cosmetic version of the first style. Style #1201 is of black Dermaplast™ with a thin outer fabric covering, crepe wedge soles, Velcro® lap closure (eases donning for those arthritics with hand involvement), and removable Plastizote® insole. There is no heel counter reinforcement. The indications for this type of shoe is last resort, severe deformities, especially in the dorsal aspect of the foot, that are difficult or impossible to accommodate in shoes of firmer and less adjustable materials. Examples of such deformities are severe hammer toes, severe hallux valgus, and/or nodules on the dorsum of the feet or toes. This shoe is fitted slightly large and then heated while on the patient's foot (with protection by socks, of course). The application of heat causes the Dermaplast® to shrink and mold to the patient's foot shape, thus accommodating the severe deformity. The shoe upper material of Plastizote® and fabric is very soft and forgiving to such deformities. In all cases, we replace the removable Plastizote® insoles with molded PVC-Pelite™ foot orthoses. The other style of Apex Ambulators® thermo adjustable shoes, #1273, is very similar to that described above. The major difference is the outer covering of the uppers, which in this second style is thin, pliable leather. This shoe is more cosmetically appealing to most patients because the leather uppers allow the choice of four colors, (the catalogue number varies with color variations). It has slightly more integrity than the #1201 style, including a moderately reinforced heel counter. It also has a removable tongue, which is secured in place with Velcro®, a feature that enhances its adjustability. It is available with either lace or Velcro® loop back closure. Accommodation of deformities can be accomplished either by heating and shrinking a loose fit as with the #1201's above or by fitting the shoes to the proper size and then stretching the uppers with shoe stretching tools over areas of deformity. Extra Depth Shoes Extra Depth® shoes are offered by several manufacturers and provide greater depth throughout the entire shoe. This depth is ideal for accommodating molded foot or ankle foot orthoses designed for arthritic foot deformities. Extra depth shoes, like molded AFO's, are a familiar item in any orthotic practice, and therefore do not necessitate detailed discussion. However, there are two important considerations regarding their application to arthritic patients: (1) the shoe style selected should be made of very soft leather, preferably calfskin or deerskin, as these leathers are most easily spot stretched to accommodate deformities, and are the most forgiving to areas of inflammation; (2) adequate width in the forefoot or toebox of the shoe cannot be overemphasized. The extra depth shoes that we recommend for our arthritic patients are manufactured and distributed by Alden Shoe Company and P.W. Minor. The designs and styles vary in leather utilized, closure (lace or Velcro®), and amount of heel counter reinforcement. All have soft crepe soles and uppers that can be modified for deformities with relative ease using shoe stretching tools and equipment. Running Shoes Running or jogging shoes should be familiar to orthotists and patients alike. Their application to patients with arthritic foot problems stem from three of their characteristics: (1) they are acceptable to many patients who do not accept the "lack of style" of other appropriate shoes; (2) most utilize separate, removable insoles, which when removed, allow adequate room for use of molded foot or ankle foot orthoses; and (3) most are very light in weight. Problems we have encountered with running shoes include seams in the dorsal aspect of the toe box, making spot stretching difficult or impossible, and construction of vinyl or other synthetic materials which also make stretching difficult or less successful. <h3>Conclusion and Results</h3> An experience based protocol for orthotic management of the arthritic foot has been described. This experience is based on over 300 arthritic patients who required orthotic management by our service since 1985. Seven patients have been fit with eight bivalve, weight-bearing rigid, molded AFO's (one bilateral). One of these seven patients benefitted from a rigid, molded AFO on his lesser involved lower extremity. The remaining patients have been managed with custom molded PVC Pelite™ foot orthoses. Many of the patients fit with PVC Pelite™ foot orthoses were successfully converted from direct molded Plastizote® shoe inserts. Through routine follow up and chart reviews, we have found less than a three percent rejection rate; more important, we have found more active patients who enjoy a better quality of life. <h3>Appendix</h3> Alden Shoe Company, Taunton Street, P.O. Box 617, Middleborough, Massachusetts 02346. Apex Ambulators, Apex Foot Products, 330 Phillips Avenue, S. Hackensack, New Jersey 07606. PPT, The Langer Biomechanics Group, 21 East Industry Court, Deer Park, New York 11729. PVC Pelite™, Durr-Fillauer Medical, Inc., Orthopedic Division, P.O. Box 5189, Chattanooga, Tennessee 37406. P.W. Minor Extra Depth Shoe Co., 3 Treadeasy Avenue, Batavia, New York 14020. References: <ol> <li>Carlson, J. Martin, and Gene Berglund, "An Effective Orthotic Design for Controlling the Unstable Subtalar Joint," Orthotics and Prosthetics, 33:1, March, 1979, pp. 39-49.</li> <li>Guerra, J. and D. Resnick, "Arthridities Affecting the Foot and Ankle-Pathology and Treatment. The Relationship Between Foot and Ankle Deformity and Disease Duration in Fifty Patients," Foot and Ankle, 2:6, 1982, pp. 325-331.</li> <li>Portwood, Margaret M., "The Foot and Ankle in Rheumatic Disorders," Principles of Physical Medicine and Rehabilitation in the Musculoskeletal Diseases, Grune and Stratton, 1986, Chapter 19, pp. 489-513.</li> <li>Short, C.L., W. Bauer, W.E. Reynolds, In Rheumatic Arthritis, Harvard University Press, Cambridge, 1957, pp. 194-195.</li> <li>Tillman, K., The Rheumatic Foot: Diagnosis, Pathomechanics, and Treatment, Stuttgart, Georg Thieme Publishers, Boston, PSG Publishing Co., 1979, pp. 3-61.</li> <li>Vaino, K., "The Rheumatoid Foot: A Clinical Study With Pathologic and Roentgenological Comments," Ann. Chir. Gynaecol. 45 (Suppl), 1956, pp. 1-107.</li> <li>Wilson, A. Bennett, Jr., David Condie, Charles Pritham, and Melvin Stills, Lower-Limb Orthotics, A Manual, First Edition, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Temple University, Drexel University.</li> </ol> *C. Michael Schuch, C.P.O. C. Michael Schuch, C.P.O., is an Assistant Professor in Orthopaedics and Rehabilitation and Associate Director of Prosthetics, Orthotics, and Rehabilitation Engineering Services at the University of Virginia Medical Center, Box 467, Charlottesville, Virginia 22908. Page Number(s) 51 - 60 Year 1988 Volume 12 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-7.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-8.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Orthotic Management of the Arthritic Foot Creator An entity primarily responsible for making the resource C. Michael Schuch, C.P.O. * https://staging.drfop.org/files/original/1191469674a4152e921228b656aa1dfe.pdf d08f2c16efeb47cb114ce1f919ffdaed 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_04_210.pdf Text Any textual data included in the document <h2>Orthotic Management of the Surgically Stabilized Spine in Quadriplegic and Paraplegic Patients</h2> <h5>Michael MacMillan, M.D. <a style="text-decoration: none;">*</a> E. Shannon Stauffer, M.D. <a style="text-decoration: none;">*</a> Daryl G. Barth, C.P.O. <a style="text-decoration: none;">*</a></h5> Recent developments in the diagnosis and understanding of spinal dysfunction have affected both surgical and orthotic management of post-traumatic spine instability. The diagnosis of spinal instability has been clarified by clinical study of its natural history and by application of advanced imaging techniques.<a></a> Biomechanical studies have defined the role of each vertebral component in maintaining structural stability.<a></a> Surgical techniques and instrumentation for treating this problem have also evolved rapidly. These advances have resulted in an improved approach toward operative management of spinal instability. First, because the outcome of spinal injury can be more accurately predicted, surgery can be elected earlier for disorders that certainly would fail with nonoperative management. Surgery systems are available which maximize their effect in both obtaining and maintaining optimal spine positions. These reliable instruments have allowed surgeons to apply operative stabilization to a wider range of spine problems. Therefore, the orthotist is presented with an increasing number of patients who have undergone surgical stabilization and require postoperative immobilization. The purpose of this paper is to review the rationale for surgical treatment of traumatic spine disorders. This review will identify both the neurological and mechanical factors which must be addressed. Some of the instrumentation systems available and a few of their advantages and disadvantages will be examined. Finally, five separate areas of the spine will be identified and the special orthotic considerations in each region reviewed. The primary concern in all injuries to the spine is the neurologic status of the patient. There are three general categories of neurologic injury for which reduction and stabilization of the spine improves recovery.<a></a> The first group includes the Brown-Sequard, anterior cord, and posterior cord syndromes. These are collectively known as incomplete cord syndromes. Stabilization of the spine in the presence of these lesions can significantly improve neurologic recovery in a majority of cases. The second class of neurologic injury which is benefited by stabilization is nerve root compression at the cervical level. The recovery of a single nerve root at the cervical level dramatically improves the function of the patient for the rest of his life. This recovery can be facilitated by stabilization. The final lesion helped by internal fixation is the progressive neurological deficit. Often motion at a site of neurologic damage aggravates the injury. Surgical stabilization can reduce irritation and promote recovery. Thus, irrespective of the integrity of the spine, surgery can be indicated for neurologic conditions alone. However, loss of structural integrity can itself be an indication of operative treatment. If an area of bony disruption has resulted in significant deformity or has compromised the spine's ability to resist further deformity, surgical stabilization may be indicated. Authors have established guidelines for angulations and displacements to define this instability, but in all cases the final diagnosis of instability is largely clinical.<a></a> Pain at an area of compromised stability may also be an indication to reduce and stabilize a lesion. However, again the final determination is made on clinical grounds. If internal fixation of the spine is indicated, the subsequent step is the selection of an instrumentation system and postoperative immobilization method for that patient. In dealing with quadriplegic and paraplegic patients, a major concern is skin insensitivity. Although postoperative cast immobilization provides the most rigid support and protection, it also presents the highest risk for skin and wound complications. It is generally agreed that orthoses which can be removed once or twice a day for skin inspection are best suited for neurologically impaired individuals.<a></a> The dilemma the surgeon faces is how to mobilize the patient as soon as possible after surgery, yet not use the rigid protection of casts. The solution to this problem has been the development of more rigid internal fixation systems for the spine. Ultimately, the characteristics of the spinal column disruption determines the choice of instrumentation. Flexion, compression, and distraction are the three major mechanisms of spinal injury. Rarely does one force occur totally independent of the others. Usually one force is predominant with variable effect of the other two. The instability resulting from each of these forces, the instrument techniques used to counteract each of the deforming forces, and finally how the postoperative orthosis is also used to counter the mechanism of injury will be discussed. Fractures which result primarily from flexion often involve crushing of the vertebral body anteriorly and distraction of the posterior elements. Generally speaking, instrumentation systems to correct this problem rely on three-point bending to reduce the fracture and maintain position. The Harrington system uses a single hook at either end of a rod to effect leverage against the kyphus and create an extension force. A long rod is required for this, so that excessive force is not generated under the single hook. In order to shorten the length of the rod and improve fixation, other systems have developed methods for attaching the rod to every segment over which it passes. The Luque, Wisconsin, and Cotrel-Dubosset instruments are examples of this segmental type fixation. These systems have three advantages over Harrington rods. By fixing the rod to each segment over which it passes, the large leverage force necessary to reduce the deformity is evenly distributed over several segments. This reduces pull-out failure. Because this force is distributed evenly, it is possible to reduce the total number of segments stabilized by the rod, thus preserving spinal motion segments. And finally, these segmental fixation systems are significantly more stable, which helps promote bony fusion of the injured segment. Another method of obtaining three-point reduction while improving instrument fixation is the use of transpedicular screws for placement of the hardware. This system uses a short plate placed over the vertex of the kyphus, and then screws placed through the plate are firmly anchored to the uninjured vertebra above-and-below the fracture. As the screws are tightened, the kyphus is slowly reduced. These devices involve the least number of normal vertebral segments to achieve reduction. They are exemplified by Steffee and Roy-Camille plates. The segmentally fixed rods and transpedicu-larly anchored plates described above have excellent immediate stability. The major requirement of the postoperative orthosis is to reduce the stress on the implant by preventing repetitive forward bending of the patient. Orthotic requirements for Harrington rods systems are more demanding. With only single hook attachment, Harrington rods require an orthosis which generates a supplementary three-point bending force to reduce the possibility of hook pull-out. Because there are multiple unfixed segments where fusion is expected to occur, postoperative mobilization should be rigid enough to prevent non-unions from rotation and side-bending movements. In fractures where axial compression is the major deformity, the vertebral body can burst both anteriorly and posteriorly. To reduce the fracture, an instrumentation system capable of distracting vertebral segments is chosen. Again, Harrington rods can be used in this situation. They have a hook in one end that can be ratcheted against the rod to distract and pull apart the segments above and below the crushed vertebra. Segmental wiring alone is ineffective in reducing vertebral body burst fractures. However, many surgeons first use Harrington rods to counteract the compressive force, then use wires attached to the rod at every level to get the advantages of segmental wiring. This combination is lightly referred to as "Harri Luque." Plates anchored to the spine with transpedicular screws are incapable of generating a distracting force. An experimental Swiss system attaches a threaded distractor to the spine with screws and can be used to distract burst-type fractures. Orthoses cannot effectively counteract an axial load, or the results of the compressive mechanism of injury. Therefore, the orthosis is used exclusively to protect the implants from stress while the bone graft is consolidating. Again, the orthosis is most clearly indicated when Harrington rods are the only instruments maintaining the reduction. These single hook rods are subject to dislodgement if excessive bending or torsional forces are encountered. The loss of structural integrity resulting from distraction injuries has different implications in the diagnosis and treatment of this instability. While flexion and compression forces generally cause anterior bony collapse, distraction injuries tend to cause posterior ligament disruption. Since the injury is a traumatic tearing of ligaments and discs, the instrumentation is used to compress or pull the separated segments together. In the thoracolumbar spine, hooks enclose the vertebrae above and below the site of injury and are connected by a threaded rod. Turning of the rod slowly approximates the hooks and reduces the deformity. However, this type of injury predominantly occurs in the cervical spine. In this location, wires are usually used to draw the separated segments together. Because of the ineffectiveness of ligamentous healing, bone graft fusion is used in conjunction with internal fixation. Postoperative orthotic management in this situation is more complementary than supplementary. Whereas the internal fixation stabilizes in flexion, it offers little resistance to extension. Therefore, the orthosis should emphasize stability in extension. For the sake of completeness, orthotic management after anterior spinal decompression and fusion should also be mentioned. When this procedure is performed, most of the affected vertebra is removed and replaced with a block of iliac bone graft. Present anterior spine instrumentation uses a threaded rod attached to the spine with screws to afford stability. Control of motion in all planes by the orthosis is required in this clinical situation. The previous section dealt with the indications and techniques of spinal internal fixation, with emphasis on the role of postoperative orthotic management. Next, five regions in the spine and some specific orthotic requirements for each will be identified. Particular emphasis will be placed on whether a specific injury requires an orthosis to restrict or only to reduce intervertebral motion. When an orthosis restricts intervertebral motion, less than ten percent of normal motion is possible at that segment with the orthosis in place. An orthosis which restricts motion is used when either no or minimal internal fixation is used to provide stability. When up to 30% of motion at an intervertebral segment is possible while wearing an orthosis, the orthosis is said to only reduce intervertebral motion and not restrict it. A reduction orthosis is indicated to protect inherently stable fractures or spines internally stabilized secondary to surgery. The first anatomic area to be discussed is the upper cervical spine. In this area, instability can result from fractures of the atlas, from fractures of the odontoid process, and from disease processes such as rheumatoid arthritis and tumors. Orthoses generally are inadequate in restricting intervertebral motion between the occipito-atlanto-axial segments. Therefore, for virtually any upper cervical disorder requiring restriction of intervertebral motion, application of a halo and vest is indicated.<a></a> One possible exception is the SOMI brace, which can be used to effectively restrict instability from ruptures and attrition of the transverse ligament of the atlas.<a></a> The second anatomical area is the lower cervical spine. This extends from C3 through T1. Restriction of motion in this region is required in at least three situations. One is a flexion injury which compresses the vertebral body anteriorly and disrupts ligaments posteriorly. A second need for restriction is for extension injuries which avulse both the anterior longitudinal ligament and the intervertebral disc. A final situation is postoperative management of lower cervical fusions in which no internal fixation is used. In these situations, a cervicothoracic four-poster device should be used. If only reduction of intervertebral motion is required, then application of a Philadelphia collar is all that is necessary. The usual clinical situation needing reduction of intervertebral motion is immobilization after posterior cervical stabilization with wires. The third anatomical region lies between T3 and T10. The thoracic region possesses the most inherent stability of the entire spine. For this reason, the bracing requirements are minimal. If no internal fixation is performed, the stabilization afforded by the thoracic cage need only be supplemented by a thoracolumbosacral orthosis (TLSO) to ensure maintenance of position. Segmental type operative fixation is especially suited for the thoracic spine. When this is performed, often no postoperative orthosis is required. Postoperative immobilization is still required in the thoracic spine when Harrington instrumentation is employed. In the fourth region, the thoracolumbar junction, the use of orthotic management is dependent on whether or not surgical stabilization is performed and if so, which instruments are used. In this area, from T11 through L3, the typical fracture occurs from a combination of flexion and compression forces and is termed a "burst" fracture. Nonoperative management of this lesion relies on bracing to create an extension moment to reduce the amount of collapse during healing. Operative treatment has a combined goal: to reduce and hold the fractured segments while leaving mobile as many normal lumbar segments as possible. For this reason either segmentally attached rods or transpedic-ularly applied plates are used in this area. Since these systems possess significant inherent stability, the TLSO provides effective postoperative immobilization. This orthosis has been demonstrated to be effective for the upper lumbar spine.<a></a> The final anatomical area, the lumbosacral spine including L4, is least subject to traumatic fractures. It does, however, present some interesting challenges to obtaining effective immobilization. Operative treatment in this area should also preserve as many mobile lumbar segments as possible. With L4 fractures, the lumbosacral articulation can often be maintained. However, the more rare L5 fractures usually require fusion to the sacrum. Because of the need for short but extremely rigid spinal instrumentation, systems using transpedicular fixation are favored for lumbosacral fusions. Although this fixation method is rigid, the high stresses at the lumbosacral junction dictate that external immobilization be used, especially if two level fusions are attempted. The TLSO has almost no ability to immobilize the lumbosacral motion segment. Therefore, the use of a one-half spica cast is recommended for use after lumbosacral surgery.<a></a> In summary, the role of orthotics in the postoperative management of spinal instability is critical. Because the lack of normal sensation precludes the use of casts in quadriplegics and paraplegics, the proper fabrication and application of an orthosis is essential. Knowledge of the original fractures forces, as well as an understanding of the principles of operative stabilization, can assist the orthotist in managing the postoperative immobilization of the injured spine. References: <ol> <li>Denis, F., "Spinal Stability as Defined by the Three-column Spine Concept in Acute Spinal Trauma," Clin Ortho, 189, 1984, pp. 65-76.</li> <li>Sances, A., J.B. Myklebust, D.J. Mainman, S.J. Larsen, J.F. Cusick, R.W. Jodat, The Biomechanics of Spinal Injuries. CRC Critical Reviews in Biomedical Engineering 11(1), 1984, pp. 1-65.</li> <li>Stauffer, E.S., "Neurologic Recovery Following Injuries to the Cervical Spinal Cord and Nerve Roots," Spine, 9(5), 1987, pp. 532-3.</li> <li>White, A.A., M.D. Panjabi, I. Posner, W.T. Edward, W.C. Hayes, "Spinal Stability: Evaluation and Treatment," AAOS Instructional Course Lectures Volume XXXIV. The Spine. Chapter 23. CV Mosby, St. Louis-Toronto-Princeton, 1985.</li> <li>Dickson, J.H., D.R. Harrington, W.D. Erwin, "Results of Reduction and Stabilization of the Severely Fractured Thoracic and Lumbar Spine, "J Bone and Joint Surg, 60A(6), 1978, pp. 799-805.</li> <li>Bradford, D.S., B.A. Akbarnia, R.B. Winter, E.L. Seljeskog, "Surgical Stabilization of Fracture and Fracture Dislocations of the Thoracic," Spine, 2(3), 1977, pp. 185-196.</li> <li>Johnson, R.M., D.L. Hart, E.F. Simmons, G.R. Ransby, W.O. Southwich, "Cervical Orthoses," J Bone and Joint Surg, 59A(3), pp. 332-339.</li> <li>Fidler, M.W., "The effect of four types of support on the segmental mobility of the lumbosacral spine," J Bone and Joint Surg, 65A(7), 1983, pp. 963-7.</li> </ol> *Daryl G. Barth, C.P.O. Daryl G. Barth, C.P.O., is Assistant Director of Orthotic and Prosthetic Services for the Division of Orthopaedics and Rehabilitation at Southern Illinois University School of Medicine. *E. Shannon Stauffer, M.D. E. Shannon Stauffer, M.D., is Professor of Chairman of the Division of Orthopaedics and Rehabilitation at Southern Illinois University School of Medicine. *Michael MacMillan, M.D. Michael MacMillan, M.D., has a Spinal Fellow with the Division of Orthopaedics and Rehabilitation at Southern Illinois University School of Medicine in Springfield, Illinois. Page Number(s) 210 - 214 Year 1987 Volume 11 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 Orthotic Management of the Surgically Stabilized Spine in Quadriplegic and Paraplegic Patients Creator An entity primarily responsible for making the resource Michael MacMillan, M.D. * E. Shannon Stauffer, M.D. * Daryl G. Barth, C.P.O. * https://staging.drfop.org/files/original/b3bb30209b6e347e141d9887fbe0dd84.pdf 8fe2d7fe613164fa18efa52b86f36da9 https://staging.drfop.org/files/original/5bc93a35ec2adce600c9b2fec1513009.jpg 0fe31995eb047f4d749816ffeec36e4c https://staging.drfop.org/files/original/570eebfc4bc5a5450dc2cee53a1356dd.jpg a27208224d59514e3a6eaab581dc3c90 https://staging.drfop.org/files/original/4af954f59f49c76eabdab685dc5eab40.jpg 319799db788cc6ab393c7443e79399a0 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 http://www.oandplibrary.org/cpo/pdf/1984_04_026.pdf Text Any textual data included in the document <h2>Orthotic Pelvis Control in Spina Bifida</h2> <h5>H.R. Lehneis, Ph.D., C.P.O. </h5> Control of the pelvis has been typically problematic in high level spina bifida patients due to the imbalance of motor power around the hip joint. This can be readily appreciated when one considers the differential innervation particularly of the hip flexors versus the hip extensors (Table 1). Note that the hip flexors are at least partially innervated at the L2 and L3 level, whereas the hip extensors are innervated below the L3 level. Such imbalance at the L2 and L3 level of involvement is the cause of lordosis so often seen in these patients, which is often aggravated by hip flexion contractures. Control of the pelvis and thus lordosis has been difficult with conventional designs. Table 1. Innervation of the Lower Limb <img src="/files/original/5bc93a35ec2adce600c9b2fec1513009.jpg" p="" width="469" height="684" /> In analyzing the force system required to prevent hip flexion and thus lordosis, it becomes clear that the rigid portion of the pelvic band needs to be reversed from the conventional location (<a href="/files/original/570eebfc4bc5a5450dc2cee53a1356dd.jpg">Fig. 1</a>). It should be noted that this consists of a plastic molded Subortholen panel which extends superiorly to the level of the xyphoid process. The uprights of the hip joints are attached to this panel. An anteriorly directed force is provided by a leather hammock covering the buttocks (<a href="/files/original/4af954f59f49c76eabdab685dc5eab40.jpg">Fig. 2</a>). Straps attached on each of the four corners of the hammock run through D rings, attached equi-distant above and below the orthotic hip joint center. This system has worked quite effectively in controlling lordosis since first initiated approximately five years ago. In cases where the patient presents a relatively severe hip flexion contracture, the hip joint uprights are attached to the panel by means of a single pivot placed approximately 5 cm. below the lateral trim line of the panel. By gradually tightening the straps of the buttock pad, some correction can often be achieved. The pivot allows the anterior panel to adapt to the changing angulation as correction is attempted. It should also be noted that in our practice, patients up to the age of approximately six years old are provided with solid ankles and knees since their legs are still short enough to sit through hip flexion without obstructing much of the space in front of the chair. The purpose of this is to provide the patient with maximum stability and lightweight orthoses. As the patient gains upper limb strength and mobility, knee joints with drop locks are added, usually of the lateral single bar type. Double bars are only used when the patient is relatively heavy and when there is a torsional problem in the orthosis. The ankle-foot portion of the orthosis remains of the solid ankle type to provide the largest possible base of support over which the patient's center of gravity can be maintained with a greater degree of latitude than is possible if orthotic ankle joints were to be used. <h3>Acknowledgment</h3> The assistance of Barry Gosthnian, CPO in developing the system described is gratefully acknowledged. Page Number(s) 26 - 28 Year 1984 Volume 8 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1984_04_026/1984_04_026-3.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_04_026/1984_04_026-1.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_04_026/1984_04_026-2.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 Orthotic Pelvis Control in Spina Bifida Creator An entity primarily responsible for making the resource H.R. Lehneis, Ph.D., C.P.O. https://staging.drfop.org/files/original/16eacc2e24fa11ba24117d1fb85c931c.pdf de0c0a58e9193f24569f1c879ad120b2 https://staging.drfop.org/files/original/606a6c31866c4d006f77d0445e543cae.jpg f4ab710fe6f916f4722e405866dc107d https://staging.drfop.org/files/original/91cd0ddfaca05e2bdc88e8aef7411353.jpg 7a64b2419fe01ec7ad868c5979c7bfa3 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_04_009.pdf Text Any textual data included in the document <h2>Orthotic Philosophies of Treatment</h2> <h5>Wallace Motloch, CO <a style="text-decoration: none;">*</a></h5> In situations when a medical condition places a physical limitation on a growing child, the orthotic treatment and devices are aimed at minimizing that limitation. Through the combined knowledge and skills of the orthotist, medical team, and family, as well as the child, the orthotic program maximizes that child's assets. To illustrate how the various aids and braces work within the orthotic program, one can compare the developmental milestones of a child with normal body to that of a child with spina bifida (<a href="/files/original/606a6c31866c4d006f77d0445e543cae.jpg">Fig. 1</a>). As the developmental need for sitting, crawling, and ambulating is encountered, an orthotic device is introduced to the spina bifida child who cannot accomplish these tasks well. Depending on the availability of funds and clinical resources, the orthotic care may start at infancy with the fabrication of devices for safe handling of the newborn, modifying equipment for play, bathing, and safe transportation. The orthotic involvement continues for the rest of that person's life as various braces for ambulation, support of the spine, contracture management, and general development of a lifestyle are designed and manufactured. <a href="/files/original/606a6c31866c4d006f77d0445e543cae.jpg">Figure 1</a>. Comparison of the developmental milestones of a normal child to a spina bifida child. As the children progress from one developmental milestone to another and their needs change, so must orthotic devices. Often these needs overlap, calling for a "wardrobe" of devices (<a href="/files/original/91cd0ddfaca05e2bdc88e8aef7411353.jpg">Fig. 2</a>). To illustrate this point let's imagine a person developmentally ready to crawl. To accomplish such exploration safely one will best be served by a wheeled device called a Caster Cart. While the Caster Cart is not a brace per se, it provides a vital part of the program by helping in a way that no brace or wheelchair can. It allows the child to move around safely, positions him close to the floor, allows for retrieving playthings from the floor, and it aids in "hand-free" sitting. <a href="/files/original/91cd0ddfaca05e2bdc88e8aef7411353.jpg">Figure 2</a>. Wardrobe of devices for a child who is ready to stand and ambulate (brace and walker). At the same time, the child retains a Caster Cart for exploration and Body Jacket for support of collapsing spine. Even though the Caster Cart has so many advantages, many parents are hesitant at this juncture, primarily because they imagine braces or some other bionic devices as restoring greater normalcy to their children. The orthotist must be very aware of the great pressure that drives the parents. They are desperate to do something! They are anxious to get the child into the best braces. They want to see the child up and ambulating. They want to see what it will be like—and that is the most normal behavior of any person. The orthotist must be compassionate at this point. He must know the dynamics of this situation. This is the most crucial moment in the parent-orthotist relationship; it will set the stage for many future meetings and achievements. Having seen several hundred Spina Bifida children and their parents go through this stage, personally I believe that not one but three devices are in order: a Caster Cart, Standing Brace (It should be pointed out here that the name "Standing Brace" is a misnomer as the device facilitates much more than standing), and Parallel Walker. The reason that this combination works the best is that crawling is very quickly followed by standing and ambulation. Oftentimes these are not demarcated clearly, and as the functions are accomplished, the devices continue to be used in an overlapping fashion—so why not have all three at once and let the child dictate the progress. While the actual design of braces can vary at this stage, as long as the child is upright safely and can stand "hand-free," the purpose is achieved. As the child gets older (two to three years), another crucial bracing decision has to be made. It has to be decided if the child is capable of ambulating with a reciprocal gait (one leg in front of the other) or whether he/she must ambulate by swing-to, swing-thru, or pivoting. It has been my experience that whenever possible the Reciprocal Gait Brace (Dual cable type) should be considered, as it has particular importance for the Spina Bifida person. The Reciprocating Gait Brace (RGB) is a dynamic orthosis unlike any conventional device made. It provides: <ul> <li> Standing Balance and Support: Wearers can have their hands free for activities of function while standing. </li> <li> Automatic Hip Joint Locking: This provides for ease of locking the brace with hands on crutches or walkers. </li> <li> Efficient Ambulation: Compared to conventional orthosis, RGB was tested (distance walked with same increase in heart rate) to be two to three times more efficient. This saves energy for people with muscle weakness, and for people likely to gain weight, it encourages more physical activity. </li> <li> Dynamic Hip Reciprocating: The special hip mechanism couples the hip joint motion so that flexing of one side causes forced extension of the opposite side (a mechanical hip extensor). This function facilitates walking, but in people prone to hip flexion contractures it also stretches the hip contractures with every step. </li> </ul> Around the age of ten another crucial decision comes up: the use of the wheelchair. There are many reasons for this. A few are: lack of physical strength for ambulation, cosmetic appearance and peer pressure, ease of assistance from others and general convenience of getting around. Many people with Spina Bifida find that ambulation in braces becomes quite energy consuming and that in the school setting in particular, it makes the carrying of books inconvenient. Many slowly, but surely, drift to greater use of the wheelchair. They find that their shorter stature in braces doesn't serve them as well as the sitting posture in a wheelchair. Also, it is harder for them to get help from others now that they are bigger and heavier. When need for assistance arises, say to go up ten steps, it is harder to help a brace wearer than a wheelchair rider. In any case, because many people choose a wheelchair in addition to, or instead of, braces, the orthotist stays involved in design and fabrication of special pressure sore prevention aids like contoured seat cushions and Suspension Body Jackets. Unfortunately, for many spinal cord injured teenagers and adults we do not have braces that can compete effectively with the wheelchair's efficiency and convenience. As things are, while there are a fair number of devices to choose from for the under-ten-years-old group, the choice is very limited for the older group. Much more ingenuity and research is needed to develop designs that will prove useful to the latter group. References: <ol> <li>W. Motloch, "Human Needs and Orthotic Goals for Spina Bifida Patients," Canadian Ortho-Pros., Summer 1975.</li> <li>W. Motloch, "Wardrobe Devices," Inter-Clinic Information Bulletin, January 1974.</li> <li>W. Motloch, "Crutchless Standing," Canadian Ortho-Pros., Spring 1973.</li> <li>W. Motloch, "New Items for Spina Bifida Programs," Inter-Clinic Bulletin, July 1970.</li> <li><a href="http://www.oandplibrary.org/al/1971_02_036.asp">W. Motloch, "Parapodium: an Orthotic Device for Neuro-Muscular Disorders," Artificial Limbs, Autumn 1971.</a></li> <li>W. Motloch, "Analysis of Medical Costs Associated with Healing of Pressure Sores in Adolescent Paraplegic," B.S. Thesis, University of San Francisco, February 1978.</li> <li>W. Motloch, "Seating and Positioning for the Physically Impaired," Orthotics and Prosthetics, June 1977.</li> <li>Personal communication with E. Hamilton, S. Walder, C. McLaurin, Dr. N. Carrol, and others from Ontario Crippled Children's Centre.</li> </ol> *Wallace Motloch, CO Wallace Motloch, CO is the Director of the Center for Orthotic Design, Inc. Page Number(s) 9 - 11 Year 1984 Volume 8 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1984_04_009/1984_04_009-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_04_009/1984_04_009-2.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 Orthotic Philosophies of Treatment Creator An entity primarily responsible for making the resource Wallace Motloch, CO * Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. Address 5 Redstar Road Perry Common City Birmingham Countries Served Ethiopia Phone +447539395674 Organization Type Including ID and tax status Non-profit Services Provided provision and fitting of artificial limbs, together with appropriate physiotherapy services Need I Financial Assistance URL https://opfafoundation.org/ Mission OPFA gives these individuals facing disadvantage the support they need and empower them to live happy and independent lifestyles. Independent mobility will take some of the stresses away from the patients’ families. OPFA strives to make this happen and enable disabled people to become self-reliant persons. State/Province United Kingdom Postal Code B23 5GZ Email info@opfafoundation.org Facebook Page https://www.facebook.com/opfafrica20 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 Orthotics and Prosthetics Foundation in Africa Description An account of the resource OPFA gives these individuals facing disadvantage the support they need and empower them to live happy and independent lifestyles. https://staging.drfop.org/files/original/646807426d786878263060044f860bb5.pdf a91cea6354ddf7b14de92ba2bb2c720d Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1977_04_001.pdf Text Any textual data included in the document <h2>Partial Foot Amputation</h2> <h3>Results of the Questionnaire Survey</h3> There were fifteen replies by mail to the questionnaire on management of patients with partial foot amputation that appeared in the Summer 1977 issue of the NEWSLETTER. Ten came from prosthetists, one from a physical therapist, and four from physicians. The answers and remarks from all but one prosthetist are given below. One prosthetist, Lewis Meitzer of Miami, Florida, took the time and trouble to write a very thoughtful letter which is printed in full after the tabulation of the questionnaires. Prepared by the American Academy of Orthotists and Prosthetists, 1444 N Street, N.W., Washington, D.C. 20005. Editor: A. Bennett Wilson, Jr., B.S. M.E.; Editorial Board: Joseph M. Cestaro, C.P.O., Charles H. Epps, Jr., M.D., Robert B. Peterson, R.P.T. <ol> <li> Do you feel that patients with partial foot amputations require prostheses that extend higher than the distal third of the tibia? <ul> <li> Certified Prosthetists <ol> <li> No. Ankle high only. </li> <li> The prosthesis should not be higher than maleoli. </li> <li> Yes. </li> <li> Very seldom </li> <li> Especially true for active people. Low activity people without deformities seem to function well with the least amount of appliance. </li> <li> Not in all cases, for example, we're using C. Fillauer's AC & PLIC socket w/posterior (6) split for a great percentage of our partial foot amputees. </li> <li> No. </li> <li> I basically avoid terminating a prosthesis on the lower tibia. Often a shoe insert with the filler works fine. If a rigid ant. is used, I definitely do not stop at any point on the tibia. </li> <li> Transmetatarsal or longer - No. All others - Yes. </li> </ol> </li> <li> M.D.'S <ol> <li> If hand users. </li> <li> Yes. </li> <li> No. </li> <li> If full, pain free, weight bearing is possible on the remaining part of the foot - No. If not, then weight needs to be taken higher. </li> </ol> </li> <li> P.T. <ol> <li> Yes. </li> </ol> </li> </ul> </li> <li> Do you feel that most patients who receive partial foot amputations would function better with a Syme's amputation? <ul> <li> Certified Prosthetists <ol> <li> No. </li> <li> No, as long as the plantar surface can tolerate weight bearing, a partial foot is better than Syme's. </li> <li> No. </li> <li> No. </li> <li> Again active people and children who can possible avoid bone spurs and eventually develop an endbearing cosmetic BK. Surgery is important. Good padding over bones is very beneficial. </li> <li> Yes, the large majority would increase their function and be relatively pain-free. </li> <li> No. </li> <li> No. I have seen too many patients function beautifully with partial foot and only a toe filler. </li> <li> For P.V.D. patients a Symes amputation usually has a better chance to heal and the prosthetic fitting is better. For traumatic amputations as much length should be preserved to increase weight bearing surface and lever arm. </li> </ol> </li> <li> M.D.'S <ol> <li> Yes, but not all. </li> <li> Not necessarily. </li> <li> Yes, at least psychologically. </li> <li> No. A Syme's is much more radical than is often necessary and will not necessarily result in better function. </li> </ol> </li> <li> P.T. <ol> <li> Yes. </li> </ol> </li> </ul> </li> <li> Do you agree with the author's list of advantages and disadvantages of this amputation? <ul> <li> Certified Prosthetists <ol> <li> Some. </li> <li> - </li> <li> Yes. </li> <li> Yes. </li> <li> I feel amputation sites for children should take bony overgrowth and foreshortening into account, i.e., disarticulation rather than partial foot types. </li> <li> Not in its entirety, but generally speaking, yes. </li> <li> Yes. </li> <li> Some of them. </li> <li> Yes we do, however, prosthetic breakdown will still occur regardless which type is fitted. </li> </ol> </li> <li> M.D.'S <ol> <li> No. They are not the indication for the procedure. </li> <li> ? </li> <li> Yes. </li> <li> Partially. </li> </ol> </li> <li> P.T. <ol> <li> Yes. </li> </ol> </li> </ul> </li> <li> Do you feel that the sole or shank of the shoes or prosthesis should be rigid or flexible? <ul> <li> Certified Prosthetists <ol> <li> Flexible. </li> <li> Flexible, to provide easy roll over the often tender distal anterior foot. </li> <li> Rigid to metatarsal break, flexible distal from this point. </li> <li> Rigid except for toe flexibility. </li> <li> The sole should extend the toe break past the end of the amputation, rigid slightly past this point. </li> <li> We think in terms of the SACH foot function using rigid soft tissue support w/flexible forefoot. </li> <li> Flexible. </li> <li> Depends on patient's gait, toe off phase especially. Generally rigid to the ball of the shoe and flexible in the toe area. </li> <li> Usually, a rigid shoe and/or prosthetic foot functions better. However, we do have success using a modified Winnipeg Symes Prosthesis, which is partially flexible. </li> </ol> </li> <li> M.D.'S <ol> <li> Rigid. </li> <li> Rigid. </li> <li> Do not know. </li> <li> It depends largely on the level of amputation, the shoe control which is achieved and the residual ankle function. In general it needs to be rigid proximal to the metatarsal heads and capable of flexing to about 15° under the metatarsal heads when loaded. Sometimes, e.g. when the metatarsal heads are painful or in a very proximal level amputation, it needs to be rigid throughout and with a rocker base. If there is adequate ankle function, and reasonable shoe control on the residual foot, the prosthesis should flex at the ankle too. </li> </ol> </li> <li> P.T. <ol> <li> Rigid. </li> </ol> </li> </ul> </li> <li> Please comment if you have experience with the "ankle-foot orthosis" type of treatment mentioned here and described by Fillauer. <ul> <li> Certified Prosthetists <ol> <li> I have been using the same basic idea for several years with good success. </li> <li> I have used this on one patient and he was quite pleased. </li> <li> - </li> <li> No experience. </li> <li> No experience. I added another approach to my repertoire. </li> <li> No experience. </li> <li> Yes. </li> <li> I have used the AFO with a toe filler attached a few times recently and am very satisfied with the results. </li> </ol> </li> <li> M.D.'S <ol> <li> Yes, only very limited. </li> <li> Yes, occasionally useful. </li> <li> No. </li> <li> - </li> <li> No experience. </li> </ol> </li> <li> P.T. <ol> <li> No experience. </li> </ol> </li> </ul> </li> <li> Would you be willing to contribute to an "atlas" or "catalog" of methods for providing prostheses for partial foot amputations? <ul> <li> Certified Prosthetists <ol> <li> Yes. </li> <li> Yes. </li> <li> Yes. </li> <li> Yes. </li> <li> Yes, although my experience is limited (which is probably the situation 90% of the time). A ready reference such as this may help us all solve the unique problems each of these amputees present. </li> <li> Enthusiastically. </li> <li> Yes. </li> <li> At present I have nothing new to contribute. </li> <li> Yes, we would. </li> </ol> </li> <li> M.D.'S <ol> <li> Yes. </li> <li> No. </li> <li> Do not feel qualified to do so. </li> <li> Yes. </li> </ol> </li> <li> P.T. <ol> <li> No, not enough experience. </li> </ol> </li> </ul> </li> </ol> <h3>Conclusions</h3> It can be seen that although there is a wide variation of opinion about partial foot amputations and prostheses, more than half of the practitioners feel that partial foot amputations can provide better function than the Syme's. Nearly all of the respondents would be glad to contribute to an "atlas" or "catalog" of methods for providing prostheses for partial foot amputations. Mr. Meltzer's letter, which follows, seems to sum up the state of the art and is reproduced here in full. September 27, 1977 Newsletter Questionnaire AAOP 1444 N Street, N.W. Washington, D.C. 20005 The following are the answers to your questions as per your request from the Newsletter Questionnaire, copy enclosed. NAME: Lewis N. Meltzer, C.P.O. <ol> <li> Do you feel that patients with partial foot amputations require prostheses that extend higher than the distal third of the tibia? <blockquote> It has been my experience that patients with partial foot amputations occasionally cannot tolerate the Fillauer type orthosis. Yet, for cosmetic purposes, they prefer it rather than something extending above the shoe. I have fitted a few and only succeeded with one. This is after extended trials by myself and the patient. Yet, the two who were not satisfied, preferred to wear nothing and have been lost to follow up. Several years ago I worked with polypropylene or similar AFO's with toe fillers and steel shanks in the shoe, and those seemed to work satisfactorily. I think that Mr. Pritham's idea merits trials. My only concern is cosmetic acceptance when compared to the Fillauer type. </blockquote> </li> <li> Do you feel that most patients who receive partial foot amputations would function better with a Syme's amputation? <blockquote> This seems like an ambiguous question which I feel I can only answer by saying it would depend on the individual. At the same time, all else being equal, partial foot amputation would be my choice were I to need that type of amputation as I could more easily walk without a prosthesis either around the house or at night. </blockquote> </li> <li> Do you agree with the author's list of advantages and disadvantages of this amputation? <blockquote> Yes. </blockquote> </li> <li> Do you feel that the sole or shank of the shoes or prosthesis should be rigid or flexible? <blockquote> Here, again, this would depend on the patient as I have seen patients desiring no prosthesis. </blockquote> </li> <li> Please comment if you have experience with the "ankle-foot orthosis" type of treatment mentioned here and described by Fillauer. <blockquote> The Fillauer method I have tried has included a section of Silastic R.T.V. in the anterior distal socket for comfort and total contact. This is laminated over the cast rather than after the prosthesis is made. With this, I still have had only one satisfied patient. The other two required several attempts at fitting and yet the patients were not satisfied. </blockquote> </li> <li> Would you be willing to contribute to an "atlas" or "catalog" of methods for providing prostheses for partial foot amputations? <blockquote> I would be willing, if I felt I had something specific to offer as an alternative, but I have not found it to date. </blockquote> </li> </ol> Sincerely, Lewis N. Meltzer, C.P.O. Page Number(s) 1 - 3 Year 1977 Volume 1 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 Partial Foot Amputation https://staging.drfop.org/files/original/f4a0dba11dbd83d1386ccb0e624bc090.pdf cdd8923abdae6f28e1a9d8d1fe8755c4 https://staging.drfop.org/files/original/681863a98ef8c1b69d476ca775d584e5.jpeg ae65dd03b074faa805393f2bb2cca1eb https://staging.drfop.org/files/original/b3f368a835f52e8d59db880235d53694.jpg 64a7ad3c59294b4014476742e34ee741 https://staging.drfop.org/files/original/bd5404308943c819bbb4f8cf4312b7c3.jpg 40b7c14dc32d98e7f4de52e02a7bd7aa https://staging.drfop.org/files/original/8377ac015b32853159b839d4e215bde5.jpg ebb48fe686c96a27f8944c39a7ea1994 https://staging.drfop.org/files/original/568455a545a488a7582cc67a53f4e0ff.jpg 39633f73e9a88bef0976b0d0d921dcb5 https://staging.drfop.org/files/original/bba2f04183e22d65f8b82db57ebb81de.jpg 56a7734fbe443f9e90a5a81715258054 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1977_03_005.pdf Text Any textual data included in the document <h2>Partial Foot Amputation - A Case Study</h2> <h5>Charles H. Pritham C.P.O. <a style="text-decoration: none;">*</a></h5> Traditionally amputations through the foot have been held in poor repute for a variety of reasons<a></a>, chief among them being the equinus deformity that can result from an imbalance between the intact triceps surae and the severed anterior muscles. In addition, the poor quality of socket fit that often occurs with older styles of fabrication can be cited as a contributing factor for the low esteem in which tarsal and mid-tarsal amputations are held. In recent years there has been an ever increasing emphasis on more distal level of amputation for peripheral vascular disease and the advantages to be accrued. Thus, today, below-knee amputations and disarticulations at the knee have supplanted to a large measure above-knee amputations. In a similar fashion Syme's and partial foot amputations are being performed by some <a></a> to ensure the patients the advantages of full limb length, distal end-bearing, retention of proprioception, and a long lever arm. The trend has gained impetus from such improved methods of predicting successful amputation levels as Xenon Radiography, and differential pulse ratios to predict accurately stump viability <a></a> as well as such improved methods of surgical technique as fixation of the pretibial muscles for Chopart and Lisfranc amputations, heel pad fixation for the Syme's, and the use of rigid dressings for all levels of amputation <a></a>. It, thus, seems correct to conclude that an increasing number of partial foot amputations for vascular insufficiency will be seen by prosthetists in the years to come. The challenge to the prosthetist, therefore, is to maximize the advantages cited by using the best products of the latest available technology. One example of this can be found in the use of a modified plastic ankle-foot orthosis with a toe filler distal to the stump in those cases where stump length is adequate to ensure proper control and fit of the shoe <a></a>. Numerous variations of the basic theme exist, and are well known. Karl Fillauer has reported recently on his experience with a prosthesis that totally encompasses the stump below the malleoli and permits free motion of the ankle <a></a>. To the extent of the author's knowledge, neither of these designs have ever been subjected to formal evaluation and while experience has been gained by many prosthetists with the first design, little is known objectively about the latter. Both designs appear to work well in selected cases, but neither design appears to provide for the broadest possible distribution of pressure (or in the case of a modified AFO, the most accurate distribution) to protect the fragile, sensitive, and often partially anesthetic skin over the dorsal surface of the remainder of the foot <a></a>. The purpose of this paper is to discuss one possible solution to this problem. <h3>Case Report</h3> W.M. is a 62-year-old male Caucasian, who sustained a right Chopart amputation in 1972, secondary to peripheral vascular disease and necrosis of the forefoot (Fig. 1). He was subsequently fitted with a prosthesis which he wore until April 1977 (Fig. 2). The prosthesis was fabricated of polyester lamination with a posterior opening and metal reinforcing elements. Because of subsequent failure an additional steel armature was added externally, and the weight of the unit when seen by us had crept to 5 lb. 4 oz. Over the years sufficient change had taken place in contour of the stump so that W.M. was experiencing pain on the distal-lateral and anterior aspects of the stump, and he walked slowly with the use of a cane. Our initial attempt to fit the patient was made with a molded ankle-foot orthosis with a toe filler, but the patient obtained no relief from the pain, and the situation was re-evaluated. <a href="/files/original/681863a98ef8c1b69d476ca775d584e5.jpeg">Fig. 1.</a> W.M.'s Chopart Amputation <a href="/files/original/b3f368a835f52e8d59db880235d53694.jpg">Fig. 2.</a> W.M.'s "Conventional" prosthesis After due deliberation, the patient was cast in the weight-bearing position, tracings were taken of both feet and vertical reference lines drawn (Fig. 3). With the tracing as a guide, a proper sized SACH foot was selected for the forefoot extension to the positive model of the stump, overwhich a polyethelene form of the heel and sole could be vacuum molded. The positive model of the stump was positioned inside the polyethelene form and the tracing and reference lines were used as guides to establish proper alignment. After plaster had been poured in the form and blended into the stump model, 1/4-in. thick polypropylene was vacuum formed about the extended model and subsequently modified to establish an AFO-type of socket with maximum rigidity about the ankle and anterior lever arm. A Plastizote interface was molded to the anterior aspect of the stump model and mated to a toe filler shaped from SACH-foot heel-cushion stock. <a href="/files/original/bd5404308943c819bbb4f8cf4312b7c3.jpg">Fig. 3</a>. Outline of feet during weight-bearing to provide references for fabrication and alignment of the molded prosthesis. The semi-completed prosthesis was fitted to the patient so that adequacy of fit and alignment could be checked. Ambulation by the patient revealed that he still experienced some pain, which was relieved by using adhesive tape to strap the shin firmly into the prosthesis and thus distribute the pressure over a broader area. While the patient was standing, strapped in the prosthesis, splints were used to cast the limb for an anterior shell that would match properly with the posterior element. Polyethelene was vacuum formed over the model to form an anterior shell that was lined with Plastizote. The two elements were then fitted to the patient and fastened proximally with "PTB-type" buttons in a fashion identical to the tibial fracture orthosis reported by Stills <a></a>. The finished prosthesis (Fig. 4, Fig. 5, Fig. 6) weighed 18 ounces and fitted more loosely in the shoe than the older prosthesis. The patient reported total comfort in the prosthesis during walking and considered the vastly decreased weight an important advantage. <a href="/files/original/8377ac015b32853159b839d4e215bde5.jpg">Fig. 4.</a> The molded prosthesis on the patient. <a href="/files/original/568455a545a488a7582cc67a53f4e0ff.jpg">Fig. 5</a>. Lateral view of the molded prosthesis. <a href="/files/original/bba2f04183e22d65f8b82db57ebb81de.jpg">Fig. 6.</a> Three-quarter anterior view of the molded prosthesis. References: <ol> <li>Alidredge, R. FF, and E. F. Murphy, The influence of new developments on amputation surgery. In: Human Limbs and their Substitutes. New York, McGraw Hill Co., Inc. 1954.</li> <li>Anderson, M. H., J. J. Bray, and C. A. Hennessey, The construction and fitting of lower-extremity prostheses. In: Orthopaedic Appliances Atlas. Ann Arbor, ). W. Edwards, 1960.</li> <li>Bingham, J. The surgery for partial foot amputations. In: Prosthetic and Orthotic Practice. London, Edward Arnold Ltd., 1970.</li> <li>Condie, D. N. Biomechanics of the partial foot amputation. In: Prosthetic and Orthotic Practice. London, Edward Arnold Ltd., 1970,</li> <li>El-Sharkaw, A., H. Abdel-Farrar, H. El-Hadidi, and M. Abdel-Hafez, A reconsideration of tarsal amputations with a new approach to the problem of equinus deformity. In: Proceedings of the International Conference, Cairo and Alexandria, Egypt, May 1- 1 1, 1972. Sponsored by Social and Rehabilitation Service, DHEW, USA and International Society-tor Prosthetics and Orthotics.</li> <li>Eillauer, K. A prosthesis tor foot amputation near the tarsal-metatarsal junction. Orthotics and Prosthetics 30 (3): 9-11, September 1976.</li> <li>Rubenstein, H. J., G. J. Sweeney, P. Strong, and C. Durrett, A foot amputation orthosis-prosthesis. Inter-Clinic Information Bulletin 14(4), April 1975.</li> <li>Rubin, G., and M. Daniso, Functional partial foot prosthesis. Bulletin of Prosthetic Research 10-16: 149-152, Fall 1971.</li> <li>Rubin, C, and M. Daniso, A functional Chopart prosthesis. Inter-clinic Information Bulletin 11(6), March 1972.</li> <li>Stills, M. Vacuum-formed orthoses for fracture of the tibia. Orthotics and Prosthetics 30(2): 43-55, June 1976.</li> <li>Wagner, W. Instructional Course in Amputation Surgery and Post-Op Care. ISPO World Congress. New York, May 1977</li> </ol> *Charles H. Pritham C.P.O. Staff Prosthetist, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, 12th St. &Tabor Rri., Phila., Pa. 19141 Page Number(s) 5 - 7 Year 1977 Volume 1 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-6.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 Partial Foot Amputation - A Case Study Creator An entity primarily responsible for making the resource Charles H. Pritham C.P.O. * https://staging.drfop.org/files/original/c6a552f1c6b8ae5f6420670481497839.pdf 923a2e99a0c425a3af0735185997492f 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 Full Text PDF Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_01_010.pdf Text Any textual data included in the document <h2>Partial Foot and Syme Amputations: An Overview</h2> <h5>John H. Bowker, M.D. <a style="text-decoration: none;">* </a></h5> <h3>Historical Aspects</h3> Until the middle of this century, partial foot and Syme amputations were done almost exclusively as a sequel to trauma. The presumption was that the normal vascular supply of the remaining foot would usually lead to healing. Both dry gangrene due to peripheral vascular disease and wet gangrene, related to infection superimposed on dysvascularity, were commonly treated by above-knee amputation or below-knee amputation, the choice often being dictated by local surgical prejudice.<a></a> The rationale was to amputate at the level where one could anticipate primary healing. This had considerable validity in the pre-antibiotic era, when failure of primary healing might mean death of the patient from secondary infection. However, in the United States at the present time, a growing number of partial foot amputations are being done for patients with arterial and/or capillary blood vessel disease, the majority of whom have diabetes mellitus. This major turnaround in attitude on the part of progressive surgeons is due to a number of technological breakthroughs of the past two decades. These may be characterized as follows: <ol> <li> A proliferation of antibiotics to cover most aerobic and anaerobic bacterial infections, largely eliminating the specter of death following failure of an initial procedure. </li> <li> Development of techniques to measure limb blood flow, both in small distal arteries by means of the Doppler effect and at the tissue level, by determination of transcutaneous oxygen perfusion and other methods.<a></a> </li> <li> The evolution of the operating microscope, which has led to the development of evermore distal arterial bypass procedures, including ankle to foot jump grafts.<a></a> These often allow healing of distal amputations which would not have healed prior to bypass. </li> <li> Development of new plastics with a variety of production-controllable characteristics in liquid, sheet, and foam versions. This has led directly to the design of more physiologic and cosmetic partial foot prostheses. </li> <li> Studies of energy consumption during gait which demonstrate the physiologic advantages of distal amputations such as the Syme.<a></a> </li> </ol> With the risk to the patient minimized and the probability of better function, the surgeon should now be willing to risk the occasional failure, that is, the need for a secondary procedure, in order to better assist the vast majority of his or her patients. <h3>Advantages of Partial Foot and Syme Amputations</h3> The partial foot amputee continues to bear weight on the residual foot in a manner which approximates the normal in regard to proprioceptive feedback, as opposed to the below-knee level in which an entirely new feedback pattern must be interpreted. The great majority of adult onset diabetics with peripheral neuropathy also retain sensation in the arch and heel areas. The heel-lever is intact and variable portion of the toe-lever remains. This will range from full-length, as in the case of a ray (toe and metatarsal) amputation, to virtually none in the case of a Chopart (midtarsal) amputation. The ease of restoration of a normal gait pattern is largely dependent on the length of toe-lever remaining. Whenever possible, therefore, toe-lever length should be preserved by election of a longitudinal (ray) amputation rather than a transverse level (transmetatarsal, tarsometatarsal (Lis-franc) or midtarsal). A further advantage is, in an emergency, the partial foot amputee is not dependent on a prosthesis. There are also two distinct psychological advantages of partial foot amputations. The less drastic alteration of body image as compared to the below-knee level may decrease the sense of loss as well as produce a smaller disruption of an active life-style. The less conspicuous and more cosmetically acceptable prostheses available today, even for the more radical partial foot amputations, may also help reduce the impact of the psychological loss. There has been disagreement about whether the Syme amputation qualifies as a partial foot amputation because all the bony elements of the foot have been removed. The preservation of the heel pad, a major soft tissue component of the foot, in the Syme amputation is what confers full weight-bearing capability and distal proprioceptive benefits on the residual limb. The notion that the heel pad is not an important element of the foot is easily dispelled by observing the difficulty in effectively reambu-lating a person who has lost the heel pad in an otherwise intact foot. Studies of gait parameters including oxygen consumption, cadence and velocity have shown the advantages of the Syme over the below-knee level.<a></a> The benefits noted are not diminished by the need for a more extensive prosthesis than is necessary for less radical partial foot amputations. <h3>Etiology</h3> Trauma continues to result in a significant number of these amputations. In wartime, booby-traps and land-mind explosions are frequent, while in peacetime, accidents with motor vehicles, especially motorcycles and lawn mowers seem to be the most frequent causes. In northern latitudes, frostbite remains a common etiology. However, the majority of partial foot and Syme amputations in our institution are an indirect result of inadequate protective sensation to the feet, secondary to peripheral neuropathy. This loss of normal sensation is commonly associated with diabetes mellitus, alcoholism, Hansen's disease (leprosy), or myelomeningocele (spina bifida). The difficulty starts with injury to the foot, either acutely as a laceration, puncture or burn or, more commonly, from pressure or shear forces associated with ill-fitting shoes, and/or chronic overuse of the foot. In response to these forces, areas of skin over bony prominences develop calluses which then break down to form ulcers. These are most common under the metatarsal heads or on the toes. Infection ensues, progressing from cellulitis to abscess formation to septic arthritis and osteomyelitis, resulting in amputation. Circulatory factors also play a role, especially in diabetic patients. Small vessel disease results in restricted passage of oxygen and antibiotics, across the capillary basement membrane, to damaged and infected tissues. Atherosclerotic changes in the arterial tree can produce major blockage of blood flow correctible only by arterial reconstruction or by-pass. Smoking can play major roles both in the onset and aggravation of atherosclerotic arterial disease and in delaying or preventing wound healing after injury or surgery. In persons with neuropathy, compliance with a careful routine of foot care is mandatory if major problems are to be prevented. It is easy to deny that a problem exists when no warning pain is felt. Depression over the long-term possibility of limb loss may so depress many diabetic patients that they are immobilized, unable to protect themselves and to prevent what they most fear, amputation. Psychological counseling, individual or group, can aid in breaking patterns of denial and in dealing with the subsequent depression. Ultimately, the patient must accept the responsibility for foot care if amputation is to be avoided.<a></a> <h3>Surgical Considerations</h3> Partial Foot Amputations The surgeon should attempt to preserve as much length and width of the foot as possible commensurate with: <ol> <li> Healing potential of the soft tissues as determined by circulatory evaluation; </li> <li> Eradication of the local disease process, i.e., removal of all necrotic and infected tissues; </li> <li> Closure of the wound with local skin flaps over all surfaces subject to major weight-bearing or shear forces (Split thickness skin grafts may be used elsewhere, such as the dorsal surface and arch of the foot.); and </li> <li> Good function. A lesser toe should not be left as the only remaining toe because of its increased susceptibility to injury. A second ray amputation is preferable to a second toe amputation alone because of the loss of lateral support to the great toe, which may result in a secondary bunion deformity. This constitutes a new bony pressure point likely to result in another ulcer. </li> </ol> With amputation at or proximal to the tarsometatarsal (Lisfranc) joint, care must be taken to balance the motor (muscle) function of the foot to prevent contractural deformity. At or above this level, release of dorsiflexor and evertor tendons without their reattachment leads to a severe equinovarus deformity due to the unopposed action of the triceps surae (gastrosoleus). Even with reattachment of the muscles at the more proximal level, their effective force is lessened due to shortening of the toe-lever. To overcome this advantage of the triceps surae, it is recommended that a fractional percutaneous heel cord lengthening of the Hoke-Hatt type be done as part of the initial surgery.<a></a> Even short transmetatarsal amputations may benefit from this procedure. <h3>Syme Amputation</h3> Full end weight-bearing on the heel pad with normally-channelled proprioceptive feedback is what distinguishes the Syme amputation from below-knee amputation. The three keys to success in Syme amputation are selection of the proper candidate, meticulous surgery to preserve the Syme's unique characteristics and maintenance of the weight-bearing heel pad in a centralized position. Since the heel pad is dependent on the posterior tibial artery for its blood supply, preoperative evaluation of the heel pad blood supply by Doppler or other means is recommended in order to reduce the chance of failure to 20% or less. Meticulous surgical technique is required throughout to avoid damage to the posterior tibial artery and to the vertically oriented, fat filled chambers of the heel pad, which provide the cushioning, allowing comfortable and long-lasting end-bearing.<a></a> Painful incisional neuromas are avoided by finding and cutting short all sensory nerves in both wound edges. Excessive laxity of the heel pad, which will cause difficulty in fitting, is avoided by several means. First, accurately planned incisions will avoid tissue redundancy. At closure, any excess skin should be trimmed, but closure under tension must be avoided. Second, suturing the deep fascial tissues of the heel pad to the anterior fascia or to the anterior tibial cortex will hold it firmly in place. Third, a light-weight carefully padded plaster cast (two 4" rolls) will prevent pad shift during the first four to five weeks of healing, when a snug walking cast can be applied. This is changed every two weeks until shrinkage has slowed. From this point on, centralization of the heel pad is a function of a carefully fit and maintained prosthesis. <h3>Basic Problems to be Solved</h3> Despite the obvious physical and psychological benefits of partial foot and Syme amputations, these procedures have not enjoyed wide popularity. In my opinion, this is largely due to a failure of dissemination of information regarding these advantages to the two groups most involved: amputation surgeons and pros-thetists/orthotists. On the one hand, amputation surgeons must be able to recognize potential candidates for conservative procedures and be willing to try them. On the other hand, the prosthetist or orthotist to whom he refers his patients must be able and willing to accept the challenge of fitting these sometimes difficult cases, e.g., producing a prosthesis which adequately meets the suspension needs of a Chopart amputation residual limb. Parenthetically, both the techniques and materials used put this area of expertise somewhere between prosthetics and orthotics, hence the name "prosthoses" for the devices constructed. Further refinement of present designs, especially in regard to cosmesis, and development of new concepts to produce better suspended and lighter prostheses are needed. Studies of gait patterns using these devices will assist in this effort and will help select the most physiologically effective designs. Elimination of shear forces, a function of both suspension and fit, will eliminate most of the criticism of these devices common in the past. <h3>Summary</h3> At the present time, partial foot and Syme amputations are considered viable alternatives to the below-knee level. This is true not only in trauma cases, but in diabetic patients with arterial and/or capillary blood vessel disease. Technological advances which have produced this change over the past two decades include: improved broad-spectrum antibiotics; effective devices for measurement of arterial blood flow and tissue oxygenation; development of arterial by-pass procedures, including the ankle and foot; and more physiologic and cosmetic partial foot and Syme prosthetic designs made possible by development of new plastics in a variety of physical forms. The end weight-bearing and proprioceptive benefits of these amputations lead to low excess energy demands on the amputee as compared to higher amputation levels. A major psychologic benefit is the relatively small alteration of body image. The etiology of these amputations and the surgical details to be observed and pitfalls to be avoided are discussed in some detail. Better dissemination of information to amputation surgeons and pros-thetists/orthotists regarding the benefits of these amputations is recommended. There is a need for the refinement of present designs as well as development of new concepts to produce better suspended, lighter and more cosmetic prostheses. References: <ol> <li>Burgess, E.M. and F.A. Matsen, III, "Determining Amputation Levels in Peripheral Vascular Disease," J. Bone and Joint Surgery, 63A:1981, pp. 1493-1497.</li> <li>DiCowden, M.A., personal communication.</li> <li>Glattly, H.W., "A Statistical Study of Twelve Thousand New Amputees," Southern Medical Journal, 57:No-vember, 1964, pp. 1373-1378.</li> <li>Hatt, R.N. and T.A. Lamphier, "A Simplified Procedure for Lengthening the Achilles Tendon," New England J. Med., 236:1947, pp. 166-169.</li> <li>Harris, R.I., "Syme's Amputation: The Technical Details Essential for Success," J. Bone and Joint Surgery, 38B:1956, p. 614.</li> <li>Taylor, L.M., Jr., E.S. Phinney, and J.M. Porter, "Present Status of Reversal Vein Bypass for Lower Extremity Revascularization," J. Vascular Surgery, 3:1986, pp. 288-297.</li> <li>Waters, R.L., J. Perry, D. Antonelli, and H. Hislop, "Energy Cost of Amputees: The Influence of Level of Amputation," J. Bone and Joint Surgery, 52A:1976, pp. 42-46.</li> </ol> *John H. Bowker, M.D., is Professor and Associate Chairman of the Department of Orthopaedics and Rehabilitation at the University of Miami School of Medicine, and Medical Director of the University of Miami/Jackson Memorial Rehabilitation Center, 1611 N.W. 12th Avenue, Miami, Florida 33136. Page Number(s) 10 - 13 Year 1988 Volume 12 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Partial Foot and Syme Amputations: An Overview Creator An entity primarily responsible for making the resource John H. Bowker, M.D. * https://staging.drfop.org/files/original/475312ad901e4ae50427aca982b96391.pdf 16c5a7f900bf5cd9f0075d663907a89c https://staging.drfop.org/files/original/f946e814ca104b1ab87b53b87b6b3c43.jpg 4eebe01c35bb30eaec673139c764c259 https://staging.drfop.org/files/original/49517f0922e98539ac3edf1a8ffdee4d.jpg d7ecf857cfc2c67c1e8a164c675ffae8 https://staging.drfop.org/files/original/e1a3036e9d2bcea88e93e31c9321ee05.jpg 8f41bfd2fd79a1fcf5b6b869231034da https://staging.drfop.org/files/original/da9fc3922ff615899e8cd528ace5c3d8.jpg c10cfb063259e8b5b8c497db3b3825ca https://staging.drfop.org/files/original/5c28655b2bac581bd2b3251173ef77d4.jpg 13d4fbf3a65ed2ac03d8aae664728070 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_01_014.pdf Text Any textual data included in the document <h2>Partial Foot Prostheses/Orthoses</h2> <h5>Melvin L. Stills, CO. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> Prostheses and orthoses prescribed for partial foot amputations vary in design and principle. Authors have described the need or the lack of need of toe lever arms, extensions above or below the ankle, and hard and soft sockets. Almost every design violates a principle thought to be a requirement of the other designers of partial foot prostheses/orthoses. The purpose of this paper is to describe some of the designs now being advocated and to give the rationale for their use. <h3>Above the Ankle</h3> Many authors and designers believe that the proper management of a mid-transverse metatarsal amputation, or more proximal, must include an extension above the ankle. Many of these designs take the form of an ankle-foot orthosis (<a href="/files/original/f946e814ca104b1ab87b53b87b6b3c43.jpg">Fig. 1</a>). This orthosis may be fabricated from thermoplastic materials (polypropylene), thermoset plastics (polyester or acrylic) which may be incorporated with graphite or other space age materials to reduce weight and increase strength (<a href="/files/original/49517f0922e98539ac3edf1a8ffdee4d.jpg">Fig. 2</a>), or may be incorporated into conventional metal and leather types of orthoses. Those devices fabricated from thermoplastics and thermoset materials are generally formed over a positive model of the amputated extremity. The portion of the device contacting the foot is designed to achieve total contact and is generally lined with a soft interface material to increase comfort and/or provide better distribution of forces. The normal profile of the foot may be restored during the initial fabrication process or added later as a buildup of foam. This foot buildup acts as an extension of the foot lever arm, or in some instances may only act as a shoe filler. If an attempt is made to extend the foot lever arm, it may be necessary to complete shoe modifications which would include a full length spring steel shank cushion heel and walker sole. It is considered that this combination of prosthesis, orthosis, and shoe will provide a smooth transition from foot flat to heel off and permit an effective push off. <a href="/files/original/f946e814ca104b1ab87b53b87b6b3c43.jpg">Figure 1</a>. Polypropylene ankle-foot orthosis with foam toe filler. <a href="/files/original/49517f0922e98539ac3edf1a8ffdee4d.jpg">Figure 2.</a> Graphite reinforced laminated posterior prosthetic shell for transtarsal amputation. Tarso-metatarsal amputations may require a solid ankle device. This device employs similar methods of construction with the addition of an anterior section extending from the level equal to the height of the posterior section and distally to the dorsum of the remaining foot. This addition acts to lock the foot and lower leg into the posterior section and eliminates ankle motion. The shortened foot is difficult to retain in the posterior section, and the addition of the anterior shell provides better purchase and retention. The proximal region of the anterior section may take the form of a patellar tendon bearing socket, or extend to midcalf, or in some designs extend only to the area just above the ankle. Variations of all three commonly exist, and the amount of ankle control will be determined by the design selected. If a design is selected which limits ankle motion, most authors agree that shoe modifications are required to achieve normal gait. A cushion heel applied to the shoe will permit smooth transition from heel strike to foot flat. Prosthetists who routinely employ these designs have reported good results with successful ambulation. <h3>Below the Ankle (Slipper Type)</h3> A number of designs exist that do not extend above the ankle joint. They appear to be divided into the following categories: (1) rigid, (2) semi-rigid, (3) semi-flexible, and (4) flexible. All of these systems are fabricated on a positive model of the residual limb. The positive model is modified to increase loading of good tissue and to relieve or decrease pressures on sensitive areas prior to the forming of the definitive socket. The rigid and semi-rigid systems are based on a laminated or thermoform socket. Limited flexibility is built into these systems, using flexible resins in fabricating the semi-rigid shells. A foam lining is generally employed to act as an interface between the rigid walls of the socket and the skin of the residual limb. The profile of the foot is restored with a buildup added to the socket. Complications may be encountered in using the rigid/semi-rigid designs when motion occurs inside the socket. Breakdown on the distal plantar surface of the residual limb is not uncommon, and this complication has led to the development of the semi-flexible and flexible designs. Semi-flexible designs utilize a combination of material, generally having a base of urethane elastomer. One such system which is semi-flexible in nature and utilizes a laminated rigid University of California-Berkley shoe insert as its base. The insert is bonded to a modified monoelastic cushion heel foot and the entire system is laminated together with a urethane elastomer.<a></a> The resultant system does not interfere with normal ankle motion, and authors report good acceptance (<a href="/files/original/e1a3036e9d2bcea88e93e31c9321ee05.jpg">Fig. 3</a>). <a href="/files/original/e1a3036e9d2bcea88e93e31c9321ee05.jpg">Figure 3.</a> UCBL thermaformed shoe insert with Lynadure forefoot. Another semi-flexible design uses solely a urethane elastomer for fabrication of the socket and foot. This design is referred to as a slipper-type elastomer prosthesis (STEP). The STEP design is somewhat complex in its design and fabrication. Permanent tooling is developed for each individual patient and may be retained by the patient for possible fabrication of replacement devices at a later date. This tooling consists of a permanent polyester resin positive model of the residual limb and a negative mold of the finished prosthetic foot. This device is fabricated using semi-flexible urethane elastomer.<a></a> If a pressure point is noted on the residual limb, modifications are made to the prosthesis by removing material from the exterior surface of the prosthesis in order to reduce rigidity in that area and to insure a smooth socket interface. Good results have been reported from the use of this prosthesis. <h3>Flexible Foot Prostheses</h3> A flexible cosmetic prosthetic foot (<a href="/files/original/da9fc3922ff615899e8cd528ace5c3d8.jpg">Fig. 4</a>) has been developed which utilizes only reinforced silicone materials. A negative weight bearing alginate impression is made of the residual limb and contralateral foot. An exact detailed dental stone positive model of the residual limb is made from this impression. A wax check socket is fabricated on this model and checked for comfort and fit on the patient. Modifications are made to relieve sensitive areas and to load appropriate surfaces. Appropriate loading is based on the prosthetist's impression of soft tissue density and how much pressure the patient can tolerate. A mirror image model of the sound foot is sculpted from wax and checked for sizing against the patient. A negative model of the sculpted foot is then made using a lost wax method. The resulting negative model of the foot may then be used in conjunction with the rectified model of the residual limb to produce the prosthesis. The material employed is a pure reinforced silicone that is precolored to match the patient's skin tones. At the fitting, the detailed colored matching is achieved using the sound side as a model for cosmetic restoration. To date, approximately 100 patients have been fit with this flexible silicone cosmetic prosthetic foot, and patient acceptance has been almost 100 percent. The developer<a></a> initially intended the prosthesis solely as a cosmetic device (<a href="/files/original/5c28655b2bac581bd2b3251173ef77d4.jpg">Fig. 5</a>). However, patients reported they had increased comfort and functional levels with the reinforced silicone prosthesis. <a href="/files/original/da9fc3922ff615899e8cd528ace5c3d8.jpg">Figure 4</a>. Reinforced silicone slipper type prosthetic foot. See Figure 2 for earlier fitting. <a href="/files/original/5c28655b2bac581bd2b3251173ef77d4.jpg">Figure 5.</a> Cosmetic functional silicone foot prosthesis. Requests for cosmetic restoration by males are almost equal in number to those requested by females. The psychological effect of cosmetic restoration has not yet been evaluated; however, it is probable that this has some influence on the functional acceptability of the prosthesis by the patient. Many of the patients fitted with a flexible silicone cosmetic prosthetic foot have previously been fit with partial foot prostheses of the types previously described. Mechanical comparisons of function of these designs would be valuable, but to my knowledge, have not yet been done. <h3>Summary</h3> A balanced foot is almost a necessity for successful fitting of any of the prosthetic systems. Trauma related amputations apparently do well with the slipper-type prosthesis, and the developer of the silicone system reports successful fitting in diabetic patients as well. The need for the prostheses to extend above the ankle appears to be limited to those patients with very short amputations, but successful fittings have been demonstrated with the slipper-type, sometimes using an ankle strap for suspension. There is no definitive statement that I can make recommending any one system over another. It appears that many partial foot amputees are being successfully managed with prostheses that do not extend above the ankle. It also appears that a higher rate of success is occurring when semi-flexible and flexible prostheses are being fit. It is believed by many that partial foot amputation can offer significant functional improvement over Symes level amputations and the use of this surgical technique needs to be reevaluated in light of the new technologies and materials available today for providing the partial foot amputee with a functional prosthesis. <h3>Acknowledgements</h3> A number of talented individuals have contributed to the information and materials presented in this paper, and in order to avoid inadvertently omitting someone's name, I wish to thank them all as a group for their assistance. <h3>Bibliography</h3> Childs, Charles and Timothy Staats, "The Slipper Type Partial Foot Prosthesis," Advanced Below Knee Prosthetic Seminar, UCLA Prosthetic and Orthotic Education Program, Fabrication Manual, 1983 Edition. Condie, David and Melvin Stills, "Biomechanics and Prosthetic/Orthotic Solutions—Partial Foot Amputations," Presented and to be Published as Proceeding "Dundee 85". Fillauer, Karl, "A Prosthesis for Foot Amputation Near the Tarsal-Metatarsal Junction," Orthotics and Prosthetics, Vol. 30, No. 3, September, 1976, pp. 9-11. <a href="http://www.acpoc.org/library/1978_01_011.asp">Hayhurst, Donald J., "Prosthetic Management of Partial Foot Amputee," Inter-Clinic Information Bulletin, Vol. XVII, No. 1, January-February, 1978, pp. 11-15.</a> Lunsford, Thomas, "Partial Foot Amputations—Prosthetic and Orthotic Management," Atlas of Limb Prosthetics, American Academy of Orthopedic Surgery, The C.V. Mosby Company, 1981, pp. 322-325. Wilson, Michael T., "Clinical Application of RTV Elastomers," Orthotics and Prosthetics, Vol. 33, No. 4, December 1979, pp. 23-29. References: <ol> <li>Lynadure, Medical Center Prosthetics, Inc., Houston, Texas.</li> <li>Calthane 1900, Cascade Orthopedic Supply, Inc., Chester, California.</li> <li>Mr. H. Buckner, C.O.T., Life-Like Laboratory, Dallas, Texas.</li> </ol> *Melvin L. Stills, CO. Melvin L. Stills, CO., is with the University of Texas Health Science Center, Division of Orthopedics, 5323 Harry Hines Blvd., Dallas, Texas 75235. Page Number(s) 14 - 18 Year 1988 Volume 12 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1988_01_014/1988_01_014-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_01_014/1988_01_014-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_01_014/1988_01_014-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_01_014/1988_01_014-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_01_014/1988_01_014-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Partial Foot Prostheses/Orthoses Creator An entity primarily responsible for making the resource Melvin L. Stills, CO. * https://staging.drfop.org/files/original/ae236bfbb39982337feabb0733c52902.pdf e72d5cf575ee14ceefaff511308e621b https://staging.drfop.org/files/original/666c4f3f407ef42ef96a9eeb30cba2cc.jpg ef072ec1bc27f9dcd672375601a67a9e https://staging.drfop.org/files/original/da001445312603a0ab4a223ff85c38d1.jpg 4f8a28f1624ff2e04786d747684a2057 https://staging.drfop.org/files/original/a32c142193dc07186843945607ee7c09.jpg 79706ff74b7376718ec3c1c01ef15ca3 https://staging.drfop.org/files/original/d6cf3cf6ad5b9329cdf3ac01b1190266.jpg f251a6a6b93993eeba8075a00dd5ac91 https://staging.drfop.org/files/original/41e3f04ea2dcb2b15a38233a0196d63c.jpg 9d90b7c57aaad093cb21238b39211ddc https://staging.drfop.org/files/original/c70f240f5eef716b30961b9ae75c899e.jpg 1e4183be00d6bedb3cc92fad6389248d https://staging.drfop.org/files/original/f4d46e9d44ec0b8a2fd85babdfade006.jpg f7682f94bed1b0ccc9e390612c5dafdf https://staging.drfop.org/files/original/d5207f95412f40949c9a0abdcc8f179f.jpg 35b4aa1ad815d9578b088cbbfd993f91 https://staging.drfop.org/files/original/dd41c84673e88dc6270e962c77261651.jpg 117eda80e9303ed50d584b0ee204d8f9 https://staging.drfop.org/files/original/4575504d9fda222439f290f7163145af.jpg 423c40aa07471e5f2cf3e718ae770e6b https://staging.drfop.org/files/original/91b675186e820e21469468d77ca70551.jpg 5afe9e85b461d2b3d97106de870921a2 https://staging.drfop.org/files/original/ac9d622bf611e960cead91b85bba30b1.jpg d785d4c25a39f7ab31ae8d5fc4053ed2 https://staging.drfop.org/files/original/554280c049e6a114db8463eaeefec20f.jpg e79e156f8cb8fe7c9dd123eec6027222 https://staging.drfop.org/files/original/c767acc60d993ecbc9a2dea3fdceafb5.jpg eaa08643ef0c977a0f9e9974a26262f3 https://staging.drfop.org/files/original/9696814c90d3a127b31bdde25d16906a.jpg 1d2ed620db67e11602f865d0cbca66a1 https://staging.drfop.org/files/original/11e6648c1da2da4e863cf22ff6b27e92.jpg 7979974fd7a2d61065ebd35791b01993 https://staging.drfop.org/files/original/0be90617be2197739e9b7215c50adcc4.jpg 761099b39d2853060144d43fd50bce9e https://staging.drfop.org/files/original/cdf2e11044f459004d4cc3bea3571520.jpg b18f89555cc3b064d9679377782bc8d8 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_02_007.pdf Text Any textual data included in the document <h2>Passive Mobilization: An Orthotist's Overview</h2> <h5>Dwain R. Faso, C.O. <a style="text-decoration: none;">*</a> Mel Stills, C.O. <a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> The application of passive motion in orthopedics has brought a new dimension to an old concept for the treatment of musculoskeletal problems. It is now recognized that the adverse effects of immobilization such as joint stiffness, poor articular cartilage nourishment, and collagen loss can be reversed by prolonged passive mobilization. R.B. Salter demonstrated significant results with his experimental work in the healing of osteochondral defects in rabbits subjected to continuous passive motion. R.D. Courts followed with clinical experiences of improved range of motion after total knee replacements. The indications for passive motion have since broadened to include knee ligament reconstructions,  joint injuires, fractures, dislocations, joint sepsis, and many others. The orthotist is often consulted for the evaluation of passive motion devices, their set up, adaptation, and implementation with fracture orthotics, external fixation, and traction. This article will provide an overview of passive mobilization as a supplement to the practitioner's database and present a variety of clinical situations encountered in the Dallas area at a large trauma and reconstruction center. <h3>Background</h3> For centuries, the clinician has vacillated between the uses and benefits of rest versus motion in the management of various disorders and injuries involving body joints. Rest or motion have been the most prescribed forms of non-operative treatment, yet the controversy of indication, duration, and value of each is far from being resolved. In the teaching of Hippocrates, the injured body was to be at 'rest and lie up.' His use of splints in musculoskeletal injuries assured rest. With the impregnation of bandages with plaster of Paris in 1852 by Flemish surgeon Antonius Mathijsen, immobilization took on a new form. The use of plaster casts in treating trauma and injury unquestionably assured the concept of immobilization by orthopedic surgeons for the next 130 years with little examination of the potential damage to articular tissue. Additional support of the rest concept was led by the British surgeon Hugh Owen Thomas. His doctrine of rest was to be complete, prolonged, uninterrupted, and enforced. This was accomplished through the use of splints of his own design, many of which are still in use today with minor modifications. Thomas' immobilization techniques routinely included uninjured joints above and below the fracture site. The mobilization concept found its roots in the Aristotelian teaching that movement is life. In the late 1900's, a school of mobilization took on a significant form through its advocate, Dr. Lucas-Champonniere. This French surgeon supported the use of massage and motion as a means of preventing muscle atrophy and joint contracture during the management of fractures and joint injuries. He believed that motion helped to relieve pain rather than to aggravate it. The use of balanced skeletal traction for fractures involving joint surfaces, initiated by Professor George Perkins, emphasized active motion in the realignment of fragments and prevention of stiffness. In the 1950's, the 'movement is life' principle found a resurgence under the guidance of the Association for Osteosynthesis (AO). They coined the term "fracture disease" for the chronic edema, joint stiffness, muscle atrophy, and disuse osteoporosis found in the treatment of fractures with immobilization. The AO group's technique of open reduction, rigid internal fixation with compression, and no casting encouraged early mobilization and provided a significant aggressive treatment. Apley, Dehane, and more recently Mooney and Sarmiento advocated the closed functional treatment of fractures through the use of cast bracing. Although these two methods vary, both preserve joint motion and encourage early function. <h3>Continuous Passive Motion</h3> The human body has evolved and developed into an organism that needs to move in order to maintain optimum efficiency. When the body is immobilized, the overall physical fitness declines rapidly: the heart rate decreases, and cardiac output no longer rises sufficiently during even mild activity; the upright position is poorly tolerated; the nervous system response slows; calcium is released by the immobilized skeleton and is excreted in urine, reflecting the extent of bone loss; muscle atrophy occurs with the reduction of fiber size, thereby resulting in the decline of tensile strength and energy absorption capacity; and the immobile body loses three percent of its original strength per day in a linear fashion for the first seven days, after which little strength is lost. The joints of the body are especially susceptible to immobilization. The articular cartilage layers depend on synovial fluid for nutrition. Motion makes for constant interchange of fluid between the layers of articular cartilage and synovial fluid. Joint motion causes alternating cartilage compression and distension. The absence of these pressure fluctuations causes a stagnation of intercellular fluid and a decrease in nutrition. Surprisingly, the adverse effects of immobilization on the human body generated little interest for evaluation. In the 1960's, Salter began investigation on the effects of immobilization versus mobilization on articular tissue in rabbits. His studies produced significant laboratory evidence that continuous passive motion offered startling benefits in the articular repair process in knee joint injuries compared to the routine care of immobilization. Salter's conclusions for his first 12 years of experimentation are: <ul> <li> Continuous passive motion (CPM) is well tolerated and seems to be relatively painless. </li> <li> CPM has a significant stimulation effect on the healing of articular tissue, including cartilage, tendons, and ligaments. </li> <li> CPM prevents adhesions and joint stiffness. </li> <li> CPM does not interfere with the healing of incisions over the moving joint. </li> <li> The principle of rest for healing tissue is incorrect. </li> </ul> Evidence for the clinical effectiveness of continuous passive motion on the process of healing is both subjective and objective. In various studies, Dr. Richard Courts demonstrated that there is a reduction in postoperative pain and an increase in post total knee joint range following the use of continuous passive motion for several weeks. The decrease in pain experienced may be caused from the rhythmic joint movement providing competitive interference to retard the pain-spasm reflex and alleviate pain at the source. The increase in range of joint motion reported may be due to the improved orientation and strength of collagen fibers formed, preventing adhesions which would limit range without disturbing or causing damage to adjacent uninvolved normal structures. Clinically, Salter has indicated CPM use immediately postoperatively for the management of open reduction internal fixation (ORIF) of the ankle, knee, hip, and elbow with usage ranging from one to three weeks. Decreases in wound edema, joint effusions, pain medications, and an increase in patient comfort and shorter hospital stays are documented as compared to non-CPM patients. Schnebel and Evans found that while active flexion is acquired earlier in CPM patients, there was no statistical difference in active flexion in late motion studies between CPM and non-CPM total knee arthroplasty patients. <h3>Design</h3> Continuous passive motion machines can be categorized into three groups by design: mattress-mounted, bed frame mounted, and single joint units. Clinical use of continuous passive motion has primarily been utilized for mobilization about the knee and hip joint due to the mechanical design of the majority of motion devices, i.e. the mattress-mounted units. These machines are similar in that the patient lies supine with thigh and calf held in the unit, and the knee and hip are mobilized simultaneously. (In these units the patient is unable to move about in the bed or make significant posture changes.) Ankle movement may also be provided. Some mattress-mounted machines and their suppliers are: <blockquote> Autoflex, Chattanooga Corp. CAPE System, Zimmer CK-7 Passive Motion Knee Exerciser, OEC Danni-Flex, Danniger Medical Technology Kinetec Passive Leg Exerciser, Richards Powerflex 3000, Biodynamic Technologies of Florida Stryker Leg Exerciser, Stryker Sutter CPM 2000, Sutter Biomedical </blockquote> The bed frame mounted units attach to standard overhead Bulkin frames and provide the versatility for mobilizing multiple joints. These systems are: <blockquote> CPM K-10, Sutter Biomedical Passive Mobilizer, 3D Orthopedic Inc. </blockquote> Single joint units address specific joints of the body only. These are: <blockquote> Miami Ankle Motion Machine, Zoya Orthopaedic Kinetec Elbow Exerciser, Richards CPM-5000, Sutter Biomedical CPM Mobilimbs L1-A, Toronto Medical Corp. </blockquote> Functional features of all systems vary from: microswitching to torque sensing, mechanical range setting to computer programmed, 110 volt to battery operated, patient-controlled cycles to programmed cycles, and one speed to variable speeds. Yet all systems have been developed more from subjective than objective data. The questions of how much force, optimum speeds, duration of cycle, direction of pull/push/lift to the joint, control of joint motion, or should the joint be loaded or unloaded need to be addressed in order to quantify CPM and avoid the potential dangers of this modality. Dangers exist when these systems are utilized by those unfamiliar with mechanical systems and/or the expectant results they are trying to obtain. The level of knowledge required varies, i.e. the mattress-mounted units are limited in application and therefore are relatively simple. The multiple joint systems would require more expertise because of the increased options of use, the mechanical advantages gained with the use of pulleys and springs, and the variations of movements occurring about the anatomic joints. These systems tend to be more cost-effective since their various uses can be applied to a greater patient population. <h3>Two Year Experience</h3> In our experience at a major trauma hospital, the need for versatility, ease of use, and reliability were of utmost importance. We utilized five machine designs over a two year period: Sutter K-10, CPM Mobilimb L1-A, Richards Passive Leg Exerciser, 3D Passive Mobilizer, and a home-grown unit. All systems functioned very reliably. The Mobilimb unit had a rechargeable battery powered system which, for our use, proved to be the least practical. The mattress mounted units were limited to mobilizing knees and hips, especially in cases of joint replacement. The trays to these units were cumbersome to housekeeping. The staff would take the tray off the bed to change linens, causing frequent malalignments when setting it back on the bed, usually due to fear of reapplying and/or the lack of understanding how the system functioned. Patient comfort was a major concern. If the patient was not comfortable in the system due to the physical design of the system or improper positioning in the unit, the staff would turn off the machine, thereby reaping no benefits. The tray would not fit properly if the patient was above or below the average height of five foot ten inches. These systems did not provide a recorder to document how long the patient had the system on or how many cycles the limb experienced. Lack of full extension and flexion became another concern in our use of any of the units utilizing the tray that the leg simply laid in. Although the tray would indicate full extension, the leg would still be flexed, and usually abducted and externally rotated (<a href="/files/original/666c4f3f407ef42ef96a9eeb30cba2cc.jpg">Fig. 1</a>). Because of these reasons and the need to be able to utilize traction, cast braces, and rehabilitative orthotics with passive motion, we began using a homegrown version utilizing the Sutter K-10 without the mattress mounted tray. Through the use of dynamic suspension, we could achieve full extension with the assistance of gravity, mobilize a patient in traction, maintain abduction and adduction, and set up bilateral limbs with only one machine. This variation enabled the patient to move about in bed and provided easier bed pan use and overall more comfort. It won favor with our ancillary staff because there was nothing in their way to be moved or replaced (<a href="/files/original/da001445312603a0ab4a223ff85c38d1.jpg">Fig. 2</a>). In March 1984, we began using the Passive Mobilizer by 3 D Orthopedic Inc. This system had incorporated many of the features of our homegrown unit with some significant improvements. The system provides a linear pull rather than the rotating arc of the Sutter K-10 so that flexion and extension limits are more easily controlled and eliminates the potential hazard of the rotating arm (<a href="/files/original/a32c142193dc07186843945607ee7c09.jpg">Fig. 3</a>). Also, the unit includes a cycle counter to document how many cycles the patient has experienced. These two additional features were found to be very useful in our practice. <a href="/files/original/da001445312603a0ab4a223ff85c38d1.jpg">Figure 2.</a> Home grown unit using Sutter K-10 motor and control system. <a href="/files/original/a32c142193dc07186843945607ee7c09.jpg">Figure 3.</a> Patient with a right acetabular fracture with 30 lbs. of tibial traction in continuous passive motion (3D Passive Mobilizer). Hip flexed 0-90° and kept abducted. The use of passive mobilization should begin as soon as possible. The earlier the application, the better the results that can be anticipated. In the case of elective procedures, such as total joint replacements, the passive mobilization system should be set-up before surgery to familiarize the patient with the machine and its operation. At our center, the majority of the cases are trauma related and of a fracture variety. Patients are placed in passive motion postoperatively in the O.R., recovery room, or when transferred to the orthopedic floor. The unit is set to allow 30-40° of motion initially post-op with the rapid increase of range of motion to tolerance. In this two year experience, we have had 168 cases involving the use of continuous passive motion. These are broken down into three major categories: <dl> <dt></dt> </dl> Articular Fractures Knee—79 Hip—17 Elbow—4 Ankle—3 Joint Replacement Knee—14 Hip (Cup)—8 Other Knee Problems Sepsis—20 Lig. Repair—12 Edema Control 6 Continuous passive motion was also applied to mobilize the cervical spine (in halter traction post soft tissue trauma), the shoulder (post manipulation or rotator cuff repair), and the lumbar spine (post laminectomy or decompression). These were not listed because the applications are still under evaluation. Our goal in utilizing the modality of continuous passive motion is full range of motion. Initially we target for 0-40° of motion the first day, cycling the limb approximately one complete cycle per minute. Increase in ROM is aggressively addressed daily to pain tolerance. Since time minimums in CPM have not yet been established, patients are kept in passive motion except during meals, physical therapy, or bathroom use. The goal established for ROM of the knee and hip is 90+°. It was felt that if the joint could go through a passive 0-90 +° range pain free, and prior to discharge 0-90+° active range, that normal knee and hip motion could be achieved on an out-patient basis with aggressive physical therapy. Many factors influenced the outcome. Patient compliance and willingness to participate in this treatment plan is a major factor. Competent application and training in the use of continuous passive motion is also critical to the outcome. <h3>Cases</h3> Case 1 A twenty-nine year old male sustained a high caliber gunshot wound to the left knee (<a href="/files/original/d6cf3cf6ad5b9329cdf3ac01b1190266.jpg">Fig. 4</a>), traversing the lateral femoral condyle through the joint space and through the lateral tibial plateau. Open reduction internal fixation (ORIF) and ligamentous repairs were made. Postoperatively, the patient was placed in a standard cast brace due to the inability to provide adequate medial-lateral stability of the knee surgically (<a href="/files/original/41e3f04ea2dcb2b15a38233a0196d63c.jpg">Fig. 5</a>). The cast brace was attached to a continuous passive motion dynamic suspension system to restore and maintain motion (<a href="/files/original/c70f240f5eef716b30961b9ae75c899e.jpg">Fig. 6</a>). At the time of the initial cast bracing, the patient had considerable soft tissue edema about the knee. The use of passive motion quickly reduced that swelling to the point where the cast brace provided little support. After one week, the cast brace was reapplied with the addition of a varus producing strap (<a href="/files/original/f4d46e9d44ec0b8a2fd85babdfade006.jpg">Fig. 7</a>) and the patient began ambulation training and was discharged. (If atrophy or swelling should continue, the varus producing strap can be easily adjusted to maintain force on the knee and another cast change would not be required). Case 2 A twenty-five year old female sustained a fracture dislocation of the left knee (<a href="/files/original/d5207f95412f40949c9a0abdcc8f179f.jpg">Fig. 8</a>). The fracture and ligaments were internally fixed, and the patient was placed in a continuous passive motion dynamic suspension system utilizing a Mobilizing Brace (3 D) and a bootie (<a href="/files/original/dd41c84673e88dc6270e962c77261651.jpg">Fig. 9</a>). The patient achieved 0-90° of motion in two days and was maintained in passive motion for five days until she could achieve the same range of motion actively without excessive pain. The patient was then cast braced for increased medial-lateral stability, received gait training, and was discharged from the hospital. Case 3 A nineteen year old male sustained a distal fracture with a split condylar fracture to the right leg (<a href="/files/original/4575504d9fda222439f290f7163145af.jpg">Fig. 10</a>) and a lateral condyle fracture on the contralateral side (<a href="/files/original/91b675186e820e21469468d77ca70551.jpg">Fig. 11</a>). Fractures were stabilized, but were not internally fixed at time of admission because of emergency vascular repairs being required. Three days post injury, the patient underwent ORIF of his fractures (<a href="/files/original/ac9d622bf611e960cead91b85bba30b1.jpg">Fig. 12</a> and <a href="/files/original/554280c049e6a114db8463eaeefec20f.jpg">Fig. 13</a>). The right leg was placed in a free knee Mobilizing Brace and the left leg was placed in the rehabilitative free knee orthosis. A continuous passive motion dynamic suspension system was placed on the lower right extremity (<a href="/files/original/c767acc60d993ecbc9a2dea3fdceafb5.jpg">Fig. 14</a>). The lower left extremity had normal pain free motion following surgery. The patient was kept in passive motion for five days and achieved 0-100° of pain free motion. A cast brace was applied on the right extremity; the patient received gait training and was discharged. Case 4 An eighteen year old male sustained bilateral femur fractures and bilateral patella fractures. The patient underwent bilateral closed inter-medullary (IM) rodding of the femur and the patellas underwent bilateral ORIF (<a href="/files/original/9696814c90d3a127b31bdde25d16906a.jpg">Fig. 15</a> and <a href="/files/original/11e6648c1da2da4e863cf22ff6b27e92.jpg">Fig. 16</a>). The patient was placed in a free knee Mobilizing Brace on the left leg and attached to a continuous passive motion dynamic suspension system immediately postoperatively. The right leg was maintained in a straight position and in a denotation boot to prevent the fractured femur from spinning on the IM rod. In two days, the left knee had 0-90° of pain free passive motion. Active motion on the right lower extremity was limited to 0-15° of motion. At that time, the patient's right leg was placed in a free knee Mobilizing Brace and bilateral passive motion began (<a href="/files/original/0be90617be2197739e9b7215c50adcc4.jpg">Fig. 17</a>). Right leg motion progressed to 0-90° passive motion in four days, while the left leg was maintained in the 0-90° range. (This passive motion device, providing bilateral application from one power source, can be adjusted for varying degrees of motion independent of each other by varying the tension on the attachment lines.) Ambulation training began utilizing the bilateral Mobilizing Braces with drop locks in position (<a href="/files/original/cdf2e11044f459004d4cc3bea3571520.jpg">Fig. 18</a>). The patient was fully ambulatory with this system, achieved full range of active motion in ten days, and was discharged. Passive motion was maintained for a longer period than normal due to the degree of articular damage to the patellas. <h3>Summary</h3> Passive range of motion has proven itself as a useful treatment modality for increasing or maintaining range of motion of the hip, knee, ankle, shoulder, and elbow. Clinically, we have observed improved wound healing and reduction of edema. Septic joints that are or have been opened and drained appear to clean up sooner than joints treated with only incision and drainage (I & D) and daily whirlpool. Patients are comfortable with reduced requests for pain medications. Patients also seem happier and this may be due to the fact that something is being done to help them get better on a continuous basis. Therapy time can now be devoted to improving muscle control and independent activity levels rather than painful ROM exercises. Of the 168 cases presented in this paper, all but two patients did or would have benefited from passive mobilization. The degree of success depended to a large extent on patient compliance. All patients who cooperated with this treatment modality improved their motion and reduced their hospitalization with two exceptions. One patient had undergone total knee replacement and was placed in CPM in the recovery room. Approximately 20° of motion was achieved initially. All attempts to increase her motion failed in that the 3D device would stall at a given point and reverse itself. The referring physician was contacted in order to report the difficulties. It was learned that the patient, some 40 years earlier, had undergone a spontaneous hip fusion probably due to infection. Conventional CPM can not be utilized for ROM of the knee if the hip is immobilized. The second failure was with a young sickle cell disease patient also having severe sepsis of the knee. All attempts of passive mobilization were painful and limited to less than 30° of flexion. The patient underwent arthrodesis of the knee and was later discharged with granulating wounds. Patients with fractures involving articular surfaces of the knee have done well with 0-90° of pain free active motion obtained in generally less than ten days. Depending on the degree of internal fixation or patient compliance, a cast brace was applied prior to discharge. As stated earlier, cast bracing and passive mobilization is a common treatment modality. References: <ol> <li>Burks. R.. Daniel. D,. and Losse. G.. "The effect of continuous passive motion on anterior cruciate ligament reconstruction stability." Amer. J. Sports Med., 212:323, 1984.</li> <li>Coutts, R.D., Toth C., and Kaita J.H., "The role of continuous passive motion in the rehabilitation of the total knee patient." Total knee arthroplasty-a comprehensive approach. Hungerford D. ed.. Baltimore: Williams & Wilkins, pp. 126-32. 1983.</li> <li>Dehne. E., Torp, R.P., "Treatment of joint injuries by immediate mobilization," Clin. Orthop. 77:218, 1971.</li> <li>Frank, C., Akeson, W.H., Woo, S.L.Y., Amiel, D., and Courts. R., "Physiology and therapeutic value of passive joint motion." Clin. Orthop., 100:113-125, 1984.</li> <li>Korcok, M., "Motion, not immobility, advocated for healing of synovial joints," J.A.M.A., 246:2005, 1981.</li> <li>Lynch, J.A., et al., "Continuous passive motion: A prophylaxis for deep venous thrombosis following total knee replacement," Scientific paper 143, AAOS 51st. meeting, 1984.</li> <li>Muller, "Influence of Training and of Inactivity on Muscle Strength." Arch. Phys. Med. Rehab., 51:449, 1970.</li> <li>Mooney, V., and Ferguson, A.B., "The influence of immobilization and motion on the formation of fibrocarti-lage in the repair granuloma after joint resection in the rabbit." J. Bone Joint Surg., 48A:1145, 1966.</li> <li>O'Driscoll, S.W., Kumar, A., and Salter, R.B., "The effect of continuous passive motion on the clearance of a hemarthrosis from a synovial joint: An experimental investigation in the rabbit," Clin. Orthop., 176:305-11, 1983.</li> <li>Perry, C.R., Evans, L.G., Rice, S., Fogarty, J., and Burdge, R.E., "A new surgical approach to fractures of the lateral tibial plateau," J. Bone J. Surg., 66A:1236, 1984.</li> <li>Richardson, W.J., and Garrett, W.E., Jr., "Clinical use of continuous passive motion," Contemp. Orthop., 10:75-79, 1985.</li> <li>Salter, R.B.: Presidential address, Canadian Orthopaedic Association, Halifax, N.S. J. Bone Joint Surg. 64B:251, 1982.</li> <li>Salter, R.B., and Hamilton, H.W., "Clinical application of basic research on continuous passive motion for disorders and injuries of synovial joints: A preliminary report of a feasibility study," J. Orthop. Research, 1:325-342, 1984.</li> <li>Schebel, B.E., and Evans, J.P. "The use of continuous passive motion in the rehabilitation of total knee artho-plasty," Scientific poster, AAOS 52nd meeting, 1985.</li> <li>Steinberg, F.U., The Immobilized Patient, New York, Plenum, 1980.</li> <li>Strang, E.L., and Johns, J.L., "Nursing care of the patient treated with continuous passive motion following total knee arthoplasty," Orthop. Nursing, 3:27-32, 1984.</li> </ol> *Mel Stills, C.O. Mel Stills, CO., Instructor, Orthopedics, South Western Medical School, 5323 Harry Hines Boulevard, Dallas, Texas 75235. *Dwain R. Faso, C.O. Dwain R. Faso, CO., Manager, Research and Development, 3D Orthopedics, 11126 Shady Trail, Dallas, Texas 75229. Page Number(s) 7 - 19 Year 1985 Volume 9 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-14.jpg Figure 15 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-15.jpg Figure 16 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-16.jpg Figure 17 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-17.jpg Figure 18 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-18.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Passive Mobilization: An Orthotist's Overview Creator An entity primarily responsible for making the resource Dwain R. Faso, C.O. * Mel Stills, C.O. * https://staging.drfop.org/files/original/557e23aa1d087b7c2f923c835fba0ffc.pdf ad1cf6296e80bdb87d62d1953933265f 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/1979_04_004.pdf Text Any textual data included in the document <h2>Phantom Limb Pain</h2> <h5>Gustav Rubin, M.D., FACS <a style="text-decoration: none;">*</a></h5> This article is reprinted with authors permission from the Feb. 1979 issue of "The Amp." Doctor Rubin discusses Phantom Limb Pain on a basic and objective level that is easily understandable, especially to the amputee. This column was prompted by a letter from John Riegel, N.S.O., of Cleveland, Ohio. Let me expand on some of the points he wanted discussed. First: A definition of terms. Phantom Sensation is the feeling that the absent limb is still there but not necessarily painful. Phantom pain is the same feeling but the absent limb (or part of it) is painful. Almost every amputee experiences phantom sensation but statistically only five to ten percent have varying degrees of phantom pain. Second: Some of my medical colleagues still think that this type of pain is imagined by the amputee. It is not. It is a very real pain and can sometimes be so severe and continuous as to be disabling. However, in the great majority of instances it is intermittent, although it may last for days (and nights) at a time. Third: The cause and cure are unknown, just as the cause and cure of the common cold, and even cancer, are unknown. We have difficulty satisfactorily treating such ordinary conditions as chronic arthritis and severe flat feet, so the difficulty in adequately treating phantom limb pain should not be surprising. Fourth: The Cause. There are many theories about the cause. None is completely explanatory. As a working basis, the theory most acceptable to me is based on the fact that there is an area in the central nervous system which is a sort of way-station for messages on the way to our consciousness where they can be interpreted, in this specific case, as pain. Signals can either go up from the absent limb, or down from the conscious part of the brain (cortex) and affect the way-station. Sometimes if an amputee talks about or thinks about phantom pain he will trigger an episode. The signals that go up can be described as either "excitatory" or "inhibitory." These terms require no explanation. The inhibitory effect is partly maintained by messages from the skin. If a leg is amputated then a large part of the inhibitory messages that would ordinarily come from the skin of that part will be absent. The excitation messages will dominate and pain could be experienced. A way of thinking about the effect of inhibitory messages from the skin could be exemplified by the instance of the person who bumps his shin and then rubs the skin over a broad area to relieve the pain. He sends skin inhibitory messages to the brain to relieve the pain. Fifth: Treatments. Many different methods of treatment have been used. It is a simple fact that, when there are many ways to treat a condition, not one of them is much good. If there was one good way that would be the method used. Treatments attempted have ranged from the use of a freezing spray, to injections of novocaine, either locally or into the lower spine, cutting the nerves to the stump, cutting the roots of the nerves near the spinal cord, cutting the nerve pathways in the spinal cord itself, and even cutting out parts of the brain. Drugs, acupuncture, biofeedback, hypnosis, electrically stimulated implants around the nerve or in relation to the spinal cord; and even reamputation have been employed as methods of treatment. The most recent, and, at this writing, the most popular approach has been the use of transcutaneous electrical nerve stimulation (TNS or TENS). In contrast to many of the other previously mentioned methods it is harmless to the amputee. It is not destructive. Sometimes wrapping the stump tightly with an Ace bandage or percussing the stump will help. Putting the leg back on will often help. As one amputee said he wraps the stump and just "lies there and curses." If the pain in unrelieved by simple, non-destructive, non-damaging techniques, the amputee should be referred to one of the highly specialized pain centers. There are now many of these throughout the country. *Gustav Rubin, M.D., FACS V.A. Prosthetics Center <div style="width: 400px;"></div> Page Number(s) 4 - 5 Year 1979 Volume 3 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 Phantom Limb Pain Creator An entity primarily responsible for making the resource Gustav Rubin, M.D., FACS * https://staging.drfop.org/files/original/ea5cb965d7cc12d8d6b0c436964b44d9.pdf e5e3dd0a8d1c47e6d18a93f0e7dde31d https://staging.drfop.org/files/original/eb8ca65bd9a979fad277a91a57b0e631.jpeg 43dae3e86044e9e9337edfa12f8d523c https://staging.drfop.org/files/original/b99d31ef707acfb4cb39459306f929ae.jpg 1f0a63be299196ddf613145c782f8bb2 https://staging.drfop.org/files/original/fac91bdfc7e7039cf0393d7300667e49.jpg 4f4ff35f2fa8689775893928003e2f4d https://staging.drfop.org/files/original/17601e26a1ee85e6b6d571785e2d2278.jpg b0ffbc512dbf96e101590a70c9834f21 https://staging.drfop.org/files/original/3c565e3e3e82d1e16dd0bc2c8487a402.jpg edc1b0783e1722653e72676e255cecdc https://staging.drfop.org/files/original/f60360f716924225bb6b1b92e24d5971.jpg ccb584ca57daf2499edbf1d0c9c55314 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_004.pdf Text Any textual data included in the document <h2>Physical Therapy and Hydraulic Knee Units</h2> <h5>Bernice Kegel R.P.T. <a style="text-decoration: none;">*</a></h5> Without a thorough understanding of the principles of operation and functional benefits engineered into the sophisticated hydraulic knee mechanisms, the therapist will be unable to help the amputee gain maximum benefits and use the system effectively. It is important that the prosthetist ascertain that the therapist knows what adjustability is incorporated into the prosthesis. Much of the adjustment will be done during dynamic alignment at the prosthetic facility, but modifications will need to be made as the patient gains confidence and his ambulation pattern improves. An understanding of the fundamental differences between hydraulic control and mechanical friction will help in training the amputee to take full advantage of the flexibility of hydraulic mechanisms. Amputees can walk over a wide range of cadences instead of being limited as with mechanical friction. There are two reasons for this. First, hydraulic friction increases with speed to balance the increase in kinetic energy of the prosthesis while mechanical friction remains essentially constant. The programmed hydraulic characteristics give little frictional resistance during initial extension and flexion but build to a peak at terminal flexion and extension. This helps to provide a natural appearing gait regardless of cadence. The stability of hydraulic systems permits alignment nearer the trigger point and thus results in less energy expenditure required for walking. If a patient has previously used a mechanical knee, he needs to be reminded that no exaggerated residual limb motion is necessary to gain adequate flexion and extension of his hydraulic prosthesis. For purposes of brevity, I will limit my discussion to gait training with one knee unit-the Mauch S-N-S (Fig. 1). The Mauch S-N-S knee unit can be set to provide 3 functions: <a href="/files/original/eb8ca65bd9a979fad277a91a57b0e631.jpeg">Figure 1</a>. Cutaway diagram of the Mauch Unit <ol> <li> Swing and Stance phase control. </li> <li> Swing phase control only. </li> <li> Manual knee lock. </li> </ol> A stirrup shaped lever near the top of the piston rod operates as a selector switch. When the lever is in the down position, swing and stance control are both operative. This would be the adjustment chosen for normal walking. The major advantage of stance control is that it offers the patient stumble recovery. If the prosthetic knee buckles, it will give way slowly enough that the patient should be able to regain his balance before falling. When training a patient with a conventional knee unit, he is taught to forcefully contract his hip extensors late in swing phase to accelerate the shank forward (with resulting terminal impact) to ensure extension of the knee at heel strike. Amputees wearing fluid-controlled mechanisms need not do this. The amputee should be instructed to swing his thigh forward, decelerate it, and end the movement with the residual limb pointing to the point on the ground where the heel should strike. The shank, aided by the built-in extension bias will swing forward smoothly, and at heel strike will be in full extension. With the stance phase control engaged, the prosthetic knee will be stable in the initial portion of stance phase without forceful extension of the hip musculature being necessary. The feature makes gait training markedly easier. It is extremely important during the end of stance phase on the prosthetic side that the hip be ahead of the knee and weight on the ball of the foot. This hyperextension moment is necessary to disengage the stance phase control momentarily and allow the knee to bend freely in swing phase. If the amputee does not exert this hyperextension for 1/10th of a second, he might experience difficulty in flexing the knee to begin swing phase. When walking on soft ground, it is even more important to exert this hyperextension moment. The benefits of stance control are also used when walking down stairs and ramps in a step-over-step manner. This ability to walk down steps in a step-over-step manner rather than one step at a time or by jack-knifing is one of the key advantages of the Mauch knee unit. The patient needs to be taught to place his prosthetic heel on the lower step with the forefoot extending beyond the edge of the step (Fig. 2). He is then told to flex his hip forward while simultaneously putting weight on the prosthetic leg. This will cause a controlled bending of the prosthetic knee. As the prosthetic knee yields, the sound leg is brought forward and placed on the lower step. If the patient has to wait for the prosthetic knee to bend, then stance phase resistance is too high and should be reduced. This activity is probably the most difficult to teach an amputee, especially if he has used a conventional knee unit in the past. This same technique is used for going down ramps. When walking up steps and ramps the same techniques are used as in conventional training. <a href="/files/original/b99d31ef707acfb4cb39459306f929ae.jpg">Figure 2</a>. Correct placement of the prosthetic heel When sitting down in a chair, the patient can either use the weight bearing resistance of the S-N-S unit to control the rate of sitting, or release the stance phase control and use the sound leg to control sitting rate in the same fashion as with a conventional knee unit. How quickly the knee bends under weight is determined by the stance adjustment screw, which is turned with a 22mm Allen wrench (Fig. 3). The adjustment is extremely sensitive with a range of only 120 degrees. Slowest bending and maximum stability is obtained with a full clockwise adjustment. Most patients like to start with a high degree of stability. <a href="/files/original/fac91bdfc7e7039cf0393d7300667e49.jpg">Figure 3.</a> Allen wrench inserted into the stance adjustment screw To eliminate stance phase control the patient is told to stand with his prosthetic leg behind his sound leg. With weight on the toe of his prosthesis, he pulls the selector switch lever up (Fig. 4). This mode would be used for bicycling and other activities needing a free swinging leg. Swing resistance is adjusted by moving the serrated cap. The verticle black line under the serrated cap is the extension resistance marker. When the black line is all the way to the right (4 o'clock) extension resistance is lowest, and all the way to the left (8 o'clock) is the maximum setting. A good resistance for beginning walking would be at 5 o'clock (Fig. 5). <a href="/files/original/17601e26a1ee85e6b6d571785e2d2278.jpg">Figure 4</a>. Eliminating the stance phase control. <a href="/files/original/3c565e3e3e82d1e16dd0bc2c8487a402.jpg">Figure 5</a>. Good resistance settings for beginning walking. The same serrated cap that adjusts extension resistance also adjusts flexion resistance. When the "H" in the word HYDRAULIC is over the line marker (regardless of the position of the line marker), flexion resistance is lowest. "K" over the marker indicates maximum resistance. A good resistance for beginning walking is at the "D" position (as shown in Fig. 5). To engage the knee lock, the selector switch is pulled into up position with the knee flexed and bearing no weight (Fig. 6). The knee may now be extended from this flexed position, but increased flexion is not possible. <a href="/files/original/f60360f716924225bb6b1b92e24d5971.jpg">Figure 6</a>. Engaging the knee lock. A right-legged amputee might choose to lock the prosthetic knee while driving and pressing the pedal by a forward motion of the hip. For standing at work for any length of time or while standing on a bus, the amputee could be taught to lock his knee. The Mauch S-N-S units have also been successfully used by bilateral amputees. The two units are likely to be adjusted differently because different residual limb lengths call for different resistance settings. The patient should be taught that the hydraulic unit may require servicing every one to two years. He should also be told that small amounts of air in the hydraulic system are no reason for concern. An automatic selfbleeding feature will eliminate the air after he walks a few steps, or if he bends the knees several times before applying the prosthesis. The leg should be stored upright with the knee fully extended so that air does not enter the hydraulic spaces. References: <ol> <li>Kegel, B., Byers, J.L., "Amputee's Manual-Mauch S-N-S Knee." Medic Publishing Co., P.O. Box 1636, Bel-levue, WA 98009, 1977.</li> <li>Lewis, E.A., "Elements of Training with the Mauch S-N-S System for Above-Knee Amputees." Research and Development Division, Prosthetics and Sensory Aids Service, Veterans Administration, 252 Seventh Avenue, New York, New York 10001.</li> <li>Lewis, E.A. and Bernstock, W.M., "Clinical Application Study of the Henschke-Mauch Model A Swing and Stance Control System." Bulletin of Prosthetics Research Fall, 1968.</li> <li>Mauch, H.A., "Stance Control for Above-Knee Artificial Legs-Design Considerations in the S-N-S Knee." Bulletin of Prosthetics Research, Fall 1968.</li> <li>Knee Prostheses, Mauch Laboratories, Inc., 3035 Dryden Road, Dayton, Ohio 45439, January 1974.</li> <li>Murphy, E.F., "The Swing Phase of Walking with Above-Knee Prosthesis." Bulletin of Prosthetics Research, Spring 1964.</li> <li>Staros, A. and Murphy, E.F., "Properties of Fluid Flow Applied to Above Knee Prostheses." Bulletin of Prosthetics Research, Spring 1964.</li> </ol> *Bernice Kegel R.P.T. Seattle, Washington Page Number(s) 4 - 7 Year 1983 Volume 7 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-6.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 Physical Therapy and Hydraulic Knee Units Creator An entity primarily responsible for making the resource Bernice Kegel R.P.T. * https://staging.drfop.org/files/original/14dab09afcbc5615d309c124ec22c656.jpg 348f6b53ce5be2f3269878e017aa45ed Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. URL www.physiciansforpeace.org Contact Name/Title Ron Sconyers - Director Address 500 East Main St. Suite 900 City Norfolk State/Province Virginia Countries Served USA Regions: Central America, Middle East, AsiaCountries: Turkey, Dominican Republic, Jordan, Iraq, Guatemala, Haiti, PhilippinesSpecific cities, regions, or groups of people: Santo Domingo, Guatemala City, Basra, Amman, Port-au-Prince, Manila, Diyarbakir, AdanaAge Group: Adults, ChildrenFees Charged: Sometimes Postal Code 23510 Phone 757-625-7569 Email info@physiciansforpeace.org Organization Type Including ID and tax status Non-profit Tax ID 54-1532165 Not-for-profit Type 501(c)(3) Services Provided Prosthetic Fitting, Orthotic Fitting, Medical Equipment / Supplies, Education, Prosthetic Fabrication, Orthotic Fabrication, Rehabilitation / TrainingThere is a facility/physical building for patient care at the specified location. Accomodations for volunteers near or at the specified location. Need I Financial Assistance Need II Volunteers: Prosthetists, Orthotists, Physicians, Therapists Need III Materials, Components, and Equipment: New, Disassembled, Equipment, Used, Medical Supplies 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 Physicians for Peace https://staging.drfop.org/files/original/f84bb0c475ca9d030e23df9e4e80658d.pdf 94375248bcccdaeab873ef4e4c97c777 https://staging.drfop.org/files/original/6ec0d5b59e7d232d595707c15372a97c.jpg de00e861806273a4296343544b6bf106 https://staging.drfop.org/files/original/15c0eaaa0b4778e274016ee3e4f0eaef.jpg 2a616dc0bb2ebcf0e39110254f7214fe https://staging.drfop.org/files/original/5349fa590d8d8b526c3f243a7bd1bdd1.jpg f22b164a89f5fea857cfaad0f802eacc https://staging.drfop.org/files/original/cab9f2ad9f641a085d9079b6e82bbc7e.jpg 98f7040eb022de51e27dbc7ee91ab790 https://staging.drfop.org/files/original/544d0554c74d2d5950384e2e1dfd6aff.jpg 559149ef240dff1d7a44a72d9e261ebf https://staging.drfop.org/files/original/cbd70b676214f45b70d3cf9ff79514fd.jpeg 355eedf11c055b25646f742ec329eb73 https://staging.drfop.org/files/original/9872c7817353817cc6a62cc57c60d007.jpeg f54103ca4b7342b6319599df2a9f0aeb 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_003.pdf Text Any textual data included in the document <h2>Plastic Ankle-Foot Orthoses: Indications and Functions</h2> <h5>H. Richard Lehneis, Ph.D., C.P.O. </h5> Prescription of plastic ankle-foot orthoses at the Institute of Rehabilitation Medicine, New York University Medical Center (IRM-NYUMC) has, over approximately the past 12 years, been based on the identification of a pathomechanical condition affecting the ankle-foot complex for the purpose of matching that condition with a bio-mechanical device (plastic ankle-foot orthosis). Over the years, this basic system has been improved to include modifying factors such as spasticity and sensory status.  Table I. <img src="/files/original/6ec0d5b59e7d232d595707c15372a97c.jpg" p="" /> Table II.<img src="/files/original/15c0eaaa0b4778e274016ee3e4f0eaef.jpg" nbsp="" represents="" an="" elaboration="" of="" the="" system="" in="" describing="" addition="" to="" indications="" bio-mechanical="" actions="" each="" ankle-foot="" orthosis="" as="" well="" contraindications="" afo="" s="" described="" is="" shown="" b="" /> Fig. 1, Fig. 2, Fig. 3, Fig. 4, and Fig. 5. <a href="/files/original/5349fa590d8d8b526c3f243a7bd1bdd1.jpg">Figure 1.</a> Posterior Leaf Spring Ankle Foot Orthosis. <a href="/files/original/cab9f2ad9f641a085d9079b6e82bbc7e.jpg">Figure 2</a>. Hemi Posterior Leaf Spring Ankle Foot Orthosis. <a href="/files/original/544d0554c74d2d5950384e2e1dfd6aff.jpg">Figure 3</a>. Spinal Ankle Foot Orthosis. <a href="/files/original/cbd70b676214f45b70d3cf9ff79514fd.jpeg">Figure 4</a>. Hemi Spiral Ankle Foot Orthosis. <a href="/files/original/9872c7817353817cc6a62cc57c60d007.jpeg">Figure 5</a>. Posterior Solid Ankle Foot Orthosis. Table I and Table II have been used successfully in the training of physicians, orthotists, therapists, and other health-related personnel. We hope that the readers of the Newsletter find these tables useful in their respective clinics to clarify indications and contraindications for the various AFO's. Page Number(s) 3 - 6 Year 1980 Volume 4 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1980_02_003/1980_02_003-3.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1980_02_003/1980_02_003-4.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1980_02_003/1980_02_003-5.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1980_02_003/1980_02_003-6.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1980_02_003/1980_02_003-7.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 Plastic Ankle-Foot Orthoses: Indications and Functions Creator An entity primarily responsible for making the resource H. Richard Lehneis, Ph.D., C.P.O.