11 20 371 https://staging.drfop.org/files/original/ee61dd08d73b1cad17151d32ba21665a.pdf 00de1488d4f6818f709108234fc1fd5a https://staging.drfop.org/files/original/30c5fecef8a972c9d044dc4d99f003e8.jpg 51ba0ecca6e54631dcd919a2c26a692f https://staging.drfop.org/files/original/1ea58d09d331e165282d3da5cc9f227d.jpg bf16b3b914da6223c95f0a83bf29956b https://staging.drfop.org/files/original/4fd62f8f90674af658c40281e2d37b8a.jpg f7926bbf8fc79875b7a3224beafaffed 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_01_002.pdf Text Any textual data included in the document <h2>Plastics in Lower-Limb Orthotics</h2> <p>Polypropylene has been in use for lower-limb orthoses in various parts of the U.S. and Canada for more than 5 years. Although polypropylene itself was introduced and used in orthotics slightly before vacuum forming was introduced, most of the fabricators have used this technique in fabrication. Some AFO designs are being offered "off-the-shelf" in a series of sizes. Some suppliers stress that the purpose of these prefabricated units is to determine if the patient will benefit from a custom made device or devices.</p> <p>A partial bibliography on the use of plastics in orthotics is included on this page.</p> <p>We invite readers of the Newsletter to give us the benefit of their experiences with respect to both custom-made designs and off-the-shelf units by filling out the questionnaire on page 3 and returning it to AAOP, 1444 N Street, N.W., Washington, D.C. 20005. You are asked to be as complete as possible in the information you give so that meaningful conclusion can be obtained. If additional space is needed please use a blank piece of paper and attach it to the original.</p> <p><a href="/files/original/30c5fecef8a972c9d044dc4d99f003e8.jpg"><b>Fig. 1</b></a>, <a href="/files/original/1ea58d09d331e165282d3da5cc9f227d.jpg"><b>Fig. 2</b></a>, <a href="/files/original/4fd62f8f90674af658c40281e2d37b8a.jpg"><b>Fig. 3</b></a></p> <p><b>References:</b></p> <ol> <li>Artamonov, Alex, <i>Vacuum forming of sheet plastics</i>, ISPO Bulletin, No. 4, October 1972</li> <li>Casson, Jerry, <i>Advanced designs of plastic lower-limb orthoses</i>, Orth. and Pros. 26:3, September 1972</li> <li>Cohen, Samuel, and Warren Frisina, <i>Polypropylene spiral ankle-foot orthosis</i>, Orth. and Pros., 29:2, June 1975</li> <li>Demopoulos, James T. and Johne E. Eschen, <i>Experience with plastic patellar-tendon-bearing orthoses</i>, Orth, and Pros. 28:4, December 1974</li> <li>Dixon, Malcolm, and Robert Palumbo, <i>Polypropylene knee orthosis with suprapatellar latex strap</i>, Orth, and Pros., 29:3 September, 1975</li> <li>Engen, Thorkild J., <i>The TIRR poly-propylene orthoses</i>, Orth. and Pros. 26:4 December 1974</li> <li>Glancy, John and Richard E. Lindseth, <i>"The polypropylene solid-ankle orthosis,"</i> Orth and Pros. 26:1, March 1972</li> <li>La Torre, Richard R., Michael Richards, and Sooklall Ramcharran, <i>Ischial-thigh-knee-ankle orthosis</i>, Orth, and Pros. 27:4, December 1973</li> <li>Lehneis, H. R., <i>New concepts in lower-extremity orthotics</i>, Med. Clin, of NA.A. 53:3:585-592, May 1969</li> <li>Lehneis, Hans Richard, Warren Frisina, Herbert W. Marx, and Tamara T. Sowell, <i>Bioengineering design and development of lower-extremity orthotic devices</i>, Bull. Pros. Res., BPR 10-20, Fall 1973</li> <li>Lehneis, Hans Richard, <i>Plastic spiral ankle-foot orthoses</i>, Orth, and Pros. 28:2, June 1974</li> <li>Marx, Herbert W., <i>Lower-limb orthotic designs for the spastic hemiplegic patient</i>, Orth, and Pros. 28:2, June 1974</li> <li>Rice, Edward, <i>A new design for the drop-foot polypropylene orthosis</i>, ISPO Bulletin No. 12, October 1974</li> <li>Rubin, Gustav, and Michael Danisi, <i>A knee-stabilizing ankle-foot orthosis with adjustable spring-loaded ankle</i>, Orth, and Pros. 29:3, September 1975</li> <li>Rubin, Gustav and Michael Danisi, <i>A "slip" cuff for ankle-foot orthoses-a piston-action absorbing polypropylene orthotic cuff</i>, Orth, and Pros. 28:1, March 1974</li> <li>Simons, Bernard C, Robert H. Jebsen, and Louis E. Wildman, <i>Plastic short leg brace fabrication</i>, Orth, and Pros. 21:3, September 1967</li> <li>Rubin, Gustav, and Robert L. Palumbo, <i>A polypropylene knee-ankle orthosis</i>, ISPO Bulletin No. 8, October 1973</li> <li>Sarno, J. E., and H. R. Lehneis, <i>Prescription considerations for plastic below-knee orthoses</i>, Arch. Phys. Med. and Rehab., 52:11:503-510, November 1971</li> <li>Stills, Melvin, <i>Thermoformed ankle-foot orthoses</i>, Orth, and Pros. 29:4, December 1975</li> <li>Stills, Melvin, <i>Vacuum-formed orthoses for fracture of the tibia</i>, Orth, and Pros., 30:2 June 1976</li> <li>Titus, Bert R., <i>A patellar-tendon-bearing orthosis</i>, Orth, and Pros. 29:1, March 1975</li> <li>Wilson, A. Bennett, Jr., <i>Vacuum forming of plastics in prosthetics and orthotics</i>, Orth. and Pros. 28:1, March 1974</li> </ol> Page Number(s) 2 - 2 Year 1977 Volume 1 Issue 1 Figure 1 https://staging.drfop.org/files/original/30c5fecef8a972c9d044dc4d99f003e8.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1977_01_002/1977_01_002-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 3 http://www.oandplibrary.org/cpo/images/1977_01_002/1977_01_002-3.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Plastics in Lower-Limb Orthotics https://staging.drfop.org/files/original/d586b041111b65540684d82a6e22f061.pdf e776f2fafbdbd45711ced14b11af8203 https://staging.drfop.org/files/original/a6c4aeadeff6b0f8ec45aad1761417bc.jpg 0335be700fe81e4e50cc3fa690fb418f https://staging.drfop.org/files/original/9621cce0bb9d571026c1d68d6c3bfdea.jpg e4ea4687449f451e36041c2e86b31857 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_02_001.pdf Text Any textual data included in the document <h2>Plastics in Lower-Limb Orthotics</h2> <p>Our October 1976 Issue of the Newsletter discussed "Plastics in Lower-Limb Orthotics" and requested information from our readers as to their experiences and preferences. The following is the results of the questionnaire on this subject.</p> <p><a href="/files/original/a6c4aeadeff6b0f8ec45aad1761417bc.jpg"><b>Fig. 1: <span>Fitting the Molded Plastic AFO.</span></b></a></p> <h3>Results of the Questionnaire and a Discussion of the Results</h3> <ol> <ol> <li> <p><i>Does your clinic use custom made orthoses formed from sheet thermoplastic material?</i></p> <blockquote> <p>YES - 71<br />NO - 2</p> </blockquote> <p>One of the respondents who answered "NO" is an institution that treats only amputees. The other "NO" came from an orthotics facility in New England who gave as the reason "We use Ortholene blanks and laminated AFO's."</p> </li> <li> <p>If the answer is "Yes" please name the materials used and show opposite the types of appliances made from the particular material.</p> <p>The responses to this question are shown in this <b>Table</b>.</p> </li> </ol> </ol> <img src="https://staging.drfop.org/files/original/9621cce0bb9d571026c1d68d6c3bfdea.jpg" /> <ol> <li> <p><i>Do you use preformed "off-the-shelf" AFO's?</i></p> <p>Thirty-one used preformed or "off-the-shelf" AFO's. Thirty-six who also used molded AFO's did not use "off-the-shelf" AFO's. Most of the respondents who used the preformed AFO's stipulated that the use was limited to initial trials or to those relatively few patients that could be fitted adequately. Those that refused to use the preformed unit felt that the better results obtained by custom molding was worth any extra effort necessary.</p> </li> <li> <p><i>Please give the reasons for the answer you gave to question "3".</i></p> <p>Some typical responses were:</p> <blockquote> <p>"They (preformed) will work on some patients....."</p> <p>"Use (preformed) on easy to fit patients or those not needing the extra support."</p> <p>"If the doctor specifically prescribes (preformed), or if the patient insists after explaining the advantages and disadvantages."</p> <p>"I use preformed AFO's for pes equinus only. I use custom made for all other orthotic treatment."</p> <p>"Because (preformed are) no good; have to reheat and mold to have work properly, so may as well start from scratch and make your own."</p> <p>"Fitting difficulties - sizes do not fit many patients who are edematous, atrophied, or need support."</p> <p>"They don't fit."</p> <p>"Doctors prefer custom-made."</p> </blockquote> </li> <li> <p><i>If you provide molded plastic orthoses, what type of equipment do you use in fabrication?</i></p> <p>The answers given were not always clear but it appears that:</p> <blockquote> <p>35 used a vacuum machine of one type or another<br />19 used hand drape with vacuum<br />14 used hand drape without vacuum<br />8 used central fabrication</p> </blockquote> <p>Some facilities used more than one method, thus accounting for a total greater than the number of respondents that use custom formed orthoses. About the only conclusion that can be drawn from these figures is that vacuum machines are probably worth the investment.</p> </li> <li> <p><i>Please give your opinions about the usefulness of sheet thermoplastics in orthotics.</i></p> <p>Nearly every respondent answered this question in some detail. Most cited lightness and cosmetic benefits.</p> <p>Some typical comments:</p> <blockquote> <p>"We feel that this is the biggest advance in orthotics in the last few years, providing the patient with a lightweight, hygienic, orthotic system."</p> <p>"We feel that molded AFO's are far superior to conventional braces in every respect. Most of our orthoses are constructed using the materials and the patients and their physicians are most pleased."</p> <p>"I am able to obtain excellent fit and control with plastics that would not be possible with a leather-metal orthosis. Also, it is lighter and more cosmetic."</p> <p>"We find it has great adaptations to orthotics, with unlimited applications."</p> <p>"It's the only way."</p> <p>"These orthoses are useful for cosmesis, function, and light weight."</p> <p>"Unlimited potential, but discretion advised."</p> <p>"I feel we have uncovered a new dimension to orthotics and look forward to further developments in the future."</p> <p>"Enables orthotists to apply new ideas toward orthotics."</p> </blockquote> </li> <li> <p><i>Have you experienced problems with the quality of the sheet plastic material? If the answer is "Yes", please explain.</i></p> <p>Twenty five respondents indicated that they had experienced problems with the quality of sheet plastic, while 32 said that they have had no problems.</p> <p>Alan Finnieston of Miami, Florida, who has had a lot of experience in the use of the sheet plastics offers the following observations:</p> <blockquote> <p>"In answer to your question #7, we have had many difficulties with the quality of thermoplastic sheet material of various types. For example: Polypropylene, polyethylene, ABS, styrene, and polycarbonate to only mention a few. We have been involved with thermoplastics and the vacuum-forming field for approximately ten years.</p> <p>Orthotics and prosthetics cannot justify, by virtue of their volume, specific formulations of material to specifications. As an example, most Orthotists or Prosthetists are buying polypropylene on a local level through a distributor. The distributor has no means of controlling what material or formulation of polypropylene he is receiving. Polypropylene is available in homopolymer, copolymer, random or block, plus many variations of grades; extrusion, injection and film, with a multitude of modifiers which can vary specifications of the base material. One then must seek out the reputable extruder with high-quality equipment and technology. This eliminates the problem of the re-ground materials of unknown formulations plus regulation of the extrusion prices."</p> </blockquote> </li> <li> <p><i>Are special courses needed to provide orthotists and other members of the clinic team with training in the prescription, fabrication and fitting of molded plastic lower-limb orthoses? Please explain.</i></p> <p>Of the 73 respondents, only 2 said that they felt that special courses for orthotists and other members of the clinic team were not needed. One of these provided only "hard corsets" and "arch supports"; the other stated "No, not in lower limb orthotics, because the basic rationale is unchanged as is the function." An institution that provided only "hand splints" said "Registered occupational therapists who are trained in splinting in their academic and clinical education fabricate all splints in the clinic." One clinic and one orthotics facility <i>both of which provided molded AFO's</i> answered with a question mark, and another clinic did not respond to this question.</p> <p>However, the remaining 67 respondents felt quite strongly that special courses are needed if orthotists and other members of the clinic team are to make maximum use of the advantages afforded by sheet thermoplastics. The vast majority felt that all members of the clinic team should be offered training, but a few felt that formal training should be restricted to orthotists.</p> <p>Some of the responses are:</p> <blockquote> <p>"Yes, any further education is valuable to the entire team."</p> <p>"Yes - exchange of ideas would be very useful particularly concerning fabrication. I have been making vacuum formed molded orthoses for 2-1/2 years and I still find it useful to exchange ideas with others who do it; to get the bugs out."</p> <p>"Yes. It would be most help to attend a course in KAFO's."</p> <p>"Definitely. Many problems can be circumvented with previous training."</p> <p>"Yes, I believe this would be very helpful. I think this could be done in the curriculum of the schools already teaching Orthotics and Prosthetics. Seminars are helpful but only touch upon the surface. I think this area has already been covered in the last 5 years and needs more advance hands-on courses and experiences by physicians, therapists, orthotists and prosthetists."</p> <p>"Yes. So many doctors still want to use old methods."</p> <p>"Orthotists only should have courses, and then show the latest uses and methods. I feel that he should be the one to explain the advantages to the other team members."</p> <p>"I think courses stressing cast modification, preparation, hand layup, and fitting problems would be helpful to the whole team. Personally, I have seen all the vacuum layup films I can stand."</p> </blockquote> </li> </ol> <h3>Overall Conclusions</h3> <p>Thus, it seems obvious that sheet thermoplastics have a great potential in all aspects of orthotics and that appropriate education programs are needed and wanted.</p> <p>Alan Finnieston included in his reply an announcement that his firm intends to offer "a series of instructional programs on the correct use of plastics in contemporary orthotic practice" and suggests that those interested in attending contact him at 1901 N.W. 17th Avenue, Miami, Fla. 33125.</p> <p>The <i>results of this survey have been forwarded to the</i> formal education programs in this country and abroad with the hope that the faculties will be stimulated to initiate programs in this area.</p> Page Number(s) 1 - 4 Year 1977 Volume 1 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 1 http://www.oandplibrary.org/cpo/images/1977_02_001/1977_02_001-1.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 Plastics in Lower-Limb Orthotics https://staging.drfop.org/files/original/e9f6b0ca0af8a979b6d3b20f2d9bf767.pdf 1bf7ecb945d70a0277568f72c0dd60e4 https://staging.drfop.org/files/original/e15daffdfb1ccd3c85ae31f758316228.jpg c7dc78f031800bd557e5e56886799610 https://staging.drfop.org/files/original/d7ecccb8dead833240dffb959177354c.jpg c31f94bc12db418af7fb09b67b391776 https://staging.drfop.org/files/original/443471c199b97e3910f5097fdeb8663e.jpg 4d1970fb7af2dcebb6d5aab2f7a0cf6c https://staging.drfop.org/files/original/8dbf7c64f23ae2955b3479bbb5fb302b.jpg 6b10e90231ab54505b1f29f0b21d1b18 https://staging.drfop.org/files/original/3a7c493869b8831afd00e9855e6c13ed.jpg f1fadc470bf7c0e5e704d5a587bda07f https://staging.drfop.org/files/original/eafcf91b4f973afa24add247a75817cf.jpg ea25252f54c00432d4ae8cdacd36ceb0 https://staging.drfop.org/files/original/eaea3592bc911874251c428e1ed0160b.jpg c21941b7ba4a91a5aa35d3e543daa7b1 https://staging.drfop.org/files/original/c585a3d3e836903584dba11878c0eac4.jpg 27ffd0226c847cdedb8ccf353f198219 https://staging.drfop.org/files/original/d7bd659b04aae888f075c506f9f1384c.jpg 53058ebbcd650e261bf37943275d6def https://staging.drfop.org/files/original/c54a555fdecec535e9a9d65b05a7edad.jpg bb55f6b1b0e326f1b85948db260a2740 https://staging.drfop.org/files/original/8cd98250a947dc0e83ffe62feb4ce885.jpg 88a53d4cfc08a94c502625bde4132277 https://staging.drfop.org/files/original/df58327f0134c1887a1fbe9da76db215.jpg a1bcc591f0218b53b85af82918d4d5a3 https://staging.drfop.org/files/original/abfc8d66ef593ba1303fdceca612b1f7.jpg 3ab086cb4672a061b9c84c4f105a6734 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_017.pdf Year 1963 Volume 7 Issue 1 Page Number(s) 17 - 30 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_01_017.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_017.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Porous Plastic Laminates for Upper-Extremity Prostheses</h2> <h5>James T. Hill, C.E., B.S. <a style="text-decoration:none;">*</a><br />Fred Leonard, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p> The problem of perspiration and its removal from the amputee's arm and leg stumps encased in sockets has engaged the attention of the doctor and limb fitter for as long as limbs have been fitted. </p> <p> In the early days of leather prostheses, a few months of wear during the summer were sufficient to cause the leather to rot and degrade because of perspiration. Since it was not possible to wash leather prostheses easily, severe hygienic problems were created. Efforts to coat leather with plastic films to overcome this difficulty were only partially successful for, in many instances, the adhesion of the coating was poor and frequent re-coatings were necessary. With the development of the all-plastic arm, it became possible to wash the socket thoroughly and virtually eliminate the hygienic problem. However, because the plastic did not permit diffusion of water vapor, sweat gathered profusely in the socket and became a source of discomfort and irritation. Efforts to permit diffusion of sweat by drilling gross holes in the plastic socket were not very successful. Although this practice permitted greater removal of sweat than in undrilled prostheses, the strength characteristics were seriously affected when a sufficient number of holes were cut to permit adequate removal. In addition, there still remained between the holes impervious plastic which could block large numbers of sweat pores-approximately 155 per square centimeter on the forearm<a></a>-and permit puddling between the plastic and the stump. </p> <p> It appeared that for optimum socket ventilation a porous-plastic socket should be developed which contained a large number of interconnnected pores. Such a socket should permit rapid diffusion of sweat with minimal blocking of sweat pores. The porous laminate envisioned would consist of a layered fabric resin composite with unbridged voids between the filler strands. Such material should be easily cleaned by soaking in detergent, followed by flushing with water. The following design criteria were outlined for the desired socket material: </p> <ol> <li>The socket material should have a uniform distribution of minute pores which would result in high porosity without blockage of sweat pores. </li><li>It should be easily cleaned.</li><li>Porous socket fabrication should conform as closely as possible with well-known fabrication techniques current in the practice of upper-extremity prosthetics.</li></ol> <p> Procedures for preparing porous upper-extremity prostheses were developed, utilizing the design criteria as a guide. In general, the method comprised the use of a solvent or diluent with an epoxy resin. After initial cure had occurred, the solvent was permitted to evaporate by removal of the outer polyvinyl-alcohol (PVA) bag. </p> <p> A series of experiments determined the combination of diluent, curing rate, and other factors necessary to produce a laminate with the optimum ratio between porosity and strength.<a></a> Evaluation at New York University indicated that the procedure initiallv developed by the Army Prosthetics Research Laboratory produced a satisfactory material insofar as porosity and strength were concerned but that use of the conventional stockinet as filler produced rough surfaces that made cleaning difficult. Subsequent experiments at the Army Prosthetics Research Laboratory showed that this problem could be overcome by using a nylon stockinet of 200-denier Banlon knit (<b>Fig. 1</b>) for the outer and inner layers of the laminate and by the reapplication of a PVA bag at a critical time in the curing process. Further testing and development resulted in a practical technique which is described in detail in a manual prepared by the Army Prosthetics Research Laboratory.<a></a> Sockets fabricated in accordance with this manual have smooth surfaces and high porosities. Patients fitted with porous sockets have reported a definite increase in comfort as a result of improved ventilation.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Porous epoxy laminate made in accordance with the procedure developed at the Army Prosthetics Re search Laboratory. Magnification approximately 21X. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Laboratory tests have shown that porous epoxy laminates are not as strong in compression and tension as nonporous laminates, but that resistance to impact loads appears to increase with the porosity and reach a maximum at approximately 17 per cent of effective porosity.<a style="text-decoration:none;">*</a> In practice, the combination of physical properties possessed by the porous laminate which has been developed is satisfactory for use in arm prostheses. Experiments in the use of porous laminates for lower-extremity prostheses are under way. </p> <p> If actual prosthetist working time is considered, the man-hours required for fabrication of porous laminates are somewhat longer than those required for the conventional plastic laminates. Depending on the technique employed, the porous laminating process may take up to one-and-one-half times as long as the conventional technique. </p> <p> The components of the liquid resin system may elicit allergic reactions in certain sensitive individuals. Therefore, fabrication should take place in a well-ventilated area and protective gloves should be used in preparing the layup. </p> <p> No stump dermatitis or other adverse reactions have been reported from the use of the porous laminates to date. </p> <p> Because the socket is porous, it is necessary that it be cleaned thoroughly and often in order to preclude an accumulation of foreign matter in the pores of the wall. It is recommended that ordinary soap and water be used for this cleaning. </p> <p> Porous laminates may be considered for application to all upper-extremity amputation levels from below-elbow to shoulder-disarticu-lation. The technique is of particular value whenever perspiration presents a significant problem. </p> <h4> Epoxy-Resin Mixture </h4> <p>The following epoxy-resin system has been found to produce a satisfactory porous laminate:</p> <table> <tbody><tr> <td> </td> <td> </td> <td>parts by weight</td> </tr> <tr> <td>Epoxy resin    </td> <td>ERL 2795<a style="text-decoration:none;">*</a>or Epon 815<a style="text-decoration:none;">*</a>    </td> <td>65</td> </tr> <tr> <td>Curing agent</td> <td>Versamid 140<a style="text-decoration:none;">*</a></td> <td>35</td> </tr> <tr> <td>Solvent</td> <td>Trichloroethylene</td> <td>43</td> </tr> </tbody></table> <p> The "pot life" of the liquid resin mixture resulting from this formulation is never less than 30 minutes and usually considerably longer. </p> <p> The individual limb fitter can best determine the actual amount of resin mixture required for a particular lamination. Appendix A (page 29) contains a table which may serve as a guide in determining the correct amounts of materials for various applications. </p> <h4> Fabrication </h4> <p> Briefly described here is the fabrication of a double-wall, below-elbow, porous prosthesis, utilizing a plaster-of-Paris (or wax) buildup; this account is followed by a brief description of the fabrication of a single-wall, below-elbow, porous prosthesis, based on the Mylar<a style="text-decoration:none;">*</a> cone method.<a style="text-decoration:none;">*</a> </p> <h4> Double-Wall, Below-Elbow, Porous Prosthesis </h4> <p> For the fabrication of a double-wall, below-elbow, porous prosthesis, the stump model is prepared in accordance with common practice<a></a>. As shown in (<b>Fig. 2A</b>), the model is then placed in a vise, distal end up, and coated with a lacquer such as Hi-Glo.<a style="text-decoration:none;">*</a> When this coating has dried, a moistened sheet of PVA is stretched over the model and tied at the base (<b>Fig. 2B</b>). The next step in preparing the layup is to cut one length of tubular Banlon stockinet with a 200-denier weave<a style="text-decoration:none;">*</a> and three lengths of tubular orthopedic stockinet so that each is at least 6 inches longer than the stump model (<b>Fig. 2C</b>). The end of each piece of stockinet is sewed in a curve to match the distal end of the model, and the excess stockinet is trimmed at the sewed end. The Banlon stockinet is turned inside out and pulled down over the model (<b>Fig. 2D</b>). Two of the orthopedic stockinets are pulled down over this. Then the remaining piece of stockinet is turned inside out and pulled down over the layup. The stockinet is smoothed, pulled down tightly, and tied at the base. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Preparing the layup. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A PVA pressure sleeve is now prepared in the usual manner, pulled down snugly over the layup, and tied at the base rod (<b>Fig. 3A</b>). The layup is ready for impregnation, and it is time to mix the resin. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Applying the resin mixture. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> To measure the ingredients for the resin mixture, it is well to balance a disposable container, such as a paper cup, on a scale. The resin, curing agent, and solvent are then put in the cup in the proper amounts by weight. By referring to the table contained in Appendix A (page 29), it can be seen that the following quantities should be sufficient for a short below-elbow socket: </p> <table> <tbody><tr> <td>ERL 2795 (resin).................</td><td>45.5 grams</td> </tr> <tr> <td>Versamid 140 (curing agent)......</td> <td>24.5 grams</td> </tr> <tr> <td>Trichloroethylene (solvent)......</td> <td>30.0 grams</td> </tr> </tbody></table> <p>To this resin mixture should be added an appropriate pigment; for example, 2.5 grams of Caucasian epoxy pigment or 3.5 grams of Negroid epoxy pigment (Appendix A, page 29). The pigment is stirred into the mixture until it is uniformly blended. </p> <p> The resin mixture is poured into the open end of the PVA sleeve and worked down into the stockinet. Twisting the end of the sleeve (<b>Fig. 3B</b>) develops considerable force and aids in the impregnation. </p> <p> When the stockinet is fully impregnated, the PVA sleeve is pulled down, and the excess resin is "strung" down to the proximal end of the layup (<b>Fig. 3C</b>). Next, the PVA sleeve is cut and removed from the layup. Care should be exercised not to spill the excess resin contained in the bottom of the sleeve. The sleeve and the excess resin are discarded. Spilled resin may be cleaned off with isopropyl alcohol or trichloroethylene. The layup is "strung" with a heavy string until no further excess resin appears (<b>Fig. 3D</b>). </p> <p> The layup is now placed for 30 minutes in a pre-heated oven set at 115 deg. F (47 deg. C), for what is known as the pre-cure. During this stage, the solvent evaporates from the layup, leaving it porous. </p> <p> Upon completion of the pre-cure, the layup is removed from the oven, and the oven is set at 212 deg. F (100 deg. C) for the cure. At this step in the procedure, the solvent has evaporated and the resin has gelled slightly. If any areas of the laminate contain excess resin, the excess is "strung" to the proximal end. When the oven has reached a temperature of 212 deg. F (100 deg. C), the laminate is placed back in the oven for one hour. During this hour, the laminate will be cured sufficiently to permit the buildup for the outer socket. </p> <p> At the end of the hour, the laminate is removed from the oven, and the oven is set at 115 deg. F (47 deg. C). </p> <p> As soon as the laminate is cool enough to handle, a sheet of Saran-Wrap or rubber sheeting is placed over the laminate as a separating medium. This sheet will facilitate the release of the outer socket which is to be laminated over the inner shell. </p> <p> For the forearm buildup, plaster of Paris is considered preferable rather than wax, for the reason that wax may enter the pores of the prosthesis. The buildup is done in the usual manner (<b>Fig. 4A</b>). After the plaster has hardened, the paper cone is removed and the plaster of Paris is shaped to the desired contour. Any plaster on the knurled surface of the wrist unit is removed. The plaster is coated with Hi-Glo or some similar lacquer. A PVA sleeve is prepared, moistened, pulled down over the buildup, and trimmed at the wrist unit (<b>Fig. 4B</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The forearm buildup. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Next, a piece of Banlon stockinet and a piece of orthopedic stockinet are cut, each about 3 to 5 inches longer than the layup. Another piece of orthopedic stockinet is cut, a little more than double the length of the layup. (Additional lengths of stockinet may be used if additional strength is desired.) </p> <p> The Banlon stockinet is turned inside out, pulled 1 to 2 inches over the distal end, and tied at the wrist unit (<b>Fig. 4C</b>). Excess stockinet that is proximal to the wrist unit is trimmed off. </p> <p> The short piece of orthopedic stockinet is pulled over the longer piece so that both pieces meet at one end. The other end of the short piece should extend just past the middle of the longer piece. </p> <p> These pieces of stockinet are extended and slipped, double end first, down over the wrist unit until the double thickness covers the entire layup (<b>Fig. 4D</b>). The double thickness of stockinet is tied at the wrist unit and pulled down and tied at the proximal end. The Banlon stockinet should be on the inside. Two PVA pressure sleeves are now prepared in the usual manner, with the shiny surface of the material on the inside. One sleeve is set aside to be used later. The other is pulled down snugly over the layup and tied to the base rod at the proximal end. </p> <p> Resin and pigment are mixed in the manner described previously. For a short or medium below-elbow forearm, the following quantities should be sufficient: </p> <table> <tbody><tr> <td>ERL 2795............</td> <td>68 grams</td> </tr> <tr> <td>Versamid 140........</td> <td>37 grams</td> </tr> <tr> <td>Trichloroethylene...</td> <td>45 grams</td> </tr> <tr> <td>Pigment..................</td> <td>As required to match previous mix</td> </tr> </tbody></table> <p> The resin is poured into the pressure sleeve (<b>Fig. 5</b>) and worked into the stockinet. When the stockinet is fully impregnated, the pressure sleeve is pulled down as far as possible, and the excess resin is "strung" down from the layup. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Impregnating the forearm layup. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> After the layup has been thoroughly "strung" down, the PYA sleeve is stripped off and discarded. The layup is "strung" once more to remove all excess resin. </p> <p> There may be considerable resin in the stockinet around the base rod. This excess resin should be absorbed in the scrap stockinet wrapped around the base, so that it will not be drawn back into the laminate during the cure. </p> <p> For the pre-cure, the layup is now placed for 30 minutes in a pre-heated oven set at 115 deg. F (47 deg. C), allowing the solvent to evaporate. </p> <p> While the pre-cure is taking place, the second PVA pressure sleeve previously prepared should be moistened by wrapping it in a damp towel for 10 to 15 minutes. The next step in the procedure gives the prosthesis a smooth surface, and it is essential that the PYA sleeve be thoroughly moistened. </p> <p> Upon completion of the pre-cure, the layup is removed from the oven. The moistened PVA sleeve is pulled down until the entire layup is in contact with the sleeve. Light contact pressure is most desirable, for this will result in a smooth surface without reducing the porosity. It is important that the sleeve slide easily over the layup; otherwise, the force and pressure may cause pooling of the resin. At this point in the procedure, there should be no pools of resin on the stockinet. If there are, they should be "strung" out. </p> <p> The PVA sleeve is taped around the wrist unit (<b>Fig. 6</b>); any severely undercut areas should also be taped. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Molding the surface. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The layup is now placed for one hour in an oven pre-set at 212 deg. F (100 deg. C). During this period the PVA sleeve shrinks around the layup, giving the surface a smooth gloss and aiding in molding the undercuts. At the end of the hour, the laminate is removed from the oven and the PVA sleeve is stripped off. At this point the laminate should be firm and free from tackiness. </p> <p> The laminate is now ready for the final cure. It is replaced in the oven, set at 212 deg. F (100 deg. C), for 75 minutes to complete the final cure. </p> <p> While the plastic is still warm, the layup is cut to the desired length. The outer socket will separate easily from the inner socket. The plaster may be removed by striking the socket with a rubber mallet. If necessary, a chisel may be used to dig the plaster out of the distal end of the socket. Remaining PVA film can be stripped off by hand or dissolved with hot water. </p> <p> The prosthesis is held firmly on the amputee's stump, and the trim line is marked, after which the socket is removed and trimmed in the usual manner. After the socket and the forearm have been properly aligned, the edges are sanded and bonded together with liquid epoxy resin (ERL 2795, 65 parts; Versamid 140, 35 parts) (<b>Fig. 7</b>). The bond may be cured with a heat gun, or the prosthesis may be placed for one hour in an oven set at 212 deg. F (100 deg. C). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Bonding the socket and forearm </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The porosity of the finished prosthesis can be tested by holding it under a water tap and allowing the water to run through the prosthesis (<b>Fig. 8</b>). If the prosthesis has been prepared properly, the laminate should show a uniform porosity. The prosthesis is now ready to be harnessed in the usual manner. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Testing the porosity. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Single-wall, Below-Elbow, Porous Prosthesis (Mylar Cone Method) </h4> <p> For the fabrication of a single-wall, below-elbow, porous prosthesis, the stump model is prepared in the usual manner,<a></a> placed in a vise, distal end up, and coated with lacquer. When the lacquer has dried, a moistened PVA sheet is pulled down over the stump model and tied at the base. </p> <p> The stockinet layup, consisting of one length of tubular Banlon stockinet and three lengths of tubular orthopedic stockinet, is prepared in the same manner as the stockinet layup for the socket of the double-wall prosthesis previously described. </p> <p> When the stockinet layup is completed (<b>Fig. 9</b>), a sheet of PVA is pulled down over the layup and tied at the base rod. This PVA cover will protect the layup during subsequent steps. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The stockinet layup on the model. A PVA sheet is pulled down and tied at the base rod. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Next, on an 8 in. X 12 in. sheet of Mylar (5-10 mils), a crayon mark is made halfway along one of the sides, about one-quarter in. from the edge. A second mark is made one-half in. inside the first mark. Then two final marks are made; one 3 in. above the first mark, the other 3 in. below the first mark. A curve is drawn from the edge of the Mylar sheet through the upper mark, through the inside mark, through the lower mark, and thence to the edge of the sheet. A cut is made along the curve. This cut side will permit the standard adult wrist unit to fit squarely to the Mylar sheet when it is fitted into a cone (<b>Fig. 10A</b>). The wrist unit should be fitted a minimum distance into the cone. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. The Mylar cone buildup and impregnation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The cone is placed over the stump model and adjusted so that the desired contour of the finished prosthesis will be obtained. Next, the prosthetist holds the cone and wrist unit in one hand, placing the unit flat on a table. With the other hand, he positions the stump model in the cone so that the distance between the elbow axis and the table surface corresponds to the required forearm length. The cone is adjusted at the proximal end, and the excess is trimmed off. The shortest cone that will give a desirable final shape to the forearm should be used, since it will provide the greatest bond area between the forearm and the socket. When the correct conical shape is obtained, the cone is closed with transparent tape, the proximal end of the cone is taped to the socket with transparent tape, the wrist unit is taped in place, all holes in the unit are closed with a sealer, and all seams are taped. </p> <p> Next, a piece of orthopedic stockinet is cut so that it is at least 10 in. longer than twice the length of the layup. The stockinet is pulled down over the entire layup in such a manner that half of the stockinet extends above the wrist unit. The stockinet is tied at the wrist unit, and the extended half of the stockinet is pulled back down over the layup. The stockinet is pulled smooth and tied at the base rod. </p> <p> The proximal edge of the Mylar is found by palpation, and a light line is drawn around the layup just distal to the edge of the cone. All the areas below this line are covered with masking tape (<b>Fig. 10B</b>). </p> <p> A batch of resin is mixed as follows: </p> <table> <tbody><tr> <td>ERL2795...................</td> <td>45.5 grams</td> </tr> <tr> <td>Versamid 140..............</td> <td>24.5 grams</td> </tr> <tr> <td>Trichloroethylene.........</td> <td>30.0 grams</td> </tr> </tbody></table> <p> Sufficient pigment is added to give a slight color to the batch. </p> <p> The entire layup is inverted and brush-coated with this resin mixture. The excess resin is "strung" down toward the wrist unit (<b>Fig. 10C</b>). </p> <p> The layup is now placed for 30 min. in a pre-heated oven set at 115 deg. F (47 deg. C) for the pre-cure. After the cone has been pre-cured for 30 min., the oven temperature is increased to 212 deg. F (100 deg. C) and the cone is cured for 30 min. at this temperature. </p> <p> The layup is then removed from the oven, the masking tape is removed from the lavup, and the cone is separated from the inner socket. The Mylar sheeting is removed from inside the porous cone. The porous cone is sanded around the wrist unit until a smooth taper is obtained (<b>Fig. 11</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Sanding the porous cone. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> With the table contained in Appendix A (page 29) as a guide, a 250-gram batch of resin mixture is prepared, including in it a suitable amount of pigment. </p> <p> At this point the PVA sheet placed over the socket layup early in the procedure is removed, and a PVA sleeve is placed over the socket layup. </p> <p> The inner socket layup is impregnated with resin in the usual manner. Excess resin is removed from the layup by "stringing," the PVA sleeve is removed from the layup, and any excess resin is "strung" out. </p> <p> Now the porous cone is pulled down over the inner socket and aligned so that the wrist unit is in the proper position. The stockinet is tied at the base rod (<b>Fig. 12A</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Preparing the layup combining the socket and the porous cone. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A piece of Banlon stockinet is cut so as to be 3 to 5 in. longer than the layup, and a piece of orthopedic stockinet is cut so as to be twice the length of the Banlon stockinet. One end of the Banlon stockinet is tied around the wrist unit. The orthopedic stockinet is pulled over the Banlon stockinet and tied at the middle around the wrist unit. (Additional layers of stockinet may be used if greater strength is required.) All layers of stockinet are pulled down over the layup and tied at the base rod (<b>Fig. 12B</b>). </p> <p> The layup is now thoroughly impregnated with the remaining resin mixture, with the use of a PVA sleeve and "stringing." It is very important that all the excess resin be "strung" down toward the proximal end, so that there will be no pooling of resin when a PVA bag is pulled down in a subsequent step. A few pieces of scrap stockinet should be wrapped around the base pipe to absorb excess resin. </p> <p> The layup is now placed for 30 min. in an oven pre-set at 115 deg. F (47 deg. C) for a pre-cure. While the layup is pre-curing, a PVA sleeve is prepared to fit the forearm. The PVA sleeve is wrapped in a moistened towel for 10 to 15 min. during the pre-cure. At the end of the pre-cure, the layup is removed from the oven and any excess resin is "strung" out. The oven temperature is increased to 212 deg. F (100 deg. C). Meanwhile, the moistened PVA sleeve is pulled down over the layup so that the entire laminate is in firm contact with the sleeve. If the sleeve is sufficiently moist, it will slide easily over the layup without causing any resin pools. However, if any resin pools do form, they should be "strung" out of the laminate. The PVA sleeve is taped around the wrist unit and any undercut areas to insure proper lamination. </p> <p> The laminate is now placed for 60 min. in the oven, previously set at 212 deg. F (100 deg. C). At the end of 60 min., the laminate is removed from the oven and the PVA sleeve is stripped off. At this point, the laminate should be free from tackiness. </p> <p> For the final cure, the laminate is replaced in the oven, still set at 212 deg. F (100 deg. C). </p> <p> After the final cure, the laminate is removed from the oven and cut to the desired length. The laminate should separate easily from the mold. </p> <p> The prosthesis is held firmly on the amputee's stump, and the trim line is marked. Then the socket is removed and trimmed in the usual manner. </p> <h4> Polyester-Resin Mixture </h4> <p> Shortly after the initial success of the porous epoxy laminates, attempts were made to produce similarly porous polyester laminates. At first these attempts were unsuccessful. Although highly porous laminates were produced, their physical strengths were inadequate for prosthetic application. </p> <p> However, because of significant improvements in the method of preparing porous epoxy laminates, particularly through the reapplication of a PVA bag at a critical time in the curing process, it was decided to reinvestigate the porous polyester system. The Army Prosthetics Research Laboratory has produced a series of cylindrical, porous polyester laminates which have shown when tested a strength sufficient for prosthesis<a></a>. Preliminary results of the evaluation are promising. The fabrication procedures presently recommended are the same as have been described for porous epoxy laminates in this article and set forth in full in <i>A Manual for the Preparation of Above and Below Elbow Prostheses, </i><a></a> published by the Army Prosthetics Research Laboratory. <b>Appendix A</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Appendix A: Color appropriate for the individual should be added to the resin mixture and stirred in until it is uniformly blended. For a 100-gram mixture, 1 to 4 grams of color is sufficient. Epoxy pigment, Caucasian, tan, No. 22826 (60% pigment) and epoxy pigment, Negroid, brown, No. 22831 (53% pigment) (Plastics Color Company, 22 Commerce Street, Chatham, N. J.) have been used successfully at New York University (7). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The following polyester-resin formulation is tentatively suggested for a medium below-elbow porous prosthesis: </p> <table> <tbody><tr> <td>Laminae 4110<a style="text-decoration:none;">*</a></td> <td>80 grams</td> </tr> <tr> <td>Paraplex P-13<a style="text-decoration:none;">*</a></td> <td>20 grams</td> </tr> <tr> <td>Luperco ATC<a style="text-decoration:none;">*</a></td> <td>3 grams</td> </tr> <tr> <td>Trichloroethylene</td> <td>43 grams</td> </tr> <tr> <td>Naugatuck Promoter No.3<a style="text-decoration:none;">*</a>   </td> <td>6 drops</td> </tr> <tr> <td>Polyester pigment</td> <td> +/- 1 gram</td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li><p>Gray, Henry, <i>Anatomy of the human body</i>, 26th edition, Charles Mayo Goss, ed., Lea and Febiger, Philadelphia, Pa., 1954. </p> </li> <li><p>Hill, James T., <i>A manual for the preparation of above and below elbow porous prostheses</i>, Army Prosthetics Research Laboratory, Washington, D. C, January 1962. </p> </li> <li><p>Hill, James T., and Egbert de Vries, <i>Evaluation of porous epoxy laminates for use in prosthetic arms</i>, Army Prosthetics Research Laboratory Technical Report No 5820, July 1958. </p> </li> <li><p>Hill, James T., Egbert de Vries, and Fred Leonard, <i>Porous plastic laminates</i>, SPE Journal, Vol. 16, No. 9, September 1960. </p> </li> <li><p>Hill, James T., <i> Porous polyester laminates</i>, Army Prosthetics Research Laboratory Technical Report No. 6217, August 1962. </p> </li> <li><p>New York University, <i>Adult Prosthetic Studies</i>, Research Division, College of Engineering, Report of evaluation of the APRL porous laminate technique, November 1960.</p> </li> <li><p>New York University, Prosthetics and Orthotics, Post Graduate Medical School, <i>Guide for fabrication of double wall porous epoxy prosthesis for short B/E</i>, September 1961. </p> </li> <li><p>Thomas, Atha, and Chester C. Haddan, <i>Amputation prosthesis</i>, J. B Lippincott Co., Philadelphia, Pa., 194S. </p> </li> <li><p>University of California (Los Angeles), Department of Engineering, <i>Manual of upper-extremity prosthetics</i>, 2nd edition, W. R Santschi and Marian P. Winston, eds., 1958. </p> </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">U. S. Rubber Co., Naugatuck Chemical Division, Naugatuck, Conn.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Wallace and Tiernan, Incorporated, Lucidol Division, 174 Military Road, Buffalo, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Rohm and Haas Company, Philadelphia 8, Pa.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">American Cyanamid Company, Plastics Division, 30 Rockefeller Plaza, New York 20, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Hill, James T., A manual for the preparation of above and below elbow porous prostheses, Army Prosthetics Research Laboratory, Washington, D. C, January 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Hill, James T., Porous polyester laminates, Army Prosthetics Research Laboratory Technical Report No. 6217, August 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper-extremity prosthetics, 2nd edition, W. R Santschi and Marian P. Winston, eds., 1958. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Wm. H. Horn and Bros., Philadelphia, Pa.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall"> Western States Lacquer, Dallas, Tex. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper-extremity prosthetics, 2nd edition, W. R Santschi and Marian P. Winston, eds., 1958. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Both accounts compiled for CPRD, NAS-NRC, from A Manual for the Preparation of Above and Below Elbow Porous Prostheses(2), published by the U.S. Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Washington 12, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">DuPont Corporation Trademark.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">General Mills Chemical Division, Kankakee, Ill.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Shell Chemical Company, New York, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Bakelite Chemical Division, Union Carbide Chemical Company, New York, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Effective porosity is the ratio of the quantity of water that flows through the laminate to the amount that flows through the stockinet alone.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, College of Engineering, Report of evaluation of the APRL porous laminate technique, November 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Hill, James T., A manual for the preparation of above and below elbow porous prostheses, Army Prosthetics Research Laboratory, Washington, D. C, January 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Hill, James T., and Egbert de Vries, Evaluation of porous epoxy laminates for use in prosthetic arms, Army Prosthetics Research Laboratory Technical Report No 5820, July 1958. </td></tr><tr><td class="clsTextSmall"><b> 4.</b> </td><td class="clsTextSmall">Hill, James T., Egbert de Vries, and Fred Leonard, Porous plastic laminates, SPE Journal, Vol. 16, No. 9, September 1960. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Gray, Henry, Anatomy of the human body, 26th edition, Charles Mayo Goss, ed., Lea and Febiger, Philadelphia, Pa., 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Fred Leonard, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Scientific Director, APRL, WRAMC, Washington 12, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>James T. Hill, C.E., B.S. </b></td></tr><tr><td class="clsTextSmall">Chief, Process Engineering Section, U.S. Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Washington 12, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-21.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-22.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-23.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-24.jpg Figure 8 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-25.jpg Figure 9 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-26.jpg Figure 10 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-27.jpg Figure 11 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-28.jpg Figure 12 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-29.jpg Figure 13 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-29b.jpg Figure 15 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-31.jpg Figure 16 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-32.jpg Figure 17 http://www.oandplibrary.org/al/images/1963_01_017/1963-Spring_OCRBatch-33.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 Porous Plastic Laminates for Upper-Extremity Prostheses Creator An entity primarily responsible for making the resource James T. Hill, C.E., B.S. * Fred Leonard, Ph.D. * https://staging.drfop.org/files/original/6c0a91f3e6ca48a7d6eb71da9b638ef1.pdf 053df77f111f816175d9cd9b8a12a789 https://staging.drfop.org/files/original/56827526320afb7bc3726a24ed19a2e1.jpg 548798c301947254e31ac1fd04ba5be2 https://staging.drfop.org/files/original/3e0affd56b0e765df6a7a25041d5dc38.jpg 20141917fda2ff9c21dc4cd7f4f9579d Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1982_02_008.pdf Text Any textual data included in the document <h2>Post Operative Management of Lower Extremity Amputees Using Tubular Elastic Compression Bandaging</h2> <h5>William M. Brady, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <h3><br />Introduction</h3> <p>Edema is inevitable in a postoperative limb and is a matter of concern to all who are involved in the postoperative care and rehabilitation of amputees. Persistent edema, that is edema that fails to subside over a period of weeks following amputation surgery, delays the rehabilitation process including the fitting of the definitive prosthesis<a></a>.</p> <p>Several systems of compression bandaging have been investigated and reported in various medical journals. These include soft dressings, pneumatic pressure sleeves, stump shrinkers, semirigid dressings, and rigid dressings with or without a program of early ambulation<a></a>. Of all of these systems, the most common one is the elastic wrap bandage<a></a>. It is readily available inexpensive, comes in a range of sizes and is washable. In spite of its advantages, however, its users are also aware that it is difficult to apply, doesn't maintain continuous pressure, must be reapplied frequently, cannot be reapplied the same way each time, and loses its compressibility after a few washings.</p> <p>Since the amount of external compression applied to the limbs seems to be a key factor in reducing edema, studies have been undertaken to define the "ideal" pressure. Some of the findings reported are as follows:</p> <ol> <li> <p>less than 5 to 10 mmHg of mercury is undersirable<a></a>;</p> </li> <li> <p>external pressure of 30 mmHg or greater decreased the venous flow rate of the leg<a></a>;</p> </li> <li> <p>external pressures above 25 to 30 mmHg, if sustained, may be potentially harmful<a></a>;</p> </li> <li> <p>pressures obtained from elastic wrap applied by skilled professionals ranged typically from 23 to 72 mmHg<a></a>;</p> </li> <li> <p>elastic compression to the lower limb markedly reduced the volume of the limb<a></a>.</p> </li> </ol> <h3>Development of a Product</h3> <p>Early in 1980 Knit-Rite, Inc.,<a style="text-decoration: none;">*</a> a manufacturer of prosthetic socks and stockinette tubing, initiated the development of a tubular elastic compression material that would be equal or superior to any compression bandage currently available on the market. Believing that such a product would have medical applications in the control of edema but uncertain of how it could be made to achieve the desired pressures and other characteristics, they contacted the Physical Medicine Department, University of Kansas Medical Center, for recommendations. Out of this inquiry evolved an amputee study involving 41 amputees, 35 below knee (B.K.) and 6 above knee (A.K.) and resulted in a paper entitled "Pressure Applied by Stump Bandages: A Comparative Study," by G. Varghese et al.<a style="text-decoration: none;">*</a> This study compared the elastic wrap, the Knit-Rite tubular elastic bandage and stump shrinker, and another brand of tubular elastic bandage. It supported some beliefs and established others:</p> <ol> <li> <p>Elastic wrap was the most difficult to apply.</p> </li> <li> <p>Pressures exerted by elastic wrap varied widely and the results were significantly different when applied by skilled and unskilled people.</p> </li> <li> <p>Elastic wrap failed to sustain constant pressures over a prolonged period of time and had a tendency to loosen with usage.</p> </li> <li> <p>Both tubular compression bandage products were more easily applied by patients and/or family members.</p> </li> <li> <p>More consistent pressure over a prolonged period of usage could be obtained with tubular elastic bandages.</p> </li> <li> <p>The Knit-Rite tubular compression bandage, when doubled, exerted a pressure which was in the "ideal" range, between 15 to 30 mmHg as measured by a solid state pressure transducer.</p> </li> </ol> <p>Actually, many changes in the product occurred during the course of this study.<a style="text-decoration: none;">*</a> Finally the acceptable tubular compression bandage was made available as a 10 meter Compressogrip® roll in a range of widths and lengths and as a stump shrinker item in a range of widths and lengths. The stump shrinker item is individually packaged and labeled with care instructions.</p> <h3>Field Testing</h3> <p>At the same time that the Kansas University Medical Center was conducting their research and continuing through the present time, Isle Orthotic-Prosthetic Services, of Kansas City, Missouri, was using the tubular compression bandage in the postoperative management of its referred amputee patients. Field testing was also conducted at a private prosthetics facility in the Kansas City area and at the V.A. Hospital.</p> <p>These findings, while empirical do confirm the results of the scientific researchers. The earlier a program of tubular compression bandaging is begun post-operatively, the sooner swelling will subside and tissues can be properly supported and correctly molded to a shape acceptable for prosthetic fitting. The correct size of bandage must be selected and patients or responsible family members instructed concerning the proper method of applying the tubular compression bandage and maintaining a controlled, total-contact fit throughout the period of wear. The recommendation, with the permission of the managing physician, is to wear the bandage 24 hours per day, except for bathing or during periods of muscle spasm, cramping or persistent pain. At least 2 to 3 bandages need to be supplied to the patient to allow for laundering.</p> <h3>Selecting the Proper Size Bandage</h3> <p>Care needs to be taken in fitting to insure that the width selected achieves adequate compression without overstretching the material (<a href="/files/original/56827526320afb7bc3726a24ed19a2e1.jpg"><b>Fig. 1</b></a>) and that the length selected allows for a double layer (<a href="/files/original/3e0affd56b0e765df6a7a25041d5dc38.jpg"><b>Fig. 2</b></a>). Optimum compression occurs when the tubular compression bandage is stretched at least 50% but not more than 100% of the original width. For a B. K. amputee it is recommended that a circumference measurement be taken 2" below the medial tibial tubercle, and for an A. K. amputee, 2" proximal to the distal end.<br /><strong><br /><a href="/files/original/56827526320afb7bc3726a24ed19a2e1.jpg">Fig. 1</a> Sizing Chart for Tubular Elastic Stump Shrinkers.<br /><br /><a href="/files/original/3e0affd56b0e765df6a7a25041d5dc38.jpg">Fig. 2.</a> Application Technique.<br /></strong></p> <p><br />Example: The measured circumference is 11 inches. From the chart (<a href="/files/original/56827526320afb7bc3726a24ed19a2e1.jpg"><b>Fig. 1</b></a>) we see that Size #3 is the correct size. The sizes #2 through #5 are approximately 2" through 5" in flat width. Thus Size #3 is approximately 6" in circumference and would best accommodate measurements from 9" to 12" in circumference. If the differential between distal and proximal circumferences, as in extremely tapered A. K.'s, is greater than 5", then the next size larger bandage should be selected to avoid overstretching the material and to insure ease of application.</p> <h3>Applying the Bandage</h3> <p>On a below knee amputee, apply the first layer so that the material extends approximately 3" proximal to mid-patella. Slide the nylon ring (supplied with and surrounding the bandage) forward until firm distal pressure occurs, then reflect the second layer over the first to no more than 1/2" proximal to the superior border of the patella (<a href="/files/original/3e0affd56b0e765df6a7a25041d5dc38.jpg"><b>Fig. 2</b></a>). In this way, greater pressure is maintained distally than proximally. If necessary, excess material may be marked and cut off, folding inside the cut ends of the second layer to achieve a smooth edge; however, the cut edge may ravel. Different lengths are available to eliminate cutting as much as possible (<a href="/files/original/56827526320afb7bc3726a24ed19a2e1.jpg"><b>Fig. 1</b></a>).</p> <p>Have the patient flex and extend the knee to check the security of the bandage. Then have the patient remove and re-apply the bandage several times until you are confident that the technique is mastered. Good follow-up is an important part of patient management. We recommend that the patient be rescheduled at 2 to 3 week intervals to check the progress of the shrinkage. Remeasuring and recording all pertinent circumference and diameter readings can then be done. When measurements have stabilized and no appreciable changes are noted from the last visit, casting for the definitive prosthesis can be initiated.</p> <p>The same basic procedure can be followed with A. K. amputees, except that some A. K. amputees will require the addition of a modified garter belt or webbing suspension to minimize the tendency of the bandage to roll proximally.</p> <h3>Summary</h3> <p>Our observations concur with recent research which suggests that the process of controlling and reducing edema is accelerated by using the Compressogrip® tubular compression bandage versus the conventional elastic wrap. Further, our experience indicates that the shaping of soft tissues is enhanced and that the post-operative period required to prepare the patient's residual limb for the definitive prosthesis is somewhat shortened when a tubular compression bandage is used. We project that patients managed in this fashion will have fewer post-fitting problems that are related to additional shrinkage occurring in the first few weeks of prosthetic wear and that the incidence and/or severity of phantom sensation will be reduced as a result of the controlled compression of the Compressogrip® tubular compression bandage.</p> <p><b>References:</b></p> <ol> <li>Mooney, V.; Harvey, J.P.; McBride, E.; and Nelson, R.S., "Comparison of Post-Operative Stump Management: Plaster vs. Soft Dressings", <i>Journal Bone and Joint Surg</i>., 53-A, March 1971.</li> <li>Sher, M.H., "The Air Splint: An Alternative to the Immediate Postoperative Prosthesis", <i>Arch Surg</i>., 108: 746-747,1974.</li> <li>Puddifoot, P.C.; Weaver, P.C.; Marshall, S., "A Method of Supportive Bandaging for Amputation Stumps", <i>Br. J. Surg.</i>, 60: 729-731.1973.</li> <li>Islerwood, PA; Robertson, J.C.; Rossi, A., "Pressure Measurements beneath Below Knee amputation stump bandages: Elastic Bandaging, the Puddifoot dressing, and pneumatic bandaging technique compared", <i>Br. J. Surg.</i>, 62: 982-986,1975.</li> <li>Manella, K.J., "Comparing the Effectiveness of Elastic Bandages and Stump Socks for Lower Extremity Amputees", <i>Physical Therapy</i>, 61, March 1981.</li> <li>Holloway, G.A., Jr.; Daly, Colin H.; Kennedy,D.; Chemosky, J., "Effects of External Pressure Loading on Human Skin Blood Flow Measured by 133 Xe Clearance", <i>Journal of Applied Physiology</i>, 40 April 1976.</li> </ol> <b>Footnote</b> Field, M., Manager, Textile Research and Development, Knit-Rite, Inc., Kansas City, MO 64141.<br /><br /><b>Footnote</b> Varghese, G.; Hindle, P.; Zilber, S.; Perry, J.; Redford, J.B., 'Pressure Applied by Stump Bandages: A Comparative Study', American Congress of Rehabilitation Medicine, Oct. 1980.<br /><br /><b>Footnote</b> Kansas City, Missouri 64141.<br /><b><br /><em>*William M. Brady, C.P.O. </em></b><em> President, Isle Orthotic-Prosthetic Services, Kansas City, MO</em><br /><br /> <div style="width: 400px;"></div> Page Number(s) 8 - 10 Year 1982 Volume 6 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1982_02_008/1982_02_008-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1982_02_008/1982_02_008-2.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 Post Operative Management of Lower Extremity Amputees Using Tubular Elastic Compression Bandaging Creator An entity primarily responsible for making the resource William M. Brady, C.P.O. * https://staging.drfop.org/files/original/9dbe52f7fdd35578cf5246376f655c2a.pdf a3efeb93b0ab8f0a71f9da3dd1aae1cc https://staging.drfop.org/files/original/49c519d9cfc114bc2adb3d22a688c55c.jpg 019d282606c1c336d88f88bb227ae5f9 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_02_074.pdf Text Any textual data included in the document <h2>Post-polio Syndrome: An Overview</h2> <h5>Neil R. Cashman, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Irwin M. Siegel, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Jack P. Antel, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Poliomyelitis was a dreaded disease in developed countries, affecting tens of thousands of children and adults during each of the epidemic years up to the mid-1950s. The polio virus is a small RNA virus whose only natural host appears to be man. The vast majority of exposed persons develop either an inapparent infection or a non-specific flu-like illness (non-paralytic poliomyelitis). Secondary invasion of the brain and spinal cord is associated with infection and death of motor neurons, with loss of innervation to muscle fibers, and consequent muscle weakness and atrophy. Postmortem studies show that muscle weakness in poliomyelitis is clinically apparent only when more than half of the corresponding motor neurons are destroyed.<a></a> Frequently, muscles can be reinnervated by healthy neighboring motor neurons by a process of axonal sprouting. Thus, partial or complete recovery of muscle bulk and strength can occur, in which subnormal numbers of motor neurons support increased (up to 8-fold) numbers of muscle fibers.<a></a> It is estimated that about 250,000 people in the United States have survived paralytic poliomyelitis and are alive today.<a></a></p> <p>Recently, it has become clear that some patients who had paralytic poliomyelitis may develop new complaints after decades of stable function.<a></a> These new symptoms have been designated the "post-polio syndrome" (PPS) or "late sequella of poliomyelitis." Although some reports of new weakness following polio can be found in the medical literature since 1875,<a></a> recent epidemiologic studies indicate that new symptoms are common, occurring in approximately 25 percent of patients with antecedent paralytic poliomyelitis.<a></a> If this estimate is correct, over 50,000 persons in the U.S. are at risk of developing PPS. From published reports, the mean latency of onset has been calculated to be 36 years.<a></a> Thus, an increasing incidence of new cases will probably continue into the early 1990s, reflecting the last epidemics of the mid-1950s.</p> <p>The risk of developing PPS appears to correlate with severity of the original poliomyelitis. Thus, a patient with four-limb involvement and a history of respiratory dependence during his polio is more likely to develop new symptoms than a patient with one-limb involvement.<a></a> The severity of the original onset of polio also seems to predict the latency of developing the syndrome; severely affected patients may develop new symptoms after only 10-20 years, whereas mildly affected patients are more likely to exhibit extended delays in time of onset of PPS.<a></a></p> <p>What causes PPS? Why should a patient who has had stable function for decades develop new symptoms? At the present time, there is little definitive data on this subject. Early conjecture focused on a possible reactivation of the polio virus which had remained latent in the nervous system since the original infection. However, there appears to be little or no evidence for inflammation in post-polio patients; spinal fluid is without the cells, protein, and immunoglobulin which characterize other nervous system viral infections. Some investigators have suggested that the normal attrition of neurons with aging may trigger the post-polio syndrome when superimposed on previous static damage of polio.<a></a> However, aging-related loss of neurons in the spinal cord normally begins at about age 60<a></a>; the onset of PPS most commonly occurs 30 years after polio and does not correlate with chronological age of the patient.<a></a> Weichers and Hubbel<a></a> and Dalakis, et al.<a></a> have suggested that motor units grossly enlarged by reinnervation in recovery from poliomyelitis may begin to experience peripheral disintegration with the passage of time. Our own data support this hypothesis in part; late denervation is most common in muscles with the greatest degree of reinnervation. However, we find that group atrophy, a putative indicator of motor neuronal disease (and not terminal axonal degeneration), is also common in patients with prior poliomyelitis.<a></a></p> <p>Although a bewildering variety of new symptoms are recognized as occurring in PPS,<a></a> most new complaints appear to be subsumed under the three major problems of new pain, new weakness, and fatigue (<b>Table 1</b>). Some investigators have theorized that new muscle atrophy and weakness constitutes a separate syndrome, "postpoliomyelitis progressive muscular atrophy" or PPMA.<a></a> In this scheme, other symptoms of PPS, such as pain and fatigue, are thought to be manifestations of a separate "musculoskeletal" syndrome due to chronic strain of muscles and joints that have been forced to bear weight in an unnatural fashion.<a></a> Common orthopedic deformities in patients with poliomyelitis include knee valgus, varus, and recurvatum, as well as ankle equinus.<a></a> However, new weakness can result in new joint instability, and new joint problems may interfere with efficiency of movement. Although a symptomatic approach to separate complaints of PPS patients is warranted, there is little scientific data that supports a division of sub-syndromes of PPS at present. We have found that even patients without new symptoms have evidence of an ongoing neuromuscular disorder.<br /><br /><strong>Table 1</strong><br /><img src="/files/original/49c519d9cfc114bc2adb3d22a688c55c.jpg" /></p> <p>New pain is the most common symptom in PPS based on our experience (<b>Table 1</b>) and is a frequent complaint in other series as well.<a></a> We have evaluated patients experiencing pain in conjunction with an orthopod experienced in neuromuscular disease. Several causes of pain are commonly identified in PPS patients. Perhaps the most common cause is insertional tendonitis and/or bursitis from chronic overuse and strain of muscle groups with subnormal strength. Palpation of tendons and bursae at common sites of involvement, such as the pes tendon at the medial knee and the trochanteric bursa, will often reveal profound point tenderness consistent with this syndrome. A trial of rest and non-steroidal anti-inflammatory agents may induce remission in this remitting/relapsing syndrome. For certain local sites, a steroid injection may be useful; weight reduction and readjustment of weight-bearing (through retraining and/or orthotic devices) may also produce long-range benefits. Degenerative arthritis, found most often in weight-bearing joints (where walking aids are used, the joints of the upper extremities may indeed become weight-bearing), may also respond to the same regimen. Nerve compression syndromes characterized by pain and paraesthesias, secondary to positional or repetitive stress, should also be considered in the differential diagnosis of pain in PPS patients.</p> <p>Another type of pain, unrelated to joint "wear and tear" is muscle pain. This occurs frequently during or after exercise and may be associated with cramps, fasciculations, or intense local fatigability. This may be related to muscle substitution and/or overwork in denervated muscle, and may ultimately be associated with permanently increased weakness.<a></a> Treatment of this muscle pain includes avoiding the circumstances which induce it. Rest, orthoses, or even intermittent wheelchair use should also be considered to reduce the load on overworked muscle. Medications which reduce muscle cramps (quinine, diphenylhydantoin) may increase weakness and should be avoided.</p> <p>Fatigue is also a common complaint in PPS patients, occurring in over 60 percent of our series (<b>Table 1</b>). Two types of fatigue are reported by patients: generalized fatigue requiring rest or sleep, and local muscle fatigue. Local muscle fatigue is most common in muscles previously severely affected by polio and is often associated with cramps and fasciculations. Local fatigue may be a manifestation of ongoing muscle denervation and is also reported by patients with classic denervating diseases such as amyotrophic lateral sclerosis.<a></a></p> <p>Generalized (systemic) fatigue is common in PPS, but may also be a symptom of a variety of other states, including medical conditions such as diabetes mellitus, cardiopulmonary dysfunction, and thyroid disease. Depression ("low energy") may also lead to systemic fatigue. Once medical and psychiatric diseases have been ruled out, systemic fatigue in PPS may be a symptom of widespread neuromuscular junction transmission defects. We have found that patients with fatigue and marked increased jitter in single-fiber electromyography (an indicator of defective neuromuscular transmission) respond to agents which enhance neuromuscular transmission, such as the anticholinesterase pyridostigmine (Mestinon). Rest, ambulatory aids, and activity planning may also alleviate generalized fatigue.</p> <p>New weakness is the third major component of the "post-polio triad" (<b>Table 1</b>). When new weakness occurs with new muscle atrophy, PPS patients are thought by some investigators to suffer from a specific syndrome of post-poliomyelitis progressive muscular atrophy (PPMA).<a></a> It has been suggested that evidence of ongoing denervation (fibrillations and positive waves on EMG, increased jitter on single-fiber EMG, and atrophic muscle fibers on muscle biopsy) are diagnostic for this syndrome.<a></a> However, we have found that electrophysiologic and muscle biopsy evidence of denervation is as common in polio patients who are not having new symptoms, as in patients who have clinically defined PPMA.<a></a> Moreover, evidence of denervation is most severe in muscles which show the most signs of old polio.<a></a> Thus, late denervation appears to be a concomitant of massive monophasic antecedent denervation and not a sign of new disease. In addition, we found that although 14 out of 15 patients who complained of new atrophy also reported new weakness, only about one-half of patients who reported new weakness noted new atrophy.<a></a> Thus, the relationship of atrophy to weakness is not clear.</p> <p>New muscle weakness may put extra stress on a previously borderline compensated muscle, producing pain, cramping, and an "overwork myopathy," with accelerated weakness as an end result.<a></a> It has been estimated that a partially denervated muscle graded "good" must work two and a half times as hard as a normal muscle to accomplish the same task.<a></a> We caution patients with new weakness to reduce activity. Exercise programs must be undertaken with extreme caution, and exercise should never be performed to the point of pain or muscle cramps. We advise patients to exercise limbs not previously affected by polio or, if this is impossible, participate in a carefully graded program in a therapeutically heated pool. One should exercise enough to prevent atrophy of disuse, but not enough to cause damage from overuse. High repetition, low resistance exercises are favored, as well as stretching and isometric drills. Orthotic devices, including the ankle-foot orthosis and knee-ankle-foot orthosis, may provide support for certain critically weakened muscle groups, although adequate function of other muscle groups (e.g., knee and hip extensor function for an ankle-foot orthosis) is a prerequisite for effective use. Wheelchair use should also be considered, sometimes only intermittently, as prolonged activity may predispose the patient to osteoporosis or venous thrombosis. Training in effective transfers, efficient movements, etc. by the physical and occupational therapist may also be useful, as can home help aids such as a shower chair and raised toilet seat.</p> <p>Limb weakness may result in new joint instability, which in turn may be associated with new pain and increasing deformity. It has been noted, for example, that floor reaction with knee hyperextension serves a knee-locking function when the quadriceps is weak.<a></a> However, profound degrees of weakness can provide a "positive feedback" situation where posterior knee ligaments are subjected to more torque stress, leading to further stretching.<a></a> A knee-ankle-foot orthosis (fit with a posterior offset knee hinge) may prevent progressive joint damage in this situation.</p> <p>Pulmonary complaints may occur in patients with previously weakened diaphragm, intercostals, abdominal, or accessory muscles. Frequently, a patient with previous paralytic poliomyelitis, involving muscles of respiration, will have borderline respiratory compensation for decades and will undergo precipitous respiratory failure later in life.<a></a> Increasing scoliosis, aspiration pneumonia, gradual loss of motor units with aging, and other factors may contribute to respiratory insufficiency. Respiratory symptoms (daytime somnolence, snoring, dyspnea, etc.) must be sought in all patients, particularly those with a history of respiratory involvement with polio. Baseline spirometry is also obtained in patients attending clinics. Muscle relaxants and medications which suppress respiratory drive should be avoided. Vaccines (pneumonia and flu vaccines) and cessation of smoking are also important in patient management. New respiratory muscle weakness may also present as sleep apnea, which may respond to medication (e.g., protripty-line), or may require night time oxygen or mechanical ventilation. Pulmonary complaints should always be evaluated and treated in conjunction with a pulmonary physician versed in neuromuscular diseases.</p> <p>The prognosis of the post-polio syndrome depends upon the symptoms experienced by the patient and upon individual (as yet uncharacterized) differences in disease progression. General health care measures (proper rest, nutrition, weight management, etc.) as well as psychosocial support are important. Inflammation in joints and muscles may be managed well with the treatments cited above. At least some patients with PPS fatigue respond to anticholinesterase medications. Progressive weakness, with or without atrophy, is the least responsive symptom of PPS. Respiratory complaints, particularly, should be considered seriously. Fortunately, weakness progresses slowly (about one percent per year according to a recent study),<a></a> and plateaus in function are observed. Although rapid progression of weakness does occur in some PPS patients, other diagnoses such as medical illnesses or superimposed neurologic and orthopedic problems must be considered.</p> <p>A common complaint of post-polio patients is that health professionals do not understand or even believe their new symptoms. Although a breakthrough of understanding on PPS may not occur in the immediate future, it is the responsibility of all health personnel to listen carefully to patients with new problems and provide the best care possible. Specific symptomatic treatment should be made available where appropriate. The patient who has been rehabilitated from the effects of acute polio must now be helped to accept the activity aids and lifestyle modifications necessary to ameliorate his "second disability."</p> <h3>Acknowledgments</h3> <p>This paper was based on our experience at the University of Chicago Post-Polio Clinic, which was made possible by the fruitful collaboration of R. Maselli, R. Wollmann, R. Roos, E. Salazar, F. Brown, E. Nichols, R. Simon, P. Heidkamp, and R. Martia. We thank C. René de Cotret for preparing the manuscript.</p> <p><b>References:</b></p> <ol> <li>Sharrad, W.J.M., "Correlation Between Changes in the Spinal Cord and Muscle Paralysis in Poliomyelitis", <i>Proceedings of the Royal Society of Medicine</i>, 40, 1953, p. 346.</li> <li>Cöers, C, and Woolf, A.L. <i>The Innervation of Muscle: A Biopsy Study</i>, Blackwell Scientific Publications (Oxford), 1959.</li> <li>Halstead, L.S., and D.O. Weichers, "Introduction," <i>Late Effects of Poliomyelitis</i>, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. xv-xx.</li> <li>Codd, M.B., D.W. Mulder, L.T. Kurland, CM. Beard, and W.M. O'Fallon, "Poliomyelitis in Rochester, Minnesota, 1935-1955: Epidemiology and Long-term Sequelae: A Preliminary Report," Late Effects of Poliomyelitis, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. 121-134.</li> <li>Jubelt, B. and N.R. Cashman, "Neurologic Manifestations of the Post-Polio Syndrome," <i>Critical Reviews in Clinical Neurobiology</i>, in press.</li> <li>Halstead, L.S., D.O. Weichers, and CD. Rossi, "Late Effects of Poliomyelitis: A National Survey," <i>Late Effects of Poliomyelitis</i>, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. 11-31.</li> <li>Tomlinson, B.E. and D. Irving, "Changes in Spinal Cord Motor Neurons of Possible Relevance to the Late Effects of Poliomyelitis," <i>Late Effects of Poliomyelitis</i>, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. 57-70.</li> <li>Weichers, D.O. and S.L. Hubbell, "Late Changes in the Motor Unit After Acute Poliomyelitis," <i>Muscle and Nerve</i>, 4, 1981, pp. 524-528.</li> <li>Dalakis, M.C., G. Elder, M. Hallett, et al., "A Long-term Follow-up Study of Patients with Post-poliomyelitis Neuromuscular Symptoms," <i>New England Journal of Medicine</i>, 314, 1986, pp. 959-963.</li> <li>Cashman, N.R., R. Maselli, R.L. Wollmann, R. Roos, R. Simon, and J.P. Antel, "Postpoliomyelitis Syndrome: Evidence of Ongoing Denervation in Symptomatic and Asymptomatic Patients," <i>Proceedings of the Second Annual Symposium on the Late Effects of Poliomyelitis</i>, Symposia Foundation (Miami, FL), in press.</li> <li>Maynard, F.M., "Differential Diagnosis of Pain and Weakness in Post-polio Patients," <i>Late Effects of Poliomyelitis</i>, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. 33-41.</li> <li>Tomlinson, B.E. and D. Irving, "The Number of Limb Motor Neurons in the Human Lumbosacral Cord Throughout Life," <i>Journal of Neurological Sciences</i>, 34, 1977, pp. 213-219.</li> <li>Clark, D.R., J. Perry, and T.R. Lunsford, "Case Studies-Orthotic Management of the Adult Post Polio Patient," <i>Orthotics and Prosthetics</i>, Vol. 40, No. 1, 1986, pp. 43-50.</li> <li>Bennett, R.L. and G.C. Knowlton, "Overwork Weakness in Partially Denervated Skeletal Muscle," <i>Clinical Orthopedaedics</i>, 12, 1968, pp. 22-29.</li> <li>Mulder, P.W., E.H. Lambert, and L.M. Eaton, "Myasthenic Syndrome in Patients with Amyotrophic Lateral Sclerosis", <i>Neurology</i>, 9, 1959, p. 627.</li> <li>Perry, J., "Orthopedic Management of Post-polio Sequellae," <i>Late Effects of Poliomyelitis</i>, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. 193-206.</li> <li>Ringel, S.P. and R.J. Martin, "Respiratory Complications and Their Management in Neuromuscular Disorders," <i>Interdisciplinary Rehabilitation of Multiple Sclerosis and Neuromuscular Disorders</i>, F.P. Malone, J.S. Burks, and S.P. Ringel, J.B. Lippincott Co. (Philadelphia), 1985, pp. 211-227.</li> </ol> <em><b>*Jack P. Antel, M.D. </b> Jack P. Antel, M.D. is Professor of Neurology and Neu-rologist-in-Chief at the Montreal Neurological Institute.</em><br /><em><b><br />*Irwin M. Siegel, M.D. </b> Irwin Siegel, M.D. is an Associate Professor in the departments of Orthopaedic Surgery and Neurological Services, Rush-Presbyterian-St. Luke's Medical Centre, Chicago, IL; Chairman of the Department of Orthopaedic Surgery at Louis A. Weiss Memorial Hospital in Chicago, Illinois; and Director of Muscular Dystrophy Clinics of the above facilities.</em><br /><em><b><br />*Neil R. Cashman, M.D. </b> Neil R. Cashman, M.D. is an Assistant Professor of Neurology at the Montreal Neurological Institute, 3801 University Street, Montreal, Quebec H3A 2B4, CANADA. He developed and directed the University of Chicago Post-Polio Clinic 1985-86.<br /><br /><br /></em> Page Number(s) 74 - 78 Year 1987 Volume 11 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 1 TABLE 1 http://www.oandplibrary.org/cpo/images/1987_02_074/1987_02_074-1.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 Post-polio Syndrome: An Overview Creator An entity primarily responsible for making the resource Neil R. Cashman, M.D. * Irwin M. Siegel, M.D. * Jack P. Antel, M.D. * https://staging.drfop.org/files/original/f73009e86594dcca75541df0a12e99d0.pdf 1889f60a10577651577742fa073f3c95 https://staging.drfop.org/files/original/290830ff921d3225c71b7da047de3c91.jpg 604673b43d699b8dd0e4e40b2ebc2915 https://staging.drfop.org/files/original/a35ba394e727d7f97890d44e3b4bc8f8.jpg d1d8235db6501bdc2e847d0aa6325edc https://staging.drfop.org/files/original/64c3f030f117136789588247cc666446.jpg 4f2e2336c57ccb9972606fa34fc39784 https://staging.drfop.org/files/original/80a7da92cda87b5b46d4629f021c8c94.jpg dbe15132b2e8b0856e434023c45cafd3 https://staging.drfop.org/files/original/5c1001c8613c3cdbbbeaec4168327017.jpg a0568a7d77d908e3e116118e815c1508 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_01_010.pdf Year 1966 Volume 2 Issue 1 Page Number(s) 10 - 19 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/1966_01_010.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_01_010.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Preliminary Design Analysis of Linkage Feeders</h2> <h5>Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br />Nancy V. Appoldt, B.A. <a style="text-decoration:none;">*</a><br /></h5> <!-- <sup Note="1">*Based upon a report entitled <i>Preliminary Design Analysis of Linkage Feeders, </i>published by Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, New York, N. Y., in May 1965. The report was prepared under the general supervision of Sidney Fishman, Ph.D., Project Director, Prosthetic and Orthotic Studies, New York University. The study reported upon was supported by funds from the Vocational Rehabilitation Administration, Department of Health, Education, and Welfare.</sup> --> <p>In 1962 the Committee on Prosthetics Research and Development authorized a survey of current orthotics research and development in a number of selected centers as an initial step in a proposed orthotics evaluation program. A prime purpose of the survey was the identification of orthotic devices and procedures as suitable subject matter for the evaluation program.</p> <p>One of the devices selected as meeting the requirements for inclusion in the evaluation process was the linkage feeder designed at the University of Michigan. However, it was apparent that this device, plus a number of others, was essentially a variant of the ballbearing feeder designed and developed two decades ago by the Georgia Warm Springs Foundation. Hence, a review of existing feeder designs was undertaken as a prelude to any formal evaluation program.</p> <p>The systems involved were those currently in use at the Georgia Warm Springs Foundation, Rancho Los Amigos Hospital, the University of Michigan, the Texas Rehabilitation Center, and the Texas Institute for Rehabilitation and Research. Two prefabricated units that were available commercially were also reviewed, but these units resemble the Rancho Los Amigos Hospital feeder so closely that separate consideration is not warranted.</p> <p>Ideally, a feeder supports the weight of the arm and permits the patient with severely weakened or paralyzed upper extremities to position the hand with a minimum of muscular effort. The extent of a patient's performance with a feeder and his method of performance are, of course, contingent on the nature and extent of his disability.</p> <p>The feeders considered in this article have numerous structural features and operational principles in common. An aluminum forearm trough and two stainless-steel swivel arms that rotate on ball or needle bearings support the weight of the upper extremity and provide useful motion when activated by a slight residual motor power in the head, neck, trunk, or arms. The joint cylinders may be rotated to bring the feeder assembly into an inclined plane which provides gravity assistance to the horizontal motions of the extremity. The trough pivot may be positioned to give a bias to both vertical motions of the forearm, namely, raising the hand to the head or lowering it to the table top.</p> <p>A number of accessory components may be attached to a feeder to adapt the equipment to individual requirements without modifying the basic design. Among these are metal clips, straps, and foam-rubber liners to prevent slippage <!--Page 11--> of the forearm; horizontal and vertical stops to restrict feeder motions to a controllable range; elastic-band and supinator assists to aid motion; and double T-bars to support the hand and provide attachments for self-help devices.</p> <p>The basic principles of the various feeders being the same, a matter of interest is the significance of the points on which they differ. In Appendix A the distinctive features of each of these systems are identified and illustrated in detail. The Georgia Warm Springs Foundation model is presented as the basic design, with its apparent advantages and disadvantages. The other four designs are then compared with the Georgia Warm Springs Foundation item.</p> <h3>SUMMARY AND CONCLUSIONS</h3> <p>Linkage feeders were received from the Georgia Warm Springs Foundation, the University of Michigan, Texas Rehabilitation Center, the Texas Institute for Rehabilitation and Research, and Rancho Los Amigos Hospital. With the Georgia Warm Springs Foundation balanced forearm orthesis as the frame of reference, the design and operational features of each feeder were subjected to critical examination. In summarizing the findings of the examination, two points must be emphasized:</p> <ol> <li>All feeders are in current and apparently successful use at the centers from which they were obtained.</li><li>The feeders were not applied to <i>bona fide </i>patients, but were analyzed in relation to use by a normal adult.</li></ol> <p>Thus the validity of the advantages and disadvantages cited in this report might require further verification.</p> <p>It is of value, however, to identify the <i>apparent </i>strengths and weaknesses of each feeder in relation to the Georgia Warm Springs Foundation balanced forearm orthesis. This feeder was the first of its kind, and its basic design served as a model for the subsequent feeders. The question that this review attempts to answer is: In what respects do the features of the other feeders appear to be superior or inferior to those of the Georgia Warm Springs Foundation Feeder?</p> <h3>UNIVERSITY OF MICHIGAN</h3> <p>The multiple adjustment features of the University of Michigan feeder appear to make it the most versatile of those reviewed. Moreover, this adjustment capability is maintained throughout the life of the feeder, in contrast to the reduced adjustability of the "permanent" feeder which is the end product in some of the other designs.</p> <p>The significant additional adjustment involves the rocker-arm assembly and allows the trough, and consequently the forearm, to be raised or lowered with respect to the trough pivot. The fore-and-aft adjustment found in other feeders is also available. Thus the forearm may be balanced against gravity in two dimensions, permitting maximum control of the forces acting about the trough pivot in horizontal, vertical, and intermediate positions of the forearm. The use of ball bearings in the distal link and trough pivot, as well as in the first and second joints, minimizes frictional forces in the system. The screw-adjustment system permits precise adjustment without the use of tools. The lateral location of the rocker-arm assembly, combined with the use of a triceps strap, permits a closer relationship between table top and trough, while the lateral space required for feeder operation is reduced by the use of a relatively short proximal link.</p> <p>The prime limitations of the University of Michigan feeder are:</p> <ol> <li>It is bulky and has a nonaesthetic appearance.</li><li>The nondetachable proximal link imposes the necessity for removing the entire feeder from the wheelchair when it is to be collapsed, transported, or stored.</li><li>The triceps strap may bind, reducing or eliminating elbow support.</li></ol> <h3>TEXAS REHABILITATION CENTER</h3> <p>The outstanding characteristic of the Texas Rehabilitation Center feeder is its simplicity. The adjustability of link lengths should also be useful for applications to children during the growth years.</p> <p>The absence of ball bearings in the proximal joint makes this feeder more difficult to maneuver in horizontal motions. The short swivel arms and stationary elbow dial restrict extension of the arm and thereby limit function to a reduced zone of motion. Contact of the elbow dial with the distal link obstructs lateral trough motion, while the rocker-arm assembly restricts the upward tilt of the trough. Because the trough is offset from the distal link vertically, <!--Page 12--> placement with relation to a table top is more distant than with the Georgia Warm Springs Foundation, University of Michigan, or the Rancho Los Amigos Hospital system, each of which has horizontally offset troughs. In order to change tilts at the first and second joints, the device must be returned to the orthotics shop.</p> <h3>TEXAS INSTITUTE FOR REHABILITATION AND RESEARCH</h3> <p>The Texas Institute for Rehabilitation and Research model is notably streamlined in appearance. Frictional resistance is minimized in horizontal feeder motions by the use of needle bearings at the end of the distal link.</p> <p>As with the Texas Rehabilitation Center feeder, an orthotist must make any tilt adjustments. This lack of ready adjustment might tend to hinder a patient's performance if his wheelchair were on uneven terrain. It might also delay accommodation to improvement or regression of his disability. The trough's vertical offset from the distal link and relatively long vertical rod limit the closeness of trough placement to the table top. Moreover, to bring the trough as close as possible to the table top, clearance of the distal link is minimized (1/2 to 1 in.) and the link may strike objects on the table.</p> <h3>RANCHO LOS AMIGOS HOSPITAL</h3> <p>In the Rancho Los Amigos Hospital feeder a unique tilt adjustment is provided at the distal end of the proximal link. Adjustment of the second joint, therefore, is easier and more precise. The rocker-arm assemblies permit greater ranges of motion at the trough pivot than those of the Georgia Warm Springs Foundation model. The outside rocker-arm assembly, which has a ball-bearing unit at the trough pivot similar to that of the University of Michigan feeder, minimizes friction in vertical motions and permits two-dimensional adjustment of the pivot relative to the forearm. A ball-bearing unit may also be added to the joint at the end of the distal link to minimize friction in horizontal feeder motions.</p> <p>Each of the feeders, when compared with the Georgia Warm Springs Foundation system, appears to have both positive and negative features. On the basis of the available data, resolution of the various pros and cons as to which feeder is the best is not feasible. Certainly the thought that the most advantageous characteristics of the five feeders might be combined in one superior system has appeal.</p> <p>However, selection of the optimal feeder for a particular patient depends primarily on the purpose for which the device is prescribed. Purposes may range from support of the arms in a comfortable position for the most severely disabled to increased functional independence and participation in vocational activities for others. Thus a single feeder, even one incorporating the best elements of the various designs, may not serve the needs of all patients.</p> <p>Nevertheless, the similarities and differences of the five feeders identified in this review, and particularly the significance of the differences, are worthy of further study. If patients' needs in relation to the functions offered by the various components could be precisely defined, an individual's requirements might best be met by using selected components from one or more of the available feeders.</p> <!--Page 13--> <h3>Appendix A</h3> <h3><i>A Detailed Comparison of Five Feeders</i></h3> <h4>GWSF Balanced Forearm Orthesis</h4> <p><b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The Georgia Warm Springs Foundation (GWSF) balanced forearm orthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>A round clamp <i>1 </i>attaches to the chair upright <i>2. </i>Two screws <i>3 and 4 </i>extend from the clamp to provide attachment for, and anteroposterior angular adjustment of, a ball-bearing tube 5.</p> <p><i>Advantages - </i>The proximal joint may be independently tilted anteroposteriorly and rotated mediolaterally to provide a gravity assist or to compensate for an inclined chair upright or for slopes. There is minimal joint friction.</p> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>The detachable swivel arm 6 terminates distally in a ball-bearing tube <i>7. </i>Length of proximal link is adjustable during fitting, nonadjustable in the finished unit. The proximal link is either a drop-type <i>6 </i>or straight (not shown). Accessory collars (not shown) may be used to raise the proximal link. The distal link 8, curved approximately 90 deg., terminates in a vertical tube or post <i>9, </i>the height of which may be increased by height extenders (not shown).</p> <p><i>Advantages - </i>The feeder may be removed from the chair upright without disturbing the base assembly. Minimal friction is present between proximal and distal links. Drop-type proximal link is useful in obtaining proper feeder height for short patients (without clamp adjustment). The straight proximal link may be used with collars to provide elevation of the feeder for taller patients. The curved distal link reduces interference between elbow and distal link. Height extenders are useful for gaining additional trough height and increasing elbow-distal link clearance.</p> <p><i>Disadvantages - </i>Benders must be used on the proximal link to provide anteroposterior tilts at the second joint.</p> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>A drop <i>10 </i>or straight (not shown) offset rod inserted in the tube permits rotation of the trough. Accessory collars <i>11 </i>increase rod height. The distal end of the rod fits into two sleeves <i>12 </i>which rotate on the rod. The sleeves are brazed to a 1-in. flat bar with threaded holes for attachment to the underside of the trough <i>13. </i>An L-shaped bar <i>14 </i>soldered to the rod between the sleeves holds the movable sleeve unit on the rod.</p> <p><i>Advantages - </i>The offset rod provides additional trough-link clearance. Additional height adjustment is useful in accommodating tall patients.</p> <p><i>Disadvantages - </i>The L-shaped bar imposes a "down" stop on trough motion.</p> <p><b>Trough</b></p> <p><i>Description - </i>The forearm cradle <i>15 </i>has prepunched holes interiorly for anteroposterior adjustment on the sleeve bar. The elbow dial is stationary (not shown) or hinged <i>16 </i>to the stem of the cradle and connected to the rocker-arm assembly by a linkage rod <i>17.</i></p> <p><i>Advantages - </i>The hinged dial permits full elbow extension.</p> <p><i>Disadvantages - </i>The stationary dial restricts elbow extension.</p> <!--Page 14--> <h4>The University of Michigan feeder.</h4> <p><b>Fig. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The University of Michigan (U of M) feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>A round clamp <i>1 </i>similar to the GWSF item attaches to the chair upright <i>2. </i>An adjustment assembly connects the clamp with a ball-bearing cylinder <i>3 </i>and allows positioning anteroposteriorly by screw <i>4 </i>and mediolaterally by screw 5. Feeder height may be regulated by an adjusting nut <i>6 </i>incorporated into the ball-bearing tube.</p> <p><i>Advantages - </i>Greater precision in mediolateral, anteroposterior,and height adjustments than the GWSF feeder. No tools are required for adjustments. Minimal joint friction.</p> <p><i>Disadvantages - </i>Bulky, conspicuous. Weight of unit must be supported when attaching clamp to wheelchair.</p> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>The vertical portion <i>7 </i>of a straight swivel arm is threaded to accommodate the height-adjusting nut. The proximal link, which terminates distally in a ball-bearing tube <i>8, </i>is relatively shorter than the GWSF item. The distal link is angled distally 90 deg. and has a ball-bearing tube <i>10 </i>attached. The distal link is proportionally longer than the GWSF item.</p> <p><i>Advantages - </i>Short proximal link decreases space required (laterally) for feeder excursion. Minimal friction present at second ballbearing joint. Angled distal link provides trough-link clearance. Minimal friction present between distal link and rocker-arm assembly.</p> <p><i>Disadvantages - </i>Benders must be used on the proximal link to provide anteroposterior tilts at the second joint. Linkage is not readily detachable from the wheelchair assembly.</p> <!--Page 15--> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>A short vertical rod fits into the ball-bearing tube to permit horizontal rotation of the trough. Affixed to the superior end of the rod is a U-shaped housing <i>11 </i>which supports a ballbearing unit <i>12. </i>Extending from this unit is a threaded shaft which is mounted by a grooved block and adjusting screw <i>13. </i>Affixed to the block is a curved supporting arm <i>14 </i>which extends under the trough and attaches to another grooved block and screw assembly on the inferior lateral aspect of the trough <i>15.</i></p> <p><i>Advantages - </i>Minimal friction present in vertical motions of the trough. Screw-type adjustments permit finer control of elbow-hand balance. Balance of the feeder may be adjusted in two planes, vertical as well as anteroposterior. No tools are required for adjustments.</p> <p><i>Disadvantages - </i>Conspicuous, crude appearance.</p> <p><b>Trough</b></p> <p><i>Description - </i>A triceps strap <i>16 </i>has hinged attachments to two outriggers <i>17 </i>and <i>18 </i>which are riveted to the inferior and lateral aspects of the forearm cradle <i>19.</i></p> <p><i>Advantages - </i>Triceps strap permits full elbow extension. Posterior protrusion of elbow is less with triceps strap than with elbow dial.</p> <p><i>Disadvantages - </i>Triceps strap may be displaced from support position with repetitive motion.</p> <!--Page 16--> <h4>The TRC Feeder</h4> <p><b>Fig. 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The Texas Rehabilitation Center (TRC) feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>Wheelchair Assembly One arm of a U-shaped rod <i>1 </i>inserts into the round clamp <i>2. </i>The other end is brazed to a vertical tube <i>3 </i>so that bending of the U-rod tilts the tube anteroposte-riorly. Rotating the rod within the clamp tilts the joint mediolaterally.</p> <p><i>Advantages - </i>Simple and inconspicuous. The effect of increased friction from absence of ball bearings in the proximal joint is uncertain. Some friction at this point may be advantageous, for example, to lend stability at the shoulder so that motion imparted to the feeder will occur at the elbow first. It may, however, be disadvantageous if the impedence cannot be readily overcome, particularly in the zone of hand motions about the head.</p> <p><i>Disadvantages - </i>Benders must be used to obtain anteroposterior tilt adjustments.</p> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>A detachable straight swivel arm <i>4 </i>is adjustable in length from 4 3/4 to 8 in. and terminates in a ballbearing tube 5. The distal link <i>6 </i>is a straight swivel arm, adjustable in length from 4 3/4 to 8 in., and terminates in a vertical tube <i>7.</i></p> <p><i>Advantages - </i>Feeder can be removed from chair without disturbing the base assembly. Ball bearings reduce joint friction. Short proximal link reduces lateral space required for feeder excursion.</p> <p><i>Disadvantages - </i>Short linkage lengths limit reach and permit joint toggle. As with the GWSF unit, benders must be used on the proximal link to obtain tilts at the second joint without affecting the plane of motion of the first joint. When the forearm is inclined vertically, the distal link interferes with horizontal excursion of the dial.</p> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>A rod, Y-shaped distally <i>8, </i>swivels within the tube and articulates with pre-drilled holes in the trough fenders <i>9 </i>to form the trough pivot.</p> <p><i>Advantages - </i>Pivot joints are easily adjusted on the trough without tools. The location of the trough pivot, being higher with respect to the trough than that of the GWSF feeder, more closely approximates the center of gravity of the forearm.</p> <p><i>Disadvantages - </i>Y-shaped rod imposes "up" stop on trough.</p> <p><b>Trough</b></p> <p><i>Description - </i>The trough <i>10 </i>has anteroposterior adjustment on pre-drilled holes. Forearm cradle as stationary dial <i>11.</i></p> <p><i>Disadvantages - </i>As with the GWSF stationary dial assembly, elbow extension is limited.</p> <!--Page 17--> <h4>The TIRR Feeder</h4> <p><b>Fig. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The Texas Institute for Rehabilitation and Research (TIRR) feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>Wheelchair Assembly A round clamp <i>1 </i>is attached to the chair upright. An offset plate <i>2 </i>affixed to the clamp provides the mounting for the needle-bearing tube <i>3, </i>which is adjustable anter-oposteriorly in the trial feeder, nonadjustable in the permanent model (not shown). The tube is tilted mediolaterally by rotation of the round clamp.</p> <p><i>Advantages - </i>Smaller tube with needle bearings reduces bulk of unit and provides an unobtrusive appearance. Minimal joint friction.</p> <p><i>Disadvantages - </i>In the permanent feeder, mediolateral adjustments cannot be made without affecting anteroposterior tilt which has been established.</p> <!--Page 18--> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>The proximal and distal links are straight and terminate in needle-bearing tubes 5 and <i>6. </i>The proximal link is detachable and the length of the links is adjustable in the trial model, nonadjustable in the permanent model.</p> <p><i>Advantages - </i>Feeder may be removed from the chair without disturbing the base assembly. Minimal joint friction.</p> <p><i>Disadvantages - </i>As in the GWSF unit, benders must be used to effect tilts at the second joint without altering the base assembly.</p> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>A relatively long vertical rod <i>7 </i>terminates superiorly in a clevis hinge <i>8. </i>A rectangular bar <i>9 </i>bearing two threaded holes for trough attachment is brazed to the movable portion of the hinge.</p> <p><i>Disadvantages - </i>The length of the vertical rod is not sufficient to prevent interference of the distal link with the lateral excursion of the elbow dial when the trough is in the "up" position. This means of offsetting the trough from the distal link positions the terminal end of the link approximately 1/2 in. above the table top. The path of feeder motion is obstructed by objects on the table.</p> <p><b>Trough</b></p> <p><i>Description - </i>The forearm cradle <i>10 </i>and hinged elbow dial <i>11 </i>are similar to the GWSF unit's trough. The linkage rod <i>12, </i>which is adjustable for fitting purposes, is nonadjustable in the permanent feeder (not shown).</p> <p><i>Advantages - </i>Permits full elbow extension.</p> <!--Page 19--> <h4>The RLAH Feeder</h4> <p><b>Fig. 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The Rancho Los Amigos Hospital (RLAH) feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Wheelchair Assembly</b></p> <p><i>Description - </i>As in the GWSF unit, a round clamp <i>1 </i>attaches to the chair upright. An L-shaped bracket <i>2 </i>extends from the clamp to provide attachment for and anteroposterior angulation of an adjusting plate <i>3. </i>A ball-bearing tube <i>4 </i>is soldered to the posterior lateral aspect of the plate.</p> <p><i>Advantages - </i>As with the GWSF unit, the proximal joint may be tilted mediolaterally by rotating the wheelchair clamp and anteroposte-riorly by a separate adjustment. The plate simplifies anteroposterior adjustment.</p> <p><b>Proximal and Distal Links</b></p> <p><i>Description - </i>The detachable drop swivel proximal link 5 is similar to the GWSF item and terminates distally in an adjustable ball-bearing tube <i>6. </i>A small hinge unit <i>7 </i>permits anteroposterior tilting of the tube. The selected tilt position is maintained by set screws <i>8. </i>The distal link, similar to the GWSF item, is curved 90 deg. and terminates in a vertical tube <i>9. </i>An alternate unit (not shown) for patients with limited motion in the horizontal plane replaces the vertical tube with a ball-bearing unit. Post height extenders, like those of the GWSF system, may be fitted into the vertical tube to elevate the trough.</p> <p><i>Advantages - </i>The tilt adjustment for the second joint permits greater ease and precision in providing assistance to horizontal motions of the forearm. As with the GWSF distal link, the curved offset permits adequate horizontal rotation of the rocker-arm assembly when the trough is in the "up" position. Ball bearings used at the end of the distal link reduce friction between the distal link and the rocker-arm assembly. Additional feeder height may be desirable for tall patients or for specific activities (for example, combing the hair).</p> <p><b>Rocker-Arm Assembly</b></p> <p><i>Description - </i>The standard assembly consists of a vertical rod which swivels within the tube and is surmounted by a U-shaped hinge unit <i>10. </i>Fixed to the movable portion of the hinge is a 1-in. rectangular bar <i>11. </i>Threaded holes in the bar can be aligned with drill holes in the underside of the trough for attachment and anteroposterior adjustment. The outside rocker-arm assembly incorporates a height-adjusting collar <i>12 </i>on a longer vertical rod and a ball-bearing trough pivot <i>13. </i>A clamp anchored to the hinge axis medially, attaches to an offset rod <i>14 </i>to permit vertical adjustment of the trough with respect to the hinge.</p> <p><i>Advantages - </i>The outside rocker-arm assembly reduces friction in vertical motions and permits greater control of elbow-hand balance by means of placing the trough pivot closer to the center of gravity of the forearm.</p> <p><b>Trough</b></p> <p><i>Description - </i>The trough <i>15 </i>and dial <i>16 </i>are similar to but not identical with the GWSF forearm cradle and stationary dial.</p> <p><i>Disadvantages - </i>Stationary dial restricts elbow extension.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Nancy V. Appoldt, B.A. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Scientist, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, 317 East 34th Street, New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Ave., N.W., Washington D. C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1966_01_010/sp66b-005.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 Preliminary Design Analysis of Linkage Feeders Creator An entity primarily responsible for making the resource Hector W. Kay, M.Ed. * Nancy V. Appoldt, B.A. * https://staging.drfop.org/files/original/89e34b5363a6e2997d50157f759ed25d.pdf be2d67e33fc2cf47d7f30766ca9a7815 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_01_001.pdf Year 1955 Volume 2 Issue 1 Page Number(s) 1 - 3 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/1955_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Prelude, Prophecy, and Promise</h2> <h5>John B. Dec. M. Saunders, M.B., F.R.C.S.(Edin.) <a style="text-decoration:none;">*</a><br /></h5> <p> than a dynamic mechanism. The degree of disappointment and measure of failure in these simple objectives, without change in fundamental concepts, is to be seen in the countless empirical modifications of initial designs which bestrew the literature on artificial limbs over the past hundred years and more. </p> <p> Earlier optimisms were gradually replaced by indifference and the inertia of failure, as is well known to those associated with the problem of the amputee after World War I. Locomotion, as we ordinarily understand it, is impossible on a single extremity. But it was realized insufficiently that, unlike the upper extremities, the two lower limbs together constitute but a single organ-the organ of locomotion. Consequently, the complexity of locomotion in relationship to prosthetics design never really was understood, and even where designs were in question the available information was inadequate to support newer developments of principle. </p> <p> Preliminary efforts in the study of human locomotion are to be found in the work, <i>De Motu Animalium, </i>of the Neapolitan mathematician and physician, Giovanni Borelli (1608-1679). As a pupil of Galileo, he was stimulated to take a mechanistic view of bodily function and to study locomotion as a problem in leverage, but his theories and those of his followers soon were reduced to absurdity in the attempt to apply the same mechanistic principles to the whole of medical practice. Continuation of Borelli's approach had to await the nineteenth century and the advent of the Weber brothers, Edward (1806-1871) and Wilhelm (1804-1891), physician and physicist respectively, who with primitive electrical apparatus made the first accurate measurements of gait and undertook its mathematical analysis. The development of photography as a method of recording enabled Etienne-Jules Marey (1830-1904) to avoid previous errors and to correct earlier ideas, and further improvements in photography led to the classical work of Christian Braune and Otto Fischer, <i>Der Gang des Menschen </i>(1895), which has constituted the main source in the formulation of principles for the construction of artificial legs, as in the well-known books of H. von Recklinghausen (1920) and Frederich Mommsen (1932). Over more than a decade (1933-1945) Elftman published the results of extensive locomotion studies. To these and many others we owe a great debt. </p> <p> Despite all these investigations, at the end of World War II our knowledge of human locomotion was still quite incomplete, and such knowledge as existed was only poorly understood. Thus it was that, when approached in September of 1945 by the then Committee on Artificial Limbs of the National Research Council, the representatives of the College of Engineering and of the Medical School of the University of California could point to the necessity of the adoption of a long-term outlook which envisioned the study of the fundamentals of human locomotion, of the amputee who must wear a lower-extremity prosthesis, and of the prosthesis itself. It could be shown that the experience of 400 years in trial-and-error techniques had offered little and that a firm basis for progress could be established only by a systematic approach. It was predicted that at least seven years of study would be required to collect the fundamental data necessary for improved design of artificial legs. </p> <p> That that prophecy was not needlessly pessimistic is revealed in the fact that only today can it be said with a degree of confidence that we are about to enter a period of practical development in the evolution of a truly satisfactory lower-extremity prosthesis. Within the next two or three years we should see the appearance of sound improvements based upon the preceding nine years of pioneering work. </p> <p> But the problems of the leg amputee are not wholly "prosthetic." Such a patient presents a clinical picture of considerable significance. The whole being the sum of its parts, the amputee can scarcely be looked upon as normal in the medical sense, however good general health may be. He is, indeed, quite abnormal, for from amputation of an extremity come changes in skeletal, muscular, and circulatory systems to be dealt with in the design and application of the prosthetic replacement. Complications of pain, real and phantom, and of skin disorders are other matters needing the skills and experience of the medical profession. </p> <p> Taking cognizance of this situation, the Advisory Committee on Artificial Limbs, in the spring of 1953, recommended that the University of California initiate an extensive clinical program to be integrated with the work already under way in the fundamentals of locomotion and in the techniques of lower-extremity fit and alignment. Utilizing space and services afforded by the U. S. Naval Hospital at Oakland and personnel from the University of California Medical and Engineering Schools, the Clinical Study aims to apply to the practical problems of difficult amputee cases the results of the earlier work on the Berkeley Campus. </p> <p> This issue of Artificial Limbs is concerned with two major factors in the management of the lower-extremity amputee-the solution of medical problems associated with the amputated state, and the proper application of the prosthetic replacement on the basis of established biomechanical considerations. In the first of two articles, an orthopedic surgeon and an engineer collaborate in describing the origin, observations, and objectives of the Lower-Extremity Clinical Study. In the second, an engineer develops the principles of alignment and socket fit so indispensable to comfort and function, and hence to the success, of the above-knee artificial leg. In this cooperative effort is reflected the whole basic philosophy of the Artificial Limb Program in approaching the problems of the amputee. </p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>John B. Dec. M. Saunders, M.B., F.R.C.S.(Edin.) </b></td></tr><tr><td class="clsTextSmall"> Professor of Anatomy, School of Medicine, University of California, San Francisco. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Prelude, Prophecy, and Promise Creator An entity primarily responsible for making the resource John B. Dec. M. Saunders, M.B., F.R.C.S.(Edin.) * https://staging.drfop.org/files/original/0fa05d6068c4d9c2c30ab2adf76bb0aa.pdf deefaab5793bb40f246278d00e8ccc28 https://staging.drfop.org/files/original/156df68bab8e0e67d6486f1c12d72e33.jpg 6afb18c555faff017f2713757a472544 https://staging.drfop.org/files/original/ab11f9a0172e3e77c4a779876507f1ec.jpg 953c6d12e2f388522a9851ae0b7342c1 https://staging.drfop.org/files/original/39765be2abc491c73fbb77f348b80811.jpg 75738c583a9d5fa06b2b9cc98ec8bc8a https://staging.drfop.org/files/original/8b190de4debac89f24143367201adc54.jpg afed0ba76e9ca50e2977297894f48191 https://staging.drfop.org/files/original/af863b7df0cad2ab58bb6e8daddd1fae.jpg 90d61436ff957d9a832970284d907b05 https://staging.drfop.org/files/original/f35503438fe05e1cdbc250b4e82f94d5.jpg 99c5889626100eef344a612d0ef0144b https://staging.drfop.org/files/original/b6385b9e916c2dc4ec8d882d296ffbec.jpg 903e5a50735dddcf70b53d421d8535f1 https://staging.drfop.org/files/original/cc1bcdcf0aa82448482125d7233c2050.jpg 54761632a865da1bb94d6a98a6490944 https://staging.drfop.org/files/original/d947b49fd92dd2f0d72c609efb65047e.jpg fbbe8888586ee697db72bd6897bfedbf https://staging.drfop.org/files/original/989181df6cb3cb6b55290a5bec7bf202.jpg a10287ef2e996756c2aa320a34f8dcd2 https://staging.drfop.org/files/original/b766abead8153e3f82f59b077962e0d6.jpg d553d8b4fe2b3d70ec894cad702d03f9 https://staging.drfop.org/files/original/2e918fb95e99cacf4c82973b0212bccc.jpg 005e417a4aafce0105f700f8a6515eef https://staging.drfop.org/files/original/613b9a4452de0437198cd813baaa61e1.jpg acd412db35de4685ce2b71355c40d708 https://staging.drfop.org/files/original/0e7cc252f4b3a1626acbb5dc867a5025.jpg 32c10baf22ef8472383f3c2360990a4a https://staging.drfop.org/files/original/30c3612232851dc3f8d5431dbfe34810.jpg 0a6ff1698181ad1d40fdafef9b9b5b68 https://staging.drfop.org/files/original/087223721d10e6073542b807509106fd.jpg aa7e8d1c20b1c29b8149b00326d1aa1d https://staging.drfop.org/files/original/a4305ebe705f8f02e0602b51a3c82b45.jpg c7376f54499e82996efdbdf24e3aa938 https://staging.drfop.org/files/original/8b3557f24cd0dcb0ef944b5f9d6bbdbe.jpg ad65f6bd2df274a4e558eaadbf017a68 https://staging.drfop.org/files/original/565202e80a39f6169372423c5e5c3957.jpg 31958624e459cec8528a2897b3ecdb11 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_01_001.pdf Year 1971 Volume 15 Issue 1 Page Number(s) 1 - 14 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Premodified Casting for the Patellar-Tendon-Bearing Prosthesis</h2> <h5>Joseph H. Zettl. C.P <a style="text-decoration:none;">*</a><br />Joseph E. Traub. C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>Methods for producing a functional, comfortable, and well-fitting patellar-tendon-bearing prosthesis have been the subject of considerable discussion, and in fact some controversy, since the prosthesis was first introduced several years ago. Prosthetists use a variety of techniques to cast below-knee stumps, and there is an extensive literature on the subject, not excluding the technicians' differing viewpoints. There is agreement, however, that the effectiveness of the prosthesis depends to a great extent upon how well the wrap-cast (negative) was taken and, subsequently, how precisely the male plaster mold (positive) was modified.</p> <p>The positive mold is modified in order to relieve pressure-sensitive areas by the addition of build-ups, and to increase the pressure to the pressure-tolerant (or natural weight-bearing) areas of the stump by the judicious removal of small amounts of plaster. These alterations prevent vertical displacement during stance and provide for comfortable accommodation of the stump during full weight-bearing. The precise amount of plaster removed varies with the individual patient, depending upon the muscle tone and the amount and resilience of the subcutaneous tissue. The procedure is by no means a difficult one, but timing is a complicating factor.</p> <p>Authorities on the subject encourage immediate rather than later modification of the positive cast in order to prevent improper interpretation of the individual stump characteristics. Consequently, the well-qualified prosthetist who finds himself with a large number of plaster positives to be modified, or the less experienced prosthetist who is just developing a keen sense of technical judgment, is at a disadvantage because, even with the best memory and with detailed prosthetic information, he is limited by techniques which involve nothing more than intelligent guesswork and which are conducive to at least an occasional error, regardless of the individual's experience and skill.</p> <p>This difficulty can be overcome by modifying the cast on the patient's stump when the negative-cast impression for the permanent prosthesis is taken. This paper describes such a procedure, essentially initial socket fitting during casting, which provides a plaster negative-positive that requires only a final smoothing to be ready for socket lamination. The method includes the application of felt pads to strategic areas of the stump. Elastic plaster bandage is used for the negative plaster wrap because it effectively conforms to the irregular stump surfaces, controls tissue compression and displacement, and yields a precise stump impression. The resulting positive plaster mold resembles the stump contours accurately, thus providing the basis for a comfortable, well-fitting, and functionally acceptable PTB prothesis.</p> <p>Provision of a total-contact, hard PTB socket, without a soft end or the customary insert, is the standard procedure at the Prosthetics Research Study, and the pre-modified-casting procedure results in a precise reproduction of the stump socket, so essential in hard-socket prostheses. This method has been used routinely at this facility since 1964, during which time several hundred PTB prostheses have been effectively fitted.</p> <p>The premodified-casting procedure can be used, with but relatively minor modifications, for the patellar-tendon supracondylar or the patellar-tendon supracondylar-suprapatellar (PTS) prosthesis, with wedge suspension. We have also used this technique, with promising results, for the production of interim prosthetic sockets using both synthetic rubber, Polysar X-414 (TM), and Lightcast (TM). Both these materials will produce an effective interim prosthetic socket for immediate and early fitting.</p> <h3>Procedure</h3> <h4>Negative Plaster Wrap</h4> <p><i>Prosthetic Information</i></p> <p>Examine the stump to obtain all pertinent prosthetic information. Measurements of the normal leg can also be recorded at this time on page B of the prosthetic information form, but measurement of the stump is postponed until all felt relief pads have been applied to the stump.</p> <p><i>Materials and Equipment</i></p> <p>Materials required for the premodified plaster cast for a PTB prosthesis are:</p> <ul> <li>One lightweight cast sock</li> <li>One heavyweight cast sock</li> <li>Dow Corning Medical Adhesive Spray Type B</li> <li>Two rolls of 4- or 5-in. elastic plaster bandage</li> <li>One roll of 4-in. conventional plaster bandage</li> <li>Four plaster splints, 4 in. x 15 in., extra-fast-setting</li> <li>Soft felt, approximately 5 in. x 10 in. x 1/8 in. thick</li> <li>Medium felt, approximately 5 in. x 10 in. x 3/8 in. thick (or a right or left set of prefabricated felt relief pads, as used in immediate postsurgical prosthetic fitting)</li> </ul> <p>Equipment required for this procedure is:</p> <ul> <li>Two 48-in. lengths of 1-in. elastic webbing</li> <li>Four Yates clamps</li> <li>One pair medium-size scissors</li> <li>Skiving knife</li> <li>Inside calipers</li> <li>Measuring tape</li> <li>Combination square</li> <li>VAPC knee-measuring caliper</li> <li>Preshaped piano-felt, hamstring-tendon relief pads</li> <li>Below-knee casting fixture</li> <li>Bucket or basin of clear water, approximately 70 degrees F</li> </ul> <p><i>Preparation of Patient</i></p> <p>Have the amputee sit on a table approximately 30 inches high, with the knee of the amputated leg extending six to eight inches beyond the table edge (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Roll the heavy cast sock onto the stump and attach the proximal portion of the cast sock with two Yates clamps to the 1-in. elastic-webbing strap which encircles the amputee's hips and crosses the amputated leg approximately four inches proximal to the patella (<b>Fig. 2</b>). The strap should exert considerable tension on the cast sock in order to support all soft tissues of the stump, particularly those located distally. <i>This is most important </i>because improper tissue support would result in too large a cast, necessitating modifications of the positive model or prosthetic socket to achieve proper fit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Direct the amputee to flex his knee approximately 35 degrees and to maintain this flexion in a relaxed attitude throughout the entire casting procedure.</p> <p><i>Preparation of Pressure-Relief Pads</i></p> <p>By palpation, locate the surface areas of the stump which require pressure relief.</p> <p>For the <i>tibial crest:</i></p> <ol> <li>Measure the entire length of the crest of the tibia from the proximal border of the anterior tibial tubercle to 1/2<i> </i>in. beyond the posterior edge of the transected tibia.</li><li>Measure the width of the anterior tibial tubercle and the cut end of the tibia.</li><li>Cut a piece of <i>soft </i>felt, 1/8-in. thick, to the length dimension taken in step 1 and width dimension taken in step 2. This results in a felt relief pad (<b>Fig. 3</b>) which has a long rectangular form and widens in its distal aspect into a well-rounded teardrop shape, approximating the contours of the cut end of the tibia.</li><li>Neatly skive the periphery of the tibial relief pad to assure a smooth transition between the stump sock and pad.</li><li>Usually, additional relief of the distal anterior tibial area is indicated. The additional relief pad should represent the contours of the cut end of the tibia, resulting in the general shape of a large metatarsal pad. The periphery of the pad is smoothly skived to blend in with the tibial relief pad (<b>Fig. 4</b>).</li></ol> <p>For the <i>head of the fibula:</i></p> <ol> <li>Measure the proximal-distal and anterior-posterior dimensions of the head of the fibula.</li><li>Fashion a piece of <i>soft </i>felt, 1/8-in. thick, to those dimensions, rounding off all corners and neatly skiving the periphery. The fibular relief pad should have a shape similar to a large metatarsal pad.</li></ol> <p>VARIATION: If the cut end of the fibula is prominent, sensitive, or close to the surface, provide another felt relief pad according to its dimensions and skive all edges.</p> <p>For the <i>anterolateral condylar ridge of the tibial plateau:</i></p> <ol> <li>Measure the length and width of this area.</li><li>Fashion a piece of <i>soft </i>felt, 1/8-in. thick, to the dimensions obtained in step 1 (<b>Fig. 5</b>).</li><li>Round off all corners and neatly skive the entire periphery. This results in an oval-shaped condylar-ridge relief pad.</li></ol> <p><i>Application of Pressure-Relief Pads</i></p> <ol> <li>Spray all felt relief pads with Dow Corning Medical Adhesive Type B on the reverse, or unskived, side and allow the adhesive to dry for five seconds.</li><li>Spray the appropriate areas on the cast sock where the relief pads will be located and allow the adhesive to dry for five seconds.</li><li>Apply the felt relief pads in their pre-established locations and recheck to be sure they adequately cover the bony prominences on the stump (<b>Fig. 6</b> and <b>Fig. 7</b>).</li></ol> <p><i>Stump Measurements</i></p> <ol> <li>Remind the patient to maintain his stump in an attitude of 35 degrees of flexion, with the stump musculature relaxed.</li><li>Place the appropriate portion of the VAPC knee-measuring caliper on the femoral condyles. Measure the mediolateral stump diameter and record on the prosthetic-information form (<b>Fig. 8</b>).</li><li>Place the appropriate portion of the VAPC knee-measuring caliper on the patellar tendon and the popliteal tissues. With the stump relaxed, measure the anteroposterior diameter and record on the prosthetic-information form (<b>Fig. 9</b>).</li><li>Mark the apex of the patellar tendon with an indelible pencil (<b>Fig. 10</b>). Place one end of the combination square rule on the patellar tendon and rest the blade of the rule against the long axis of the tibial-crest felt relief pad. Square the distal stump end and record the resulting stump-length measurement in the appropriate box on the prosthetic-information form.</li></ol> <p><i>Second Cast Sock and Hamstring-Tendon Relief</i></p> <ol> <li>The second cast sock, lightweight, is applied very wet. Carefully roll the sock onto the stump without displacing the previously applied felt relief pads.</li><li>The posterior socket brim line should have a well-rounded flare for comfort during prolonged sitting. Appropriate relief for the hamstring tendons provides additional comfort when the knee is maintained in an attitude of 90 degrees of flexion. For this purpose, two standard sets of relief pads in sizes large and average are fashioned from one-inch-thick piano felt. Each set consists of a right and left relief pad. They must resemble the finished rounded contours of the posterior socket brim and include skived distal projections for medial and lateral hamstring-tendon relief. Pad selection is based on matching the distal projections against the hamstring tendons.<br />Select a right or left piano-felt hamstring-tendon relief pad of the proper size (<b>Fig. 11</b>) and place it at the approximate level of the posterior socket brim behind the knee, between the first and second cast socks (<b>Fig. 12</b>). The projections on either side of the relief pad should be located directly over the hamstring tendons behind the knee. Maintain the knee in 35 degrees of flexion.</li><li>With the hamstrings relief pad in place, the second, or lightweight, cast sock is pulled up tight and attached with Yates clamps to a second 1-in. elastic-webbing strap which encircles the amputee's hips and crosses the amputated leg approximately 4 in. above the patella (<b>Fig. 13</b>). This elastic-webbing strap must also exert considerable tension on the second cast sock, without creating wrinkles.</li><li>Recheck all felt relief pads for retention of their proper locations and adjust if indicated.</li></ol> <p><i>Preparation of Compression Pads</i></p> <p>By palpation, locate the surfaces of the stump which are pressure tolerant.</p> <p>For the <i>pretibial area lateral to the tibial crest:</i></p> <ol> <li> Measure the length of the crest of the tibia from the inferior border of the anterior tibial tubercle to within 1/2<i> </i>in. of the anterior cut end of the tibia.</li><li> Measure the distance between the lateral edge of the previously applied tib-ial-relief pad to the anterior border of the fibular head.</li><li> Cut a piece of 3/8-in. <i>medium </i>felt to the dimensions recorded in steps 1 and 2.</li><li> Round off all corners of the pad. The entire periphery is now provided with a 1/2-in. skived border, with a uniform gradual taper, finishing in a feathered edge (<b>Fig. 14</b>).</li></ol> <p>For the <i>pretibial area medial to the tibial crest, </i>including the medial tibial condylar flare:</p> <ol> <li>Measure the length of the crest of the tibia from the inferior border of the tibial tubercle to within 1/2<i> </i>in. of the anterior cut end of the tibia.</li><li>Measure the distance between the medial border of the previously applied tibial relief pad at the level of the tibial tubercle and the medial head of the gastrocnemius muscle.</li><li>Cut a piece of <i>medium </i>felt, 3/8-in. thick, to the dimensions recorded in steps 1 and 2.</li><li>Measure down from one end of the felt compression pad 2 in. and mark that point with chalk.</li><li>Palpate the width of the tibia medial to the crest and measure this distance.</li><li>Mark the felt compression pad at the same distance from the long edge one inch below the mark made in step 4 (<b>Fig. 15</b>). Mark on the felt compression pad a smooth S curve from the posterior edge of the felt to the marks in steps 4 and 5.</li><li>Continue the mark made in step 5 with a straight line to the distal end of the felt compression pad (<b>Fig. 16</b>).</li><li>Cut the felt along the marked lines made in steps 4, 6, and 7 (<b>Fig. 17</b>).</li><li>Round off all corners. The entire periphery of the felt compression pad is now provided with a 1/2-in. skived border, with a uniform, gradual taper, finishing in a feathered edge.</li></ol> <p>For the <i>long shaft of the fibula:</i></p> <ol> <li>Measure the length of the fibula from the inferior border of the head to within 1/2 in. of the distal cut end of the bone.</li><li>Measure the anteroposterior dimension of the head of the fibula.</li><li>Cut a piece of <i>medium </i>felt, 3/8-in. thick, to the dimensions recorded in steps 1 and 2 (<b>Fig. 18</b>).</li><li>Round off all corners. The entire periphery of the fibular compression pad is now provided with a 1/4-in. skived border with a uniform, gradual taper, and finished in a feathered edge.</li></ol> <p><i>Application of Compression Pads</i></p> <p>Apply the felt compression pads to the second (lightweight) sock.</p> <ol> <li> Spray all felt relief pads with Dow Corning Medical Adhesive Type B on the reverse, or unskived, side and allow the adhesive to dry for five seconds.</li><li> Spray the corresponding areas of the cast sock where the felt compression pads will be located and allow the adhesive to dry for five seconds.</li><li>Carefully locate the felt compression pads in their pre-established positions on the thin cast sock (<b>Fig. 19</b>, <b>Fig. 20</b>, and <b>Fig. 21</b>). These pads <i>must not overlap </i>the areas of the previously applied pressure-relief pads. The felt compression pads should be in firm smooth contact with the thin cast sock to avoid reproduction of wrinkles, rough edges, or other irregularities in the plaster wrap.</li></ol> <p><i>Application of Elastic Plaster Bandage</i></p> <p><i>Wraps One and Two. </i>The wrap is always started on the distal lateral aspect of the stump, approximately 1 in. from the distal stump end, to avoid medial displacement of the gastrocnemius muscle (<b>Fig. 22</b>). Minimal tension is applied to the bandage with this circumferential wrap, which is applied clockwise for a right stump and counterclockwise for a left stump (viewed anteriorly). One and three-quarter circumferential wraps will secure the felt compression pads and anchor the elastic plaster bandage to itself (<b>Fig. 23</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Wrap Three. </i>The wrap is now at a posterior-lateral point on the stump. Bring it anteriorly in a diagonal direction over the distal <i>lateral </i>portion of the stump, pulling the plaster bandage almost to its limit of elasticity. At the anterior stump margin, release the tension slightly and carry the wrap medially and then posteriorly, with only a slight pull to the plaster bandage (<b>Fig. 24</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Wrap Four. </i>This wrap is almost identical to wrap three, except that now the bandage covers the distal <i>center </i>of the stump, bandaging in an anteroposterior plane. The direction of the wrap is altered anteriorly and carried toward the lateral side of the stump, as if to resume circumferential wrapping.</p> <p><i>Wrap Five. </i>The wrap is brought anteriorly up over the distal <i>medial </i>stump aspect with the same controlled tension to the plaster bandage (<b>Fig. 25</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Wrap Six. </i>To achieve sufficient cast strength, a second layer of elastic plaster bandage is applied by repeating wrap five.</p> <p><i>Wrap Seven. </i>Repeat wrap four, again altering the direction of the wrap to the medial side, which will cover the distal <i>center </i>of the stump with a second layer of plaster bandage.</p> <p><i>Wrap Eight. </i>Repeating wrap three will now cover the distal <i>lateral </i>stump aspect with a second layer of plaster bandage. The remainder of the elastic bandage is wrapped in a circular manner to a level 1/2 in. superior to the adductor tubercle of the femur.</p> <p>A second roll of elastic plaster bandage is applied when indicated. Pull the plaster bandage firmly so that it conforms smoothly to the stump without leaving wrinkles or ridges. Maximum tension should be applied to the bandage distally, with gradually decreasing tension as the wrap is extended proximal to the knee joint. Smooth the plaster gently to assure complete adherence of all layers, but avoid molding of the plaster as it hardens (<b>Fig. 26</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Application of Below-Knee PRS-Model Casting Fixture</i></p> <p>With the plaster still wet, apply the BK casting fixture (<b>Fig. 27</b> and <b>Fig. 28</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>Open the casting fixture and place the patellar bar on the patellar tendon.</li><li>Push the patellar bar into the joint space until firm resistance is felt, then release slightly. Push in a direct line with the femur (<b>Fig. 29</b>).</li><li>Attach the posterior popliteal section to the anterior portion of the casting fixture. Contouring of the plaster cast in the area of the popliteal space is achieved by joining the two sections of the casting fixture in proper relationship to the casted stump (<b>Fig. 30</b>).</li><li>Be sure that the patient is completely relaxing his stump musculature and that the knee-flexion angle is maintained at 35 degrees.</li><li>Adjust the casting fixture to the patellar size by rotating both halves of the patellar inverted-horseshoe section.</li><li>Recheck and maintain the outline of the patella. Makes necessary adjustments by means of the thumbscrews as indicated.</li><li>Hold the casting fixture in place until the plaster has hardened completely. Check the distal end of the cast to determine final firmness of the plaster wrap.</li><li>Open the casting fixture and remove carefully (<b>Fig. 31</b>).</li></ol> <p><i>Reinforcement of Negative Plaster Wrap</i></p> <p>Apply conventional plaster bandage to reinforce the cast.</p> <ol> <li>Two double layers of 4 in. x 15 in. plaster splints are applied over the distal portion of the cast, one anteroposteriorly and one mediolaterally (<b>Fig. 32</b>).</li><li>Reinforcement of the plaster wrap is completed with a roll of 4-in. conventional plaster bandage, starting at the distal stump aspect (<b>Fig. 33</b>) and wrapping prox-imally with even, overlapping, circular wraps.</li></ol> <p><i>Removal of Negative Plaster Wrap</i></p> <p>Remove the cast negative only after the plaster wrap has completely hardened.</p> <ol> <li>Release both elastic-webbing straps which hold the cast socks suspended.</li><li>Roll the proximal portion of the second (or thin) cast sock down over the brim of the cast negative.</li><li>Remove the posterior piano-felt hamstring-relief pad from between cast socks 1 and 2. If necessary, use a pair of long-nose pliers or the equivalent (<b>Fig. 34</b>).</li><li>Roll the top of the first (or heavy) cast sock down over the brim of the plaster wrap.</li><li>Place your fingers in the popliteal space and your thumbs in the patellar-tendon depressions. Direct the amputee to completely relax his stump.</li><li>With the amputee's knee flexed and relaxed, pull the proximal portion of the plaster wrap towards you to release the area of the patellar tendon by compression of the posterior soft tissue (<b>Fig. 35</b>).</li><li>Carefully remove the first (or heavy) inner cast sock from the negative (<b>Fig. 36</b>). Be extremely careful not to disturb the thin cast sock that adheres to the inside of the plaster-cast negative.</li><li>Inspect the cast critically to be sure that it is smooth and well contoured throughout (<b>Fig. 37</b>).</li></ol> <p><i>Negative Plaster-Cast Measurements</i></p> <p>To check the inside dimensions of the cast negative:</p> <ol> <li>Place the inside calipers in the cast to measure the anterior-posterior dimensions between the patellar-tendon shelf and the posterior popliteal bulge. Record this measurement on the prosthetic information form, side B. The measurement should be the same as the AP dimension plus 1/8<i> </i>inch.</li><li>Place the inside calipers in the cast at the level of the medial and lateral condyles of the femur. Record this measurement on the prosthetic information form, side B. The dimension should not be more than 3/8 inch larger than the ML stump dimension.</li></ol> <p>To check the length of the cast:</p> <ol> <li>Place a ruler in the socket and measure the dimension from the deepest point of the cast to the center of the patellar-tendon bar. Keep the edge of the ruler parallel to the line of the crest of the tibia.</li><li>Compare this measurement to the length of the stump dimension on the prosthetic information form. It must be within ! <i>s </i>inch of the recorded length.</li></ol> <p>NOTE: If any of the measurements recorded in steps 1 and 2 are not within the tolerances stated and cannot be reconciled by remeasurement of the stump, it will be necessary to make a new negative plaster wrap. Also, a new plaster negative must be taken if the plaster wrap has collapsed or if the wrap shows deep ridges or other severe irregularities.</p> <p>The Negative-Positive Plaster Mold</p> <p><i>The Positive Cast Model</i></p> <ol> <li>Fill the negative wrap cast with liquid plaster of paris in the usual manner.</li><li>As the plaster begins to harden, insert a length of vacuum pipe to a sufficient depth, but avoid contacting the negative plaster wrap.</li><li>After the plaster has set for 20 to 30 minutes, cut and strip off all wraps, exposing the positive model. Be careful not to disturb the contours of the model (<b>Fig. 38</b>).</li><li>If necessary, fill all holes in the model left by air bubbles in the plaster. Usually, this will not be necessary if proper care has been taken when filling the negative-cast wrap.</li><li>With a Surform (TM) rasp, smooth off all minor bumps and the irregularities on the model caused by the seam in the cast sock.</li><li>Provide a final smooth finish over the entire model with screen wire and finish with wet-or-dry Fabricut (TM) silicon carbide, 180 grit (<b>Fig. 39</b>). (Screen-baked Durite [TM] would be equally satisfactory.)</li><li>Seal the completed plaster model positive with Hosmer-Lac or the equivalent to prevent the dampness in the plaster from affecting the inner PVA bag during lamination.</li></ol> <h4>Socket Fabrication</h4> <p>Proceed with the standard PTB lay-up used for fabricating a polyester hard-socket laminate. The resulting prosthetic socket accommodates the stump very snugly, in most instances with a three-ply wool stump sock. If preferred, the conventional Kemblo (TM) insert can be prepared in the usual manner prior to the polyester lamination procedure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Fajal, Guy, Stump casting for the PTS below-knee prosthesis: prothese tibiale supra condylienne, <i>Prosthetics International</i>, 3:4-5:22-24, 1968.</li> <li>Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, <i>Artif. Limbs</i>, 6:2:25-73, June 1962.</li> <li>Gardner, Henry, A pneumatic system for below-knee stump casting, <i>Prosthetics International</i>, 3:4-5:12-14, 1968.</li> <li>Hampton, Frederick L., The suspension method for casting of below-knee stumps,<i> Prosthetics International</i>, 3:4-5:9-11, 1968.</li> <li>Murdoch, George, The "Dundee" socket for the below-knee amuptation, <i>Prosthetics International</i>, 3:4-5:15-21, 1968.</li> <li>Radcliffe, C. W , and J. Foort, <i>The Patellar-Tendon-Bearing Below-Knee Prosthesis</i>, Biomechanics Laboratory, University of California, Berkeley andSan Francisco, 1961 (rev. ed.).</li> <li>Wilson, Leigh A , and Erik Lyquist, Plaster bandage wrap cast: procedure for the below-knee stump, <i>Prosthetics International</i>, 3:4-5:3-7, 1968.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Joseph E. Traub. C.P. </b></td></tr><tr><td class="clsTextSmall">Consultant, Rehabilitation Engineering, Social and Rehabilitation Service, Department of Health, Education, and Welfare, Washington, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Joseph H. Zettl. C.P </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetics Research Study, Seattle, Wash.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-22.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-23.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-24.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-25.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-26.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-27.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-28.jpg Figure 10 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-03.jpg Figure 11 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-04.jpg Figure 12 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-05.jpg Figure 13 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-06.jpg Figure 14 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-07.jpg Figure 15 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-08.jpg Figure 16 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-09.jpg Figure 17 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-10.jpg Figure 18 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-11.jpg Figure 19 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-12.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Premodified Casting for the Patellar-Tendon-Bearing Prosthesis Creator An entity primarily responsible for making the resource Joseph H. Zettl. C.P * Joseph E. Traub. C.P. * https://staging.drfop.org/files/original/39661617c0a9eba6b610fe42b024ce94.pdf 80938ab1a7c2213a21e860229c9f5c1c https://staging.drfop.org/files/original/d2190975fcf22aaf4d36cd1f1486eadc.jpg 52102233724241493879e8180f7fe559 https://staging.drfop.org/files/original/c229382fb9182331c340914d8f7e4521.jpg 9c97aed7e57f467d273fe1b5df97c576 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_001.pdf Text Any textual data included in the document <h2>Preparatory Prosthetics</h2> <h5>Bruce P. McClellan, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Donald R. Cummings, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The use of preparatory prostheses has for some time been a widely accepted methodology for the immediate or early management of the amputated limb. Burgess, et al., first introduced and popularized the immediate postoperative fitting procedure back in the late 60's.<a></a> Since that time, the use of early weight bearing prostheses has become the norm in fitting centers around the country and indeed in other parts of the world.</p> <p>This paper will deal primarily with preparatory prostheses as they relate to the below-knee amputee. The rationale for such devices will be emphasized in a generalized fashion, as opposed to presenting a different array of commercially available systems or components.</p> <p>The word "preparatory" denotes that these prostheses are used to prepare the amputated limb for definitive fitting with a prosthesis. Within this context, the scope of prostheses which may be considered preparatory in nature ranges from immediate postoperative fitting to the laminated socket with pylon and S ACH foot. In between these two ends of the spectrum are such devices as the pneumatic air cast and Wu early fitting prosthesis. All of these devices have the major purpose of either controlling postoperative swelling or promoting the inevitable atrophy of muscles which were transected during surgery.</p> <h3>Short Term Versus Long Term Devices</h3> <p>The differences between prostheses used for immediate or very early fitting and those used for long term are worth noting. We will clarify the terms "temporary" and "intermediate" to distinguish between the two types of devices. The term "temporary" will be used to describe those prostheses which are intended for relatively short usage; they are applied soon after amputation, and usually are applied directly to the patient using plaster or a plaster substitute. "Intermediate" describes those prostheses which are intended for relatively long-term use; they are generally applied following the use of a temporary prosthesis and are fabricated from plastic over a positive model instead of being formed directly over the patient.</p> <h3>Temporary Prostheses</h3> <p>A temporary prosthesis is primarily used to control postoperative edema and is often the initial step in the residual limb maturation process. But the temporary prosthesis has many additional functions, one of which is early mobilization of the patient. This is especially critical to the physiological well-being of elderly patients. The less time the generally debilitated patient is confined to a bed or a wheelchair, the better the chances for overall recovery and successful long-term prosthetic use.<a></a> Indeed, the early mobilization of any patient can shorten the hospital stay and, therefore, save the patient and the insurance company the costs of increased hospitalization.</p> <p>Another benefit of the temporary prosthesis is the psychological lift it can give the new amputee by reducing phantom pain and permitting early ambulation. Temporary fitting may also help offset some of the anxiety the patient experiences after an amputation.</p> <h3>Temporary Design Concepts</h3> <p>A temporary prosthesis is essentially a rigid dressing with a foot and pylon attached (<a href="http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-1.jpg"><b>Fig. 1</b></a>). It is a total contact system, encapsulating the amputated limb, including the patella, and extending to the mid-thigh. The knee is maintained in five to ten degrees of flexion. Suspension is by total contact, with some purchase over the adductor tubercle of the femur, and by a waist belt incorporated into the cast. Padding is provided for the distal end and bony prominences.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-1.jpg"><strong>Figure 1. Temporary below-knee prosthesis.</strong></a><br /> <p>The standard mid-thigh height of the temporary prosthesis serves some definite purposes. This design assists in sharing weight bearing over a larger surface area, which reduces the load on the amputation site itself. The amputee can also ambulate with less risk of traumatizing the residual limb.</p> <p>Encapsulating the knee also helps prevent knee flexion contractures, which are a very real threat to successful rehabilitation. In spite of the well-documented benefits of early fitting, all too often patients are sent home in an Ace® wrap to languish in a wheelchair for a period of weeks until their "stump toughens up enough" to be fitted with a prosthesis. This is the scenario that results in the elderly patient appearing for prosthetic fitting with hip and knee flexion contractures and an edematous residual limb.</p> <p>Although the knee is fully encapsulated in the traditional temporary prosthesis, knee contractures are rare; partially because the cast is usually changed at weekly or biweekly intervals over the period of use. To enhance knee motion, the patient should be encouraged to flex and extend the knee through its range of motion at the time of each cast change. Intermittent weight bearing in the prosthesis also prevents a knee contracture, much as it does in the case of a long leg weight bearing case used in fracture management.</p> <p>The non-removable nature of the temporary prosthesis has the advantage of continuous control of the tissues. When left to the patient to control via an Ace® wrap or shrinker, the limb is often wrapped intermittently or not at all. Rigid dressings have proven in most cases to be far superior to elastic wrappings in reducing the limb's soft tissue volume, especially in conjunction with controlled weight bearing.<a></a></p> <p>The inclusion of a waist belt, or billet, is essential in maintaining suspension in this type of system. As the residual limb shrinks, the prosthesis will piston on the limb if not supported by this auxiliary suspension.</p> <p>The pylon system is equally important with respect to the success of the temporary prosthesis. Although the patient walks with a stiff knee, appropriate alignment is essential for single limb stance stability.</p> <h3>Intermediate Prostheses</h3> <p>The primary role of the intermediate prosthesis is to act as a preparatory device to reduce the limb to a definitive fitting status. It is generally fit when the postoperative swelling and distal edema have been reduced to a point where the bulbous end can be introduced into a socket. This prosthesis acts as the interim step between the temporary and definitive, thus the term "intermediate." The intermediate differs significantly from a temporary in that it is removable and allows free flexion of the knee. Residual limb shrinkage is accommodated by prosthetic socks as opposed to cast changes. Aside from the obvious advantages of full range of motion and free access to the residual limb, the intermediate prosthesis allows the patient to learn appropriate sock ply management prior to being fitted with a permanent prosthesis.</p> <p>The length of time a patient wears his intermediate prosthesis varies from person to person. Body type, cause of amputation, level of activity, and other considerations all play a part in how rapidly a residual limb will mature to a definitive fitting status. The duration of use can be anywhere from two months to six months, or longer. A general guideline which may be used to determine whether a limb has "plateaued" with regard to shrinkage is when weight bearing and wearing time have stabilized, and the patient has gone approximately three weeks without adding any additional plys of socks.</p> <h3>Intermediate Design Concepts</h3> <p>The design of the intermediate socket is generally consistent with the standard PTB or TSB configuration (<a href="http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-2.jpg"><b>Fig. 2</b></a>). A soft liner may or may not be incorporated in the system. In either case, it is appropriate to fit the socket to the patient with as few ply of socks as possible. A one ply or even a nylon sheath fit is preferable in light of the fact that shrinkage, and thus the need for additional plys, is inevitable. As with the temporary, dynamic alignment plays an important role. This importance is now magnified by the fact that the patient is ambulating in essentially the same manner as he will in his definitive prosthesis. Again, it is recommended that the patient be fit with some sort of waist belt suspension to minimize relative motion between the socket and limb as shrinkage continues.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-2.jpg">Figure 2. Intermediate below-knee prosthesis.</a><br /></strong><br /> <h3>Gait Training</h3> <p>At the time of fitting of the intermediate prosthesis, gait training becomes most significant. This is one of the great advantages of preparatory prostheses: the patient can be monitored and guided by a physical therapist in regard to an appropriate gait pattern while a prosthetist can periodically make alignment modifications as the patient becomes a more proficient ambulator. This advantage is lost, of course, in some of the commercially available systems, which do not allow for fairly precise alignment adjustability.</p> <h3>The Forgotten Limb</h3> <p>One of the least considered aspects of the benefits of preparatory fitting is the contralateral leg. Not only does the preparatory device make it easier for the amputee to maintain his balance, it also allows him to share his weight partially on the prosthesis instead of totally on his remaining limb. In the case of the diabetic or peripheral vascular disease patient, this can be critical, as the remaining leg is usually at risk as well. Any additional trauma, such as prolonged single limb body support or hopping, should be avoided. Preparatory prostheses make this weight sharing possible, and thus prevents overuse or trauma to the remaining leg and foot.</p> <p>It is clear that the role of preparatory prostheses and the management of the new amputee is a necessary and essential component in reaching the fullest rehabilitation potential of the patient.<a></a> The encroachment of non-traditional providers into the prosthetic arena, especially with regard to early fittings, poses a real threat to the realization of these patients' full potentials. It is critical that the prosthetist understand and appreciate the important role of preparatory prostheses in the total regimen of medical and prosthetic care. Success with preparatory fittings depends upon competent management by all members of the rehabilitation team. Temporary and intermediate systems must be applied and managed competently by the prosthetist. Weight bearing, gait training, and residual limb atrophy must be monitored carefully.</p> <p>The term "preparatory" implies that such systems are designed to achieve specific desirable objectives. In this case, the objectives are the maturation of the residual limb and optimum patient readiness for definitive fitting. Comprehensive patient management with preparatory systems produces many advantages, including the provision of maximum early function, improved evaluation of the patient's long-term needs, and reduction of rehabilitation time and expense.<a></a></p> <p><b>References:</b></p> <ol> <li>Burgess, E.M., M.D., "Amputation Surgery and Post-Operative Care," In Bonjeree, Sikhar Nath (ed)., <i>Rehabilitation Management of Amputees</i>, Baltimore/London; Williams &amp; Wilkins, 1982.</li> <li>Burgess, E.M., "Post-Operative Management," <i>Atlas of Limb Prosthetics</i>, St. Louis, The C.V. Mosby Company, 1981.</li> <li>Burgess, E.M. and Zettl, J.H., <i>The Management of Lower Extremity Amputations</i>, Washington, D.C., U.S. Government Printing Office, 1969.</li> <li>Friedmann, Lawrence W., <i>The Surgical Rehabilitation of the Amputee, Springfield</i>, Charles C. Thomas, 1978.</li> <li>Mooney, Vert, M.D., McClellan, Bruce, C.P.O., Cummings, Donald, B.S., and Smith, Patty, R.P.T., "Early Fitting of the Below Knee Amputee," <i>Orthopedics</i>, 8:2, February, 1985, pp. 199-202.</li> </ol> <p><em><b>*Donald R. Cummings, CP. </b> Donald R. Cummings, CP., is Chief Prosthetist at Prosthetic-Orthotic Associates of North Texas, Inc. in Lewisville, Texas.</em></p> <em><b>*Bruce P. McClellan, C.P.O. </b> Bruce P. McClellan, C.P.O., is Director of Orthotics and Prosthetics at the Dallas Rehabilitation Institute in Dallas, Texas.<br /><br /><br /></em> Page Number(s) 1 - 4 Year 1987 Volume 11 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-2.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Preparatory Prosthetics Creator An entity primarily responsible for making the resource Bruce P. McClellan, C.P.O. * Donald R. Cummings, CP. * https://staging.drfop.org/files/original/d58593ef39362194114423665e739f0c.pdf fcbe907f83e666b1ec1ef034e62a0e0e Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1982_01_010.pdf Text Any textual data included in the document <h2>Professionalism Or What?</h2> <h5>John Sabolich, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><i>Editor's note: This article originally appeared in the September, 1981 issue of the AOPA Almanac. Mr. Sabolich has kindly given his permission to reprint the article so that it may be shared with a larger audience.</i></p> <p>Are you a professional? If so, how do you know? Our field is struggling with this question. There must be more to being a professional than wearing a white lab coat!</p> <p>Let's start with us, the Prosthetist or Orthotist. Sometimes the words that come out of our own mouths are the greatest obstacles to being fully recognized as professionals. We are engaged in advertising and are placed next to store ads in many publications that medical personnel read. We call our patients "customers," our lab and office a "shop" or "store"; our fee schedules are called "price lists." We go to hospitals to "sell our wares" without even charging a consultation fee! Prostheses and orthoses are called "appliances." (Does this sound professional, or like a washing machine and dryer?) We are called "low bidder" on contracts in which we need not even be involved. Maybe we would be happy to move up one more notch to a "vendor"! I hope we shudder at the term!</p> <p>There are other areas in which we could improve our professional status in the community, such as what we call our facilities. The words "artificial limb," "brace" or "shop" are not conducive to our professional status. We refer to a patient's leg or residual leg as a "stump," prosthetic socks are called "stump socks." Patients feel rushed in clinical or office situations. Interoffice conduct, such as loud talk in patient care areas, the manner in which we answer our phones, or allowing patients in the lab, all reflect on our professionalism. Seemingly insignificant things are important, such as parking areas that say "customer parking" instead of "patient parking." Yes, we present ourselves to the patient in many ways. One of the most important is the appearance of our front offices, reception areas and examination rooms. Many times there are items for sale or on display, even prostheses and orthoses. This does not make us look professional to the patient but rather gives our office a store front appearance and lends to uncomfortable and impersonal feelings.</p> <p>A professional practitioner should be opposed to anything or anyone who blocks patient care. We avoid calling the doctor if we disagree with prescription rationale, when the patient is the ultimate beneficiary. All medical as well as paramedical people must realize they are not the most important person in a clinical situation. It must be made clear, the patient reigns supreme!</p> <p>The patient and medical community could view us as paramedical professionals. In this setting, it can be better understood that payment is not being made for a "piece of plastic" but for expert knowledge, ability and education. The device itself only represents a contributing factor in designing and implementing an efficient and successful prosthetic and orthotic program. A prosthesis or orthosis is the only tangible thing the patient sees, therefore patients tend to equate the fee charged with the plastic object provided for him. When a doctor operates, does he charge $5000.00 for the $1.50 worth of cat gut? Again, this is the only thing the patient can actually see and feel.</p> <p>The public at large is not familiar with the terms "Prosthetics" or "Orthotics". It would force them to become educated to these more professional terms if, under Artificial Limbs and Braces, the telephone books across the country referred the public to Prosthetics or Orthotics in a cross reference. Suppose you are John Doe looking up artificial limbs in the yellow pages. You simply would not find it because you would be referred to the word Prosthetic. Think how far that would go on a national scale to educate people to these important terms. In Oklahoma we were able to accomplish this goal. The practitioners in this state all agreed to be moved to the more professional title and even reduce their listings to only three lines. We will all feel more professional this year!</p> <p>We must strive to increase our credibility by being more precise in our practices, turning away from the empirical and moving toward the scientific and quantitative approaches by increasing our support dramatically which can effectively increase our knowledge and technology. Our educational criteria must remain high. Board certification exams should remain comprehensive with lower level technical schools to supply the manpower.</p> <p>I realize that I am also guilty; yet if we care enough, we must attempt to correct these problems for ourselves, our profession and, most importantly, for the patients who seek our help. My fellow practitioners, I suggest to you, this problem lies with us; our attitudes, what we say, what we do.</p> <h3>Acknowledgements :</h3> <p>I express my sincere appreciation to these people for directly influencing the contents of this article.</p> <p>Steven D. Prock, CPO<br />Michael T. Wilson, CPO<br />Henry L. Schufletowski, CO<br />William J. Barringer, CO<br />Thomas Haslam, CO<br />Alvin C. Pike, CP<br />Charles Pritham, CPO<br />Lester Sabolich, CPO<br />Melvin Stills, CO<br />Lorene Sabolich<br />Lee Sabolich<br />Karen Mondie<br />Tina Prince</p> <em><b>*John Sabolich, CPO. </b> Sabolich Inc., Artificial Limb and Orthopedic Appliance Co. Oklahoma City, Oklahoma<br /><br /><br /></em> Page Number(s) 10 - 10 Year 1982 Volume 6 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 Professionalism Or What? Creator An entity primarily responsible for making the resource John Sabolich, C.P.O. * https://staging.drfop.org/files/original/3448d7dd1f3b869e445982db2d59f981.pdf 56435bb25ac8133541df9f7615933fde https://staging.drfop.org/files/original/b92e747ec2d4c7fcbfb142f3b21fe188.jpg 15743c372ab5f5bfd9b131b52786f267 https://staging.drfop.org/files/original/162bfd1cff0200013041316cd03e4205.jpg 503fcd8d3eb91b82ee443d8c094e848d https://staging.drfop.org/files/original/649c45f292a3e6abbcfd67f3e7cad646.jpg bc5d177879ac5d8d63ba74148f139e50 https://staging.drfop.org/files/original/f8c103b59e1186b3debc06b41e7fa8da.jpg ff5d40912d24dc4437c5e3e86637ad0f https://staging.drfop.org/files/original/5bd55cdc8130e022cb74e9ef9310851c.jpg 877f6a2bef161af85baa70b0a7e0fc56 https://staging.drfop.org/files/original/5a13f50435edc580bd20bc0b92e39199.jpg f36ffbe912c1327a31adc0871b9584a2 https://staging.drfop.org/files/original/09f2f692fb4fb8baed50b8c404c39ff4.jpg 95dc00e192231965d2df32a4557237c3 https://staging.drfop.org/files/original/98186d2e80f51ab2c05b8e921e8b4a7c.jpg 6a7d4c0dc2f96f891e8d6f648eccb65a https://staging.drfop.org/files/original/cfb1f9e83cd52dba6e8367990403d0e7.jpg cb6459e8aa8f964867d06e310b8fb963 https://staging.drfop.org/files/original/a7526ae779090df35051bf5f19108e0f.jpg 157c3ae9edb18f10067093236eef0ecd https://staging.drfop.org/files/original/6000d92905f47758878821ee2247dd59.jpg 97191c9616d9b52f95fe7c1f3d48d26d https://staging.drfop.org/files/original/05be51461b9c231a36fab727850aafb9.jpg d2ac320312732a0ac60358b403acf8c6 https://staging.drfop.org/files/original/3d81a73baf2da2320112f7beab21a3f5.jpg 79eaca67e92aeaf4a3255846ed2f5c2d https://staging.drfop.org/files/original/3d6a53a092ad8f47d3ba47cba434cce8.jpg 0b274fe90d766da8a3eca6a1f8cbb030 https://staging.drfop.org/files/original/645ce73fcf7da4e641a02f0187a49867.jpg 7ce207a9c89481e48d4da20607137601 https://staging.drfop.org/files/original/e1898cc9379d33c5f9b2be176e2cdc18.jpg 674e6e6f3c9cfc86f882142cd90c70ad https://staging.drfop.org/files/original/1706a0b2db516be5330eec15cb82cf18.jpg 87ba92355dc1039809f33e711d681192 https://staging.drfop.org/files/original/1078a3e62aee9846acde9c3a5e792575.jpg b6a854f1571ededd167b2be93409c9d2 https://staging.drfop.org/files/original/90c35927fcd50eee702738338ce53b66.jpg da617dcbd9573aa9f0636c23afc99e41 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1961_01_052.pdf Year 1961 Volume 6 Issue 1 Page Number(s) 52 - 75 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1961_01_052.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1961_01_052.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Prostheses for Syme's Amputation</h2> <h5>A. Bennett Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>Whereas detailed information on Syme prostheses prior to the turn of the 20th century is not readily to be had, the catalogs issued by limb manufacturers in the early 1900's seem invariably to include a description of a prosthesis for the Syme stump. Of many different designs offered, some used articulated ankles (if space were available below the stump and socket), some used rubber feet without ankle joint. Wood sockets, steel-reinforced leather sockets, and even cast aluminum sockets were available. Though most manufacturers showed prostheses with a full-length anterior opening for entry of the stump, there also were designs employing a partial anterior opening, and at least one used a full-length posterior opening.</p> <p>The descriptions accompanying the catalog presentation of these devices indicate that the originators were themselves aware of most of the problems involved in designing a prosthesis for the Syme stump. One design of the Winkley Artificial Limb Co.<a></a> had no ankle joint because, according to the designer, in many cases no known ankle unit small enough to fit into the available space could withstand the high stresses involved. When ankle joints were provided (<b>Fig. 1.</b>, left), a steel-reinforced leather socket was used; when space limitations precluded use of an ankle joint (<b>Fig. 1.</b>, right), use was made of a willow wood socket, presumably to provide a base for attaching the felt or sponge-rubber feet available at the time.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Two types of Syme prostheses offered by the Winkley Artificial Limb Company, Minneapolis, <i>circa </i>1910. Design at left incorporates an articulated ankle, that at right a foot without ankle joint, presumably of rubber. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Gaines-Erb<a></a> used a wood socket with a full below-knee socket at the top and only a partial opening on the anterior aspect so that it was possible to make any desired distribution of weight-bearing between distal and proximal areas of the stump <b>Fig. 2.</b>. Marks<a></a> was aware of the need for distributing uniformly along each side of the tibia the loads developed on the stump during roll-over and, realizing that this requirement was rarely met with an anterior opening and lacing, attempted to solve the problem by using a cast aluminum socket with appropriate relief for the tibial crest and other sensitive areas <b>Fig. 3.</b>. A leather cuff closing the posterior opening encircled the shank to an anterior lacing, and the Marks rubber foot must have permitted a good cosmetic effect. An earlier version of the Marks foot, one of wood, illustrates the extent to which the inventor went to achieve resistance to the high forces developed in the area of the ankle <b>Fig. 4.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Syme prosthesis offered by the Gaines - Erb Company, Denver, <i>circa </i>1915. Note provision for weight-bearing about the proximal portion of the shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Syme prosthesis offered by A. A. Marks, Inc., New York, early in the 20th century. The shank-socket, cast from aluminum, contained a posterior opening. A rubber foot was used routinely. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. An early version (<i>circa</i> 1889) of a Syme prosthesis manufactured by A. A. Marks, Inc. Socket and keel were formed from a single piece of wood so selected that the grain afforded maximum strength. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In a 1919 design by Bowler,<a></a> dorsiflexion bumpers were replaced by a strap between the posterior surfaces of the socket and the foot <b>Fig. 5.</b>, a feature also suggesting an appreciation of the high stresses involved in the ankle-joint mechanism. Not only were the unit stresses in the resisting material thus reduced but during dorsiflexion the forces on the ankle joint itself remained compressive instead of becoming tensile, a condition favoring longer life. Instead of being in the usual medial and lateral positions, the metal straps reinforcing the leather socket were anterior and posterior, where they were least bulky and most effective structurally. A Syme prso-thesis available from the Columbus Artificial Limb Company<a></a> employed the posterior strap patented by Bowler and added an anterior elastic strap, presumably to maintain compressive forces on the ankle joint during plantar flexion <b>Fig. 6.</b>, but the idea of anterior and posterior reinforcing straps, as proposed by Bowler, was discarded.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Syme prosthesis patented by Bowler<a></a> in 1919. First known attempt to improve appearance by use of an opening on the side of the socket, reinforcing straps on the anterior and posterior surfaces. A flexible cable, another novel feature, provided resistance to dorsiflexion without placing the ankle parts in a state of tension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Syme prosthesis offered by the Columbus Artificial Limb Company, Columbus, Ohio, <i>circa </i>1925. Some of the features of the Bowler patent<a></a> are incorporated. Cf. Fig. 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In almost all cases, lack of materials easily molded and with adequate strength but light in weight resulted in a certain bulkiness and heaviness that tended to produce a certain amount of discomfort for the wearer even if the fit itself were comfortable. In an effort to decrease weight and size, some prosthetists fabricated devices with marginal strength characteristics, devices which seldom lasted as long as comparable ones intended for leg amputations at other levels. The prosthesis that by 1940 seems to have been fitted almost routinely in both the United States and Canada consisted of a leather socket, reinforced with steel straps along the medial and lateral sides and made with a lacer and soft leather tongue along its anterior aspect <b>Fig. 7.</b>. Feet were generally of the so-called "conventional" type employing a single-axis ankle joint (often placed lower than usual) and incorporating foreshortened rubber bumpers. It was often uncomfortable, usually bulky because the sidebars projected beyond the bulbous end of the stump, and highly subject to mechanical failure of the sidebars.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Syme prosthesis typical of the era before introduction of plastic laminates into the fabrication of Syme prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the introduction of plastic laminates<a></a> into the practice of prosthetics, research workers at the Prosthetic Services Centre of the Department of Veterans Affairs, Toronto, were quick to realize that the use of plastic laminates might well result in the development of a Syme prosthesis to a great extent free from the shortcomings of Syme prostheses previously used. Prior attempts to use laminated wood-veneer sockets had failed to produce practical prostheses owing to the difficulty of molding about the bulbous end, but the results encouraged the investigators to proceed with the then newly developed fabric-plastic laminates. The first model that showed promise<a></a> consisted of a socket molded of a polyester-Fiberglas laminate with a neoprene-crepe foot reinforced by a polyester-Fiberglas keel extending from the distal end of the socket <b>Fig. 8.</b>. To provide more comfort along the anterior aspect of the stump, the opening for entry of the stump was cut out of the rear section of the socket, stability being obtained by replacing the cutout section and holding it in place by a metal fitting at the bottom and a strap and buckle at the top.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. An early version of the Canadian-type plastic prosthesis for Syme's amputation. The nonarticulated foot was in this instance constructed of a neoprene crepe of uniform density. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although use of plastic laminate materially reduced bulkiness, and although the nonartic-ulated foot eliminated many of the problems associated with the so-called "conventional" unit, mechanical failure in the socket where the cutout was largest occurred too frequently for the new prosthesis to be adopted as a standard item.<a></a> Fiberglas roving (loosely spun cords of Fiberglas molded in place along the edges of the cutout) increased the strength of the socket, but it was necessary to substitute epoxy resins (much better adhesion to the glass fibers) for the polyesters before fully adequate strength could be obtained. With a few refinements, this prosthesis <b>Fig. 9.</b> is in use routinely today by the Canadian Department of Veterans Affairs.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The Syme prosthesis now adopted as standard by the Canadian Department of Veterans Affairs. The plastic laminate consists of Fiberglas cloth and roving impregnated with an epoxy resin, and the posterior opening extends the length of the shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Attempts by workers in the Artificial Limb Program in the United States to employ the Canadian technique using polyester-Fiberglas laminates led to the same kinds of mechanical failures experienced by the Canadians.<a></a> In addition, a good proportion<a></a> of the Syme cases fitted could not continue to assume full end-bearing comfortably throughout the entire day. This experience, coupled with a reluctance to employ Fiberglas if the more convenient nylon stockinet<a></a> could be used, or to use the first-available epoxy resins because of the inherent toxicity of the wet, uncured resin when mixed with the hardener, [*The recent introduction of polyamide hardeners has since greatly reduced the risk of the fabricator's contracting dermatitis.] led to the development of the "Medial-Opening Plastic Syme Prosthesis" <b>Fig. 10.</b> at the Veterans Administration Prosthetics Center.<a></a> To reduce the unit stresses along the periphery of the cutout necessary for entry of the stump, the cutout was made in the medial wall of the socket (page 68). Unlike the posterior cutout in the Canadian version, the medial opening does not extend upward to the brim of the socket but resembles a door, an arrangement which permits the Syme case to be so fitted that all or any part of the weight may be carried along the brim of the socket. The foot is a commercially available version of the SACH foot.<a></a>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Syme prosthesis developed by the Veterans Administration Prosthetics Center, New York. The nylon-dacron-polyester socket is provided with an opening in the medial wall. Weight-bearing may be divided, in any proportion, between the proximal rim and the distal portion of the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Concurrent with the development of the medial-opening plastic Syme prosthesis at the Veterans Administration Prosthetics Center, the Prosthetics Research Center of Northwestern University introduced into the Canadian technique a number of refinements which might also be applied in fabricating and fitting the medial-opening type of prosthesis. Of especial interest are a new method of obtaining casts of Syme stumps and a method of attaching a SACH foot to permit greater latitude in alignment of the foot with respect to the socket, including also a method of reinforcing the keel of a SACH foot should that be necessary in individual cases.</p> <p>Manuals<a></a> containing detailed, step-by-step procedures for fabricating, fitting, and aligning the Canadian and the medial-opening Syme prostheses are available, and details of the Northwestern techniques have been published.<a></a> An outline of all of these procedures is given here so that any might be adopted singly or in combination to meet the requirements of individual patients.</p> <h3>THE CANADIAN-TYPE PLASTIC SYME PROSTHESIS</h3> <h4>TAKING THE MEASUREMENTS AND MAKING THE MODEL</h4> <p>All anatomical measurements necessary for constructing the Canadian-type plastic Syme prosthesis are taken while the patient bears his body weight on the end of the stump. Placed under the stump is a block of wood of such thickness as to maintain the pelvis in a horizontal position, and the anteroposterior dimension, the width, and the circumference of the stump are recorded, all at the level of the largest part.[*A special device, consisting of two wedges that can be moved with respect to each other so as to provide for rapid adjustment <b>Fig. 11.</b>, has been found to be a useful improvement over the single wood block.] For use later on in the alignment procedure, a line perpendicular to the floor and passing through the mediolateral center of the patella <b>Fig. 12.</b> is marked on the stump with indelible pencil for eventual transfer to the plaster model.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Special device used in taking measurements of the Syme stump while the stump is bearing weight. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Stump measurements required for fabrication of socket for the Canadian-type plastic Syme prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After all sensitive areas and bony prominences, including the tibial crest throughout its length, have been similarly marked with indelible pencil, a cast is made using plaster-impregnated bandage, a longitudinal cut being made along the posterior mid-line to permit removal of the cast. Thereafter, a model of the stump is made by filling the cast with liquid plaster of Paris, a bar or pipe being inserted in the soft plaster at the proximal end to provide an extension to be used later in holding and handling the model.</p> <h4>MODIFICATION OF THE MODEL</h4> <p>Upon removal of the cast, a finishing nail <b>Fig. 13.</b> is driven all but 1/4 in. into the bottom of the model at the intersection of an anteroposterior extension of the vertical reference line and a medio-lateral line bisecting the area on the bottom of the model. The bulbous end is now built up by adding plaster until the dimensions conform to those recorded while the stump was bearing weight. At the same time, in order to allow space for a sponge-rubber pad in the finished socket, a layer of plaster 1/8 in. thick is added to the bottom portion and faired in, leaving the nail protruding 1/8 in. So that a recess to receive a foot nut will be formed in the finished socket, a piece of leather or other suitable material 1/8 in. thick and 1 1/4 in. in diameter is pierced at its center and positioned on the protruding nail. To provide relief for the sensitive areas and bony prominences, skived leather patches are added to the model as appropriate.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Plaster model of stump just before application of Fiberglas. It is easier to modify the model before the plaster has hardened completely. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The path of the sawline to be used in forming the cutout for stump entry is marked on the model, and metal wedges <b>Fig. 14.</b> are inserted to facilitate the later re-establishment of the sawline on the exterior of the socket. The saw-line itself is located by establishing on each side of the model a point 3/8 in. behind the anteroposterior mid-line of the model at the top and another point 1/4 in. behind the same mid-line at the level where the stump begins to bulge <b>Fig. 13.</b>. Two metal wedges are inserted well apart on each of these lines, 1/4 in. being left to protrude. After the model has dried thoroughly and three coats of cellulose-acetate lacquer have been applied, it is ready for use in fabricating the prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Steel wedge used to outline cutout, shown twice actual size. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>LAMINATION</h4> <p>In the lamination of Fiberglas with epoxy resins, rapid work is essential to obtain the best structural results, and accordingly it is desirable here that this operation be performed by two persons working together. The model is held vertically in a vise, a brush coat of epoxy resin is applied, and a length of 10-strand Fiberglas roving is laid along the anterior side of each of the vertical portions of the sawline and fanned out over the end of the bulbous portion of the model <b>Fig. 15.</b>. The multiple-strand roving is held in place by encircling the model and roving with a piece of single-strand roving.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. First layup of Fiberglas roving and cloth. Note that roving is fanned out over ball of model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A piece of Fiberglas cloth 4 in. longer than the length of the model and 2 in. wider than its circumference at the largest part is laid up over the model so that the surplus length is placed distal to the bulbous end, and the whole is tied in place with single-strand roving <b>Fig. 15.</b>. The surplus length is then slit vertically every 2 in. along the periphery and laid over the bulbous end of the model, and the entire piece of cloth is saturated with the resin. Three additional pieces of Fiberglas cloth of the same size are applied in the same manner but are so placed that none of the vertical overlaps coincide.</p> <p>To complete the lamination, four pieces of Fiberglas cloth 2 in. wide and about 2 in. longer than twice the length of the model are applied, one at a time, with the transverse centers of the strips located over the bulbous end and positioned approximately 45 deg. apart <b>Fig. 16.</b>. The entire assembly is held in place by a spiral wrapping of single-strand roving, and after application of a final brush coat of resin a snugly fitting sleeve of polyvinyl alcohol film (PVA) is pulled over the layup, the lower end being tied snugly to the holding rod, the top end model. To compress the laminate and to re-trimmed to a point 5 in. from the end of the move air and excess resin, the layup is wrapped tightly in spiral fashion with a strip of PVA 2 in. wide, the wrap starting from the holding end of the model <b>Fig. 17.</b>. To the excess resin thus forced upward into the top end of the sleeve there is now added as much chopped roving as possible so as to form an extension around which the foot may be fabricated.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Layup of longitudinal strips of Fiberglas cloth just before application of PVA bag. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Lamination for socket, ready for curing. Note extension for keel, formed by introducing resin and chopped Fiberglas roving into end of PVA bag. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After curing for 30 min. at room temperature (or 45 min. at 250° F. if time is important),[*In an alternate, and preferable, procedure, the layup is allowed to gel at room temperature overnight and then, after the cutout has been made, replaced over the model, fastened in place by suitable straps, and cured for 30 min. at 225° F.] the laminate is cut, with a cast cutter or other suitable device, along the lines defined by the protruding wedges. At the lower portion of the cutout, large radii are used, and the lowest point reached is just proximal to the point of maximum anteroposterior socket diameter.</p> <h4>MAKING THE FOOT</h4> <p>After the laminated parts, socket and cutout, have been removed from the model, the extension is so shaped by grinding that the foot may be built around it. By means of a standard foot nut and a bolt 1 1/4 in. in diameter <b>Fig. 18.</b>, the keel <b>Fig. 19</b>, formed from a strip of aluminum alloy (7075-T6) 1 1/4 in. wide and 0.128 in. thick, is fastened to the extension at the point indicated by the recess formed in the bottom of the socket. For most adults, two thirds of the length of the keel is placed ahead of the center of the socket, but the proportion may be varied to suit individual cases. To provide reinforcement during the fitting procedure, a piece of wood is bonded temporarily to the keel and socket extension by use of epoxy paste.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Standard steel foot nut used by the Canadian Department of Veterans Affairs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Cross-section of foot and lower end of Canadian-type plastic Syme prosthesis. Before final assembly, the wood block is replaced by epoxy resin and chopped Fiberglas roving. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A 4-ply rubber-fabric belting 4 in. wide and four pieces of 18-iron neoprene sponge are now laminated (with Barge's cement) to the configuration shown in <b>Fig. 19</b>, the neoprene layers being slotted to receive the keel. A wood block 4 in. wide and shaped to conform to curve A-A in <b>Fig. 19</b> should be used to assist in holding the layers in place while bonding is effected.</p> <p>When the initial bonding of the neoprene and belting is fully set, a layer of 9-iron neoprene sponge is bonded to the underside of the belting, and a wedge of some resilient material is added to form the heel. Material for the heel, selected to meet the particular requirements of the individual patient, may be neoprene sponge, rubber sponge, solid rubber, or some other elastomer. Finally, the foot is cut and ground to the shape necessary to fit the shoe.</p> <h4>ALIGNMENT AND ASSEMBLY</h4> <p>Temporary attachment of the foot to the keel <b>Fig. 20</b> is effected by driving a 1/8-in. steel pin transversely through the heel section just ahead of the end of the keel <b>Fig. 19</b>. The corset, the portion of the socket that has been cut out, is now provided with the means for holding it in place-a tongue-and-slot arrangement at the bottom <b>Fig. 21.</b> and an encircling leather strap in the calf area <b>Fig. 9.</b>. Details of the parts required are shown in <b>Fig. 22.</b>, <b>Fig. 23.</b>, and <b>Fig. 24.</b>. The metal pieces are bonded and riveted to the laminated parts. Two buckles are recommended as a precaution against the possible loss of use of a particular eye in the strap <b>Fig. 9.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Insertion of keel into neoprene portion of foot. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Tongue-and-slot method of holding corset in place. Tongue and slot are held in place temporarily by the bolts and wing nuts. Epoxy resin and rivets are used for permanent attachment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Slot, shown actual size. Aluminum 0.040 in. thick. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Tongue, shown actual size. Aluminum 0.125 in. thick. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Double-buckle assembly used to secure corset in place. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After a pad of felt or neoprene sponge, carved to fit the bottom of the socket and the end of the stump, has been placed in position, the prosthesis is ready for final alignment. The relationship between the keel and the socket may be changed by removing the attaching bolt and keel and changing the configuration of the socket extension, either by grinding or by adding shims. When the desired alignment has been obtained, a 1/8-in. hole is drilled through the aluminum keel into the socket extension, and a 1/8-in. dowel of cold-rolled steel <b>Fig. 19</b> is driven into the hole. The established alignment may thus be reproduced upon reassembly during the finishing process. To achieve maximum rigidity of the keel, the temporary wood block is removed, two steel rods each 1/8 in. diameter are inserted into holes drilled in the anterior surface of the socket extension and allowed to extend into the cavity, and the cavity is filled with a mixture of epoxy resin and chopped Fiberglas roving.</p> <p>The aluminum surfaces must be clean to ensure an adequate bond. All gaps between keel and neoprene are filled with epoxy resin, and a fairing between the foot and socket is fashioned from a mixture of epoxy resin and fine sawdust, which after curing can be ground and sanded to shape. If desired, small holes may be drilled through the socket wall to furnish ventilation. When, after sanding, the outside of the socket and corset have received a coat of enamel, and when the neoprene parts of the foot have been sealed with two light coats of cellulose-acetate lacquer, the prosthesis is ready for use <b>Fig. 25.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Completed Canadian-type plastic Syme prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>THE MEDIAL-OPENING PLASTIC SYME PROSTHESIS</h3> <h4>TAKING THE MEASUREMENTS</h4> <p>The anatomical data considered necessary for fabrication of the medial-opening socket are somewhat more extensive than are those suggested as being needed in the Canadian technique. In addition to determining the distance from the end of the stump to the floor while the stump is bearing half of body weight,[*Because a neoprene sponge-rubber pad will be used later in the end of the socket, it is recommended by VAPC that a sponge-rubber pad 1/4 in. thick be used between the stump and the supporting block <b>Fig. 26.</b>.] circumferential measurements of the stump are made at 1-in. intervals in the first 5 in. of the stump while it is in the weight-bearing condition. Besides this, circumferences at these five levels and also circumferences at 2-in. intervals from a point 5 in. from the end of the stump to the medial tibial plateau are read while the stump is free of weight-bearing. At each level measured, marks are made with indelible pencil. A form for recording the required information is shown in <b>Fig. 26.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Form for recording measurements and other information necessary for fabrication and fitting of a Syme prosthesis (VAPC type). From Iuliucc.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>MAKING THE CAST AND THE MODEL</h4> <p>To protect the stump from the plaster of Paris used in making the cast, a length of cotton stockinet, sewed at one end, is pulled over the stump and secured by an elastic band above the knee. Outlines of sensitive areas and bony prominences are made on the stockinet with an indelible pencil so that they will be transferred to the cast and in turn to the model for guidance in making appropriate modifications.</p> <p>Although the particular method of obtaining a cast is not critical provided a faithful model of the stump can be obtained ultimately, the Veterans Administration Prosthetics Center suggests a method wherein the cast is made in two pieces, so as to eliminate the need for cutting the plaster to remove the stump.[*The same technique can, of course, be applied in obtaining any cast that requires separation for removal of the stump.] To obtain the two-piece mold, the end of the stump is first wrapped with 3-in. plaster bandage to the level of greatest circumference <b>Fig. 27.</b>. A slab of five layers of plaster bandage 6 in. wide is then molded against the entire anterior half of the stump and secured in place by a few turns of 3-in. plaster bandage at the narrow part of the shank and again at the area just below the patella <b>Fig. 28.</b>. So that the cast, and hence the model, will approach the configuration of the stump in the weight-bearing condition, the plaster is allowed to harden while the patient bears weight through the distal end <b>Fig. 29.</b>, a sponge-rubber pad being placed between the bottom of the cast and the supporting block. As the plaster hardens, the edges should be faired to the stump. Lateral and medial centerlines are now drawn on the anterior portion of the cast for guidance in forming the parting line, petrolatum is applied to the exposed stockinet, and a similar slab of plaster bandages is molded to the posterior portion of the stump up to the lateral and medial centerlines <b>Fig. 30.</b>. Lines drawn transversely across the seams at several levels serve at reference points for proper reassembly of the cast after removal from the stump. Before pouring of the model is started, the indelible marks on the interior of the cast should be retraced to ensure a satisfactory transfer. For the pouring operation, the two halves may be held together by a wrapping of plaster bandage.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. First step in obtaining a plaster impression of a Syme stump. A plaster bandage 3 in. wide is applied over the end of the stump to the level of greatest circumference. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Application of a slab of plaster bandage to anterior surface of stump to provide one half of a two-piece casting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Stump under weight-bearing conditions while anterior and distal portions of plaster impression are allowed to harden. The posterior portion of the impression is applied later. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Application of plaster-bandage slabs to form posterior portion of two-piece casting. Note parting line drawn on anterior casting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>MODIFICATION OF THE MODEL</h4> <p>So that the finished socket will fit snugly along the sides of the tibia and yet not press unduly on its crest, plaster is removed from the model along each side of the area representing the tibial crest <b>Fig. 31.</b>, and a long leather patch, skived in the usual manner, is glued in place on the plaster. Skived leather patches also are attached at the points representing the malleoli, over areas corresponding to the flare of the condyles, and at any other points that will require relief in the finished socket <b>Fig. 32.</b>. Then the posteroproximal end of the model is flattened somewhat to provide for stability between socket and stump about the longitudinal axis. Finally, to make certain that the distal end of the socket will be of the proper volume to accommodate a sponge-rubber pad for cushioning the end of the stump, a circular piece of sponge rubber 1/4 in. thick is skived and glued to the distal end of the model (<b>Fig. 33.</b>) All modifications of the model are made with reference to the circumferential measurements taken earlier, <i>i.e., </i>the measurements over the distal 5 in. of the stump during weight-bearing and those above during relaxation are maintained.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Model showing where plaster should be removed so that in finished socket forces may be taken along each side of the tibial crest. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Model with skived leather patches applied to provide in finished socket relief for sensitive areas. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Model with socket liner and sponge-rubber pad applied. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>THE SOFT SOCKET LINER</h4> <p>To provide more comfort for those patients expected to take some or all weight-bearing along the proximal end of the socket, a liner of neoprene sponge rubber covered with horse-hide is provided. When a liner is to be used, a horsehide sleeve is molded around the model upward from a point 5 in. below the medial tibial plateau. Sponge-rubber sheet 1/8 in. thick is formed over the horsehide, 3/4 in. of the distal end of the leather being left exposed <b>Fig. 33.</b>. The distal end of both the horsehide and neoprene are skived.</p> <h4>LAMINATION</h4> <p>Unlike the procedure described for fabrication of the Canadian-type plastic Syme prosthesis, wherein the corset (or cover for the cutout) consists of the laminate that was cut from the socket, in the VAPC prosthesis the socket and the cover for the cutout may be laminated separately. Thus, it is here possible to begin with a socket cutout a little too small, trim away only as much material as necessary to permit easy entry of the stump, and still have available a piece of laminate large enough for a cover.</p> <p>To prevent adherence of laminate to the sponge-rubber pad (and to the soft socket liner if one is used), a snugly fitting sleeve of polyvinyl alcohol is pulled over the model and tied neatly at each end. The recommended laminate filler consists of two layers of dacron felt inside and ten layers of nylon stockinet outside. Like the PVA, the dacron felt must also be tailored into snugly fitting sleeves. If the nylon stockinet is cut into lengths slightly more than twice the length of the model, and if each length is then sewed transversely at the middle, a very neat layup can be obtained by successively pulling one half of a length over the model as far as possible and then pulling the other half over while turning it inside out. Instead of coinciding with one another, the individual transverse stitchings should be spaced equally as spokes in a wheel, the second being 36 deg. away from the first, the third 36 deg. away from the second, and so on <b>Fig. 34.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Application of stockinet over model in preparation for laminating. Two layers of dacron felt have already been applied. Note seam sewed across stockinet to form neat layup at distal end of socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A sleeve of PVA film is now drawn over the layup, and a polyester resin is introduced. To date, best strength characteristics have been obtained from a mixture of 70 percent of the "rigid" type of resin and 30 percent of the "flexible" type.<a></a></p> <p>Material for the medial cover is made by laminating three layers of nylon stockinet over the socket layup after it has been allowed to stand for one hour at room temperature. Resin is introduced on the medial side only (or only in that area selected for the cutout). After an additional hour of curing at room temperature, the entire assembly is subjected to a temperature of 180-190° F. for 25 min. The outer shell can now be cut and removed and the impregnated portion saved for use later <b>Fig. 35.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Removal of laminate to be used later in fabrication of cover for opening in socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>MAKING THE OPENING</h4> <p>The socket opening can best be cut out while the laminate is still warm. In order that the opening shall be the minimum needed for introduction of the stump, the initial aperture is deliberately made undersize, later enlarged by trimming the edges little by little until the patient can insert the stump without experiencing discomfort. The outline of the initial opening is determined by a horizontal line 1 in. above the point of maximum circumference of the bulbous portion of the socket, two lines parallel to and medial to the line of the tibial crest (one being 3/4 in. medial, the other medial by 3/4 in. plus 1/4 of the circumference of the bulbous portion 1 in. above its maximum circumference), and a horizontal line at that point on the socket where the circumference is the same as that 1/4 in. above the point of maximum circumference at the bulbous end <b>Fig. 36.</b>. Because further trimming will be necessary, the dimensions of the radii at the corners are not critical at this stage.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Outline of initial cutout in socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the initial cutout has been made, the excess material trimmed away, the plaster removed, and the proximal border of the socket trimmed, the cutout is enlarged enough that the patient can introduce his stump <b>Fig. 37.</b>. The radii of the corners should now be kept as large as possible, and the edges of the cutout should be smooth so as to contribute to the strength of the finished product by eliminating the high-stress areas commonly associated with mechanical nicks and notches.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Introduction of stump in socket to determine trim lines of cutout and, later, of proximal border. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>ALIGNMENT AND ASSEMBLY</h4> <p>In most instances, satisfactory use can be made of one of the commercially available SACH feet constructed especially for Syme prostheses. If not, a suitable SACH foot can be fabricated in accordance with the instructions given in the Canadian manual<a></a> or in the University of report, or use can be made of the reinforcement technique introduced by Northwestern University.<a></a> <!-- (page 71) --></p> <p>When the commercial version is used, it is first shaped to fit the shoe, and a guide hole 1 1/4 in. in diameter is drilled in the keel to a height above the heel sole equal to the height of the block used while the anatomical measurements were taken <b>Fig. 38.</b>. The keel and neo-prene crepe are then hollowed out to receive the bulbous end of the socket. Because of the tendency of Syme stumps to bow toward the cen-terline of the body, usually both guide hole and hollow should be offset medially. Moreover, the foot should be placed as far forward as possible with respect to the socket and be set in a small amount of dorsiflexion <b>Fig. 39.</b>, and care should be taken to ensure that the bottom surface of the heel is parallel to the floor <b>Fig. 40</b>. Such alignment should be effected by actually having the patient don the socket, place the distal end into the recess in the SACH foot, and assume a position of normal standing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Simplified cross-section of SACH foot showing certain modifications needed for use in Syme prosthesis. A hole 1 1/4 in. in diameter is drilled in keel to a depth corresponding to the height of the block used when measurements were taken [link26]. The hole is used as a guide in removing material at top of foot to accommodate socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Alignment of foot and socket in lateral view. Usually a slight amount of dorsiflexion results in best performance. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. Alignment of foot and socket in posterior view. The foot must be so located that the sole is parallel to the floor when the wearer stands in his own habitual position with hips level. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When initial, or static, alignment has been achieved, reference marks are made on the socket and foot to be used as a guide in reassembly, and masking tape <b>Fig. 41.</b> is applied around the juncture of the two units to hold them in place while a 3/8-in. hole is drilled through the keel and socket to receive the attaching bolt. The hole in the socket is now enlarged to 5/8 in., and the hole in the keel is provided at the bottom with a 5/8-in. countersink to accommodate the nut <b>Fig. 42.</b>, both operations best being done with the prosthesis disassembled. A cover that will overlap the socket opening 3/4 in. around the periphery is cut from the section of laminate made for the purpose. After two single-buckle straps have been riveted to the cover, a felt pad exactly fitting the opening is glued to the concave side, and the entire inner surface of the closure is lined with thin horsehide, care being taken to effect a rabbetlike contour along the periphery of the felt <b>Fig. 43.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Application of masking tape to secure foot to socket for drilling alignment hole through socket. Note reference marks used to ensure same alignment upon reassembly. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Simplified cross section of foot and lower end of VAPC prosthesis showing attachment of foot to socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Final step in fabrication of cover for opening in side of socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the prosthesis has been assembled, dynamic alignment is effected under conditions of actual walking. Inserted into the socket in the form of contoured discs of sponge rubber is enough distal padding to distribute the forces as desired between the proximal end of the socket and the end of the stump. Slight changes in alignment can be brought about by enlarging the hole in the end of the socket.</p> <p>Final finishing of the prosthesis includes bonding the foot to the socket, building up a smooth transition between foot and socket by use of a mixture of epoxy resin and chopped Fiberglas, and gluing the soft liner in place in the proximal area of the socket.</p> <h3>DEVELOPMENTS AT NORTHWESTERN UNIVERSITY</h3> <h4>TAKING THE CAST</h4> <p>Plaster of Paris in one form or another has been used for nearly a century in making impressions of limb stumps, and especially with the relatively new, quick-setting formulations it has proved to be fairly satisfactory. There are nevertheless certain disadvantages inherent in the use of plaster. Unless a separating medium is used, plaster will adhere to the skin. Cured plaster of Paris is extremely rigid, so that when plaster is used to take a cast of a stump like the Syme it is necessary either to cut the cast or to form it in two pieces. Furthermore, plaster is very dense and therefore heavy and comparatively hard to manage.</p> <p>In an effort to overcome some of the difficulties associated with plaster, the Prosthetics Research Center at Northwestern University's Medical School has developed a procedure for taking a cast of a Syme stump with alginate, a material used by dentists in taking impressions of the gums and teeth. Because when mixed with water alginate gels rather rapidly into a rubbery solid, it seems especially useful in taking casts of bulbous stumps and of those intended to take end-bearing. To enable the gelled material to yield when the stump is withdrawn, the impression is made in a rigid, tapered cylinder lined with an oversize canvas bag which can be withdrawn so that the rubbery alginate is left free to be displaced as the bulbous portion is pulled through the narrow section of the impression <b>Fig. 44.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Removal of stump, alginate mold, and canvas bag from canister. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since alginate solidifies so rapidly, and since so many factors (such as temperature and various impurities in the water used[*In certain areas best results can be obtained only with distilled water.]) affect the rate of gelling, it is important always to check the gelling time on a small sample before actually taking an impression. The correct mixture should gel in about six minutes. A tapered can about 20 in. long, 5 1/2 in. in diameter at the bottom, and 6 1/4 in. in diameter at the top has been found satisfactory for taking impressions in adults. The impression is taken while half of the body weight is borne by the stump, <i>i.e.,</i> while the pelvis is level and the patient is standing with feet together.</p> <p>After the stump has been removed, the bag and alginate are replaced in the conical can for pouring of the model, which should take place as soon as possible because the alginate has a tendency to shrink rather rapidly after gelling.</p> <h4>INSTALLATION OF THE SACH FOOT</h4> <p>To provide for wider degree of alignment adjustment than has been the case heretofore between the socket and the commercially available SACH foot, there has been developed a method of attachment employing a bolt with a spherical head <b>Fig. 45.</b>. Combined with an oversize hole in the socket, it permits some swivelling action between socket and foot. Adequate bearing area for the spherical bolt head is provided by laminating into the end of the socket a spherical washer <b>Fig. 45.</b> having the same spherical radius as the head of the bolt.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Spherical-head bolt (top) and spherical washer used in attaching SACH foot to plastic socket to permit relatively wide range of adjustment. Spherical washer and spherical part of bolt head can be made using plastic-laminating techniques. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Both washer and bolt head can be fabricated easily by use of plastic-laminating techniques. A mold suitable for forming both pieces can be made by immersing in wet plaster of Paris a PVA-covered rubber ball, or other spherical object of suitable size, to a depth equal to about a third of its diameter <b>Fig. 46.</b>. The washer is formed by placing in the mold about eight layers of Fiberglas cloth saturated with epoxy resin, then placing the ball in the cavity and weighting it, and then curing the resin. Trimming the periphery of the washer and drilling a 1-in. hole in the center completes the job. The spherical bolt head is constructed by placing under the head of a standard 3/8-in. machine bolt 10 discs of Fiberglas cloth drilled with 3/8-in. holes, screwing the bolt into a hole drilled into the plaster mold, filling the cavity to the top of the bolt head with epoxy resin, and curing the plastic. When curing is complete, the top may be finished by sanding.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Mold used in fabricating spherical washer and spherical bolt head. Convex portion consists of a rubber ball covered with PVA film. Concave portion is formed from wet plaster of Paris by pressing the ball in to a depth equal to approximately one third its diameter. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>So that the spherical washer may be laminated into the socket, it is attached to the plaster model of the stump with beeswax <b>Fig. 47.</b>, care being taken at this point because the location of the washer with respect to the model determines the location of the foot with respect to the socket in a horizontal plane.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Placing the spherical washer on the plaster model of the stump so that it may be laminated into the socket. Beeswax is used both to support it in the proper position and to fasten it to the model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To enable the socket to be attached to the foot, a bandsaw is used to make in the keel of the foot a cutout conforming to the radius of the bulbous portion of the socket <b>Fig. 48.</b>. When the length of the stump dictates that the keel be so cut away as to weaken it significantly, the keel must be reinforced. In such a case, a wood screw is used to fasten the socket to the remaining portion of the keel <b>Fig. 49.</b>. The heel wedge and balata belting are peeled back, some nine layers of Fiberglas cloth, tailored to fit the keel and the end of the socket (which is covered with PVA film to prevent adherence), are laid up and saturated with epoxy resin, and the balata belting is screwed back in place <b>Fig. 50.</b>. After curing of the resin has been effected, a 3/8-in. hole is drilled through the keel reinforcement and the socket at the center of the spherical washer, the foot is removed, and that part of the hole which is in the socket is enlarged to 1 in. so as to match the hole in the spherical washer <b>Fig. 51.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. View showing the type of cut made in the top portion of a SACH foot to accommodate a Syme socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Fastening the socket to the keel of the SACH foot with a wood screw. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Fiberglas cloth, used to reinforce keel of SACH foot, being tailored to fit bottom of keel and socket. Note PVA film placed over socket to prevent adherence to Fiberglas during laminating process. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. Cross-section of completed prosthesis showing spherical head bolt, spherical washer, modified keel, and laminated Fiberglas reinforcement. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Finally, a hole 1 1/4 in. in diameter is formed in the heel wedge and sole in such a way as to receive the wrench needed to tighten the attachment nut <b>Fig. 51.</b>. The heel wedge having been modified to fit the contours of the reinforced keel and then cemented in place, the socket and foot can be assembled for walking trials. When all necessary adjustments have been made, the socket is bonded to the foot with epoxy resin and the space around the socket is filled with a mixture of resin and sawdust which, when cured, is ground and sanded to provide a suitable contour.</p> <h3>CONCLUSION</h3> <p>The several methods presented here for fabrication of a prosthesis for Syme's amputation have all been found to be useful. It seems reasonable to believe that some of the features of each method may be combined in order to suit the equipment of the individual prosthetist as well as to meet most effectively the requirements of the individual patient. For example, the technique offered by VAPC for fabrication of a cover for the cutout might well be applied to fabrication of a prosthesis with a full-length posterior cutout as used by the Prosthetic Services Centre. The use of alginate as an impression material may be the method of choice for some prosthetists, while others may find the two-piece mold best for their use, especially if the local water supply contains certain minerals. The measurement-and-modification techniques described might be combined advantageously. Thus most of the individual methods are interchangeable between the basic prostheses described.</p> <h3>ACKNOWLEDGMENT</h3> <p>Any reliable article on the recommended methods of construction of a limb prosthesis must necessarily be based on the cumulative experience and the collective judgment of many workers in many places. Most of the material for this article was drawn from three pre-existing publications-<i>Construction of the Plastic Symes Appliance </i>(Technical Bulletin No. 32, Prosthetic Services Centre, Canadian Department of Veterans Affairs, Toronto, August 1959), <i>VAPC Technique for Fabricating a Plastic Syme Prosthesis with Medial Opening </i>(U. S. Veterans Administration, New York, September 1959), and <i>Recent Developments in the Fitting and Fabrication of the Syme Prosthesis (Orthopedic and Prosthetic Appliance Journal,</i> March 1960). Much valuable advice and counsel was forthcoming from a number of highly accomplished persons, among them R. M. Turner, of the Canadian Department of Veterans Affairs, Ottawa, and C. S. Boccius, of the Prosthetic Services Centre, Toronto; Colin A. McLaurin and Fred Hampton, of the Prosthetics Research Centre of Northwestern University in Chicago; and Anthony Staros and Louis Iuliucci, of the U. S. Veterans Administration Prosthetics Center, New York City. Of the 51 illustrations, the drawings not credited to original publications are the work of Annette Kissel, illustrator for the Veterans Administration Prosthetics Center in New York City, and of George Rybczynski, freelance artist of Washington, D. C. Miss Kissel executed Figures 26 through 43. Mr. Rybczynski prepared Figures 11, 12, 13, 14, 15, 16, 17, 19, 22, 23 and 24. The cooperative efforts of all these individuals are gratefully acknowledged and duly appreciated.</p> <p><b>References:</b></p> <ol> <li>Bowler, Bartholomew, U. S. Patent 1,323,444, Dec. 2, 1919.</li> <li>Columbus Artificial Limb Company, catalog, Columbus, Ohio, ca. 1925.</li> <li>Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, <i>Syme's amputation and prosthesis, </i>January 1, 1954.</li> <li>Department of Veterans Affairs, Prosthetic Services Centre, Toronto, Canada, <i>Construction of the plastic Symes appliance, </i>Technical Bulletin No. 32, August 1959.</li> <li>Foort, J., <i>The Canadian type Syme prosthesis</i>(Series 11, Issue 30), Lower-Extremity Amputee Research Project, Institute of Engineering Research, University of , Berkeley, December 1956.</li> <li>Gaines-Erb Company, catalog, Denver and Pueblo, Colo., ca. 1915.</li> <li>Gardner, Henry F., <i>A report of the checkout of the UC-Berkeley Syme prosthesis and fabrication manual. </i>Veterans Administration Prosthetics Center, New York, January 31, 1958.</li> <li>Gardner, Henry F., <i>First addendum to the January 31, 1958, report of the checkout of the UC-Berkeley Syme prosthesis and fabrication manual, </i>Veterans Administration Prosthetics Center, New York, May 1, 1958.</li> <li>Hampton, Fred, <i>Recent developments in the fitting and fabrication of the Symes prosthesis, </i>Orthopedic and Prosthetic Appliance Journal, March 1960, p 45.</li> <li>Iuliucci, Louis, <i>VAPC technique for fabricating a plastic Syme prosthesis with medial opening, </i>Veterans Administration Prosthetics Center, New York, September 1959.</li> <li>Kay, H. W., and A. Staros, <i>Plastic laminate. Syme prosthesis, </i>Prosthetic Devices Study, New York University, and Veterans Administration Prosthetics Center, New York, January 1960.</li> <li>Marks, A. A., Inc., <i>Manual of artificial limbs, </i>New York, 1889.</li> <li>Marks, A. A., Inc., <i>Manual of artificial limbs, </i>New York, 1931.</li> <li>New York University, Prosthetic Devices Studies, College of Engineering, <i>Progress report, test of the Canadian type plastic Syme prosthesis (modified)</i>, New York, December 1958.</li> <li>University of (Los Angeles), Department of Engineering, <i>Manual of upper extremity prosthetics, </i>2nd ed., William R. Santschi, ed., 1958.</li> <li>Winkley Artificial Limb Company, <i>Artificial legs with the patent adjustable double slip socket, </i>descriptive catalog, Minneapolis, Minn., ca. 1910.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Foort, J., The Canadian type Syme prosthesis(Series 11, Issue 30), Lower-Extremity Amputee Research Project, Institute of Engineering Research, University of , Berkeley, December 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, Prosthetic Services Centre, Toronto, Canada, Construction of the plastic Symes appliance, Technical Bulletin No. 32, August 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Kay, H. W., and A. Staros, Plastic laminate. Syme prosthesis, Prosthetic Devices Study, New York University, and Veterans Administration Prosthetics Center, New York, January 1960.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">University of (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed., 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Iuliucci, Louis, VAPC technique for fabricating a plastic Syme prosthesis with medial opening, Veterans Administration Prosthetics Center, New York, September 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Hampton, Fred, Recent developments in the fitting and fabrication of the Symes prosthesis, Orthopedic and Prosthetic Appliance Journal, March 1960, p 45.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, Prosthetic Services Centre, Toronto, Canada, Construction of the plastic Symes appliance, Technical Bulletin No. 32, August 1959.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Iuliucci, Louis, VAPC technique for fabricating a plastic Syme prosthesis with medial opening, Veterans Administration Prosthetics Center, New York, September 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Foort, J., The Canadian type Syme prosthesis(Series 11, Issue 30), Lower-Extremity Amputee Research Project, Institute of Engineering Research, University of , Berkeley, December 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Iuliucci, Louis, VAPC technique for fabricating a plastic Syme prosthesis with medial opening, Veterans Administration Prosthetics Center, New York, September 1959.</td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Kay, H. W., and A. Staros, Plastic laminate. Syme prosthesis, Prosthetic Devices Study, New York University, and Veterans Administration Prosthetics Center, New York, January 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">University of (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed., 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Studies, College of Engineering, Progress report, test of the Canadian type plastic Syme prosthesis (modified), New York, December 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Foort, J., The Canadian type Syme prosthesis(Series 11, Issue 30), Lower-Extremity Amputee Research Project, Institute of Engineering Research, University of , Berkeley, December 1956.</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Gardner, Henry F., A report of the checkout of the UC-Berkeley Syme prosthesis and fabrication manual. Veterans Administration Prosthetics Center, New York, January 31, 1958.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Gardner, Henry F., First addendum to the January 31, 1958, report of the checkout of the UC-Berkeley Syme prosthesis and fabrication manual, Veterans Administration Prosthetics Center, New York, May 1, 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, Prosthetic Services Centre, Toronto, Canada, Construction of the plastic Symes appliance, Technical Bulletin No. 32, August 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">University of (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed., 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bowler, Bartholomew, U. S. Patent 1,323,444, Dec. 2, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bowler, Bartholomew, U. S. Patent 1,323,444, Dec. 2, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Columbus Artificial Limb Company, catalog, Columbus, Ohio, ca. 1925.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bowler, Bartholomew, U. S. Patent 1,323,444, Dec. 2, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Marks, A. A., Inc., Manual of artificial limbs, New York, 1889.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Marks, A. A., Inc., Manual of artificial limbs, New York, 1931.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Gaines-Erb Company, catalog, Denver and Pueblo, Colo., ca. 1915.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Winkley Artificial Limb Company, Artificial legs with the patent adjustable double slip socket, descriptive catalog, Minneapolis, Minn., ca. 1910.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Staff Engineer, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Ave., Washington 25, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1961_01_052/c001.jpg Figure 2 http://www.oandplibrary.org/al/images/1961_01_052/c002.jpg Figure 3 http://www.oandplibrary.org/al/images/1961_01_052/c003.jpg Figure 4 http://www.oandplibrary.org/al/images/1961_01_052/c004.jpg Figure 5 http://www.oandplibrary.org/al/images/1961_01_052/c005.jpg Figure 6 http://www.oandplibrary.org/al/images/1961_01_052/c006.jpg Figure 7 http://www.oandplibrary.org/al/images/1961_01_052/c007.jpg Figure 8 http://www.oandplibrary.org/al/images/1961_01_052/c008.jpg Figure 9 http://www.oandplibrary.org/al/images/1961_01_052/c009.jpg Figure 10 http://www.oandplibrary.org/al/images/1961_01_052/c010.jpg Figure 11 http://www.oandplibrary.org/al/images/1961_01_052/c011.jpg Figure 12 http://www.oandplibrary.org/al/images/1961_01_052/c012.jpg Figure 13 http://www.oandplibrary.org/al/images/1961_01_052/c013.jpg Figure 14 http://www.oandplibrary.org/al/images/1961_01_052/c014.jpg Figure 15 http://www.oandplibrary.org/al/images/1961_01_052/c015.jpg Figure 16 http://www.oandplibrary.org/al/images/1961_01_052/c016.jpg Figure 17 http://www.oandplibrary.org/al/images/1961_01_052/c017.jpg Figure 18 http://www.oandplibrary.org/al/images/1961_01_052/c018.jpg Figure 19 http://www.oandplibrary.org/al/images/1961_01_052/c019.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Prostheses for Syme's Amputation Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/8c11b3cbe55906e1a1186e314abc12de.pdf 89e25364859efdc360a9591d8eafde92 https://staging.drfop.org/files/original/6cd45f3b1fecdd1934f70f5984f7f04e.jpg 17a303332067cd2cc381bb5fef3e72a9 https://staging.drfop.org/files/original/280c3bdf5f55120e4c0ff0ca8df2cef8.jpg 9a6fcac68852c85bdace0fecdbd25448 https://staging.drfop.org/files/original/e27129c49cee597181f097ae05458f31.jpg 70e3eb3d448acc0502e384554fc7add8 https://staging.drfop.org/files/original/09cab4907fea00930e6fcb6e8e4313e4.jpg 47629a5785f7d3b3038584a0bf02b2e2 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_04_171.pdf Text Any textual data included in the document <h2>Prostheses to Achieve Independent Ambulation for a Geriatric Quadruple Amputee</h2> <h5>Gustav Rubin, M.D., FACS&nbsp;<a style="text-decoration: none;">*</a><br />Fred Harris, B.S., CO.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The elderly quadruple amputee presents a challenge to a prosthetic clinic team. Although this problem is occasionally noted in children with congenital amputations,<a></a> it is much less commonly encountered in adults. During the past fifteen years there has been only one other total quadruple amputee-a young adult who was treated at our center and did not wish to have his case published.</p> <p>Here we have the opportunity to present a report on the prosthetic fitting of a 64 year old veteran who was referred to our Special Clinic Team in 1981, from the VA Medical Center in Cleveland, Ohio, with a history of quadruple amputations secondary to frost bite.</p> <p>H.F. was found on January 8, 1981, on a cold winter day, lying outside his home. He was unresponsive and had a rectal temperature of 77°. After a period of conservative care, amputations on all four limbs were done on February 4, 1981, at the private hospital in Canton, Ohio, to which he had been initially taken. The surgery resulted in a right wrist disarticulation, a left distal forearm amputation just proximal to the carpus, and bilateral below-knee amputations. The residual limbs healed without complications and the patient was transferred, on March 11, 1981, to the V.A. Medical Center in Cleveland, Ohio, where he was started on a course of physical and corrective therapy, including daily strengthening exercises to all four extremities.</p> <p>He was considered highly motivated and an "excellent candidate" for prostheses. He was referred to our center, which was then the V.A. Prosthetics Center, and was examined by the Special Prosthetic Clinic Team on May 21, 1981.</p> <p>H.F. also had a background history of gastrointestinal surgery ten years earlier for a perforated peptic ulcer. The report of the physical examination at the hospital prior to referral for prosthetic prescription revealed a normal cardiovascular examination, a blood pressure of 110/70, but a liver enlarged three cm. below the costal margin. The popliteal pulses were good.</p> <p>The evaluation by the clinic team confirmed that H.F. was well-motivated. He was an intelligent, cooperative, slender individual, whose amputations were all well-healed. The right below-knee residual limb measured 4 inches to the bone end and the left below-knee limb measured 4 1/2 inches to the bone end. There were mild knee flexion contractures which were not considered fitting problems. On the right below-knee limb there was a palpable, slight, irregular, distal anterior tibial bone prominence, unattached to the overlying tissues. On the left side the below-knee limb was poorly padded by soft tissue. As the examiner attempted to mimic piston motion of the soft tissue sleeve by drawing the soft tissue proxi-mally, the distal skin, overlying a slight bone irregularity, blanched. X-rays of the left below-knee residual limb confirmed the clinical impression of bone irregularity and x-rays of the upper extremities confirmed the right true wrist disarticulation and the left amputation just proximal to the carpus at the level of the distal radius and ulna.</p> <p>The amputee had been through a great deal (<a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-1.jpg"><b>Fig. 1</b></a>) prior to referral to the Clinic Team and it was the consensus, at this time, that referral for a lower extremity revision would have adverse impact on his motivation. It was the aim of the staff to make the patient as independent as possible by adapting the prostheses to his donning and doffing capabilities. PTS prostheses were prescribed to be fabricated with loops on the soft socket inserts (<a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-2.jpg"><b>Fig. 2</b></a>) to aid donning. The prostheses for the upper extremities employed a Northwestern ring for the figure of eight harness, double wall sockets, friction wrists, and Dorrance Lyre hooks.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-1.jpg"><strong>Figure 1. H.F., a 64 year old veteran and quadruple amputee.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-2.jpg"><strong>Figure 2. Below-knee prostheses were adapted with loops on the soft socket inserts to aid in donning.</strong></a><br /> <p>In addition, he was prescribed for platform crutches, which were modified with distal rings for the hooks and forearm loops (<a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-3.jpg"><b>Fig. 3</b></a>). The forearm loops had to be pre-adjusted into a fixed position so that H.F. could slip the prostheses through the loops and avoid the need for repeatedly adjusting the Velcro® straps.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-3.jpg"><strong>Figure 3. Platform crutches were also modified with distal rings for the hooks and forearm loops.</strong></a><br /> <p>On June 11, 1981, fabrication of the below-knee prostheses was completed and the amputee demonstrated that he could stand and take several steps in parallel bars with assistance on each side. An exercise and training program with the prostheses was outlined at the hospital. The instructions included careful monitoring of the stumps during this time.</p> <p>On June 18, 1981, the amputee was observed to be doing "extremely well," as indicated by the clinic team's notes. By this time he had also been fitted with his upper extremity prostheses and forearm crutches. He rapidly progressed to unassisted ambulation with crutches (<a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-4.jpg"><b>Fig. 4</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-4.jpg"><strong>Figure 4. H.F. progressed to unassisted ambulation with crutches.</strong></a><br /> <p>When seen by the clinic team on August 10, 1981, H.F. walked with the aid of a platform crutch. Because of irritation over the right ulnar styloid process, which was unresponsive to modification of the socket, a new socket was prescribed incorporating a soft liner and he had no further problems with this.</p> <p>On September 16, 1981, four months after his initial presentation to the team, H.F., who had been under continuous training by the Rehabilitation Service at the VAMC, NY, demonstrated that he was able to don and doff his own prostheses and even walk without crutches. He did, however, have more confidence when using one crutch. He was advised to continue using at least one crutch at all times. He reported the prostheses to be comfortable. Objectively, they appeared to fit satisfactorily and they were accepted. The amputee was returned to the VA Medical Center in Ohio. Subsequent attempted follow-up has been unsuccessful.</p> <p><b>References:</b></p> <ol> <li><a href="http://www.acpoc.org/library/1977_11_001.asp">Sullivan, Richard A., and Celikyol, Felice, "Prosthetic Fitting of the Congenital Quadrilateral Amputee: A Rehabilitation-Team Approach to Care," <i>Inter Clinic Information Bulletin</i>, XVI:11-12, November-December, 1977, pp. 1-6.</a></li> <li><a href="http://www.acpoc.org/library/1972_11_013.asp">D'onofrio, F. and Cope, P.C., "Crutches for the Quadrimembral Amputee," <i>Inter Clinic Information Bulletin</i>, XI:11, August, 1972, pp. 13-15.</a></li> </ol> <em><strong><b>*</b>Fred Harris, B.S., CO</strong>. Fred Harris, B.S., CO., is also with STAMP, NY.</em><br /> <p><em><b>*Gustav Rubin, M.D., FACS </b> Gustav Rubin, M.D., FACS, is Director of the Special Team for Amputations, Mobility, Prosthetics/Orthotics, New York (STAMP, NY), 252 Seventh Avenue, New York City, NY 10001.</em></p> <br /><br /><strong></strong> Page Number(s) 171 - 173 Year 1986 Volume 10 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-4.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Prostheses to Achieve Independent Ambulation for a Geriatric Quadruple Amputee Creator An entity primarily responsible for making the resource Gustav Rubin, M.D., FACS * Fred Harris, B.S., CO. * https://staging.drfop.org/files/original/b6eb0984e5194084f16aa1bb9f96f8cf.pdf 9ceae6af2557c11b5e7c66bcaacd9215 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1978_04_003.pdf Text Any textual data included in the document <h2>Prostheses, Pain and Sequelae of Amputation, As Seen By the Amputee</h2> <h5>H. C. Chadderton&nbsp;</h5> <blockquote> <p>Reprinted from Prosthetics and Orthotics International, Vol. 2, No. 1, 1978, by permission</p> </blockquote> <p><i>The War Amputations of Canada, Ottowa, Ontario</i></p> <h3>Abstract</h3> <p>Results of a survey of 19 organizations belonging to World Veterans Federation indicate that major complaints of amputees include; poor fitting, poor dissemination of knowledge to doctors and amputees regarding new prostheses, lack of opportunity for "input" from amputees at research level and inadequate measures to deal with phantom and stump pain. Suggested improvements by amputees; decrease in weight of prostheses, reduction in maintenance for swing and stance-phase control units, development of recreational prostheses, more frequent checks through use of X-ray and film techniques, particularly during the "break-in" of a new appliance. Older veterans showed increasing concern in regard to development of consequential disabilities arising from amputation; premature arthritic changes in spine and remaining limb, circulatory problems and gastro-intestinal problems due to ingestion of drugs to control pain.</p> <h3>Introduction</h3> <p>With the co-operation of the World Veterans Federation, information was requested from 19 veteran organizations in 14 countries. Replies were received of varying significance from all. The enquiries were based on a questionnaire, the basic elements of which were:</p> <p><i>Legs</i></p> <p>Weight of the prosthesis.<br />SACH feet versus articulated feet.<br />Wearing of rubber-soled shoes.<br />Cosmetic appearance.<br />Soft socket versus hard socket, below-knee.<br />Plug socket versus quadrilateral socket, above-knee.<br />Swing phase control units, above-knee.<br />Modular versus standard limb.</p> <p><i>Arms</i></p> <p>Munster fitting versus harness.<br />Myo-electric hands.<br />Cosmesis—hands.<br />Wearing of prosthesis, above-elbow.</p> <p><i>Adjustment</i></p> <p>Do you see yourself in your dreams as an amputee?<br />Psychological effect of dismemberment.<br />Sequelae (medical) of amputations.<br />Recreational limbs.</p> <p>The replies to the questionnaire were, in the initial stages of review, sent to a computer firm for analysis. It was evident, however, that the response could not be measured in terms of "yes" or "no" and it was recommended that an attempt be made to obtain a "feeling" from the replies which might be useful. Therefore, this survey should not be considered as a fully accurate statement of response and the views herein must be seen in this light.</p> <p><i>Fitting</i></p> <p>It seems possible to draw a startling conclusion from the replies concerning comfort. It appears that many amputees were prepared to accept an uncomfortable fit as "part of the game".</p> <p>A significant number of amputees suggested that use should be made of X-ray and film techniques and of bio-mechanical devices in measuring the accuracy of a prosthetic fit.</p> <p><i>Information on new prostheses</i></p> <p>The amputees seemed to be overwhelmingly of the opinion that there was a lack of information on the part of medical doctors in this area.</p> <p>It was evident also that, with certain exceptions the amputees themselves were poorly informed on new prostheses. Understandably, a number of amputees commented that they knew far more about the new models of automobiles than about the new models of limbs.</p> <p><i>Input at the research level</i></p> <p>The respondees stated they were unaware of any concerted effort to obtain opinions from amputees concerning the types of research which should be done to improve prostheses. To be fair, some replies indicated that "amputee input" may be going on but they did not know about it. Significantly, however, they felt that there should be more liaison at the "user" level with the researchers.</p> <p><i>Pain</i></p> <p>Universally, phantom limb pain appeared to be a significant problem and the amputees felt that very little was being done to develop remedial measures. A review of the replies indicated that the usual advice was to take aspirin and a hot drink. Obviously this has not been effective and the amputee is looking for something more concrete.</p> <p>Many amputees complained also of stump pain, as separate from phantom limb pain, stating that massage, heat treatments and sometimes surgery had been successful in its elimination.</p> <p><i>Weight of prostheses</i></p> <p>There were two distinct "camps" in the replies, some 62 per cent wanted lighter prostheses but 12 percent stated some weight was essential and felt that good hardware should be used, despite additional weight.</p> <p><i>Feet</i></p> <p>No trend was evident on the question concerning SACH versus articulated feet. There was, however, a small but dedicated group of amputees who sincerely believed that an articulated foot was much superior. This group described the SACH foot as "too springy" or "unstable".</p> <p><i>Rubber-soled shoes</i></p> <p>By far the majority of leg amputees preferred rubber-soled shoes for stability and heel strike.</p> <p><i>Cosmetic appearance</i></p> <p>This did not appear to be a factor. However, the respondees were all war amputees whose average age would be 60 which is perhaps significant.</p> <p><i>Sockets</i></p> <p>By far the majority of below-knee amputees preferred a soft socket for reasons of comfort.</p> <p>The question on the plug versus quadrilateral socket for the above-knee amputee elicited the information that, for the most part, the quadrilateral socket users were well aware of the advantages, stating them as being "better circulation ", " more comfort", "easier standing", "taking the weight on the ischium", etc. Tragically, perhaps, many plug socket users were unaware of the difference between the two types.</p> <p><i>Controls</i></p> <p>The question concerning swing phase controls elicited a very high response, indicating that a large proportion of the amputees were not familiar with these devices. (We had not dared ask for information on stance phase controls as we were reasonably certain that the concept is not known to the majority of amputees.) It would seem, from the replies, that many more amputees would be prepared to try these devices if they knew of their existence!</p> <p><i>Modular versus exo-skeletal</i></p> <p>Here again the majority of the amputees replying (approximately 60 per cent) did not know the difference. There were, however, a dedicated group of modular users who recognized the advantages of alignment, light weight and cosmesis who were "sold" on modulars. Here again, a conclusion can perhaps be drawn regarding the necessity for the dissemination of more information.</p> <p><i>Munster versus harness fitting</i></p> <p>The answer was predictable. The below-elbow amputee is very partial to a light fitting for a passive hand. Alternatively, he seems to have a passionate love affair with his hooks and harness when he wants to do heavy work or engage in recreation. This was an area in which the amputee seemed to be fairly well satisfied, except as brought out below.</p> <p><i>Myo-electric hands</i></p> <p>There was a distinct feeling among World War II veterans that they had been passed over by the myo-electric stage. Many had apparently been told that they were too old to adjust to myo-electric fittings. The majority of the replies stated "yes" to the question of whether they would like an opportunity to be fitted with a myoelectric hand.</p> <p><i>Cosmesis</i></p> <p>The replies on cosmesis (or lack of it) for hands contained comments such as "disgusting" and "lack of sensitivity". Surprisingly, many hand amputees appeared to have no knowledge of the cosmetic skins and stated they were wearing either brown or black leather gloves over their passive hands.</p> <p><i>Wearing of prosthesis, above-elbow amputees</i></p> <p>The rejection rate was predictably high. Some farsighted individuals (amputated one side only) suggested that they should get used to wearing a prosthesis in the event that they developed medical difficulties in their other arm, arising from strokes, arthritis, etc. The second part of this question indicated there was little knowledge of lighter prostheses now available through the use of modular designs.</p> <p><i>Dreams</i></p> <p>The question on dreams was thrown in only for general interest. The respondees seem to divide 50-50 as to whether they visualize themselves as amputees in their dreams or not.</p> <p><i>Psychological effect</i></p> <p>Perhaps surprisingly, a large number of war amputees describe their feelings about the loss of their limb in terms of being "grief stricken", "lost my best friend", "embarrassed", etc. It should be remembered that this survey asked for truthful answers. Psychological effect is perhaps an area which we tend to ignore as it could be interpreted as indicating a lack of machismo, etc. The Adolph Meyer school of psychiatric thought may be of interest on this subject should any one wish to develop it further, that is, depression can follow from a physical disorder such as amputation.</p> <p><i>Sequelae</i></p> <p>Most of the replies indicated consequential disabilities. Leg amputees; bad backs, arthritis in the remaining leg and foot. Arm amputees; cervical pain, headaches. Both; gastro-intestinal problems which were believed due to ingestion of drugs as well as "inner tension" associated with the continuing discomfort of amputation. The respondees were careful to suggest they were not trying to prove their case, but felt that more study should be done upon the medical after effects and side effects of amputation.</p> <p><i>Recreational limbs</i></p> <p>This question resulted in possibly the most significant response. There were requests for special legs for swimming, golfing, skiing, tennis, rowing and motor sports. The arm amputees were almost frightening in their requests for the development of special prostheses for fishing, playing baseball, cricket (for holding bats), golf, tennis and rowing.</p> <h3>Conclusion</h3> <p>It must be said that the information presented in this paper was not the subject of any strict statistical treatment. In this sense this is not a "scientific paper". This highlights the problem of communication in this field between the consumer on the one hand and the professionals involved on the other. However, it is essential that such communication be fostered if energies and resources are to be channelled in the most fruitful direction. It is hoped that against this background the views contained herein will prove useful, highlighting as they do the opinions of a substantial number of patients.</p> Page Number(s) 3 - 5 Year 1978 Volume 2 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 Prostheses, Pain and Sequelae of Amputation, As Seen By the Amputee Creator An entity primarily responsible for making the resource H. C. Chadderton  https://staging.drfop.org/files/original/8277c91972142419fd80861e1c073b3d.gif 9f40d65d4ca0c615ca5a59946c478dc3 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 https://www.prosthetichope.org/ Contact Name/Title Rob Kistenberg CP, FAAOP - Director Address Prosthetic Hope International Inc. 5165A Buford Highway City Doraville State/Province GA Countries Served Belize Postal Code 30340-1104 Phone 706-804-2744 Email prosthetichopeinternational@gmail.com Services Provided Prosthetic Fitting, Medical Equipment / Supplies, Education, Funding, Prosthetic Fabrication, Rehabilitation / Training Need I Financial Assistance Need II Volunteers: Prosthetists, Orthotists, Technicians, Therapists, Warehouse Volunteers Warehouse volunteers sort donated orthotic and prosthetic components and help package supplies to be sent to clinics/individuals requesting materials. Need III Materials, Components, and Equipment: New or Used Anything bigger than an envelope ship to: P&O Clearinghouse c/o Rob 1947 Briarwood Ct. NE Atlanta, GA 30329 Mission Prosthetic Hope International’s Mission is to expand access to prosthetic and orthotic (P&O) rehabilitation services. We achieve our mission by: • partnering with individuals and P&O service providers all over the world • developing, operating, and/or supporting P&O clinics & non-governmental organizations • recovering, recycling and re-using precious resources through our P&O Clearinghouse Volunteer Contact https://www.prosthetichope.org/contact-us Facebook Page https://www.facebook.com/ProstheticHope/ 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 Prosthetic Hope International Description An account of the resource Prosthetic Hope International’s Mission is to expand access to prosthetic and orthotic (P&O) rehabilitation services. https://staging.drfop.org/files/original/14e71685d71f779f2e221b6ce3752c7b.pdf 7f5b513db755d91f0fee0e97ce868617 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_01_005.pdf Text Any textual data included in the document <h2>Prosthetic Knee Mechanisms: A Guide for the Prosthetist</h2> <h5>Bert Goralnik, CP&nbsp;</h5> <h3>Introduction</h3> <p>A function of the Veterans Administration Prosthetics Center (VAPC) is to assist VA Clinic Teams nationally in prescribing prosthetic devices, including, of course, prosthetic knees. Prescribing knee mechanisms, however, is a complex task because of the large variety available. Most often these devices differ not that much in function but in size, type of material used for the setup, and additional characteristics related more to assembly and installation processes than prescription rationales.</p> <p>All too often clinicians prescribe either limited numbers or certain types of knee mechanisms found to be reliable in the past. Another inhibitor may be a lack of specific information on the full range and variety of all available systems. The clinician rarely has an opportunity to compare the relative merits of one knee with another.</p> <p>In 1972, the Veterans Administration, through the Department of Medicine and Surgery, Washington, D.C., published a program Guide (M-2, part IX, G7) on "The Selection and Application of Prosthetic Knee Mechanisms." The guide was slightly modified and updated in 1976. A new Program Guide, reflecting developments of recent years and incorporating most commercially available knee mechanisms, will soon be published. This later Program Guide will provide a summary description of the various knee mechanisms thus far evaluated by the VAPC. It is intended to help maximize patient benefits.</p> <h3>Description of Program Guide</h3> <p>The Program Guide comprises six sections: Knee Function, Definitions, Classification, General Requirements, Prescription of Prosthetic Knee Mechanisms, and Catalog of Knee Mechanisms.</p> <ol> <li> <p>Knee Function: Here are described the normal function of the anatomical knee, specifically the relationships of its various parts during the gait cycle, and alignment stability as a key factor in prosthetic fitting. Discussion centers on the TKA line relative to the center of the knee in maintaining stability during the stance phase. Understanding these relationships and utilizing the special features of knee mechanisms for the patient's benefit is an asset for the prosthetist. The Clinic Team thereupon must strive to provide the patient with the specific knee mechanism whose features most closely match his individual needs.</p> </li> <li> <p>Definitions: Reference terms are given to describe the variety of knee functions.</p> </li> <li> <p>Classification: A chart classifying all types of commercially available knee mechanisms is provided. The chart shows functional criteria, specifically swing phase control and stance phase control. Additional topics in this section include extension aids, extension stops, mechanical locks, mechanical friction, and fluid resistance of hydraulic and pneumatic knees.</p> </li> <li> <p>General Requirements: This section consists of a checklist on knee mechanism requirements.</p> </li> <li> <p>Prescription: Prescription rationale is discussed, emphasizing the needs of the individual patient. Although the Program Guide concerns knee mechanisms, socket, shank, foot and suspension are also discussed to achieve the best type of prosthesis available. A chart shows the type of prosthesis best suited for different types of amputees. A classification chart of knee mechanisms is also included. To further assist the clinician, variations of basic prescriptions are given, i.e., for a short residual limb, a very long residual limb, and differences based on level of activity.</p> </li> <li> <p>Catalogue of Knee Mechanisms: this section, the heart of the Program Guide, lists most commercially available knee mechanisms. Illustrations furnished by the manufacturers are included. A chart lists type of knee mechanisms, materials, exact dimensions, and types of control offered.</p> </li> </ol> <h3>Conclusions</h3> <p>The new Program Guide on "The Selection and Application of Prosthetic Knee Mechanisms," will be available on or about June 1, 1980. It should prove to be of significance to all clinic teams. To obtain a copy of this publication, please write to the Veterans Administration Prosthetics Center, Attention: Mr. Bert Goralnik, 252 Seventh Avenue, New York, New York 10001.</p> <p>I wish to thank Mr. Max Nacht, Technical Writer/ Editor, VA Prosthetics Center, for his aid in preparing this article.</p> Page Number(s) 5 - 6 Year 1980 Volume 4 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 Prosthetic Knee Mechanisms: A Guide for the Prosthetist Creator An entity primarily responsible for making the resource Bert Goralnik, CP  https://staging.drfop.org/files/original/1bfbe5548da1f1f787c5f9b69ac77ae4.pdf 11ca54b65800177402546316e1352c8c https://staging.drfop.org/files/original/802ddce4e368ab0f321e2bdc98173842.jpeg 69d07f495f9362b3076d7c0c53fec5da https://staging.drfop.org/files/original/d017fceacd06924dce3634293e3e615b.jpg 97c81669de828d6ffc77b59c510d05c2 https://staging.drfop.org/files/original/f23d96f97d854059d735a6faad5512bf.jpg c266c715736592a367b2d55d47b3a24d https://staging.drfop.org/files/original/96f6e7ec405077c1caca5aedbaa75f75.jpg 3f17afffe7cbfb411e498760677497e4 https://staging.drfop.org/files/original/a98c8f64d3c51b152bb32d0b1711eb89.jpg 867a3d79bedf809260590f74ce87e77e https://staging.drfop.org/files/original/116b9b3e583ae10ac88748d7f2091f23.jpg b664cf731070925b4db7aecacdf2b205 https://staging.drfop.org/files/original/8ce37ee8d1e152a826a64cddbff91402.jpg 13d16f86a53a7698aab3c0bf5c088144 https://staging.drfop.org/files/original/7f4d31c4953101fb3dac69063e9fd876.jpg d103dfa8fc9520418b1e36fdf51a7b1d 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_01_004.pdf Text Any textual data included in the document <h2>Prosthetic principles in bilateral shoulder disarticulation or bilateral amelia</h2> <h5>G. Neff&nbsp;<a style="text-decoration: none;">*</a></h5> <blockquote> <p><i>The following article by Dr. Neff originally appeared in German in the November 1978 issue of Orthopaedie Technik. At the suggestion of Siegfried Paul we had the article translated for publication of the Newsletter because it seems to supplement the material on external power included in earlier issues of the Newsletters. As we were about to begin editing the rather literal translation provided by the commercial service, Volume 2, Number 3, of "Prosthetics and Orthotics International" arrived and we were pleased to see that it included an excellent English version of Dr. Neff's article. Accordingly with permission from the editors of both journals we are pleased to provide the readers of Newsletter the English version developed by the International Society for Prosthetics and Orthotics.</i></p> <p><i>This article is presented not with the idea that the hardware shown is available for use, but rather to provide the readers of this publication with the findings of a very experienced clinical team as given in the discussion.</i></p> <p><i>A. Bennett Wilson, Jr.</i></p> </blockquote> <p><i>Based on a paper presented at the Second World Congress, ISPO, New York, 1977.</i></p> <h3>Abstract</h3> <p>Following a brief survey of the historic development of pneumatic prostheses the actual principles of prosthetic management in bilateral shoulder disarticulation or bilateral amelia are explained.</p> <p>The active functions are restricted to active pronation and supination, active gripping of the terminal device "hook" or "hand", combined with pneumatic locking of free swinging shoulder and elbow joints in one artificial arm; the cosmetic arm provides only space for the power package in the resin socket of the upper arm. Both arms are suspended on a Simpson frame.</p> <p>Thus optical control is concentrated on the movements of the functional arm. The reduction of valve control makes prosthetic training and use easier.</p> <p>Recently hybrid systems came into use because electric power proved superior to pneumatic power for pronation and supination and gripping, whereas CO₂ is still necessary for locking the elbow and the shoulder joint. The accumulator can be recharged daily at a plug socket, the CO₂ container need only be refilled after one or two weeks ensuring more independence for the disabled. The advantage of such a prosthesis is the better appearance in public combined with a certain functional use.</p> <p>However only intensive foot training without prostheses provides independence in daily activities, because even sophisticated prosthetic systems cannot make up completely for body loss.</p> <h3>Introduction</h3> <p>Whereas an amputee with shoulder disarticulation and one healthy upper limb generally finds a cosmetic prosthesis without active functions adequate, there is an obvious problem in the fitting of cases of bilateral disarticulation or congenital absence of both upper extremities with functionally satisfactory prostheses. No unexplored possibilities remain for the body powered positioning of artificial arms and for opening and closing the terminal device "hook" or "active hand"; so external power for a functional prosthesis becomes indispensable.</p> <p>In 1948 the first experiments with CO₂ driven pneumatic prostheses were undertaken by Hafner and Weil; CO₂ was used as a safe, easily controllable, easily applied and at the same time cheap propellant. In 1957 Marquardt and Hafner first fitted a child with bilateral amelia of the upper limbs with pneumatic prostheses.</p> <p>The initial aim of the most extensive motorisation possible of both prostheses rapidly proved itself inexpedient. The absence of suitable body parts for operating the control valves and the limited capacity of coordination, even in the most intelligent patients, was opposed to the increasing number of necessary control signals. The insufficient sensory "feedback" necessitated an exclusively optical control over the actions of the terminal devices. The independent use of each prosthesis at the same time beyond a small, optically controllable area was bound to fail for this very reason. The heavy weight and increasing energy consumption required finally led to reflection on the practicability of such "fully motorised" prosthetic systems. As a consequence there was a step by step reduction to the necessary functions and the improvement or new development of better suitable fittings.</p> <h3>Present practice</h3> <p>Partly manufactured by the industry and partly handmade in our own workshops the following pneumatically driven modular parts are available today:</p> <ul> <li> <p>a hook for children,</p> </li> <li> <p>a hook for teenagers,</p> </li> <li> <p>the pneumatic Otto-Bock-system hand,</p> </li> <li> <p>joints for pronation and supination,</p> </li> <li> <p>an active pneumatic elbow joint with lock,</p> </li> <li> <p>a free mobile elbow joint with pneumatic lock,</p> </li> <li> <p>for children, a free swinging shoulder joint manufactured from a standard modular elbow joint with pneumatic lock and extremely small CO₂ consumption combined with a friction joint for abduction,</p> </li> <li> <p>for older children and teenagers a free swinging shoulder joint with pneumatically lock-able forearm linkage.</p> </li> </ul> <p>The philosophy of prosthetic fitting of such seriously disabled patients, as described by Marquardt, is based on the idea that the prosthesis is only to be prépositioned, that is, a rough adjustment is obtained and held. Fine coordination is achieved by body movements, for example by bringing the mouth to the cup or to the spoon, which is already prepositioned with the prosthesis within the range of the body movements (<b>Fig. 1</b>).</p> <strong><a href="/files/original/802ddce4e368ab0f321e2bdc98173842.jpeg">Fig. 1.</a> Prepositioned prosthesis permits the patient to bring the mouth to the spoon.</strong><br /> <p>Connected with this is the reduction of prosthetic technique to the minimal yet indispensable functions. The dominant side is provided with a functional arm for active use. The opposite side is fitted with a cosmetic arm without active functions; in the moulded resin socket of its upper arm the CO₂ storage cylinder is accommodated. The functional arm has at its disposal:</p> <ul> <li> <p>a free swinging, pneumatically lockable shoulder joint,</p> </li> <li> <p>either a free or pneumatically movable elbow joint, in both cases pneumatically lockable,</p> </li> <li> <p>a pneumatic joint for active pronation and supination,</p> </li> <li> <p>a pneumatic "hook" or a pneumatic "system hand" (if possible interchangeable) for active gripping.</p> </li> </ul> <p>The cosmetic arm of the opposite side has only a free swinging shoulder joint and a passively adjustable elbow friction joint. Occasionally the hand of the cosmetic arm may be additionally pneumatically activated to allow a certain amount of hand to hand coordination. Both artificial arms are suspended on a Simpson frame (<b>Fig. 2</b>), which has replaced our former frame constructions (<b>Fig. 3</b>) due to its reduced weight and superior confort in wearing.<br /><br /><strong><a href="/files/original/d017fceacd06924dce3634293e3e615b.jpg">Fig. 2</a>. Prosthetic system with active arm on the right side with pneumatically lockable shoulder and elbow joint, pneumatic pronation and supination and pneumatic hand; on the left side, a free swinging shoulder and elbow friction joint, and built-in CO₂ storage cylinder in the upper arm. Both arms are suspended on a Simpson frame.</strong></p> <strong><a href="/files/original/f23d96f97d854059d735a6faad5512bf.jpg">Fig. 3</a>. Former frame construction for pneumatic prostheses for a child with phocomelic upper limbs.</strong><br /> <p>The individual functions are controlled by means of valves. For locking or unlocking of the free swinging shoulder and the elbow joints, flip-flop valves have proved successful since in these the pressure points are clearly defined. The pronation and supination of the forearm is controlled by means of a doublepoint pressure valve, situated above the acromion, or by a doublepoint traction valve, operated by a shoulder strap while lifting the shoulder (<b>Fig. 4</b>). The opening and closing of the gripping device is effected by activation of a flip-flop valve in front of the shoulder.</p> <strong><a href="/files/original/96f6e7ec405077c1caca5aedbaa75f75.jpg">Fig. 4</a>. Detail of doublepoint pressure valve in front of the shoulder and doublepoint traction value fitted to the Simpson frame.</strong><br /> <p>The few active functions can be easily controlled and, in general, learning problems in prosthetic training do not occur. The optical control is directed exclusively towards the activity of the functional arm. Energy consumption is limited, the contents of a CO₂ container, corresponding to about 500 actions, is sufficient for a normal day's use, as shown by experience. The weight of such a complete prosthetic system for a 10 year old child is about 1750 g with a pneumatic hook and about 1950 g with an Otto-Bock-system hand.</p> <p>One thing which remains unsatisfactory, is the dependence on refilling the CO₂ storage container carried in the prosthesis from a stationary CO₂ pressure cylinder by means of a reduction valve and a special adaptor. With regard to this inconvenience electrical power from batteries or from rechargeable accumulators has proved superior to CO₂ pneumatics.</p> <p>On this account we changed over to electromechanical prostheses. The first patients were children with phocomelic upper limbs; their forearmlike prostheses were attached to a modified "Ring-bandage" instead of the uncomfortable stiff frame, permitting maximum freedom of movement (<b>Fig. 5</b>). The phocomelic limbs were fitted into the moulded resin sockets in such a way as to give the impression of an actively movable elbow joint and to enable the fingers to operate microswitches which in turn controlled the electromechanically driven hands (<b>Fig. 6</b>). The result was an improvement upon wearing comfort, cosmetic appearance and function.</p> <strong><a href="/files/original/a98c8f64d3c51b152bb32d0b1711eb89.jpg">Fig. 5</a>. Recent prosthetic fitting of a phocomelic girl with electromechanical prostheses and suspension on a modified "Ringband-age"; Hosmer outside locking for elbow joints. Extreme right, cosmetic result.</strong><br /><br /><strong><a href="/files/original/116b9b3e583ae10ac88748d7f2091f23.jpg">Fig. 6</a>. Microswitch which is operated by the movements of the one finger phocomelia.</strong><br /> <p>For the reasons mentioned above it seemed sensible to convert also the prostheses for patients without arms to electrical power. So far, however, no comparably efficient electromechanically lockable shoulder and elbow joints have been developed. Thus in the meantime, we are developing hybrid systems which exploit the advantages of the pneumatic as well as of the electrical external power (<b>Fig. 7</b>).</p> <strong><a href="/files/original/8ce37ee8d1e152a826a64cddbff91402.jpg">Fig. 7.</a> Hybrid prosthesis in bilateral amelia with pneumatically lockable shoulder joint (controlled by valves in the left side) and pressure and traction microswitches for gripping and forearm rotation. Built-in accumulators fitted to the frame of the right upper arm.</strong><br /> <p>The shoulder and elbow joint of the functional arm is pneumatically lockable as before. The CO₂ consumption for these actions is extremely small; the volume of the container carried in the prosthesis is now sufficient for one or two weeks, according to the amount of use, assuring greater independence from the stationary energy reservoir at home. The energy consuming functions, such as pronation and supination and gripping movements, are electrically driven. The accumulator can be recharged at the nearest, most convenient plug socket or, with little interruption in prosthetic use, it can be exchanged for a charged second accumulator. In our experience this hybrid system can be most recommended.</p> <h3>Discussion</h3> <p>In spite of these improvement excessive enthusiasm concerning the extent of functional use of such prostheses in daily life is out of place. Their actual value lies in the indisputable "normalization" of the patient's appearance in public (one should perhaps say: <i>for</i> the public), combined with an optimizing of the functional possibilities of such prostheses by exploiting the technical knowledge available today. Therefore an intensive training in daily activities without prostheses is also essential. Besides simple technical aids, as for example, an eating aid attached to and moved by the leg, foot training is of the utmost importance, especially for overcoming daily recurring problems not only in toilet use, dressing and undressing, washing (<b>Fig. 8</b>), combing hair, teeth cleaning, but also in eating, drinking and in writing (with or without typewriter). Not only can many things be <i>handled</i> better with the feet but functional independence of (meaning freedom <i>from</i>) the prosthesis-at least at home in privacy-releases the patient from the unpleasant feeling to be capable of living only as a "perfect operator of a sophisticated prosthetic robot". This consideration should be uppermost in the mind while prescribing such a costly AID: it protects against the over-evaluation of technology and the concomitant under-evaluation of the individual, whom the technology should serve.</p> <strong><a href="/files/original/7f4d31c4953101fb3dac69063e9fd876.jpg">Fig. 8.</a> Result of self-care foot training, independence from prostheses in daily activities at hom</strong>e.<br /> <p><em>*Developed by H. Kramer, Research Lab. of the Dept. for Dysmelia and Technical Orthopaedics, Heidelberg University</em>.</p> <p><b>References:</b></p> <ol> <li>Marquardt, E. and Hafner, O. (1956). Technische Bewahrung und prakhische. Anwendung der Heidelberger pneumatische Prosthese. <em>Archiv fur Orthopadische und Unfallchirurgie</em> 48,115-135.</li> <li>Marquardt, E. (1957). Muskelsteuerung von pneumatischen Unter-und Oberarmprothesen. <em>Archiv fur Orthopadische und Unfallchirurgie</em>, 49,419-426.</li> <li>Marquardt, E. (1965). Erfahrungen mit pneumatischen Prothesen. <em>Verh. Dtsch. Orthop. Ges.</em>, 52, 346-352.</li> <li>Marquardt, E. (1974). Pneumatische Prothesen, Eigenkraftprothesen und technische Hilfen fur schwere Armfehlbildungen in:¹⁰<em>Jahre Entwicklung und Erprobung von Hilfen und Hilfmitteln fur behinderte Kinder</em>. Hrsg.: AG Technische Orthopadie und Rehabilitation, R. Schunk Verlag, Konigshofen.</li> <li>Neff, G. Marquardt, E. (1977). Stand der Versorgung mit pneumatischen Prothesen in: <em>Amputation und Prothesenversorgung bein King</em>. Ed.: R. Baumgartner, F. Enke Verlag, Stuttgart.</li> <li>Neff, G. (1978). <em>Prinzipien der prothetischen Versorgung nach beidseitiger Schulterexartikulation oder bei beidseitiger Amelie Orthopadie-Technik</em>, (In press.).</li> <li>Simpson, D.C. and Kenworthy, G. (1973). Entwurf eines voll-stangigen Amersatzes (Teil 2) <em>Orthopadie-Technik</em>, Feb. 41-44.</li> </ol> <em><b>G. Neff<br /></b>Orthopädische Universitätsklinik, Tubingen</em><br /> <div style="width: 400px;"></div> Page Number(s) 4 - 7 Year 1979 Volume 3 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-7.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/1979_01_004/1979_01_004-8.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 Prosthetic principles in bilateral shoulder disarticulation or bilateral amelia Creator An entity primarily responsible for making the resource G. Neff * https://staging.drfop.org/files/original/971d394bd3cab6b56131702cf9304cfc.pdf f2823830773aab477c31ef87b7ef4503 https://staging.drfop.org/files/original/19d63adbf4fba399327be2d43c975736.jpeg ddab110728e3ce26e0c64c15d5a8fee2 https://staging.drfop.org/files/original/5f71f091dd01239060dbc584eb8435a2.jpg 06f5cd1d15bf80197630f436ea40479a 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/1981_03_001.pdf Text Any textual data included in the document <h2>Prosthetic Sensory Feedback Lower Extremity</h2> <h5>Frank W. Clippinger, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />James H. McElhaney, Ph.D&nbsp;<a style="text-decoration: none;">*</a><br />Maret G. Maxwell, Ph.D.&nbsp;<a style="text-decoration: none;">*</a><br />David W. Vaughn, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Grace Horton, R.P.T.&nbsp;<a style="text-decoration: none;">*</a><br />Linda Bright, R.N.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>This is a progress report of a Duke University research project involving sensory feedback from lower extremity amputation prostheses.</p> <p>It has been assumed for many years that replacement of sensory function in prosthetic limbs was a nearly impossible task. Developments in electronics have made possible small amplifier systems and usable transducers, but the basic difficulty remains that of getting the signals into the central nervous system in a fashion that is interpretable, comfortable, consistent, and convenient.</p> <p>The problem has not been ignored and the obvious routes-auditory signal, electrical stimulation of intact skin, mechanical stimulation, and developments leading to solving the skin barrier with compatible percutaneous materials have been explored.</p> <p>From 1969 to 1975, this laboratory developed the mechanism to produce sensation from upper limb prosthetic terminal devices. This system was built around the concept of proportional peripheral nerve stimulation by means of a surgically implanted, induction coupled radio receiver-pulse generator, driven by an external amplifier and transmitter that relayed frequency modulated signals, controlled by a strain gauge transducer in the terminal device.</p> <p>The conclusions from this study were:</p> <ol> <li> <p>The system is feasible and signals can be interpreted with reliability relative to the stimulating activity.</p> </li> <li> <p>The brain interprets the signal as coming from the normal peripheral distribution of the nerve stimulated.</p> </li> <li> <p>Signal threshold and nerve excitability does not deteriorate with time, at least in this application.</p> </li> <li> <p>The implanted device is reliable, and durable, there having been no implant failures in twelve years.</p> </li> </ol> <p>In 1975, a grant was received from the National Cancer Institute to apply this technique to the lower limb amputee. This study is to determine whether sensory feedback, in addition to that provided normally from the stump-socket interface and terminal knee impact, useful or advantageous.</p> <p>To date, 21 patients have been fitted with a lower extremity sensory feedback system, including below knee, above knee, and hip disarticulation amputees. The majority of these have been cancer patients.</p> <p>The new amputee from malignancy presents a special problem. It is difficult to subject a person recently amputated for cancer to another surgical procedure to insert a stimulator implant. In addition, the amputation is followed by months of chemotherapy during which time wound healing is compromised and the patient does not feel well. Emotional factors must be considered also.</p> <p>For this reason, it was necessary to develop a noninvasive system as well as the implanted nerve stimulator. After a brief unsuccessful trial with a skin vibrator, the auditory route was selected.</p> <p>The electronic systems of both the implanted and auditory devices are similar. The system consists of a set of strain gauges which measure anteroposterior and mediolateral bending moments incorporated into the below knee segment of the prosthesis utilizing an endoskeletal unit developed by the Department of Bioengineering at Duke, hybridized with Ottobock endoskeletal prosthetic components.</p> <p>In addition to the strain gauges, a pressure activated piezo-electric crystal is imbedded in the heel of a SACH foot. This is activated on heel strike.</p> <p>When the weight is balanced in mid stance or when the prosthesis is unloaded, as with the patient sitting, there is no signal produced by any of the transducers. The system is designed to provide proportional feedback as soon as weight is biased in any direction.<br /><br /><a href="/files/original/19d63adbf4fba399327be2d43c975736.jpeg"><strong>Figure</strong></a></p> <p>For the implant system, the signal to the nerve is frequency-modulated with the frequency of stimulus increasing from 0 to 90 Hertz proportionate to the load. With frequencies greater than 90 Hertz, a decrease in signal or complete loss of signal has been experienced routinely. Voltage is adjusted to a level that is comfortable for the patient. Threshold in these patients has varied between .5 and .9 volts.</p> <p>The implanted receiver is identical to that used in the upper limb project except that four electrodes are placed around the sciatic nerve in the buttock rather than the two that were used for the median nerve in the upper limb project. The receiver is placed subcutaneously in the lower abdominal wall and the antenna is taped to the overlying skin. Only two electrodes are stimulated and the pair which produces the best response is selected. Electrode orientation is important and this is a compromise. The alternative would be to do the surgery with the patient awake which has obvious disadvantages.</p> <p>In all patients, an interpretable signal was produced although the mental imaging, which was 90 percent correct in the upper limb, has been haphazard in the lower. No patient has reported that the stimulus or the mental image produced was uncomfortable, unpleasant, or confusing, however.</p> <p>The auditory system uses the same external transducer unit, but the signal is fed to a hearing aid earpiece placed behind the ear without blocking the external auditory canal.</p> <p>In that the end result of any sensory feedback is a subjective response, it is difficult to determine its effect in scientific terms.</p> <p>A gait laboratory has been developed to analyze walking with and without the sensory feedback system. This provides computer-assisted analysis of force plate and segmental accelerometer data. This facet of the study has just started and at the moment, insufficient data analysis is available to be meaningful.</p> <p>It is felt, however, that the subjective individual patient response will actually be more helpful in the long run. This is "quality of life" response and is voiced as statements like: "I can walk out in the driveway at night without worrying", "I feel better about going downstairs", "I can play basketball better with it turned on", "I can control the accelerator on my car far better".</p> <p>Not all the subjects have found the system useful. <b>Table I</b> outlines the patients who have had the sensory feedback systems and their outcome. Most of those who have abandoned it, however, have had the auditory unit.<br /><br /><strong>Table I</strong></p> <img src="/files/original/5f71f091dd01239060dbc584eb8435a2.jpg" h3="" />Conclusions <ol> <li> <p>Sensory feedback systems in lower extremity amputees appear to have advantages. How much better the amputees are is still under investigation and whether the system is cost effective is still not determined.</p> </li> <li> <p>The auditory system is somewhat confusing and cumbersome. It may end up being a good training apparatus but not appropriate for long term use.</p> </li> <li> <p>The electronics package in the below knee segment of the prosthesis presents some problems related to the cosmetic cover which has to allow frequent access for adjustment and battery changes. An attempt is underway at present to replace the instrumented pylon with an instrumented ankle bolt.</p> </li> <li> <p>Investigation is still needed to determine exactly what information is useful. Knee position, for instance, may be more useful information than the direction and magnitude of loading.</p> </li> </ol> <em><b>*Linda Bright, R.N. </b>Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><b><br /><em>*Grace Horton, R.P.T. </em></b><em> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><br /><em><b>*David W. Vaughn, C.P.O. </b> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><br /><em><b>*Maret G. Maxwell, Ph.D. </b> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><br /><em><b>*James H. McElhaney, Ph.D </b> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><br /><em><b>*Frank W. Clippinger, M.D. </b> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em> Page Number(s) 1 - 3 Year 1981 Volume 5 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1981_03_001/1981_03_001-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 2 http://www.oandplibrary.org/cpo/images/1981_03_001/1981_03_001-2.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Prosthetic Sensory Feedback Lower Extremity Creator An entity primarily responsible for making the resource Frank W. Clippinger, M.D. * James H. McElhaney, Ph.D * Maret G. Maxwell, Ph.D. * David W. Vaughn, C.P.O. * Grace Horton, R.P.T. * Linda Bright, R.N. * https://staging.drfop.org/files/original/12c366995fac640412262b97e21e05bc.pdf 5425bdb7fa0bf0a71fba5604a71cbe09 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_01_003.pdf Text Any textual data included in the document <h2>Prosthetic-Orthotic Research - A New Thrust is Needed: A Clinician's Perspective</h2> <h5>Charles H. Epps, Jr., M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Since the prime supporter of research, the federal government, has sharply reduced some areas of funding, the efforts of many established investigators and programs have been curtailed. Hardest hit has been the young aspiring investigator without a track record, who has found it virtually impossible to acquire funding for initial research efforts. Basic research as well as clinical research has suffered. Prosthetic and orthotic research programs which have never had abundant or even adequate funding also have been adversely affected.</p> <p>In the area of upper extremity prosthetics, much research remains to be done. For the patient who wears a prosthesis, cosmesis is still a major concern. Cosmetic acceptability must be improved and sensory feedback must be developed; sockets must be made more comfortable and suspension must be improved. Myoelectric control systems and other methods of external power must be made more functional, more compact, and more economical.</p> <p>In the lower extremity, newer materials and techniques must be developed to make prostheses lighter in weight, especially for the geriatric wearer. Although there seems to be less enthusiasm today for skeletal attachment of prostheses, the concept remains a challenge. The mechanical integrity and durability of knee devices can be improved along with fitting and alignment techniques.</p> <p>Because of basic lack of knowledge about the effects of forces on bone, ligaments and tendons, the need for orthotic research is even greater than in prosthetics. More needs to be known about the magnitude and patterns of forces that are necessary and safe to orthotic applications. Workers in kinesiology and gait laboratories around the country are endeavoring to find more answers to diagnostic problems and to collect useful data for orthopaedic assessment and even surgical treatment. New materials offer the orthotist new versatility. The pneumatic orthosis, a new concept, is ready for full development. Electrical applications are at an embryonic stage in the stimulation of paralyzed muscles, inducing therapeutic exercises, and providing afferent or feedback systems. New interest has developed to improve powered mobility devices to replace the conventional electric wheelchair for the high level spinal cord injured patient. Specially adapted vans can be operated safely by paralyzed, limb deficient patients and other severely handicapped. In view of the potential offered by computer applications and rapidly improving robot technology, environment control devices are on the threshold of great advances. So much remains to be done in prosthetic-orthotic research that even the casual observer must be concerned.</p> <p>At the same time that public research dollars have decreased, private research dollars have not increased sufficiently to fill the void. Obviously, research needs offer a challenge to orthopaedic surgeons who must increase the amount of personal time and funds given for research. At least one encouraging sign of private sector philanthropy exists. Bristol-Meyers/Zimmer U.S.A. has donated 1.2 million dollars to the Orthopaedic Research and Education Foundation (OREF) for the 1983-1984 Campaign. To date, more than 150 orthopaedic surgeons have given $1,000 each to OREF for the current campaign. This is in sharp contrast to the previous years' total of $200,000 from all sources. Other members of the industrial community should duplicate and even surpass the example set by the Zimmer group.</p> <p>If this instance of giving by the orthopaedic surgeons and a prime industrial supplier is replicated by prosthetic-orthotic practitioners and members of the corresponding industrial manufacturing community, the funding for prosthetic-orthotic research can be adequately raised to support needed research programs.<br /><b><br /><em>*Charles H. Epps, Jr., M.D. </em></b><em> Division of Orthopaedic Surgery, Howard University Hospital, Washington, D.C.<br /><br /><br /></em></p> Page Number(s) 3 - 4 Year 1984 Volume 8 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 Prosthetic-Orthotic Research - A New Thrust is Needed: A Clinician's Perspective Creator An entity primarily responsible for making the resource Charles H. Epps, Jr., M.D. * https://staging.drfop.org/files/original/eadb68192d9b2fd8666172557a83275b.pdf 8628bf8a26a7358be776d63ecd50ba6b https://staging.drfop.org/files/original/683a272758a01a47d6dd619c491baf61.jpg 7ea1b0286f3578fec1cf44dd5a141b9e https://staging.drfop.org/files/original/daa86023b71672f0a988e985dd93a419.jpg 5eb13779da4b535642b8ac5e1a5c5226 https://staging.drfop.org/files/original/cac34132ec07e39e8a9063fc6f68b271.jpg 9bef4a8ac31752e52b0f209b8931e0c7 https://staging.drfop.org/files/original/407678256598a48985a5feb419cc10d5.jpg a2ec8084e42fc4e0b67846e1a2bba35a https://staging.drfop.org/files/original/c93608737f30dfd643676d669a794a64.jpg 2ed98b712bd84d285f960a725db0fcf7 https://staging.drfop.org/files/original/22027ce38ca9febc705ae68ae2d16d29.jpg d0562d55da5fc853efdff575c4b3b3a4 https://staging.drfop.org/files/original/14871e7f9a505732ae822f2edbca77f7.jpg 43818bdcb8084b609ccc5bf9c32af638 https://staging.drfop.org/files/original/ddc66f3e4c72ff82e42e8f893269b9bd.jpg 669fc27dd0a2411e77fc9fcbf0a70eff https://staging.drfop.org/files/original/0cec4ba5780fb4f35866dc6af5c54369.jpg 6aecaf5252c3c3574490ef7a65c71e61 https://staging.drfop.org/files/original/345253512930834516888667968141f5.jpg 257a926d196f4a06d609e70a91762ed0 https://staging.drfop.org/files/original/abff7786ca0707d90e783c3c76bbdd31.jpg 9a00399a1136593653b1fd885778d8b5 https://staging.drfop.org/files/original/8b502451ff1f3d43c09d55eb60739c97.jpg 5df759b91e24e21517cafeee940aaebe https://staging.drfop.org/files/original/0210b549389d0d1b7535a201fae94c59.jpg efb4ea591ef51d962f2784a5b9be02ca https://staging.drfop.org/files/original/d5875f021ebf8d742348602b3a498be5.jpg 1ff76c735ab9211f0bb7ac2323c571b0 https://staging.drfop.org/files/original/592e7093372ede7dc18e9aba9afdc43a.jpg 26778cea8e1db5412ea480d941294dd3 https://staging.drfop.org/files/original/2c4da75e6ccb1c8871d09849b20b2ccc.jpg b9e1e2ba106d0e7a9a3ffd6c9ed5d4cd https://staging.drfop.org/files/original/550140a7e8d57308f9dcee01377b0e5f.jpg e28e9978a9f3891ea1c3cc360c261c4a https://staging.drfop.org/files/original/9791acd3b4bc1ea260a21ef4f3386641.jpg 7d78e1beb99b5ec8d612e7e97a9d6982 https://staging.drfop.org/files/original/19341294a016736c920b22eb3d7c6c29.jpg 7e6bc6f995213c9adcf5f7fa316d613e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_03_004.pdf Year 1954 Volume 1 Issue 3 Page Number(s) 4 - 46 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_03_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_03_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Prosthetics Research and the Amputation Surgeon</h2> <h5>Rufus H. Alldredge, M.D. <a style="text-decoration:none;">*</a><br />Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Except in abnormal circumstances, man is born into his world with four mobile members which extend from his trunk like branches from a tree. These so-called "limbs" he uses in manifold complex patterns, first to serve his immediate personal needs and second to shape his own environment as best he can. Although in early life man reveals the history of the race by crawling about on all fours, he shortly assigns to two of the limbs chiefly, but not exclusively, the functions of supporting the body and of moving it from place to place. The "legs" thus become the principal weight-bearing members and the generally accepted means of locomotion.<a style="text-decoration:none;">*</a> To the more versatile "arms" man assigns most of the more complex functions of daily living and of creative activity. No doubt to this "division of labor" can largely be attributed the rather remarkable development of art and science and literature and industry and most of the other creative manifestations of human life.</p> <p>Because, however, the limbs extend from the body proper, they are particularly susceptible to damage, either from lack of nutrition and disease or by external forces of one kind or another. Since the limbs are not "vital" organs in the same sense as, say, the heart or the liver, it is possible under favorable conditions to remove one or more without loss of the whole living organism, especially since the advent of modern surgery, anesthesia, and the newer drugs and blood substitutes. That is to say, a man has a chance of living on, though a natural member be discarded. We thus have as a result of war, accident, and disease a sizable number of individuals lacking part or all of one or more limbs, and to these must be added those persons born with malformed or missing limbs. All these people, now known generally as "amputees," are obviously handicapped, to greater or lesser degree, in the performance of all those functions ordinarily carried out by the arms and legs, and in extreme cases there may be no residual function at all. To restore lost functions in as great a measure as possible has long presented a challenge to certain people, mostly, as might have been expected, to amputees themselves.</p> <h4>The Background</h4> <p>Early amputations undoubtedly were more often than not traumatic events leading to a prompt death. Occasionally, however, history records amputees who survived their bloody and painful experiences. One famous example was Hegesistratus, who, captured and chained by the Spartans, amputated his own foot in order to escape.<a></a> With the slow development, over the centuries, of surgery in general, amputations came to be performed more frequently. Typically they were desperate efforts to save life. Such works as those of Pare,<a></a> of the sixteenth century, described the techniques. In some cases, a tight tourniquet was applied and left intact until the distal portion was lost by spontaneous amputation. In others, the amputation was conducted with knife and saw, and bleeding was controlled by cauterization.</p> <p>From the beginning it seemed obvious that the amputation should be as distal as feasible in order to conserve the maximum bony lever. Many surgeons, however, preferred a disarticulation at a joint whenever that was possible. For they had found that infection was relatively unlikely to enter the bone through the normal surfaces which could be retained with disarticulation, whereas, in the days before aseptic surgery, osteomyelitis was all too common when the marrow cavity was opened by amputation through the shaft of a bone.</p> <p>Roughly a century ago the introduction of anesthetics made prolonged surgery possible, and not long after that the germ theory and antiseptic and aseptic surgery greatly increased the chances of surviving either accidental wounds or surgery. These factors made possible the comparatively long and complicated amputations now taken for granted, the revision of otherwise unsuitable stumps, and the elective amputations in cases of serious disease or deformity.</p> <p>At about the same time, wars involving European powers, and especially the American Civil War, led to large numbers of surviving amputees. Also, and again more or less simultaneously, the rapid development of heavy industry and of railroading resulted in many traumatic amputations in civilian life, especially in the United States. All these factors increased interest in amputation surgery and in limb-making for the large numbers of surviving amputees.</p> <h4>Amputation Surgery and the Art of Prosthetics</h4> <p>Artificial limbs of one kind or another date from antiquity. Particularly during the fifteenth, sixteenth, and seventeenth centuries, crudely functional artificial arms came to be made, chiefly by armorers, who were already experienced in a related field. Of many known examples, the arm and hand made about 1509 for Goetz von Berlichingen <a></a> is by far the best known (<b>Fig. 1</b>), numerous copies having been constructed for museums. In this and others of the period, joints were flexed by the other hand and locked by ratchets. Springs returned the joints when the ratchets were released by pressure on a projecting knob. In all such armorlike arms and hands, iron was used, sometimes with holes punched to reduce weight. Leather doublets or sockets, often with laces, commonly were used for several centuries.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> <p class="clsTextCaption"><br /> Fig. 1. Typical "sites of election" for amputation in the upper extremity, from well-known texts, by permission of the respective publishers. In general the sites became progressively less restricted. <i>A, </i>Recommendations of zur Verth,<a></a> as reproduced by Vasconcelos<a></a> reporting to the 3rd Brazilian and American Surgical Congress, Rio de Janeiro, November 1943. Original caption labels left drawing as representing functional values for an "intellectual," right drawing as for a "workman." Note that zur Verth favors more lever for a "working man." <i>B, </i>Recommendations of Langdale-Kelham and Perkins.<a></a> They state, ". . . but limb-makers are unable to fit a limb that allows the patient to pronate and supinate, for the circumference of the forearm changes its shape during rotation and the socket is either too tight to permit the change of shape or too loose to secure a firm hold on the stump. . . ." C, Recommendations of Kirk .<a></a> Note increasing emphasis on saving all length possible. Kirk's text suggests that wrist disarticulation is rather unsatisfactory and that few if any prostheses make use of pronation. The elbow disarticulation is tolerated but criticized. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Near the end of the eighteenth century, Klingert<a></a> introduced an above-elbow arm with most of the natural motions controlled by ten catgut cords fastened to a vestlike garment and moved individually by the sound hand. Since in most cases the sound hand might better have performed the intended action, this impractical prosthesis was a classic pioneer in exceeding what some nowadays call the "hardware tolerance" of the amputee. In 1818, Peter Ballif<a></a> of Berlin developed the first voluntary control by use of trunk and shoulder muscles. His hand was of the voluntary-opening type<a></a> with springs to close the fingers and thumb. To the Dutch sculptor, Van Peeterssen, is attributed the first above-elbow prosthesis with harness control permitting voluntary flexion of the artificial elbow joint.<a></a> </p> <p>As the art of armormaking declined, limb-making on the Continent came to be carried on usually in conjunction with the making of braces, and consequently the artificial legs produced there typically evidenced steel sidebars and molded leather corsets similar to those used in braces. At the time of the Napoleonic Wars, the wooden leg, used from earliest times, was provided, for example, by Potts of London for the Marquis of Anglesey and others.<a></a> Wood reinforced by rawhide was used customarily in the United States, although a variety of other structural materials has been suggested in the journal literature and in patents.</p> <p>Comte de Beaufort<a></a> invented a number of artificial arms as well as legs, some of which were approved for French veterans of the Crimean and Italian campaigns. In 1858, he presented to the French Academy of Medicine a hand with an alternator mechanism and a double-spring hook.<a></a> Dorrance<a></a> introduced in America the well-known voluntary-opening split hook with rubber bands to close a movable finger against a rigid one. He and others rapidly produced a variety of hook shapes intended for specific trades.</p> <h4>World War I</h4> <p>World War I led to a revival of interest in amputations and in artificial limbs, notably in Germany, Belgium, and England. All these countries had rather extensive programs involving the cooperation of surgeons, limb-fitters, and engineers. Publications based on World War I experience<a></a> indicated considerable progress in understanding of amputation techniques, of the need for prompt rehabilitation of amputees, and of the importance of fit and alignment of the prosthesis. The development of many new devices and components for artificial limbs for both upper and lower extremity was described perhaps most impressively in Ersatzglieder und Arbeitshilfen.<a></a> Martin's second book <a></a>, prepared for the International Labour Office, and Little's text <a></a> were particularly useful because they offered critical analyses following impartial descriptions of prostheses and mechanisms.</p> <p>The wooden leg came to be used widely throughout the Continent as well as in England and in the United States. Aluminum, introduced by Desoutter<a></a> in England in 1912, was used particularly in England and to a lesser extent elsewhere. The fiber leg was used by a substantial number of limbmakers, particularly in the United States. Despite the large number of knee locks and ankle joints permitting lateral motion, described in patents and in medical and technical literature, most above-knee amputees used a simple uniaxial hinge for the knee joint and a single-axis ankle joint. Rubber bumpers were used widely in place of the tendons popular in the nineteenth century. It is interesting to note that in 1922 Little remarked<a></a> that most leg amputees had to use at least one stick.</p> <p>For the upper extremity, a great many artificial arms, hands, and working tools were developed during World War I, as can be seen from the major books on prostheses of the period .<a></a> American designers generally used the split mechanical hook closed by rubber bands and separated from the forearm by a rubber washer which provided stability by friction but which at the same time permitted pronation-supination by means of the other hand. Europeans generally preferred passively operated clamps and special tools so designed as to be interchangeable by a disconnect at the wrist. Either a clamp, as on a machine tool, or a locking bolt engaging any one of a series of holes in a disc was used to fasten the tool in the selected position of pronation or supination. For working purposes, the attachment for the tool was often placed at the end of the socket, far above the normal hand level, so as to decrease the leverage of the load on the stump. For dress wear, a cosmetic forearm and terminal device could be attached in place of the tool.</p> <p>Various wooden hands, usually with spring-loaded or voluntarily controlled thumbs, were shown in the literature of many countries. Generally, it was assumed that such hands were for dress and for light office use only, either bare or covered with a leather or fabric glove. Often the fingers were curved permanently to carry a briefcase. The Carnes arms and hands,<a></a> patented in 1912, 1922, and subsequently, were widely sold in the United States for many years. During World War I they were widely admired abroad and were described in detail by Schlesinger<a></a> and to a lesser extent by Martin<a></a> and by Little.<a></a> </p> <p>Similar devices, under the general name "Germania," were built in Germany after entrance of the United States into hostilities. Most authors admired the dexterity achieved by the Carnes devices-particularly because of their ingenious construction, the passively adjustable wrist flexion, and the possibility of coordinating supination with elbow flexion to assist in eating-but criticism was leveled at complexity, relatively heavy weight, lost motion, and the restriction against interchange of a hook for the hand.</p> <h4>World War II</h4> <p>Surgical authorities during World War II advocated<a></a> typical "sites of election" <b>Fig. 1</b> and <b>Fig. 2</b>) based upon the extensive practical experience of the surgeons as well as on the advice of many of the more active limb-fitters, who were notably successful in fitting good stumps at these "sites of election" but who had encountered serious difficulty in fitting such stumps as the wrist disarticulation, the very short below-elbow stump, the knee disarticulation, or the Syme stump. Typical prostheses for the so-called "sites of election" are shown in <b>Fig. 3</b>, <b>Fig. 4</b>, <b>Fig. 5</b>, and <b>Fig. 6</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Typical "sites of election" for amputation in the lower extremity, from well-known texts, by permission of the respective publishers. <i>A</i>, Recommendations of Langdale-Kelham and Perkins.<a></a> These authors condemn the Syme. <i>B, </i>Recommendations of Kirk <i>. </i><a></a> Although Kirk does not show a Syme, he agrees with the Canadians that a properly fitted Syme's amputation is ideal for the "laboring man." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Typical prosthesis for amputation below the elbow, made about 1945-47. Note modled leather socket, steel sidebars and single-axis joints permitting elbow flexion only, full upper-arm cuff with two straps, heavy leather shoulder saddle and webbing cheststrap, and double leather thong passing over pulleys at the elbow joint to open the voluntary-opening hook. Rubber bands closed the hook and determined the gripping force. Changing the number of rubber bands to vary the gripping force was possible but inconvenient. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans A administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Conventional prosthesis for amputation above the elbow, made about 1945-47. Note the molded leather socket (with the unusual rear opening and laces), wooden elbow shell and forearm, and push button projecting from lower surface of forearm to control elbow locking by pressure on table top through the sleeve or by use of the opposite hand. Such elbows provided a maximum of five locking positions. A relatively complex harness of cotton webbing supported the prosthesis on the stump and controlled a helically wound rawhide thong sliding through short lengths of stiff housing rigidly mounted above and below the elbow. Tension in the thong flexed the elbow when it was unlocked. When the elbow was locked, tension was transmitted to close the hand, which could be locked by means of the button projecting from the volar portion near the wrist. A desirable disconnect in the thong and a screw thread at the wrist permitted substitution of a hook for the hand. The harnessing pattern for a given level of amputation varied markedly among different limb-makers. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Conventional wooden prosthesis for amputation below the knee, made about 1947. Note the usual leather thigh corset, leather thong or lace, leather back-check to prevent hyperextension of the knee, single-axis mechanical knee and ankle joints, and wooden toe fastened to wooden foot by a belting hinge. Usually a webbing waist belt was connected by an elastic strap to an inverted Y-strap straddling the patella and attaching near the front brim of the shank to help suspend the prosthesis and to extend the knee. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Conventional wooden prosthesis for amputation above the knee, made about 1947. Note reinforced pelvic band and single-axis hip, knee, and ankle joints. Elastic straps from front and rear of pelvic band are joined by a leather strap passing under a roller ahead of the knee bolt so as to extend the knee from a flexed position. In other prostheses of the same type, refinements of workmanship included inlaying the hip joint into the wood and reinforcing it with rawhide, covering the metal pelvic-band reinforcement with leather, and providing a continuous leather-covered sponge-rubber layer on the sole of the foot. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It will be noted, for example, that all levels of forearm amputation, from the wrist disarticulation to the short below-elbow, were fitted with the same type of forearm composed of a molded leather socket, usually laced, extending into a cosmetic shell and reinforced by volar and dorsal metal sidebars which formed a crosspiece at the wrist supporting a screw thread or bayonet-type attachment for the hook or artificial hand. Typically, the terminal device could be rotated passively by the opposite hand against the friction of a rubber washer but could not be pronated or supinated actively. The metal sidebars were hinged in line with the humeral epicondyles to permit elbow flexion in relation to a buckled or laced cuff about the upper arm. Usually the terminal device was operated by a leather thong which passed over a pulley or through a short length of helical wire housing at the elbow joint so as to be independent of elbow flexion. Since the prosthesis did not provide for pronation-supination, whatever of this function was originally available in a stump amputated at the "site of election" soon disappeared owing to muscular atrophy.</p> <p>The elbow lock for above-elbow arms generally was operated, in the case of a unilateral amputee, by the opposite hand, or, in the bilateral arm amputee, by pressure against the body or against a table. It usually consisted of a sliding bolt engaging one of three or four holes in a metal strap surrounding the carved wooden elbow portion below the molded leather or fiber humeral socket. Cotton webbing and rather heavy leather shoulder saddles were commonly used in the arm harness, and leather thongs transmitted forces to flex the elbow and to operate the terminal device.</p> <p>During the period of World War II, the typical unilateral leg amputee in the United States, including many hip-disarticulation cases, walked without the aid of a cane, although the above-knee amputee usually walked with the relatively fixed cadence for which the fixed friction about the knee bolt was adjusted. Any attempt to walk faster or slower led to excessive heel rise or to a tendency to drag the toe. The below-knee artificial leg was often carved from a wooden block by trial-and-error fitting. Alternatively, a leather socket, molded over a modified plaster replica of the stump, was inserted into a fiber, metal, or occasionally a wooden shank. Sometimes, in an effort to increase conformity to the stump, a certain degree of softness or of ability to flow plastically was imparted by a thin lining of felt, wax, or relatively pliable leather.</p> <p>The above-knee leg was occasionally held to the body by suspenders, but by 1945 a large percentage of above-knee amputees used a pelvic band and metal hip joint. Usually the hip joint permitted the leg to swing in one plane only, although in some designs an additional axis permitted abduction and adduction. In England, and rarely in the United States, a third axis, substantially vertical, also permitted a limited amount of rotation, although about an axis outside the body several inches from the ball and socket of the natural hip joint.</p> <h4>Era of Antobacterial Techniques</h4> <p>During World War II, blood, plasma, and antibiotics came to be used widely to increase the chances of survival at the time of injury as well as to permit more extensive surgery. The Surgeon General of the U.S. Army ordered open amputation exclusively, to be followed by skin traction until a revision operation could be performed. This flat order unquestionably reduced the incidence of infection and gangrene<a></a> from combat injuries to U.S. Servicemen in World War II, as compared to experience in previous wars or to the experience of certain other military forces. It undoubtedly led also to the conservation of many stumps which, under other circumstances, would have been reamputated at the "site of election" above the next joint in order to avoid rapid spread of infection and gangrene. According to Veterans Administration records, for example, the U.S. forces had over two thirds of their lower-extremity amputations below the knee, whereas during the American Civil War and among the Filipino Scouts and guerrillas<a></a> and the Yugoslavian guerrillas<a></a> in World War II, it was estimated that at least half of all lower-extremity amputations were above the knee. Little, <a></a> in a sample of 1030 amputations among the English forces in World War I, found only 219 "leg" (below-knee) and 441 "thigh" (above-knee) stumps in a total of 723 lower-extremity amputations.</p> <p>On the other hand, there is no question that the order for open amputation, followed by traction and a second, or revision, operation, led to prolonged hospitalization for some cases which safely could have been performed primarily as closed amputations, particularly as antibiotics became available late in World War II. Furthermore, many of these "military" amputations, performed as they were far behind the lines, were really essentially civilian in nature. It seems very questionable that there would be a need for performing as many open amputations in civilian practice where risk of infection and gas gangrene is relatively low. The surgeon has a responsibility to use open amputation and traction when there is a clear risk, yet to consider prudently the much shorter care which will be needed with a primary closed amputation when it is feasible medically.</p> <h4>New Concepts in Rehabilitation</h4> <p>The large military amputation centers in World War II provided an excellent opportunity to study the entire problem of amputee rehabilitation.<a></a> Although civilian surgeons generally had been in the habit of dismissing the patient when the amputation scar had healed, leaving him to search for limbfitting services with only the guidance of the classified telephone directory and the perplexing visits of amputee salesmen and demonstrators, the military Services reawakened the responsibility of the surgeon for more complete rehabilitation through the stages of prosthetic fitting, training, and subsequent follow-up. Similarly, the Services assumed responsibility for the necessary vocational guidance and counseling.</p> <h4>Wartime Problems</h4> <p>Because of the dramatic concentration of hundreds of amputees in a single hospital, however, the large military amputation centers drew considerable public attention-both favorable and unfavorable and generally over-dramatic. In operating their limbshops, they encountered difficulties because of the scarcity of experienced personnel (P). This problem was partially corrected, though never completely solved, by diligent effort to locate limbfitters who had been drafted and to see that they were reassigned to limbshops at amputation centers. In every case, however, the bulk of the limb-shop staff was necessarily made up of men who perhaps had mechanical aptitude but who were without previous training or experience in the limb industry.</p> <p>At the same lime the commercial artificial-limb industry was kept very busy with its private cases from civilian life and with the veterans from previous wars, while some of its younger men were drafted into the Services. Besides this, the generally good business conditions during and immediately following World War II, together with the manpower shortage, led to the employment or advancement of a great many amputees who, during the previous depression, had had great difficulty in finding and holding jobs. Many of these people wished to procure new limbs, thus further overloading the commercial limb industry.</p> <p>To add to the difficulties, the industry was then neither certified nor licensed, and it consisted, as it does today, of several hundred relatively small workshops. While some of its members had had formal education in other fields, there had never existed in this country any means for formal training in the arts and sciences basic to limbmaking and limbfitting. The sudden release, within a limited number of months, of some 21,000 veterans from military amputation centers imposed upon the industry an exceptional burden. These men had been fitted in the military centers with a serviceable, adequate, but admittedly "temporary" prosthesis, with the understanding that soon after their release the Veterans Administration, through civilian contractors, would provide a permanent prosthesis. Indeed, an additional or spare permanent prosthesis also was provided as a matter of policy.</p> <p>The confused state of affairs about the end of World War II, and during the year or so immediately thereafter, was further complicated by a series of sensational stories in some of the newspapers concerning difficulties with the limbs provided by the military centers and covering a series of indictments and trials of certain members of the commercial limb industry for alleged violation of the Antitrust Acts. The rather emotional atmosphere then prevailing in regard to amputees led to dramatic stories but in many cases to neglect of the basic difficulties.</p> <h4>Casualities From Korea</h4> <p>Substantially all factors concerned have since been greatly improved, so much so in fact that there were no difficulties of this type over the treatment of amputees returning from the Korean conflict. The relatively calm and orderly handling of these casualties, with the close cooperation of all concerned, was a tribute to the progress which had been made since 1945 in both technical and administrative aspects. Much of this change has been due to the fine cooperation of the commercial limb industry, now emerging into a prosthetics profession. It also has been influenced by the greater interest of surgeons in amputations and amputee rehabilitation, by the development of the team concept in this area as in so many other areas of medicine (and indeed in science generally), by the contributions of many sound administrators, and by the results of much hard work in the research and development laboratories.</p> <p>Some of the major changes which have influenced the amputation surgeon have been proven clinically by experience with casualties from Korea. Concepts of level of amputation and certain of the techniques of surgery have been affected. Perhaps most important, there is now a greater interest in postoperative care and in the rehabilitation responsibilities of the medical profession.</p> <h4>Level of Amputation and Modern Prosthetic Replacement</h4> <p>The surgeon's first decision in amputating is the selection of the site. Perhaps the influence of the Artificial Limb Program, sponsored by the Government and coordinated by the Committee on Artificial Limbs of the National Research Council, can be shown most dramatically by a review of the changes in recommended level. From a few definite "sites of election," the development of new principles and devices has made possible reaffirmation of the policy<a></a> of "save all possible length." Every level, with the possible exception of the below-knee amputation, has benefited, particularly in the upper extremity, where it is now possible to define at least nine amputee types (<b>Fig. 7</b>), all of which can be fitted successfully. In many cases the new devices not only permit satisfactory fitting of longer stumps but often replace additional functions beyond the important increase in bony lever.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Definitions of upper-extremity amputee types. Lengths above elbow are measured as percentages of distance from acromion to epicondyles; lengths below elbow are measured as percentages of distance from epi-condyles to styloid. From <i>Manual of Upper Extremity Prosthetics.</i><a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Upper Extremity</h4> <h4><i>The Below-Elbow Cases</i></h4> <p><i>The Wrist-Disarticulation Case. </i><br /> The wrist-disarticulation prosthesis is a good example of the development of a simpler appliance which yet permits better appearance and additional function than did the conventional prosthesis of 1945. At the end of World War II, the wrist disarticulation, if retained at all and not later reamputated at a higher level, was fitted with a laced, molded leather socket supported by steel sidebars jointed at the elbow, quite similar to that shown in <b>Fig. 3</b>, with rather bulky harness and a leather thong for power transmission. Elbow flexion and terminal-device operation were the only functions provided, pronation-supination being prohibited by the single plane in which the elbow hinge operated. The entire appliance was bulky, the uncoated leather soon absorbed perspiration and became objectionable, and the almost complete encasing of the forearm made the prosthesis uncomfortable in warm weather. Because of the screw thread attaching it to the wrist, the terminal device, whether hook or mechanical hand, projected appreciably beyond the opposite natural hand, resulting both in limited function and in undesirable appearance. No cosmetic covering faired the gap between the mechanical hand and the wrist.</p> <p>In contrast, there has been developed under the program of the Advisory Committee on Artificial Limbs a light and sanitary plastic-laminate prosthesis (<b>Fig. 8</b>) which covers only the distal portion of the stump and extends only a short distance up the radial side to support tipping loads while still permitting pronation and supination. <a></a> Extending farther up the ulnar aspect, the socket provides adequate leverage and bearing area to permit comfortable resistance to large loads on the terminal device which tend to tip the socket about the stump when the forearm is in the horizontal position. The snug, "screw-driver" fit of the bony prominences at the wrist into the terminal portion ensures rotation of the socket and terminal device as the radius glides around the ulna. Since this rotation decreases progressively up the forearm until, at the elbow, there is no relative displacement, it is necessary to cut away as much as possible of the radial aspect from the socket. But removal of socket material decreases both the weight of the prosthesis and discomfort in warm weather. The plastic-laminate socket and nylon coating of any leather<a></a> used in this or any other prosthetic or orthopedic appliance will prevent absorption of perspiration and the consequent development of odors.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Cutaway views of light and simple plastic prosthesis for wrist disarticulation, with APRL hand attached to plate embedded in end of forearm to conserve length. The plastic cosmetic glove drapes neatly over the junction. A separate socket similarly attached to a hook (as in Figure 9) is easily substituted to avoid disconnecting the terminal device, as is customary in the usual forearm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Very simple harness is adequate. For the rare amputee requiring only an extremely light-duty prosthesis, the socket can be held on the bulbous stump by a strap like that for a wrist watch to close a keyhole slot so as to clamp the socket firmly just above the bulging styloids. In this case, the only harness necessary is the cable and loop about the opposite shoulder. Practically all amputees, however, require a somewhat more secure, yet still minimum harness, as shown in <b>Fig. 9</b>, with a light triceps pad held by an inverted Y-strap whose fork is higher than the fully tensed biceps. A very simple figure-eight harness is used, and the steel Bowden cable transmits energy quite efficiently without stretching and without catching the shirt sleeve.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Prosthesis and harness for wrist disarticulation or long below-elbow stump. Note simple figure-eight webbing entirely across back, with no cheststraps. A steel Bowden cable transmits energy to the hook with improved efficiency. An open upper-arm harness, consisting of triceps pad and inverted Y-strap, leaves biceps free from pressure. Flexible leather straps as elbow hinges, suggested years ago but seldom used, permit pronation and supination as well as elbow flexion. The APRL hook case may be laminated into the forearm to conserve length. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To shorten the prosthesis markedly in order to match the length of the opposite arm, the proximal wall of the APRL No. 4C hand<a></a> may be fastened to a plate built into the distal wall of the plastic-laminate socket, as shown in <b>Fig. 8</b>. Thus the plastic cosmetic glove can readily bridge the gap between the hand and the prosthesis and extend up under the shirt or coat sleeve of the wearer. A similar plan can be followed with the APRL hook<a></a> by removal of the stainless-steel stud and plate by which the hook case is normally fastened to the wrist disconnect. On other types of hooks, the stainless-steel stud can be removed or shortened and a suitable fastening plate added by welding or brazing. For wrist friction, thin rubber 0-rings may sometimes be used instead of thicker rubber washers, thus further decreasing length.</p> <p>In many cases, it has been found entirely feasible, both technically and economically, to supply two sockets, one laminated to a hand and the other to a hook, to be worn interchangeably. The added length due to a conventional wrist disconnect and stud is thus avoided. Snap fasteners between the flexible leather elbow hinges and the forearm socket, plus the disconnect feature of the control-cable attachment post, permit interchange of prosthesis without changing the harness. Thus the amputee can make the interchange from hand to hook simply by rolling up his sleeve, it being unnecessary for him to remove his shirt.</p> <p><i>The Long Below-Elbow Case. </i><br />In many shorter below-elbow stumps, a similar type of prosthesis, but without the bulges for the styloids, can be applied to permit the amputee to use his remaining pronation and supination. The key factors are flexible elbow hinges and the "screw-driver" fit of the end portion of the stump in the socket with increasingly loose fit proximally. The fact that pronation and supination may be retained encourages the surgeon to make every effort to avoid fusion of the radius and ulna owing to bone spurs or similar causes and to instruct the amputee to participate in physical therapy designed to redevelop muscular control.</p> <p><i>The Medium Below-Elbow Case. </i><br />In the medium below-elbow stump, the limited amount of pronation and supination is worth retaining, yet it is inadequate to permit direct control of the prosthesis. Accordingly, the step-up type of rotation device (<b>Fig. 10</b>) has been developed. Early attempts at an automatic lock were frequently disappointing, particularly if the amputee tended to snap the prosthesis when used with a wrist-flexion unit, because the high inertia forces jammed the locking surfaces and caused permanent dents which thereafter caused chattering or even failure to lock. Instead, a simple lock has been supplied on an experimental basis, some mechanical problems remaining to be solved. A simple bolt in the stabilized outer socket engages one of a series of holes in the rotating portion of the wrist whenever the elbow is flexed more than a few degrees but is withdrawn at maximum elbow extension (<b>Fig. 10</b>, detail). This device is particularly desirable even with a short, almost conical below-elbow stump which, with elbow extended, participates in humeral rotation from the shoulder. The entire extremity rotates within the triceps pad and outer socket, which are stabilized by the harness. With the socket and terminal device rotated to the desired position, the amputee returns his stump to its normal position with the elbow axis parallel to the mechanical elbow hinges, flexes the stump, and thus locks the wrist in the desired position.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. APRL-Sierra wrist-rotation step-up unit showing details of locking mechanism and of hinges used in control of lock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In such applications, step-up gears are normally provided to increase the rotation of the terminal device in relation to that of the socket. A lock is desirable partially to transmit torsional loads on the terminal device through the elbow hinges to the open humeral cuff, but it is particularly desirable with outside Bowden-cable control of the terminal device to permit the torsional component of tension in the cable, when it spirals about the forearm, to be transmitted to the upper arm without stress upon the stump. The mechanical advantage of torque at the terminal device or control cable over the stump is due, of course, to the step-up gearing used to increase rotation of the terminal device.</p> <p><i>The Short Below-Elbow Case. </i><br />For rather short below-elbow amputations, a geared poly-centric hinge (<b>Fig. 11</b>) has been developed. In some cases, it permits easier fitting of the socket and may hold the socket more firmly on the stump. For still shorter stumps, the socket may be attached to the link connecting the two axes of rotation, while the forearm is attached to the lower geared segment (<b>Fig. 12</b>), thus providing a <i>fixed </i>ratio of 2:1 between degree of flexion of the artificial forearm and degree of flexion of the below-elbow stump and socket. It has been found, however, that this fixed ratio has only limited application.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Hosmer PC-100 polycentric hinge, particularly suited for medium to short below-elbow stumps. By virtue of the mechanical linkage, it sometimes aids in permitting extreme flexion in cases where the stump retains a full range of motion so that step-up hinges are unnecessary. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Geared step-up hinge (Hosmer MA-100) for very short below-elbow stumps of limited range of motion. The stump socket is fastened to the center link connecting the two geared links, which in turn are fastened to the upper-arm cuff and the forearm shell. The ratio of flexion of the forearm shell to that of the short stump is thus 2:1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The short below-elbow stump is another example of the new principle of saving all possible length. Formerly, most surgeons and limbmakers would have agreed that such short below-elbow stumps could not be fitted satisfactorily. Such a stump tends to slip out of the conventional socket and also may exhibit no useful control of the elbow joint. Frequently, it was advised that such cases be reamputated at the "site of election" in the humerus. Late in World War II, however, both in Canada and in at least one U.S. Army amputation center, hinges were developed, similar to those shown in <b>Fig. 13</b>, which permitted a step-up of forearm movement as compared to stump movement, a <i>variable </i>ratio compensating roughly for the resistance encountered and the strength of the stump at various positions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Typical occupational-aid terminal devices, all European. The screened boxes indicate the devices recommended for the various activities. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As seen in <b>Fig. 14</b>, the short below elbow, biceps are feasible.<a style="text-decoration:none;">*</a> Since there is no appreciable pronation-supination at this level, the biceps tendon remains in a fixed position rather than tending to migrate from medial toward lateral as it does when a longer stump moves from pronation to supination. The posterior rim of the socket is carried as high as possible, substantially to the olecranon. In some cases it is possible to hook the socket brim over the olecranon to help pull the stump into the socket during flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Prosthesis with variable-ratio step-up hinges for short below-elbow stumps. An above-elbow type of cable control assists in flexing the forearm shell. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The middle pivot of the step-up hinges is substantially opposite the humeral epicondyles, which define the anatomical elbow axis. The lower hinge moves in its slot during elbow flexion, as indicated in <b>Fig. 13</b>. The lower proximal end of the forearm shell must be cut out in order to clear the short stump at extreme elbow flexion. But since this type is used on short below-elbow stumps, there is no serious protrusion of the stump beyond the general line of the forearm socket and, therefore, no appreciable bulge in the coat sleeve.</p> <p>Customarily, an auxiliary lift for the forearm is provided by an above-elbow type of harness, with two separate pieces of cable housing attached to the forearm and to the triceps cuff but bare cable running from a space between the two separated pieces of housing, as shown in <b>Fig. 14</b>. By voluntarily controlling the position of the stump, the amputee can effectively "lock" the forearm as if by a mechanical elbow lock and can thus operate the terminal device by increased tension on the control cable without causing further flexion of the forearm. By means of stump action, he also can press downward firmly enough on the forearm to perform functions such as holding papers on a table or holding a fork to stabilize a piece of meat while it is cut by a knife held in the opposite hand.</p> <p><i>The Elbow-Disarticulation Case</i><br /> The elbow disarticulation was for many years frowned upon because of the difficulties of fitting it with a conventional prosthesis with laced molded-leather socket and elbow lock and joint requiring a bolt extending the full width of the elbow. In such a design, of course, the mechanical lock was necessarily fitted below the end of the stump, thus making an overly long humeral section and a correspondingly short forearm section, usually preventing the amputee from reaching his mouth with the terminal device, as well as creating an awkward appearance and difficulty in using the amputated elbow as a support on the desk top, and the like. Capable of end-weight-bearing, the elbow-disarticulation stump, however, is useful as a support without the prosthesis, as in rolling over in bed. Its bulbous and irregular shape serves as a key to stabilize the prosthesis against rotation about the long axis of the humerus.</p> <p>To conserve these functions, therefore, the external lock shown in <b>Fig. 15</b> and <b>Fig. 16</b> was developed to fit on the <i>outside </i>of the socket in line with the humeral epicondyles and the anatomical axis. The artificial forearm can thus be of a conventional length, and the terminal device can be brought to the mouth readily. The locking circle is, however, necessarily of a smaller diameter than would be available in a conventional above-elbow type of prosthesis, so that in the present model the number of locking positions is reduced to five (<b>Fig. 16</b>). Although numbering more than in the earlier conventional above-elbow or brace locks, the five positions are less than the 11 or even infinite number of positions provided by above-elbow locks which have been developed in the ACAL research program.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Prosthesis for elbow disarticulation, with APRL-Sierra external elbow lock (Figure 16) and same dual control as used on above-elbow prostheses. To accommodate bulbous humeral condyles, a channel may be left in the socket, a lacer may be used, or a slotted, flexible, plastic-laminate socket and clamping strap may be loosened and expanded enough to permit entry and withdrawal and yet provide adequate control during use. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Schematic diagram of APRL-Sierra external elbow lock, intended for elbow disarticulation but also useful with very short below-elbow stumps or with paralyzed arms. Top, locked position. Next pull on lock-operating cable in upper right withdraws locking plunger from the wedge-shaped notch in forearm piece and raises the alternator crosshead, thereby compressing the two helical springs. Pin on the thin leaf spring follows right side of inverted heart-shaped cam until it slips into notch at bottom of cam. Relaxing cable drops the alternator cross-head slightly until the pin and leaf spring hold the cam and locking plunger in the unlocked position (middle). Subsequent tension on the cable raises the alternator crosshead enough so that the leaf spring can straighten until its pin follows the left side of the heart-shaped cam back to original position. Meanwhile the helical springs force the crosshead down and push the locking plunger into a tooth in the lower portion attached to the forearm (bottom). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The APRL-Sierra outside-locking elbow hinge has another special application in the very short below-elbow stump where range of motion is insufficient to operate a forearm through a step-up elbow hinge but where a small residual motion is adequate to operate the locking mechanism diagrammed in <b>Fig. 16</b>. In the arrangement shown in <b>Fig. 17</b>, elbow locking is effected by stump motion rather than by motion of the shoulder, thus giving a more natural appearance and more freedom than could be obtained with an elbow disarticulation or an above-elbow stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Prosthesis for very short below-elbow stumps of such limited motion that step-up hinges are inadequate. The external elbow lock is controlled by a convenient cam, lever, or cable system triggered by the limited stump motion, and the forearm shell is flexed by an above-elbow type of harness. By this system the elbow lock is more easily operated than in a conventional above-elbow type of control. The Northrop-Sierra voluntary-opening two-load hook <a></a>shown here is usually considered to be a left hook, that is, as used on a right arm the operating lever is in the little-finger position rather than in the thumb position. This arrangement results in <i>a. </i>more nearly straight control cable of higher efficiency than is possible when the operating lever is on the medial side, in which case the cable must spiral over the forearm. More often, particularly in the case of bilateral arm amputees, voluntary-opening hooks are fitted with the operating lever, and also the control button for changing the load, located on the medial side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The external elbow lock has already been used occasionally for applying artificial-arm principles to arm braces. The situation in that entire field should improve rapidly in the near future. Occasionally, patients have requested, or surgeons have recommended, amputation of an arm when disease or injury have left a flail elbow. It has seemed that improved artificial arms would actually provide the patient with more function. It must be remembered, however, that the damaged arm provides at least some support and perhaps sensation, and consequently every effort should be made to replace the lost functions of stability, control, and voluntary movement by suitable bracing. Polio cases, retaining sensation and an erratic distribution of muscle activity, offer a special challenge.</p> <p>The outside-locking hinge of <b>Fig. 16</b> is normally fitted as shown in <b>Fig. 15</b> and <b>Fig. 17</b> for control from the proximal joint. Presumably, though, it could be inverted and controlled from the distal end of the arm if some portion capable of even a little voluntarily controlled movement with very nominal forces were available in the hand or wrist. A ring on a finger or extreme hyperextension of the wrist could, for example, be used to trigger the elbow lock, thus simplifying the harnessing, particularly if the shoulder were also weakened.</p> <p>It may be noted parenthetically that some work has been done<a></a> both by rehabilitation centers and by prosthetists and orthotists to drive paralyzed fingers with mechanisms adapted from the artificial-hand field or to hyperextend a paralyzed hand on a "cock-up" wrist splint and substitute a hook on a rotary or even on a ball-and-socket mounting on the volar aspect of the wrist. Even with a quadriplegic there has been enough control of shoulder movement to provide the necessary voluntary control for the hook, supplementing at least a weak biceps action for forearm flexion and supination. The relatively heavy hook extending from the volar aspect of the wrist will provide by gravity forearm extension and a tendency toward pronation. Since the degree of paralysis and of loss of sensation may be so variable, in the entire field of arm bracing the role of the doctor is even more important than it is in rehabilitation after amputation. Correspondingly, there is an even greater challenge to the ingenuity of the prosthetist, the engineer specializing in prosthetics, and the manufacturer in adapting or developing special appliances for the individual case and to the patience of the therapist in redeveloping even faint voluntary movements which might control triggers for locking mechanisms.</p> <h4><i>The Above-Elbow Cases</i></h4> <p>In the above-elbow stump, as much as possible should be saved consistent with the nature of the injury or disease. Even a very short above-elbow stump may be useful as an anchor point, and in experimental work on electric arms<a></a> such a stump has been used to control the necessary switches and clutches (<b>Fig. 18</b>). A stump of nothing more than the head of the humerus helps to round out the shoulder and to provide a much more secure stabilization of the "shoulder-disarticulation" socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Shoulder cap for electric control by shoulder motion or by short humeral stump or both. From Alderson .<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Nevertheless there remains a challenge to the engineer and prosthetist in providing improved shoulder-disarticulation and very high-above-elbow arms with passive or voluntarily controlled humeral flexion and abduction. A number of designs were shown in the literature<a></a> after World War I, but none appears to have been practical. The sectional plates<a></a> used in the ACAL research program have facilitated independent construction of the socket and remainder of the prosthesis and their subsequent alignment. Sometimes they have been provided with rotation to facilitate donning of clothing with the humeral section flexed, followed by return of the humerus to a vertical position. Such joints of the humeral section to the shoulder cap have not permitted abduction, however, and have not normally permitted voluntary or passive forward flexion of the humeral section about the shoulder joint to bring the elbow forward and permit the terminal device to reach the mouth.</p> <p>The conventional sectional plates have been solid and thus have been suited only for a true shoulder disarticulation, but it should be feasible to leave an opening through which a very short stump, such as the head of the humerus and its surrounding socket, could protrude into the hollow humeral section. Provision of a sector of a complete circular track, rather than the elongated D-shape which has been used, would also result in better cosmetic appearance when the artificial humeral section is flexed forward. Possibly a simple lock to stabilize such humeral flexion could be controlled by a very short above-elbow stump, even if passive adjustment with the other hand, or by gravity in connection with torso movement, were necessary because of the weakness of the stump.</p> <p>Attempts to provide voluntary control of humeral abduction and rotation have been reported in the literature. Alderson <a></a> developed an experimental arm of the shoulder-disarticulation type in which shoulder lift against the anchorage of a groin strap generated either elbow flexion followed by humeral abduction or humeral abduction alone, depending on whether the elbow were free or locked. At least one commercial limb manufacturer recently has experimented with a "universal shoulder joint" permitting a combination of actively and passively controlled motions including upper-arm rotation by means of a turntable located in the humeral section.</p> <h4>The Lower Extremity</h4> <p>In the lower extremity, although there have been definite changes in techniques and devices, the influence of the Artificial Limb Program has not as yet markedly changed the levels of amputation. Work is, however, going forward rapidly, particularly at the Lower-Extremity Clinical Study operated at the University of California using facilities of the U.S. Naval Hospital at Oakland. It is to be expected that in the next few years more definite changes can be recommended.<a></a> Meanwhile, the principal effects of wartime experience and of the ACAL research program have been increased emphasis on the Syme and knee disarticulation and a better understanding of muscle functions, particularly in relation to the suction socket for above-knee amputees.</p> <h4><i>The Below-Knee Cases</i></h4> <p><i>The Syme Amputation. </i><br />While the Syme amputation is more than a century old, it has until recently been considered controversial, with firm advocates and bitter opponents. In some cases, criticism has rightly been directed toward very long below-knee stumps which, however, were not true Syme amputations with the normal heel flap and capable of full end-weight-bearing. Experience at military amputation centers during World War II seems to have confirmed the successful results which have been reported by the Canadians ever since World War I<a></a>. A recent Canadian report<a></a> on the Syme amputation describes surgical precautions, conventional and experimental Syme prostheses, and clinical experience.</p> <p>Although the Syme amputation requires meticulous surgery, in the absence of sepsis, and careful attention to all details, a successful result provides much greater freedom of action for the amputee and enables him to remain on his feet for long periods. The broad surface of tissues anatomically adapted to weight-bearing offers the Syme amputee a great advantage over the below-knee amputee with limited areas offering a wedgelike support for the stump and pressing upon tissue which has not been accustomed to weight-bearing.</p> <p>The prosthesis for the Syme has been improved, on an experimental basis, by the Canadians (<b>Fig. 19</b>) and, more recently, by the Prosthetic Testing and Development Laboratory of the Veterans Administration (<b>Fig. 20</b>). Both types use a plastic laminate in place of molded leather for greater sanitation as well as for greater strength with decreased weight and bulk. Both use Fiberglas extensively for high strength.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Prostheses for Syria's amputation. Above, conventional Syme prosthesis with typical bulky and unattractive design at ankle and with bothersome shank lacer. Below, Syme prosthesis developed by the Canadian.<a></a> Same stump in the two cases. Note improved cosmetic appearance and simplified method of donning. The Canadian model consists ol a perforated plastic-laminate shell with thin, cellular-rubber lining, the whole considerably lighter than the conventional design above. Rear portion can be opened to admit bulbous stump. yet material is effectively distributed to withstand large bending loads. No ankle joint is used, but the foot is formed of cemented layers of cellular rubber around a reinforcing tongue projecting from the socket to the ball of the foot. Pressure on heel compresses the rubber to give the equivalent of plantar flexion. <i>Photos courtesy Canadian Department of Veterans Affairs.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Experimental Syme prosthesis designed and tested at the VA's Prosthetic Testing and Development Laboratory on request of the Orthopedic and Prosthetic Appliance Clinic Team, New York. It combines a molded plastic-laminate shell with rear opening, thin sponge-rubber lining, and an adaptation of the U.S. Navy functional ankle <a></a> using two-durometer rubber block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Considerable success has attended efforts to reduce the bulk at the ankle by eliminating the steel sidebars which, in earlier prostheses, projected beyond the malleoli on the medial and lateral aspects, thus adding thickness to a zone already the broadest portion of the ankle. The steel sidebars had, in any case, been mechanically rather ineffective in sustaining bending loads, as when the weight of the amputee is supported on the ball of the foot, because the material was close to the neutral axis or central portion of the bars.<a></a> In the newer designs, this portion over the malleoli is relatively thin, but bending moment is resisted more effectively by the most anterior portion, ahead of the tibial crest, and by the posterior portion at a greater lever arm than was available in the older, narrow, metal bars. To avoid fatigue failures, special care must be taken to achieve a smooth posterior cut in the shell-like prosthesis. The bulbous malleoli are introduced into the prosthesis by opening a posterior portion, which may then be closed either in trap-door fashion by a hinged portion of the shell or by a fabric- or nylon-coated leather portion held by a slide fastener, laces, or adjustable straps.</p> <p>The shell-like combination socket and shank section, with the end-bearing pad, is molded over a plaster model of the stump to attain uniform fit. A slightly soft lining may be used throughout the socket. Relief is provided along the sharpest portion of the tibial crest so as to maintain comfort when weight is carried on the ball of the artificial foot and there is a tendency for the socket to press sharply on the upper portion of the tibia. Under such conditions, firm counterpressure, distributed comfortably, is also required just above the malleoli on the posterior portion of the tibia and fibula. Ankle action may be provided by a laminated sponge-rubber heel which is compressed at heel contact, giving the equivalent of plantar flexion, or by a rubber-block ankle joint with a shallow V-shaped section removed to accommodate the long stump.</p> <p><i>The Short Below-Knee Case. </i><br />Short, badly scarred, below-knee stumps have heretofore sometimes been reamputated above the knee or have been used in a permanently flexed position in the so-called "bent-knee" or "kneeling-knee" prosthesis reminiscent of pirate tales. In either case, the advantages of voluntary control of knee-joint movement are lost.</p> <p>The U.S. Navy below-knee "soft" socket, <a></a> an outcome of recent research, consists of a plastic lining backed by a thin layer of sponge rubber and a rigid or, recently, a rather flexible shell (<b>Fig. 21</b>). An improvement on earlier commercial sockets with felt or wax lining, it may be fitted to any below-knee stump, but particularly it has permitted conservation of short, sensitive, badly scarred stumps. The weight-bearing impression of the stump dipped in plaster yields a much more accurate replica than do most wrapped plaster-bandage impressions. In general, it seems reasonable to believe that any technique for making a socket from a cast is likely to produce a more accurate fit more rapidly and with less discomfort than is a trial-and-error carving process.<a></a> The thin sponge-rubber lining giving the "soft" socket its name seems to be only one of several factors contributing to its usefulness.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. U.S. Navy "soft" socket for below-knee amputation, cut to show plastic sheet lining rolled over brim, thin (1/8-inch) sponge-rubber lining, and flexible plastic-laminate outer shell, all formed over male plaster model of the stump. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Careful location of the mechanical knee joints is always important. The work of the University of Denver<a></a> indicated the possibilities, for below-knee amputees in general, of improved fitting of conventional legs with single-axis knee joints by more careful location of the knee joints. Particularly recommended were fixtures and tools to ensure that the mechanical joints on opposite sides of the prosthesis are on a common axis. Poly-centric joints did not seem necessary. The report considered, however, the possibility of a mechanical joint of the single-axis type at the knee, but mounted high up on the thigh corset by a pivoting joint of limited angular range, in place of rigidly riveting the upper joint bar to virtually the full length of the corset. This idea has been proposed in the German literature.<a></a> In such a case, probably a reinforcing band should be mounted in the thigh corset to ensure that the upper joints are kept on a common axis.</p> <p>The very short below-knee stump, with the tibia amputated in the broad condylar area and with trabecular bone structure, is often suited to take a high fraction of weight-bearing on the distal end, in contrast to the usual below-knee stump of much smaller diameter, limited bearing area, and with thick, hard cortex surrounding a medullary canal. If the thickness of pads at the end of the stump is gradually increased, particularly if the pad in contact with the stump end is carefully molded to the irregularities of the stump, an increasing fraction of end-weight-bearing may often be tolerated.</p> <p>These circumstances deserve careful investigation before any thought is given to re-amputation above the knee, which in the past has often been suggested for such stumps. End-weight-bearing is both more nearly normal with respect to mechanical characteristics, promoting calcification, and is desirable in avoiding any tendency toward lordosis. The very short below-knee stump often can be fitted successfully by very careful forming of the socket. Special care is needed in shaping the posterior brim to accommodate the hamstring tendons, yet to rise into the popliteal space as much as possible without cutting off circulation. The "slip" socket, elastically supported to stay in contact with the stump during the swing phase, is an old idea often indicated for short stumps.</p> <p>Even if a very short below-knee stump cannot take appreciable weight-bearing on its end and on the flaring tibial condyles, it may be fitted with a long, ischial-supporting thigh corset and the sturdy external mechanical joints which would be used in a knee-disarticulation prosthesis. In this case the below-knee amputee, like the above-knee amputee, must rely upon mechanical stability of the prosthesis during the stance phase with the knee in full extension, but at a minimum he has proprioceptive sense of knee position and usually some limited ability to control slight knee flexion to return the knee to full extension, thus saving himself from some falls. Partial control of heel rise at the beginning of the swing phase and of knee extension at the end of the swing phase permit a more graceful gait and a better range of cadence than generally can be attained with above-knee prostheses.</p> <h4><i>The Knee-Disarliculation Case</i></h4> <p>The knee disarticulation, an old type of amputation, typically has been fitted with a molded leather socket provided with a lacer to permit the entry of the bulbous end of the stump. This type of prosthesis has mechanical joints and sturdy metal sidebars similar to those in the below-knee prosthesis. Normally, no mechanical friction has been used, and consequently gait tends to be limited to a single cadence. Any attempt to walk more rapidly leads to excessive heel rise and to "slamming" of the artificial shank into full extension just before heel contact.<a></a> Normally, extension is limited by thongs similar to the back-check in a below-knee artificial leg. Since the knee cannot be extended or stabilized voluntarily, the joints are arranged to give mechanical stability at full extension, as in an above-knee leg.<a></a> </p> <p>Many prosthetists have objected to the knee disarticulation as a level of amputation because of discomfort of the long, molded, leather socket, tendency toward breakage of the sidebars, and the lack of mechanical friction. Amputation at a higher level has frequently been advocated. The knee disarticulation, however, provides definite advantages over the above-knee amputation. If the end of the stump is properly fitted, a broad weight-bearing area is available. Normal transmission of weight through the shaft of the femur minimizes the tendency toward the lordosis often developed in above-knee amputees as the result of weight-bearing on an ischial support located back of the normal hip joint. <a></a> Clearly, disarticulation offers the maximum bony lever of any amputation at or above the knee.</p> <p>A recent informal survey of some of the knee-disarticulation cases performed under supervision of one of the authors (R.H.A.) at Thomas England General Hospital during World War II has indicated satisfaction of the patient with this type of amputation and prosthesis. In spite of the gait deficiencies noted, these knee-disarticulation amputees feel that they walk well, continue to prefer this level of amputation, and refuse any consideration of reamputation above the condyles to become more conventional above-knee amputees. Although some knee-disarticulation prostheses providing knee friction are reported in the literature, <a></a> much more needs to be done in this respect.</p> <h4><i>The Above-Knee Cases</i></h4> <p>In the above-knee amputation, at all locations as much length as possible should be conserved. Gritti-Stokes and similar end-bearing stumps have in many cases been fitted successfully with the suction socket,<a></a> although attachment of the muscles is then particularly important to avoid development of excessive negative pressure owing to displacement of muscle bulk in the necessarily limited clearance volumes available with long stumps and end-bearing pads. Some have found difficulties in fitting such cases with the suction socket and have preferred to rely on a conventional pelvic-band suspension, perhaps with a second hinge permitting abduction. In either case, the longer the above-knee stump the better.</p> <p>As regards the above-knee case, the principal development thus far of the Artificial Limb Program has been the reintroduction of the suction socket, with many far-reaching effects on stump shape, muscle conservation, socket fit, and alignment, accompanied by increased need for the cooperation of many disciplines and the launching of a program of education and certification. As for the first of these, the suction-socket program shifted emphasis from the excessively flabby, conical stump (<b>Fig. 22</b>) desired for the so-called "plug" fit to a more nearly cylindrical stump with firm muscles stoutly attached to the bone. In the suction socket, the muscles are needed both to control the newly found freedom about the hip join and to provide a gripping action by bulging against the walls of the socket, thereby decreasing the negative pressure required to carry the weight of the prosthesis. Similarly, introduction of the suction socket led to replacement of the typical conical socket of triangular or circular cross section (<b>Fig. 23</b>) by a more nearly rectangular socket (<b>Fig. 24</b>). The latter, developed in Germany within the last generation, has a better basis in physiological and anatomical fact, appears to be a necessity with the suction socket, and has, of course, also been used successfully with an increasing number of pelvic-band conventional limbs without use of suction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. An above-knee socket with nearly circular cross section and steeply conical form intended to support a conical, atrophied stump by side-bearing. Typically, a substantial roll of flesh developed over the rim around most of the circumference. The straps were used with suspenders. Adjustment for atrophy and shrinkage of the stump was easily made by additional stump socks, since the stump was regarded as a jellylike mass whose shape was easily distorted, with little definite relation between socket shape and stump shape. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Conventional socket for "plug" fit of above-knee stumps, showing rounded, triangular top portion of prosthesis for right thigh (looking forward and laterally). Note shelving flare below gluteal crease and ischium and broad, horizontal flare through perineum and adductor region. A considerable roll of flesh develops over this flare also, as in Figure 22. Socket shown here is made of metal and perforated, but the style often was used in wooden sockets as well. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Substantially rectangular or quadrilateral plan of top of socket for left above-knee prosthesis (seen from the rear), typically used for the suction socket but also applicable with soft belt or mechanical hip joint and pelvic band. Note the definite but narrow ischial support, slightly sloping forward and down and well rounded on its forward edge. The medial wall is thinner than the flare in a "plug" fit, since it should <i>not </i>provide a shelf or support against vertical load but should, in order to provide horizontal support during the stance phase, reach into the perineum as high as feasible without striking the pelvis. A nearly square anteromedial corner provides relief for the prominent adductor tendons. A high forward wall keeps the ischium on its support. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As for alignment, introduction of the suction socket has forced the prosthetist to pay more attention to details, since, unlike the case of the conventional above-knee leg, errors in alignment cannot here be concealed by trial-and-error bending of the pelvic band and metal, single-axis hip joint which forced conventional legs to swing in a single plane regardless of their inertia and the gait of the amputee. With the suction socket in correct alignment, the amputee balances his weight completely on the leg, since he has no pelvic band and hip joint to lean against for support. Conversely, however, attention to better alignment has led to decreased stress in the hip joints and pelvic bands of those legs which, for one reason or another, are still fitted with pelvic bands. If one thinks of the suction socket as being fitted with an imaginary hip joint carrying zero stress, it is apparent that a comparable alignment will result in minimum stress in a real hip joint and pelvic band of a conventional leg and, therefore, to greatly reduced risk of breakage.</p> <p>In a very short above-knee leg, the suction socket <i>plus </i>auxiliary suspension, either the Silesian bandage (<b>Fig. 25</b>) or the conventional hip joint and pelvic band (<b>Fig. 6</b>), has permitted conservation of greater <i>effective </i>stump length than would be possible with the same stump in a conventional leg with hip joint and pelvic band but with a "plug" fit. In donning the suction socket, the flesh is pulled into the socket with stockinet, in contrast to the tendency of the conventional stump sock and "plug" fit to push the soft tissues upward and out of the socket. The auxiliary suspension provides greater control and stability than would be available in a pure suction socket. The more logical anatomical fit of the quadrilateral shape, including some ischial support, avoids the roll of flesh in the adductor region and the skin irritations and furuncles so commonly seen with the "plug" fit. Thus, some very short above-knee stumps fitted with this combination of suction socket and auxiliary suspension can function as if with a conventional above-knee leg without the necessity of flexing the stump permanently in a tilting-table type of socket such as would be used for a hip disarticulation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Model of German suction-socket prosthesis with Silesian bandage, or trochanteric belt, with padded horseshoe encircling the trochanter, soft leather belt posteriorly around the pelvis, and V-shaped strap from anterior of socket through ring of the belt. The pelvic belt aims to assure vertical support during the swing phase, while the V-strap provides support against unwanted abduction and external rotation. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Extremely short above-knee stumps, with little more than the neck of the femur, can be fitted in some cases with the "saucer" type of socket<a></a> in place of the tilting-table type generally used throughout the world with a true hip disarticulation.<a></a> Often the knee joint is locked during standing and walking, so that the amputee walks stiff-legged. In this case the prosthesis is often built shorter than the sound leg. Sometimes, however, adequate alignment stability can be obtained to permit a free knee joint. The thigh section is sometimes locked to the tilting-table socket so that the back muscle can function to stabilize a free knee as do the hip extensors in the above-knee amputee.</p> <p>Hiyeda, <a></a> in 1942, and independently the Canadian Department of Veterans Affairs<a></a> have used free joints at both hip and knee, with the hip joint farther forward and the knee farther to the rear than usual (<b>Fig. 26</b>). A posterior elastic strap helps to extend the hip joint. Either the saucer socket or the tilting-table type may be built of plastic laminate instead of from the older, molded leather, but if for some reason leather is used, the nylon coating developed at the Army Prosthetics Research Laboratory<a></a> will make it much more sanitary.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Hip-disarticulation prosthesis developed by the Canadian Department of Veterans Affairs. Anterior view-shows three points of suspension© and full width of hip joint. Lateral view shows standing and sitting positions. From McLaurin.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Partial Amputations</h4> <p>Wherever possible, of course, partial hand or foot amputations should be performed in preference to major amputations.<a style="text-decoration:none;">*</a> Much work was done during and immediately following World War II on the surgery of the hand,<a></a> and interest has been lively since the formation of the American Society for Surgery of the Hand. In the recent Korean conflict, a great many partial hand and partial foot amputations were performed safely, whereas in previous times many of these cases would have required major amputations, probably as below-elbow or below-knee amputations at the former "sites of election."</p> <p>In recent years, satisfactory cosmetic gloves have been developed by the commercial prosthetics industry<a></a>, at the Army Prosthetics Research Laboratory, <a></a> in the Navy,<a></a> and in the Veterans Administration's Plastic Artificial Eye and Restorations Clinics. These have made possible adequate cosmetic fitting of many partial hand amputations while retaining some function. Moreover, various operable terminal devices for partial hand amputations have been developed both commercially and on an experimental basis in the ACAL program. Sometimes a small hook is mounted on a molded socket and controlled by a conventional cable or by wrist movement. On an experimental basis, the mechanism and wrist plate of an APRL hand have been removed, the transmetacarpal stump allowed to fit within the hand shell, and the side frames of the mechanical hand hinged opposite the anatomical wrist joint to a light forearm cuff. Thus wrist flexion and forearm rotation are preserved. Such cases clearly present individual challenges to the prosthetics clinic team <a></a> and to the designer and manufacturer.</p> <h4>Recapitulation</h4> <p>Decision as to the level of amputation, then, can be recapitulated in terms of saving all length possible.<a style="text-decoration:none;">*</a> This policy is justified not only by new devices, developed predominantly in the Artificial Limb Program, but also by the spectacular advances in recent years in many fields of medicine and related sciences. Blood, plasma, and antibiotics have helped to control shock and infection and have made possible prolonged and precise operations. Medical schools and residency training programs are only beginning to give more attention to education in the broad field of prosthetics to make the new findings available to the practitioner. The various medical societies are now devoting to this broad field more and more time on their programs and more space in their exhibits. Special courses, such as those on the suction socket held at various locations throughout the country, and the Institutes on Upper-Extremity Prosthetics at UCLA,<a></a> are bringing specialized knowledge to the doctor, the prosthetist, and the therapist. More attention is given to individual prescription rather than to "sites of election," with increasing cooperation and expert consultation from the prosthetist as to devices available but without dictation of sites merely because they might be more convenient. Best of all, there is now greater interest in over-all rehabilitation and continued follow-up on the part of the medical profession to see that every amputee, regardless of level of amputation, achieves the greatest possible restoration to normal life.</p> <h4>New Techniques in Amputation Surgery</h4> <p>There is no need here to describe in detail the techniques of amputation surgery, since they are all so well presented in numerous other sources, for example, by Slocum.<a></a> Certain points reflecting the experience of the Artificial Limb Program<a></a> may, however, be worthwhile. These may first be illustrated in terms of a typical amputation with primary closure, chiefly that producing an above-knee stump for which suction socket is intended, followed by notes on some of the special conditions at other levels of amputation.</p> <h4>The General Case</h4> <p><i>Skin Flaps and Subcutaneous Tissue</i></p> <p>In general, the skin flaps are approximately equal on the anterior and posterior sides and are so curved as to meet neatly without undue skin tension but without leaving "dog ears." The usual amputation has a central scar, although in some of the special cases of weight-bearing stumps there is usually a longer flap on one aspect so as to move the scar out of the end-weight-bearing zone. Even for the belowknee amputation without end-weight-bearing, a longer posterior flap has sometimes been advocated to take advantage of the presumably richer blood supply and more liberal muscle and fascia, but the advisability of this technique has not yet been sufficiently evaluated for it to be recommended here. Since when divided the skin and other soft tissues retract, the skin flaps are initially outlined distal to the intended level for sawing the bone, thus compensating for the successive retraction of the various layers and permitting the bone eventually to be sawed through at the edge of spontaneously but temporarily retracted tissues.</p> <p>The subcutaneous tissue may be regarded as a gliding mechanism, enabling the skin to move freely over the deeper fascia and achieving the goal of freely movable skin without an adherent scar. The subcutaneous tissue is cut perpendicularly to the skin, without beveling, and both are allowed to retract as they are cut, without undermining.</p> <p><i>Fascia</i></p> <p>A complete fascial envelope is very desirable, primarily to secure the severed muscles to each other and to the bony lever. Besides this, as Lawrence<a></a> has suggested, piston action of the bone within the soft tissues of the stump may help to pump fluid from the stump. Presumably this action is more effective if the fascial envelope is completely closed in order to force fluid displacement upward through the veins and lymphatic channels. In contrast, an opening in the fascial envelope may permit a compensating pulsation of the soft tissues through the defect, thus failing to generate effective pumping action. Although as yet there is little direct evidence to support such views, the reasoning seems logical.</p> <p>A further advantage of the fascial envelope is to avoid bulging of muscle through a defect in the deep fascia. Accordingly, it is also desirable, when feasible, to repair traumatic defects in the fascia and to refrain from removal of fascia during any plastic operations intended to remove bad scars.</p> <p>The tough fascia lata plays a special role while the above-knee amputee is on the artificial leg during the stance phase. Acting as a guy wire at the most favorable leverage to balance body weight falling medial to the ischial support, it helps to support the pelvis in a substantially horizontal position with minimal expenditure of muscular energy. Hence every reasonable effort should be made to secure firm attachment of the severed end of the fascia lata to the bony lever and to the fascia on the medial side of the stump in order to replace its former anchorage below the knee, as in the intact leg.</p> <p>The incision through the fascia is parallel to the initial skin incision but at the level of the retracted superficial tissues. Like all aspects of amputation surgery, it should be clean and precise.</p> <p><i>Muscles</i></p> <p>The importance of muscles has been emphasized by the Artificial Limb Program in connection with the suction socket <a></a>as a vital part of the cineplasty studies<a></a> and in analysis of the forces, motions, and hence the energy costs of both normal and pathological gait.<a></a> Only from reattachment of the severed ends of the muscles is it possible to attain control of the stump, particularly when greater freedom of action is made possible by improved devices, as, for example, by the suction socket. Moreover, the muscles must be held at substantially their original "rest length" in order to attain the greatest force during contraction.<a></a> Appreciation of this fact was brought out especially in connection with the cineplasty program, but of course the principle applies to all other muscles. A brief review of muscle physiology, mostly of features known for over 50 years but re-emphasized by recent research, is in order.</p> <p><i>The Nature of Muscle Forces. </i></p> <p>The muscle studies at the University of California in connection with cineplasty <a></a> have re-emphasized the importance of the early studies by Blix <a></a> of force-length characteristics. Briefly, as shown in <b>Fig. 27</b>, the force developed by a muscle is related to the length of the muscle at the time the force is exerted. Any attempt to stretch a relaxed muscle beyond its rest length results in an increasing resisting force, as shown by the "passive-tension" curve. If the muscle is restrained at its rest length and then stimulated as vigorously as possible, a certain maximum force can be generated. Full excitation of all the fibers, as by electrical stimulation, yields this maximum force for isometric contraction, although in practical voluntary use only part of the muscle fibers are activated at a given instant, so that a much lower value is attained when the subject "tries as hard as possible."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Idealized length-tension curves for a typical muscle. Note that the passive-tension curve rises sharply when the relaxed muscle is stretched beyond rest length and that maximum voluntary force with isometric contraction is available at or near rest length. Clearly, use of a muscle in a contracted position yields both lower force and less available energy. From Inman and Ralston.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If now the muscle is allowed to shorten, that is, to move toward the left of the rest length in <b>Fig. 27</b>, stimulation results in some maximum isometric muscle force less than the value attained at rest length. Continued shortening results in decreasing forces measured isometrically until, at some value of contraction varying somewhat in different muscles but roughly 60 percent of the original length of the muscle, no force can be exerted.</p> <p>Beyond rest length, an increased total tension may be developed upon isometric contraction. The exact shape of the curve varies with the nature of the muscle, its past history of stretching or contraction <i>over </i>prolonged periods (especially noticeable in muscles in which the cineplastic operation has been performed), and with the individual case. When the passive-stretch force is subtracted from the total tension attained by isometric contraction, the resulting <i>net </i>force available voluntarily tends in general to decrease again as the muscle is elongated beyond the rest length. Thus the curve of the <i>net </i>force is roughly an inverted parabola with its maximum at or slightly beyond rest length. Since this curve varies with individuals and with training and exercise (which affect both the cross-sectional area of a muscle and the shape of the passive-stretch curve), examples can be found which depart markedly from this schematic pattern. Nevertheless, the general principle leads to a number of interesting conclusions relating to the surgery of both upper and lower extremities.</p> <p><i>Applications of Muscle Mechanics. </i></p> <p>It is immediately apparent from <b>Fig. 27</b> that, if a muscle is allowed to retract, temporarily or permanently, it cannot attain a voluntary force as great as would be possible at or near the original rest length. Prosthetic devices should be utilized, as far as practicable, with the appropriate muscles near, perhaps slightly beyond, the rest length. A cineplastic tunnel, for example, should be so harnessed that most objects will be picked up with the tunnel near the rest length.<a></a> As is well known, the hamstrings, if reattached to the end of the femur in an above-knee amputee, can serve as hip extensors. On the basis of known muscle mechanics, they will be most effective when the hip is somewhat flexed but will be considerably less effective when the hip is fully extended or when it is hyperextended just at the end of push-off. The amputee may then attempt to supplement hip extension by using his back muscles, thus producing lumbar lordosis. Alignment of the socket bore and condition of the back-check controlling extension of the thigh socket relative to the shank will both affect the length of the hamstrings and hence the ability of the amputee to stand securely and to push off forcefully.<a></a> Permanent contracture of a muscle will result in a movement of the passive-tension curve toward the left in <b>Fig. 27</b> and, in general, in a steeper shape of the curve, thus resulting in greater passive tension with only little stretching of the muscle. Thus the maximum force which can be attained voluntarily will be reduced substantially, and the effect may be more serious than the simple reduction in range of motion. Avoidance of contractures is thus mandatory.</p> <p>Workers at the University of California have studied the moment (or force X leverage) available about the hip joint in relation to the angle of adduction or abduction of the stump. Since the gluteus medius and tensor fasciae latae are at their rest length when the stump is in its normal position, under slight passive stretch with an adducted stump, but allowed to contract when the stump is abducted, it is not surprising to find that the available moment about the hip joint decreases markedly from the adducted into the abducted region. Forcible abduction of the stump against the socket wall is essential to keep the pelvis level during the stance phase ,<a></a> and consequently maximum available abduction moment about the hip is desirable to avoid an apparent gluteus medius limp. Therefore, workers at the University of California have reasoned, it is highly desirable to maintain as much adduction as feasible of the socket bore in space and in relation to the remainder of the prosthesis. Experiments with controlled fitting and alignment on the University of California adjustable leg<a></a> have indeed shown this reasoning to be valid. In contrast, fitting of the socket to an abducted stump and "straight" alignment of the shank to the socket result in an appreciable limp.</p> <p><i>Stump Muscles in Prosthetic Control. </i></p> <p>Muscles may have within a socket several actions particularly favorable in the above-knee suction-socket leg. General bulging of the muscle belly during contraction increases the diameter of the stump in the zone of the maximum muscle belly, thus helping to grip the walls of the socket and producing frictional forces which help to support the prosthesis. Muscle bulging and even the contour of the relaxed muscles help to key the correspondingly irregular socket against rotation about its longitudinal axis and thus aid in voluntary control of rotation of the prosthesis.</p> <p>Conversely, the muscles of the thigh sometimes become detached from the cut end of the bone and the overlying fascia but by some mischance become attached to the superficial tissues, as through the scar. Contraction of such muscles causes a pistonlike retraction of the end of the stump, a condition that may cause discomfort in any case, especially if simultaneous contraction of opposing muscles tends to stretch the scar, and one that is particularly undesirable in a suction socket. Pistonlike retraction of the stump end, analogous to withdrawal of the plunger from a hypodermic syringe, develops additional negative pressure in the space between the end of the stump and the floor of the socket. Such excessive negative pressure, far beyond that necessarily created by the weight of the prosthesis, may tend to cause edema.</p> <p>If stump retraction seems apt to occur, the physician should consider all factors carefully before prescribing a suction socket and, if he decides to proceed with one, should caution the limbmaker to leave adequate clearance volume between the end of the stump and the sealing floor. In that case, the change of volume owing to movement of the soft tissue will be only a small percentage of the original volume, so that the resulting negative pressure will be only a correspondingly small fraction of the barometric pressure. But with long above-knee stumps, because of the problem of locating the mechanical knee joint, it may not be feasible to allow adequate clearance volume, in which case the suction socket may be contraindicated.</p> <p>Movements of muscle bellies also may create a wedging action within a relatively conical socket, thus tending to force the socket off the stump and to increase negative pressure in a suction socket, but this effect is not likely to prove serious in the relatively cylindrical, well-muscled stump recommended.<a></a> Wedging action may, however, be desirable in the thigh muscles of a below-knee amputee so as to provide additional support on the somewhat conical thigh corset, thus relieving the below-knee stump of some of the pressure to which it would otherwise be subjected.</p> <p>Muscles or tendons passing over the brim of the socket may also tend to force the prosthesis from the stump when the muscles are tensed, again tending to increase negative pressure in a suction socket. This effect can be minimized by careful fitting of the socket.</p> <p>Muscle tissue acts as a pump to promote return circulation of blood and lymph, as is well known. Obviously, this effect is particularly important in the suction socket to reduce tendency toward edema, and hence vigorous muscle activity is doubly desirable.</p> <p><i>Securing Muscles at Rest Length. </i></p> <p>For all these reasons, it is highly desirable that the muscles be secured to the end of the stump at their rest lengths. Accordingly, the muscles are cut at the levels of the spontaneously retracted superficial tissue and fascia. If necessary, the cut muscles may be sutured to their overlying fascia. Later, when the fascia is closed and sutured over the end of the stump, the muscles will be carried back from their spontaneously retracted position substantially to their rest lengths. It is desirable to have not a mass of loose muscle tissue over the end of the stump but rather a neatly tailored muscle and fascial closure with the muscles restored to their rest length, that is, simply pulled back against the natural tone.</p> <p>To suture muscles to each other at the end of the stump, as has sometimes been recommended in the past, is unnecessary. In fact, the sutures would probably pull out of muscle alone. Suturing of the tough fascia is much more effective, so that it is unnecessary, as well as undesirable, to suture muscles to holes drilled in the bone.</p> <p>In a few special cases, the tendons of the muscles may be sutured together. For example, in the case of knee disarticulation, the tendons of the hamstrings and quadriceps may be sutured in the patellar notch. Generally, the intention is to secure, by healing and scarring processes, the cut ends of the opposing muscles to each other, to their overlying fascia, and to the bone.</p> <p><i>Bone</i></p> <p>With the possible exception of the below-knee amputation (see footnote, page 30), the surgeon will plan to save the maximum practicable length of bony lever. The saw line is made at the level of the naturally retracted soft tissues. Before the bone is sawed, the periosteum is cut cleanly around with a sharp scalpel, taking special care to avoid loose flaps of periosteum, which may later form bone spurs. The bone is then sawed off squarely. There is no need to remove a periosteal cuff, and there should be no attempt to elevate the periosteum.</p> <p>In general, it is not necessary to bevel the bone cortex.<a style="text-decoration:none;">*</a> Preliminary anatomical studies of bone ends at the U.S. Naval Hospital at Oakland, California, and at the University of California Prosthetic Devices Project have shown that the bone end, when treated as already described, may round over spontaneously within a few months so that the medullary cavity tends to become sealed <a></a>. This simply confirms clinical observations already made from amputation of long duration.</p> <p><i>Nerves</i></p> <p>The aim of the surgeon is to sever the nerves in such a manner that the inevitable neuroma will be embedded in soft tissue at a point where it will not be stimulated. Thus, it should not be permitted to reattach to scar or bone in such a manner that the fibrils of the neuroma become stretched at every step owing to piston action of the bone within the tissues or to movement of the scar as a result of muscular action. The neuroma should also be far enough up the stump so that it is not subjected to unusual pressure from use of the prosthesis.</p> <p>The most desirable technique, it has been realized for some years, is to dissect the nerve carefully from the neurovascular bundle, pull it gently from its sheath, and cut it cleanly with a sharp instrument. The severed nerve is then allowed to retract up its nerve sheath into soft tissue. The major cutaneous sensory nerves, which are less obvious, deserve the same careful attention given to the major nerve trunks.</p> <p>Contrary to the advice in some earlier texts, experience of the past decade has shown clearly that no injections of alcohol or other chemicals should be given. Rather, the nerve should be left entirely alone after it has retracted into the tissue. Much clinical experience, and recently the studies of the Pain Project at the University of California <a></a>have indicated that formation of a neuroma must be expected at every cut nerve. Resection of a neuroma once formed will therefore merely lead to development of another neuroma at a higher level. Difficulties are encountered from a neuroma only if it is stretched or compressed. Although phantom pain is sometimes triggered by the stimulation of a neuroma, there are so many other possible causes that repeated surgery to remove a neuroma each time one forms generally is not justified.</p> <h4>The Special Cases</h4> <h4><i>The Upper Extremity</i></h4> <p><i>The Wrist-Disarticulation Case. </i><br />In the wrist disarticulation, the distal joint between the radius and ulna must carefully be preserved to permit free motion of the radius over the ulna during pronation and supination. Occasionally it may be wise to round off any exceptionally sharp surfaces on the styloids, but in general the styloids can be accommodated by careful fitting of the molded plastic-laminate socket (<b>Fig. 8</b> and <b>Fig. 9</b>).</p> <p><i>The Long Below-Elbow Case </i><br /> Similarly, in the long below-elbow stump, every effort should be made to preserve free motion of the radius over the ulna to retain pronation and supination. Cutting of the bones permits the radius to approach the ulna, resulting in shortening, and hence weakening, of the pronator teres. Although with training the weakness can be overcome, the proximity of the radius to the ulna makes bone spurs or actual bony bridging between the two bones much more of a hazard to adequate pronation-supination. Thus careful, clean cutting of the periosteum is of particular importance.</p> <p><i>The Short Below-Elbow Case </i><br />Where there is the possibility of a very short below-elbow amputation, the short stump always should be preserved if at all medically feasible, in preference to amputation at or above the elbow. In some cases, for example where rolling and notching of the socket brim (<b>Fig. 14</b>) might be inadequate to prevent an intact biceps from pushing the socket from the stump during elbow flexion, the surgeon may consider cutting the biceps tendon to permit fitting the socket brim higher than usual. If biceps cineplasty is performed for such cases, the biceps tendon will, of course, be resected and the cut end carefully covered over or imbricated to prevent reattachment. In this case severing the biceps tendon may in some instances permit higher fitting of the socket while simultaneously preserving a useful function for the biceps muscle.</p> <p><i>The Elbow-Disarticulation Case </i><br />The elbow-disarticulation prosthesis with the new external lock (<b>Fig. 15</b>) has encouraged the preservation of the elbow-disarticulation stump whenever feasible medically. As with any end-bearing stump, it is probably desirable to place the scar line away from the weight-bearing area. The irregular shape of the humeral condyles may be retained to assist in anchoring the socket against rotation. Careful attention to the nerves is desirable to prevent formation of sensitive neuromata in the areas which will be subject to load during end-weight-bearing or as a result of bending loads upon the prosthesis when the elbow is locked.</p> <p><i>The Short Above-Elbow Case </i><br />The very short above-elbow stump should be preserved so far as medically feasible in preference to a true shoulder disarticulation or, worse, forequarter amputation. Even the short stump will serve to key the socket and provide greater stability. In some cases the short stump can be used for control of a lock. In experimental work on an electric arm, a very short above-elbow stump has been used to operate a keyboard of switches and clutches (<b>Fig. 18</b>) for control of the electrically driven motions as well as to control an electric elbow lock while a turntable lock above the elbow joint was controlled by a button pressed by the pectoral muscle.<a></a> </p> <p><i>Cineplasty Cases </i><br />In general, upper-extremity candidates for later cineplasty operations<a></a> can undergo the original amputation in the same manner as do those amputees who will use conventional prostheses. Thus far ACAL has accepted cineplasty in the intact biceps of a below-elbow amputee only (<b>Fig. 28</b>; see also <b>Fig. 12</b>, page 61), and in the case of a veteran prior approval from the VA Central Office is required. For many years cineplasty has been performed in a variety of locations and by many different techniques. In the Artificial Limb Program, it has been performed experimentally in a number of locations in various individuals, including the biceps in above-elbow amputees and the pectoralis major for short above-elbow and shoulder-disarticulation cases.<a></a> But before such procedures can be recommended, problems remain to be solved.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Typical biceps muscle tunnel in below-elbow case, six months postoperative. <i>Courtesy Army Prosthetics Research Laboratory.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The general principle is to preserve muscle length and attachment at the time of the original amputation so as to prevent permanent contraction. The distal end of the muscle is released only at the time of the cineplasty operation so as to permit prompt exercise and stretching of the muscle soon after the tunnel has healed. Special attention should, of course, be given to repair of any injuries proximal to the intended saw line in order to assure full innervation and blood supply and to avoid serious scarring of the remaining stump.</p> <h4><i>The Lower Extremity</i></h4> <p><i>The Syme Amputation. </i><br />In the Syme amputation, in contrast to amputation at many other levels, preservation of the normal heel flap permits weight-bearing on tissue normally accustomed to full body weight and impact. The incision has a special shape across the instep so as to permit the shelling out of the calcaneus from the heel flap and the later formation of a suture line across the anterior aspect of the stump. <a></a>To provide good bearing, the bones are sawed just above the articular cartilage and in such a plane that the cut surfaces will be parallel to the floor when the amputee stands (not necessarily perpendicular to the long axes, as, for example, in the case of a bowlegged or knock-kneed patient).</p> <p>To ensure preservation of circulation in the heel flap, little if any tailoring is performed. Dog ears left at each side of the heel flap will disappear with proper postoperative wrapping. Contrary to the usual rule, the tendons are simply cut and permitted to retract without attempting to suture the tendons in place or to attain fascial closure. If a good Syme stump cannot be obtained, the surgeon should perform a conventional below-knee amputation, since a very long below-knee stump extending to the lower third of the shank frequently breaks down from poor circulation.</p> <p> <i>The Knee-Disarticulation Case</i><br />In the knee disarticulation, an exceptionally long anterior flap is necessary for closure of the stump and so that the suture line may be posterior and out of the end-weight-bearing zone. In general, the cartilage is simply left in place. The patella, although routinely left in place, may be removed to give extra length to the anterior flap when needed for adequate closure. The patellar tendon is sutured to the hamstring tendons in the patellar notch between the femoral condyles, but no attempt is made to prevent the tendons from gliding.</p> <h3>Summary</h3> <p>Techniques advocated, partly as a result of World War II and subsequent experience and partly as a result of the ACAL program, may be summarized as follows:</p> <ol> <li>With the possible exception of the below-knec amputation, save all length of stump considered surgically feasible.</li><li>Preserve the muscles at their rest length.</li><li>Attempt to secure attachment of opposing muscles to each other and to the bony lever during the healing process through suturing of the opposing fasciae, without attempting to suture the muscles to each other or to the bone.</li><li>Avoid attachment of the muscles to the scar.</li><li>Secure a complete fascial envelope.</li><li>Secure a smooth and freely movable scar, usually central but displaced in the case of end-weight-bearing stumps (or possibly where skin on one side of the stump has a much better blood supply and gliding fascia than that on the other).</li><li>Sever a nerve cleanly and allow it to retract into soft tissue, without injection and with as gentle treatment as possible.</li></ol> <h4>Postoperative Care</h4> <p>The doctor should in every case maintain continuing supervision and responsibility for the postoperative care of the amputee. Just what are the relative responsibilities of the surgeon and of the doctor of physical medicine, where the latter is available, is subject to discussion and, in the present state of knowledge, will necessarily vary from place to place depending upon their respective interests, training, and available time for both professional and administrative duties. But it is important for the patient's welfare that there always be available some single physician who is familiar with the case and who can take responsibility for seeing that the patient receives maximum cooperative service from the nurses, therapists, prosthetist, vocational counselors, and others concerned.</p> <h4>Bandaging</h4> <p>Although the extremely shrunken, conical stump of former days is no longer desired, it is obvious that some muscles (such as the vastus group of the thigh in an above-knee amputation or the soleus in a below-knee case) will no longer have as important functions as before and can be expected to atrophy. It is desired that these muscles atrophy slowly without deposition of an equivalent amount of fat. Careful application of an adequately wide elastic bandage, in accordance with well-known techniques <a></a> will hasten the desired shrinkage.</p> <p>Immediately after the amputation, therefore, the wound is dressed and the stump wrapped with broad elastic bandage. But the bandage will become loose in a few hours and should be replaced by a fresh one, usually every four hours during the day. The used bandage is washed and dried, the usual precautions being taken to restore its elasticity. After a suitable interval, usually 10 to 14 days, sutures are removed, the wound re-dressed, and elastic bandage again applied. Meanwhile, the patient should be taught to cooperate in the application of the elastic bandage so that, when dressings are no longer needed, he may himself learn to reapply fresh elastic bandage several times a day as needed to prevent edema and to encourage shrinkage of tissues no longer functional.</p> <p>The bandage is made snug at the distal end, with no constriction at a higher point on the stump, and it must be carried above the next intact joint, for example up to the thigh in the case of a below-knee amputation or above the hip and around the waist as a hip spica in the case of the above-knee amputation. To avoid rolls of flesh, all parts of the stump must be bandaged, notably the adductor region high into the crotch in the case of the above-knee amputation. The patient must be cautioned against developing above the stump a local constriction which would lead to poor circulation. Likewise, bandaging should avoid a bulbous mass of soft tissue at the end of the stump, which would interfere with later fitting.</p> <h4>Bed Posture</h4> <p>Every effort should be made to restore full range of motion of the stump as early as possible without risk of tearing the muscles from their newly organizing attachments to the bone. The patient should be discouraged from remaining in a fixed position, such as sitting in a wheelchair with the hip and knee flexed, or lying in bed with the stump propped up on a pillow.<a></a> It should be carefully explained to him that some temporary discomfort and inconvenience will be necessary to ensure subsequent full range of motion and effective use of a prosthesis. The leg amputee should lie in bed with his legs parallel, without abduction and external rotation of a thigh stump or flexion of a below-knee stump.</p> <h4>Traction</h4> <p>In the event of a preliminary open amputation, the line of skin traction should be toward the center of the bed, and the patient should be checked frequently to be certain that he is lying with his pelvis parallel to the bottom of the bed. In no case should he be permitted to slant the pelvis and thus, in effect, to abduct the stump. In the more common closed amputation in civilian life, traction is seldom necessary unless, in an attempt to conserve greater bone length, exceptionally short skin flaps have been used and it is desired temporarily to remove tension from the suture line.</p> <h4>Exercises</h4> <p>Restoration of strength and of full range of stump motion can begin when the muscles have become adequately attached to the bone, with gentle voluntary exercises at first to prevent detachment. Restoration of strength will depend both upon developing maximum size of the cross section of the muscle and upon stretching of the muscle stump so that it operates near the amputation rest length, as already discussed. The role of a low passive-tension curve is particularly important, and of course exercises should be prescribed with due regard to the patient's general condition.</p> <p>Home exercises, conducted by the amputee first merely by setting the muscles and later by using simple and readily available apparatus, are particularly important. Much can be done with a flatiron, a pail filled with increasing amounts of water or sand, or other convenient weights attached by a piece of sash cord over a pulley or doorknob to a towel about the stump. Elaborate gymnasium equipment or exercise tables obviously are not essential, convenient as they may be for the well-equipped rehabilitation center. The amputee and his family should be convinced of the importance of sensible home exercises, not only immediately postoperatively but whenever indicated throughout the rest of the amputee's life to maintain good stump condition and to avoid the flabby, weak, and contracted stump so often seen in an amputee of long duration. The amputee should be convinced of the need for maintaining adequate range of motion and strength in order that he may use his prosthesis effectively, gracefully, and with minimum effort. But of course he should be discouraged from intermittent extremes leading only to exhaustion.</p> <h4>General Health</h4> <p>Finally, general body tone is important both for good health and good spirits as well as for effective use of a prosthesis. The leg amputee, for example, must have good triceps to use crutches when necessary and good abdominal muscles to minimize the risk of lordosis. The arm amputee will use muscles of the trunk and opposite shoulder in supporting, positioning, and operating his prosthesis. All young, healthy amputees should be encouraged to take part in swimming, skating, bowling, table tennis, or other sports as appropriate.</p> <p>Every amputee should be cautioned against obesity, which in the lower extremity increases the load on the stump and in any case increases the difficulties facing the prosthetist. Because of the difficulties encountered from alternate tightness and looseness of the socket, all wearers of prostheses, and especially those using the suction socket, should be cautioned against violent fluctuations of body weight. Where indicated, all possible conditions causing obesity should be corrected, and patients should be supervised by a physician to stabilize body weight at normal for the individual.</p> <h4>Rehabilitation Responsibilities</h4> <p>An important result of World War II military experience, of subsequent work under the ACAL program, and of the increasing numbers of amputation clinics both in the Veterans Administration and in private institutions has been the increased interest by the medical profession in its responsibilities for lifetime rehabilitation for amputees. These include not only the obvious medical responsibilities but also psychological aspects; pain and phantom sensations; teamwork with others concerned in the prescription, fitting, training, and checkout of the prosthesis; and referral for any necessary vocational counseling and retraining.</p> <p>Psychological aspects of amputation are particularly important.<a></a> In many cases the doctor can provide appropriate psychological services, but in other cases referral to a clinical psychologist or to a psychiatrist may be desirable. Sometimes preoperative discussion and psychological preparation may be possible, especially if the amputation is elective or if the need for amputation can be foreseen. The prospective amputee himself should, when possible, decide realistically that amputation is preferable to other alternatives and that it is not "the end of the road."</p> <p>In many cases the patient can be helped preoperatively or postoperatively to accept amputation and to begin a realistic estimate of the possibilities of worthwhile rehabilitation through discussion with other amputees of the same level who have been rehabilitated successfully. Clubs of amputees<a></a> are beginning more and more to provide, on request of doctors and hospitals, levelheaded, rehabilitated amputees for just this purpose. Such amputees are not to be confused with the overenthusiastic salesman type or with the psychologically disturbed exhibitionist, who so often has demonstrated his remarkable prowess without making the patient aware of the nature of his stump, the differences between his condition and that of the patient, and the fact that so much depends upon the general physical condition and the will power of the patient. Just as there are professional golfers, there are also professional amputees. These persons can often perform remarkable feats not ordinarily desirable in or to be expected of the average amputee and one, as is usually the case, unwilling to make a career of stunts with a prosthetic device. Realistic discussions of the responsibilities of the patient, yet of the many important and fascinating things which remain possible, will be most effective.</p> <p>A matter of great importance is attention to the attitudes of those associated with the patient. Members of the family will wish to help in every way, yet their efforts must be guided intelligently toward help in the real difficulties while avoiding overprotectiveness generated by pity, which all too soon might turn into rejection. The employer can be helped to realize that the amputee may again return to useful work, whether at his former job or at some other and perhaps better and more skilled job after suitable vocational guidance and retraining.</p> <p>Sometimes the handicapped person, perhaps for the first time receiving professional guidance and being forced to think carefully about his future, will aim at more education and a much higher economic level than before the amputation. After all, much of the heavy labor of industrial countries is being taken over by machines. Unaffected by the amputation, the patient's brain power and ability to make decisions and to control the machines will command a higher value.</p> <p>Friends and acquaintances too must learn to accept the amputee for the many qualities he has left and to admire his demonstrated fortitude and cheerfulness rather than to pity him or even to shrink from him because of past memories of an amputee beggar. Finally, society as a whole must learn to accept not only amputees but all handicapped and disabled persons on the basis of their inherent dignity, ability, and worth as human beings, not on the superficial basis of individual differences in physical condition due to crippling disease, congenital defects, or mutilating injuries. In the past, amputees, like members of other minority groups, have encountered unreasoning psychological prejudices unworthy of the brotherhood of man.</p> <h4>Pain and Phantom Sensation</h4> <p>The amputee will need counseling, both in the acute stage and perhaps occasionally throughout his life, about the nature of pain in the stump, phantom sensation, and phantom pain. Postoperatively, pain is handled as in the case of any other operation. But the amputee may be puzzled that he still has a sensation of the missing member, perhaps in some bizarre position. He can be assured that at least 85 percent of other amputees, and perhaps practically all amputees other than congenital, retain such feelings. Phantom sensations have long interested neurologists and psychologists and recently have come in for study in considerably more detail at the University of California.<a></a> It appears that such sensations are related to the continued activity of the cortex on which the missing limb was originally projected but which no longer receives the normal bombardment of constant new sensations of position, temperature, pressure, and so on.</p> <p>Phantom <i>pain </i>is rare. It occurs only in a small fraction of amputees. Sometimes it appears to be related to specific physical difficulties in the stump or in the remainder of the body, such as pressure on a neuroma or traction upon a neuroma which has, unfortunately, become caught in scar tissue and is stimulated by muscular movement or piston action of the stump in the socket. In other cases, it may be related to some cause further up the body which might have been sought immediately in a normal individual but which might be neglected in the amputee. For example, a ruptured disc in the spine immediately would be sought from certain classic patterns of pain radiating down the leg, but the same might be overlooked in an amputee who complains that pain radiates into his missing phantom limb.</p> <p>Studies at the University of California involved injecting salt solution, as a stimulant, into the various vertebral segments of both normal volunteers and amputees in order to produce radiation of pain which could be mapped systematically.<a></a> In some cases, radiation of the pain into the phantom limb of an amputee resulted in disappearance of the phantom sensation itself after a short period, concurrently with disappearance of pain in the rest of the body (<b>Fig. 29</b>). In other cases, distribution of phantom pain was altered, and in a few cases the phantom pain became worse. In general, however, workers at the University of California believed that phantom pain could be alleviated by one or more of a series of systematic attacks. No single remedy was found that applied to all cases.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Typical patterns of pain radiation in the phantom limbs of two subjects. <i>Courtesy University of California Medical School</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Prosthetics Clinic Teamwork</h4> <p>The duties of the physician on the prosthetics clinic team have been well outlined by Bechtol. <a></a>The increasing success of prosthetics clinic teams in overcoming the problems of the amputee, as well as those of the wearers of braces and orthopedic shoes, has brought a rapid expansion of amputee clinics in both government and private circles. Indeed, the teamwork concept has been utilized increasingly at many levels of rehabilitation for many kinds of disabilities and throughout scientific research generally. Each member of the team needs humble realization of his own limitations,<a style="text-decoration:none;">*</a> appreciation of the contributions to be made by each of the other members, and, of course, an understanding of the participation of the patient himself as a member of the team created in his behalf. Thus only can there be created a realistic basis for self-confidence in the total effectiveness of the team as an integrated unit. In the Veterans Administration's Orthopedic and Prosthetic Appliance Clinic Teams, the Chief of the Prosthetic and Sensory Aids Unit is the administrative "key" to the success of the individual clinic.</p> <h4>Lifetime Responsibility</h4> <p>The surgical responsibilities immediately after operation have, of course, long been obvious. But no more can the doctor dismiss the patient when the scar is healed-with advice to "look in the classified telephone book for a limbmaker." Rather, the doctor should serve as captain of the prescription team in its efforts to see that the amputee is provided with the best current prosthesis suited to the individual and with adequate training in its use, and he should assume continuing responsibility throughout the lifetime of the amputee.</p> <p>The doctor should, for example, have the clinic administrator arrange for periodic checkup examinations at proper intervals, perhaps once a year. Thus the amputee can be checked for adequate fitting and can be informed of new improvements as they become available, both from the commercial industry's own developments and from the Artificial Limb Program as it makes tested devices available to the industry. The gait of lower-extremity amputees can be observed, facility in the use of upper-extremity prostheses can be noted, and, if necessary, further periods of training may be prescribed. Other problems, such as obesity, spinal curvatures, skin difficulties, and so on can be detected and corrected before they become serious. Frequently, all the amputee needs is a reminder for encouragement to brush up on his old skills. Reassurance and renewed encouragement are of important psychological value to the amputee patient.</p> <p>Finally, the experienced patient, returning for his routine checkup, serves as an example to improve the morale of the more recent patients sitting in the waiting room. The successfully placed and well-rehabilitated patient, grateful for his own return to active life, will be glad to assist by visiting more recent patients in the hospital. He may be called upon whenever his unique physical condition, type of work, or hobby makes him especially suitable to help a person of similar circumstances.</p> <h4>The New Knowledge and the Medicla Profession</h4> <p>The challenge to the medical profession will thus be clear. There has been a rapid increase in knowledge of prosthetic devices themselves, in methods of performing amputations, and in the philosophy of amputee management. Medical education must somehow fit into the medical curricula and into the crowded training programs for interns and residents the new knowledge and changing viewpoint in amputee rehabilitation.<a></a> Exhibits at medical meetings and papers in the medical journals offer some of this new knowledge. The new 800-page collaboration, <i>Human Limbs and Their Substitutes </i>(see <i>Digest, </i>this issue, page 77) presents a much more extensive range of knowledge and broader point of view than is possible in a single article. The busy practitioner, especially the general surgeon to whom amputation is only a rather incidental part of practice, must somehow find time to keep abreast of new knowledge and philosophy while conserving the best principles he has learned in the past.</p> <p>Finally, there is a growing need for geographically spaced centers for performing amputations and to serve as bases for orthopedic and prosthetics clinic teams serving civilians as well as veterans. Perhaps only thus can those with specialized knowledge best serve the patients, especially those with unusual problems. Indeed, such centers could serve as agencies of the Artificial Limb Program, pointing out needs and priorities based on clinical experience and providing facilities for field tests and educational activities.</p> <h3>Conclusion</h3> <p>Thus, it can be seen that marked changes have taken place from the days of the few sharply delimited "sites of election" and the few types of prosthetic appliances available for them. The changes thus far have perhaps been most marked in the upper extremity, where a whole new armamentarium of appliances has been developed and rigorously tested both in the laboratory and in clinical studies. The findings have been made available to physicians, therapists, and prosthetists through a series of Institutes on Upper-Extremity Prosthetics at the University of California at Los Angeles. Even so, the present <i>Manual </i><a></a> shows interim devices which should be greatly improved in years to come. Improved function and appearance are certain, and perhaps there will be some limited sensibility of position, contact, and gripping force.</p> <p>In the meantime, however, a great deal of work also has been done on the lower extremity. Although relatively few new devices, such as the U.S. Navy above-knee artificial leg<a></a> and the suction socket have been accepted, a great many new devices and many changes in practice are being tested at the laboratory and clinical levels. It is to be expected that, in the next few years, <a></a> an equivalent to the upper-extremity armamentarium will be released in an array of new devices for the lower extremity, such as stable knees, means for preventing stumbling, and perhaps forcible ankle push-off. Current inventors' designs and test models eventually will be tested through a systematic transition procedure and released for routine use.</p> <p>To those close to the heart of the ACAL program for nearly a decade, the changes noted herein have occurred so slowly and so imperceptibly in the pressure of daily emergencies that they have not been realized fully. Until brought out by a systematic review or by a chance conversation with someone untouched by the genuine progress which has been made, the alterations lie buried in the seeming monotony of obvious "good practice." Yet all these little modified details in technique, new or revived appliances, and perhaps more profound changes in points of view and philosophy add up strikingly to benefit the individual amputee.</p> <h4>Acknowledgments</h4> <p>It is a pleasure to acknowledge the contributions received through past discussions with a host of associates in military amputation centers, Veterans Administration Orthopedic and Prosthetic Appliance Clinic Teams, the Artificial Limb Program, and private life. Some of the concepts described may be attributed particularly to Jerome Lawrence, of the Veterans Administration Clinic Team in New York; to Verne T. Inman, of the University of California; and to Herman Gladstone, Surgical Consultant to the Prosthetic and Sensory Aids Service of the Veterans Administration. Thanks are due George Rybczynski, who provided most of the line drawings. Photographs were supplied through the courtesy of the VA's Prosthetic Testing and Development Laboratory, the Army Prosthetics Research Laboratory, and the Canadian Department of Veterans Affairs.</p> <p><b>References:</b></p> <ol> <li>Abt, Lawrence Edwin, <i>Psychological adjustment of the amputee, </i>Chapter 5 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Alderson Research Laboratories, Inc., New York City, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on <i>Research and development of electric arms and electric arm components, </i>1954. Fig. 11 and p. 40.</li> <li>Alderson Research Laboratories, Inc., <i>op. cit.</i> p. 20, Fig. 5</li> <li>Alldredge, Rufus H., <i>The management of war amputations in a general hospital, </i>N. Y. State J. Med., 44:1763 (1944).</li> <li>Alldredge, Rufus H., and T. Campbell Thompson,<i>The technique of the Syme amputation, </i>J. Bone &amp; Joint Surg., 28A:415 (1946).</li> <li>Alldredge, Rufus H., <i>Major amputations, </i>Surg.Gyn. &amp; Obstet., 84:759 (1947).</li> <li>Alldredge, Rufus H., <i>The cineplastic method in upper-extremity amputations, </i>J. Bone &amp; Joint Surg., 30A:359 (1948).</li> <li>Alldredge, Rufus H., <i>Amputations and prostheses,</i>Chapter XII in Christopher's <i>Textbook of surgery, </i>5th ed., Saunders, Philadelphia, 1949.</li> <li>Alldredge, Rufus H., <i>Recent developments and future trends in the field of orthopedic appliances, </i>Southern Med. J., 46:7 (1953).</li> <li>Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, <i>The techniques of cineplasty, </i>Chapter 3 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Alldredge, Rufus H., and Eugene F. Murphy,<i>The influence of new developments on amputation surgery, </i>Chapter 2 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Anderson, Miles H., <i>UCLA prosthetic course to open January 12, </i>Orthop. &amp; Pros. Appl. J., September 1952. p. 14.</li> <li>Anderson, Miles H, <i>A report on the prosthetics training center at the University of California, Los Angeles, </i>Orthop. &amp; Pros. Appl. J., December 1953. p. 27.</li> <li>Bechtol, Charles 0., <i>The prosthetics clinic team.</i> Artificial Limbs, January 1954. pp. 9-14.</li> <li>Bechtol, C. O., and E. F. Murphy, <i>The clinical applications of engineering principles to the problems of fractures and fracture fixation, </i>American Academy of Orthopaedic Surgeons, Instructional Course Lectures, Vol. IX, pp. 272-275, Edwards, Ann Arbor, Mich., 1952.</li> <li>Blix, M., Skandinav. Arch. f. Physiol., 5:150(1894).</li> <li>Borchardt, M., <i>el al., </i>eds., <i>Ersatzglieder und Arbeitshilfen, </i>Springer, Berlin, 1919.</li> <li>Borchardt, <i>op. cit. </i>pp. 397, 425, 509.</li> <li>Borchardt, <i>op. cit. </i>pp. 404-405.</li> <li>Borchardt, <i>op. cit. </i>pp. 523-528.</li> <li>Brunnstrom, Signe, <i>Physical therapy in aftercare of amputations of lower extremity, </i>U.S. Nav. Med. Bull., 43:634 (1944).</li> <li>Brunnstrom, Signe, <i>The lower-extremity amputee,</i>Chapter XIX in Bierman and Licht's <i>Physical medicine in general practice,</i>3rd ed., Hoeber, New York, 1952.</li> <li>Bunnell, Sterling, <i>Surgery of the hand, </i>2nd ed.,Lippincott, Philadelphia, 1949.</li> <li>Canty, Thomas J., <i>Construction, fitting and alignment manual for the U.S. Navy soft socket below knee prosthesis, </i>United States Naval Hospital (Amputation Center), Oakland, Calif., printer's date 9-29-53.</li> <li>Carnes, W. T., U.S. Patent 1,046,966, December, 1912.</li> <li>Carnes, W. T , U S. Patent 1,046,967, December, 1912.</li> <li>Carnes, W. T., U.S. Patent 1,402.476, January 3, 1912.</li> <li>Catranis, Inc., Syracuse, N. Y., Subcontractor'sFinal Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>Improved artificial limbs for lower extremity amputations, </i>June 1954.</li> <li>Committee on Artificial Limbs, National Research Council, Washington, D. C, <i>Terminal research reports on artificial limbs </i>[to the Office of the Surgeon General and the Veterans Administration] covering the period from 1 April 1945 through 30 June 1947. See especially pp. 34-35.</li> <li>Denver Research Institute, University of Denver,Denver, Colo., Contractor's Final Report (Contract No. V-100-LM-4089) to the Advisory Committee on Artificial Limbs, National Research Council, <i>A program for the improvement of the below knee prosthesis with emphasis on problems of the joint, </i>24 August 1953.</li> <li>Department of Veterans Affairs, ProstheticServices, Toronto, Canada, <i>Syme's amputation and prosthesis, </i>January 1, 1954.</li> <li>Desoutter, E. R., <i>Back to activity, </i>DesoutterBrothers, Ltd., 73 Baker St., London W1, 1938.</li> <li>Dorrance, D. W., U.S. Patent </li> <li>1,042,413, October, 1912.</li> <li>Eberhart, Howard D., Verne T. Inman, and BorisBresler, <i>The principal elements in human locomotion, </i>Chapter 15 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Eberhart, Howard D., and Jim C. McKennon,<i>Suction-socket suspension of the above-knee prosthesis, </i>Chapter 20 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Feinstein, Bertram, John N. K. Langton, R. M.Jameson, and Francis Schiller, <i>Experiments on pain referred from deep somatic tissues, </i>J. Bone &amp; Joint Surg., A, in press 1954.</li> <li>Feinstein, Bertram, James C. Luce, and John N. K. Langton, <i>The influence of phantom limbs, </i>Chapter 4 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Fletcher, Maurice J., <i>New developments in hands and hooks, </i>Chapter 8 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Fletcher, Maurice J., <i>The upper-extremity prosthetics armamentarium, </i>Artificial Limbs, January 1954. p. 15.</li> <li>Gray, Frederick, <i>Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, </i>2nd ed., R. Renshaw, London, 1857.</li> <li>Haddan, Chester C, and Atha Thomas, <i>Status of the above-knee suction socket in the United States, </i>Artificial Limbs, May 1954. pp 29-39, especially p. 34, Fig. 4; p. 36; and p. 37, Fig.7. </li> <li>Hiyeda, Masatora, <i>Work leg for the hip exarticulation, </i>J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</li> <li>Inman, Verne T., and H. J. Ralston, <i>The mechanics of voluntary muscle, </i>Chapter 11 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Kirk, Norman T., <i>Amputations, </i>a monograph from Vol. III of Lewis' <i>Practice of surgery, </i>W. F. Prior Company, Inc., Hagerstown, Md.,1944. Fig . 7, p. 22.</li> <li>Langdale-Kelham, R. D , and George Perkins,<i>Amputations and artificial limbs, </i>Oxford University Press, London: Humphrey Milford, 1944. Fig. 3, p. 9.</li> <li>Lawrence, Jerome, unpublished lecture, 34th Suction-Socket School, New York, May 7, 1954. </li> <li>Leonard, Fred, T. B. Blevins, W S. Wright, and M. G. DeFries, <i>Nylon-coated leather, </i>Ind. Eng. Chem., 45:773 (1953).</li> <li>Leonard, Fred, and Clare L. Milton, Jr., <i>Cosmetic gloves, </i>Chapter 9 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Little, E Muirhead, <i>A lecture on a new material (duralumin) for surgical appliances, </i>Brit. Med. J., 1:236 (1912).</li> <li>Little, E. Muirhead, <i>Artificial limbs and amputation stumps, </i>H. K. Lewis and Co., Ltd., London, and Blakiston, Philadelphia, 1922.</li> <li>Little, <i>op. cit. </i>pp. 6-7.</li> <li>Little, <i>op. cit. </i>pp. 7-8.</li> <li>Little, <i>op. cit. </i>p. 8.</li> <li>Little, <i>op. cit. </i>p. 10</li> <li>Little, <i>op. cit. </i>p. 24.</li> <li>Little, <i>op. cit. </i>pp. 110-113.</li> <li>Little, <i>op. cit. </i>p. 249.</li> <li>Martin, Florent, <i>La prothese du membre inferieur,</i>Masson et cie., Paris, 1918.</li> <li>Martin, Florent, <i>Artificial limbs, </i>International Labour Office, Geneva, 1925.</li> <li>Martin, <i>op. cit. </i>pp. 260-279.</li> <li>McLaurin, C. A., <i>Hip disarticulation prosthesis,</i>Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, 19 March 1954.</li> <li>Mommsen, F., and K Buchert, <i>Kunstliche Glieder, Heft 1, </i>Enke, Stuttgart, 1932. pp 4-5.</li> <li>Mommsen and Biichert, <i>op. cit </i>pp. 86-97.</li> <li>Murphy, Eugene F., <i>The role of an amputee club,</i>summary in Bulletin of Amputees Alliance, Inc., Vol. 3, No. 5, New York, December 1952.</li> <li>Murphy, Eugene F., <i>The fitting of below-knee prostheses, </i>Chapter 22 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Naval Medical Research Institute, NationalNaval Medical Center, Report No. 1, Project NM-009003, <i>Description of a prosthetic hand appliance, </i>March 1, 1948.</li> <li>New York University, Prosthetic Devices Study,[Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Shakedown test of the Navy above-knee prosthesis, </i>May 1951.</li> <li>Northwestern Technological Institute, Evanston,Ill., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, </i>1947. pp. 1.33-1.36.</li> <li>Pare, Ambroise, <i>Ouevres completes, </i>J.-F. Malgaigne, ed., G.-B. Balliere, Paris, 1840. Vol. 2, Pt. 2.</li> <li>Personal communication from Verne T. Inman,University of California.</li> <li>Personal communication from representatives ofUNRRA, 1946.</li> <li>Possibilities Unlimited, Inc., Cleveland, Ohio, <i>Possibilities unlimited, </i>Vol. II, Issue 2, 1950.</li> <li>Putti, Vittorio, <i>Historic artificial limbs, </i>Hoeber, New York, 1930. p. 7.</li> <li>Putti, <i>op. cit. </i>pp. 1-3.</li> <li>Radcliffe, Charles W., <i>Alignment of the above-knee artificial leg, </i>Chapter 21 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Radcliffe, Charles W., <i>Mechanical aids for alignment of lower-extremity prostheses, </i>Artificial Limbs, May 1954. pp. 20-28, especially p. 24,Fig. 11, and p. 26, Fig. 14.</li> <li>Ralston, H. J., V. T. Inman, L. A. Strait, andM. D. Shaffrath, <i>Mechanics of human isolated voluntary muscle, </i>Am. J. Physiol., 151:612 (1947).</li> <li>Renfro, Clarence A., U.S. Patent 2,563,618,August 7, 1951.</li> <li>Saunders, J. B., V. T. Inman, and H. D. Eberhart,<i>The major determinants in normal and pathological gait, </i>J. Bone &amp; Joint Surg., <b>35A(3) </b>:543 (1953).</li> <li>Schede, Franz, <i>Theoretische Grundlagen fur den Bau von Kunstbeinen; Insbesondere fiir den Oberschenkelamputierten, </i>Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</li> <li>Slocum, D. B., <i>An atlas of amputations, </i>Mosby,St. Louis, 1949.</li> <li>Spittler, A. W., and I. E. Rosen, <i>Cineplastic muscle motors for prostheses of arm amputees, </i>J. Bone &amp; Joint surg., 33A:601 (1951).</li> <li>Taylor, Craig L., <i>Control design and prosthetic adaptations to biceps and pectoral cineplasty, </i>Chapter 12 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Taylor, Craig L., <i>The objectives of the upper-extremity prosthetics program, </i>Artificial Limbs, January 1954. pp. 4-8, especially p. 7.</li> <li>Tenenbaum, Milton, and Adele Tenenbaum, U.S.Patent 2,453,604, November 9, 1948.</li> <li>Thomas, A., and C. C. Haddan, <i>Amputation prosthesis, </i>Lippincott, Philadelphia, 1945.</li> <li>Thompson, T. Campbell, and Rufus H. Alldredge,<i>Amputations: surgery and plastic repair, </i>J. Bone &amp; Joint Surg., 26A:639 (1944).</li> <li>United States Army, Office of the SurgeonGeneral, Report 9940 TSU-SGO, <i>Philippine amputation and prosthetic unit, </i>n.d.</li> <li>University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies on human locomotion and other information relating to design of artificial limbs, </i>1947. Two volumes.</li> <li>University of California (Berkeley), ProstheticDevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Studies relating to pain in the amputee, </i>June 1952.</li> <li>University of California (Los Angeles), Department of Engineering, <i>Manual of upper extremity prosthetics, </i>R. Deane Aylesworth, ed., 1952. Section 7.3, Fig. 7.3-B.</li> <li>Upper-Extremity Technical Committee, ACAL,minutes of meeting at University of California, Los Angeles, February 5, 1953.</li> <li>Vard, Inc., Pasadena, Calif., Subcontractor'sFinal Report [to the] Committee on Artificial Limbs, National Research Council, <i>The development of artificial arms for amputees who have had the cineplaslic operation, </i>1947.</li> <li>Vasconcelos, Edmundo, <i>Modern methods of amputation, </i>Philosophical Library, New York, 1945.</li> <li>Wagner, Edmond M , <i>Contributions of the lower-extremity prosthetics program, </i>Artificial Limbs, May 1954. p. 16.</li> <li>Wagner, Edmond M., and John G. Catranis,<i>New developments in lower-extremity prostheses, </i>Chapter 17 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954. See especially pp. 484, 485, and 605 ff.</li> <li>War Department, Washington, D. C, TrainingManual 8-293, <i>Physical therapy for lower extremity amputees, </i>June 1946.</li> <li>Wilson, A. Bennett, Jr., <i>The APRL terminal</i><i>devices, </i>Orthop. &amp; Pros. Appl. J , March 1952.</li> <li>Wilson, A. Bennett, Jr., and Robert J. Pursley,<i>Fitting the wrist-disarticulation case, </i>Orthop. &amp; Pros. Appl. J., September 1952. p. 17. 100. zur Verth, M., <i>Die biologische Absetzung der menschlichenGliedmassen, </i>Muench. Med. Wschr., 82:525 (1935).</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">Vasconcelos, Edmundo, Modern methods of amputation, Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>67.</b> </td><td class="clsTextSmall">Naval Medical Research Institute, NationalNaval Medical Center, Report No. 1, Project NM-009003, Description of a prosthetic hand appliance, March 1, 1948.</td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">Vasconcelos, Edmundo, Modern methods of amputation, Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Recent developments and future trends in the field of orthopedic appliances, Southern Med. J., 46:7 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Websters definition of teamwork reads in part as follows: Work done by a number of associates, usually each doing a clearly defined portion, but all subordinating personal prominence to the efficiency of the whole!</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Bechtol, Charles 0., The prosthetics clinic team. Artificial Limbs, January 1954. pp. 9-14.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon,Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Feinstein, Bertram, John N. K. Langton, R. M.Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone &amp;Joint Surg., A, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>90.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies on human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Mommsen and Biichert, op. cit pp. 86-97.</td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Personal communication from representatives ofUNRRA, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Abt, Lawrence Edwin, Psychological adjustment of the amputee, Chapter 5 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Brunnstrom, Signe, Physical therapy in aftercare of amputations of lower extremity, U.S. Nav. Med. Bull., 43:634 (1944).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Brunnstrom, Signe, The lower-extremity amputee,Chapter XIX in Bierman and Licht's Physical medicine in general practice,3rd ed., Hoeber, New York, 1952.</td></tr><tr><td class="clsTextSmall"><b>97.</b> </td><td class="clsTextSmall">Wagner, Edmond M., and John G. Catranis,New developments in lower-extremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954. See especially pp. 484, 485, and 605 ff.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and T. Campbell Thompson,The technique of the Syme amputation, J. Bone &amp;Joint Surg., 28A:415 (1946).</td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, ProstheticServices, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.</td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Schede, Franz, Theoretische Grundlagen fur den Bau von Kunstbeinen; Insbesondere fiir den Oberschenkelamputierten, Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Slocum, D. B., An atlas of amputations, Mosby,St. Louis, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., The cineplastic method in upper-extremity amputations, J. Bone &amp;Joint Surg., 30A:359 (1948).</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Slocum, D. B., An atlas of amputations, Mosby,St. Louis, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., op. cit. p. 20, Fig. 5</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon,Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Feinstein, Bertram, John N. K. Langton, R. M.Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone &amp;Joint Surg., A, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>90.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies on human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Pare, Ambroise, Ouevres completes, J.-F. Malgaigne, ed., G.-B. Balliere, Paris, 1840. Vol. 2, Pt. 2.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The single exception is the anterior tibial crest in the below-knee amputation, where beveling is desirable but without extending the beveled surface to the medullary cavity. In special cases, such as the Syme, there will be modifications of the general surgical technique. See page 36.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">Putti, op. cit. pp. 1-3.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>83.</b> </td><td class="clsTextSmall">Spittler, A. W., and I. E. Rosen, Cineplastic muscle motors for prostheses of arm amputees, J. Bone &amp;Joint surg., 33A:601 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Hiyeda, Masatora, Work leg for the hip exarticulation, J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Blix, M., Skandinav. Arch. f. Physiol., 5:150(1894).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Hiyeda, Masatora, Work leg for the hip exarticulation, J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</td></tr><tr><td class="clsTextSmall"><b>77.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. pp. 20-28, especially p. 24,Fig. 11, and p. 26, Fig. 14.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Hiyeda, Masatora, Work leg for the hip exarticulation, J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</td></tr><tr><td class="clsTextSmall"><b>77.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. pp. 20-28, especially p. 24,Fig. 11, and p. 26, Fig. 14.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">1,042,413, October, 1912.</td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Renfro, Clarence A., U.S. Patent 2,563,618,August 7, 1951.</td></tr><tr><td class="clsTextSmall"><b>89.</b> </td><td class="clsTextSmall">United States Army, Office of the SurgeonGeneral, Report 9940 TSU-SGO, Philippine amputation and prosthetic unit, n.d.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Hiyeda, Masatora, Work leg for the hip exarticulation, J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</td></tr><tr><td class="clsTextSmall"><b> 77.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. pp. 20-28, especially p. 24,Fig. 11, and p. 26, Fig. 14.</td></tr><tr><td class="clsTextSmall"><b>83.</b> </td><td class="clsTextSmall">Spittler, A. W., and I. E. Rosen, Cineplastic muscle motors for prostheses of arm amputees, J. Bone &amp;Joint surg., 33A:601 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and BorisBresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Langdale-Kelham, R. D , and George Perkins,Amputations and artificial limbs, Oxford University Press, London: Humphrey Milford, 1944. Fig. 3, p. 9.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,The influence of new developments on amputation surgery, Chapter 2 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Schede, Franz, Theoretische Grundlagen fur den Bau von Kunstbeinen; Insbesondere fiir den Oberschenkelamputierten, Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Anderson, Miles H., UCLA prosthetic course to open January 12, Orthop. &amp;Pros. Appl. J., September 1952. p. 14.</td></tr><tr><td class="clsTextSmall"><b> 13.</b> </td><td class="clsTextSmall">Anderson, Miles H, A report on the prosthetics training center at the University of California, Los Angeles, Orthop. &amp;Pros. Appl. J., December 1953. p. 27.</td></tr><tr><td class="clsTextSmall"><b>84.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">An exception may be the below-knee amputation. At the present time, and until further information is available, the below-knee stump should not extend more than 6 in. below the tibial plateau.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Bechtol, Charles 0., The prosthetics clinic team. Artificial Limbs, January 1954. pp. 9-14.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>66.</b> </td><td class="clsTextSmall">Murphy, Eugene F., The fitting of below-knee prostheses, Chapter 22 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Leonard, Fred, T. B. Blevins, W S. Wright, and M. G. DeFries, Nylon-coated leather, Ind. Eng. Chem., 45:773 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>85.</b> </td><td class="clsTextSmall">Taylor, Craig L., The objectives of the upper-extremity prosthetics program, Artificial Limbs, January 1954. pp. 4-8, especially p. 7.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Bunnell, Sterling, Surgery of the hand, 2nd ed.,Lippincott, Philadelphia, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">In general, partial amputations should be considered only when normal sensation and good blood supply can be retained.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Martin, op. cit. pp. 260-279.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Lawrence, Jerome, unpublished lecture, 34th Suction-Socket School, New York, May 7, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Martin, op. cit. pp. 260-279.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United States, Artificial Limbs, May 1954. pp 29-39, especially p. 34, Fig. 4; p. 36; and p. 37, Fig.7. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United States, Artificial Limbs, May 1954. pp 29-39, especially p. 34, Fig. 4; p. 36; and p. 37, Fig.7. </td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Little, E Muirhead, A lecture on a new material (duralumin) for surgical appliances, Brit. Med. J., 1:236 (1912).</td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Martin, Florent, La prothese du membre inferieur,Masson et cie., Paris, 1918.</td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">Mommsen, F., and K Buchert, Kunstliche Glieder, Heft 1, Enke, Stuttgart, 1932. pp 4-5.</td></tr><tr><td class="clsTextSmall"><b>68.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,[Report to the] Advisory Committee on Artificial Limbs, National Research Council, Shakedown test of the Navy above-knee prosthesis, May 1951.</td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart,The major determinants in normal and pathological gait, J. Bone &amp;Joint Surg., 35A(3) :543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Committee on Artificial Limbs, National Research Council, Washington, D. C, Terminal research reports on artificial limbs [to the Office of the Surgeon General and the Veterans Administration] covering the period from 1 April 1945 through 30 June 1947. See especially pp. 34-35.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and BorisBresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>78.</b> </td><td class="clsTextSmall">Ralston, H. J., V. T. Inman, L. A. Strait, andM. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and BorisBresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">Putti, op. cit. pp. 1-3.</td></tr><tr><td class="clsTextSmall"><b>96.</b> </td><td class="clsTextSmall">Wagner, Edmond M , Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 16.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Catranis, Inc., Syracuse, N. Y., Subcontractor'sFinal Report to the Advisory Committee on Artificial Limbs, National Research Council, Improved artificial limbs for lower extremity amputations, June 1954.</td></tr><tr><td class="clsTextSmall"><b>96.</b> </td><td class="clsTextSmall">Wagner, Edmond M , Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 16.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">McLaurin, C. A., Hip disarticulation prosthesis,Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, 19 March 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Denver Research Institute, University of Denver,Denver, Colo., Contractor's Final Report (Contract No. V-100-LM-4089) to the Advisory Committee on Artificial Limbs, National Research Council, A program for the improvement of the below knee prosthesis with emphasis on problems of the joint, 24 August 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Murphy, Eugene F., The role of an amputee club,summary in Bulletin of Amputees Alliance, Inc., Vol. 3, No. 5, New York, December 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Canty, Thomas J., Construction, fitting and alignment manual for the U.S. Navy soft socket below knee prosthesis, United States Naval Hospital (Amputation Center), Oakland, Calif., printer's date 9-29-53.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Bechtol, C. O., and E. F. Murphy, The clinical applications of engineering principles to the problems of fractures and fracture fixation, American Academy of Orthopaedic Surgeons, Instructional Course Lectures, Vol. IX, pp. 272-275, Edwards, Ann Arbor, Mich., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">Vasconcelos, Edmundo, Modern methods of amputation, Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, ProstheticServices, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, ProstheticServices, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and T. Campbell Thompson,The technique of the Syme amputation, J. Bone &amp;Joint Surg., 28A:415 (1946).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">Vasconcelos, Edmundo, Modern methods of amputation, Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New York City, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954. Fig. 11 and p. 40.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., op. cit. p. 20, Fig. 5</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New York City, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954. Fig. 11 and p. 40.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New York City, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954. Fig. 11 and p. 40.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., op. cit. p. 20, Fig. 5</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>92.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952. Section 7.3, Fig. 7.3-B.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">In only apparent contradiction, Shallenberger, from experience in 1946-47 with two short-below-elbow amputees on whom the cineplastic operation had been performed, with consequent severing of the biceps tendon, recommended a high and almost horizontal front brim with adequate corners on the medial and lateral sides. He found that the flesh was thus restrained at the top and front of the stump and was instead forced out at the sides, where it could not interfere with elbow flexion. He thus found the bearing area to be much greater, with consequent relief of pressure on the stump. In general the same situation would not prevail in the ordinary below-elbow amputee whose biceps tendon is intact.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">War Department, Washington, D. C, TrainingManual 8-293, Physical therapy for lower extremity amputees, June 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">War Department, Washington, D. C, TrainingManual 8-293, Physical therapy for lower extremity amputees, June 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Lawrence, Jerome, unpublished lecture, 34th Suction-Socket School, New York, May 7, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>99.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., The APRL terminaldevices, Orthop. &amp;Pros. Appl. J , March 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Major amputations, Surg.Gyn. &amp;Obstet., 84:759 (1947).</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Amputations and prostheses,Chapter XII in Christopher's Textbook of surgery, 5th ed., Saunders, Philadelphia, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., The management of war amputations in a general hospital, N. Y. State J. Med., 44:1763 (1944).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>55.</b> </td><td class="clsTextSmall">Little, op. cit. p. 10</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>71.</b> </td><td class="clsTextSmall">Personal communication from Verne T. Inman,University of California.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>88.</b> </td><td class="clsTextSmall">Thompson, T. Campbell, and Rufus H. Alldredge,Amputations: surgery and plastic repair, J. Bone &amp;Joint Surg., 26A:639 (1944).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>87.</b> </td><td class="clsTextSmall">Thomas, A., and C. C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Kirk, Norman T., Amputations, a monograph from Vol. III of Lewis' Practice of surgery, W. F. Prior Company, Inc., Hagerstown, Md.,1944. Fig . 7, p. 22.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Kirk, Norman T., Amputations, a monograph from Vol. III of Lewis' Practice of surgery, W. F. Prior Company, Inc., Hagerstown, Md.,1944. Fig . 7, p. 22.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">Little, op. cit. p. 24.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Martin, Florent, Artificial limbs, International Labour Office, Geneva, 1925.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Borchardt, op. cit. pp. 523-528.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Carnes, W. T., U.S. Patent 1,046,966, December, 1912.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Carnes, W. T , U S. Patent 1,046,967, December, 1912.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Carnes, W. T., U.S. Patent 1,402.476, January 3, 1912.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Little, E Muirhead, A lecture on a new material (duralumin) for surgical appliances, Brit. Med. J., 1:236 (1912).</td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Little, op. cit. p. 249.</td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Martin, Florent, La prothese du membre inferieur,Masson et cie., Paris, 1918.</td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart,The major determinants in normal and pathological gait, J. Bone &amp;Joint Surg., 35A(3) :543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Little, op. cit. pp. 110-113.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Desoutter, E. R., Back to activity, DesoutterBrothers, Ltd., 73 Baker St., London W1, 1938.</td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">Leonard, Fred, and Clare L. Milton, Jr., Cosmetic gloves, Chapter 9 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>86.</b> </td><td class="clsTextSmall">Tenenbaum, Milton, and Adele Tenenbaum, U.S.Patent 2,453,604, November 9, 1948.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Little, E Muirhead, A lecture on a new material (duralumin) for surgical appliances, Brit. Med. J., 1:236 (1912).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Martin, Florent, La prothese du membre inferieur,Masson et cie., Paris, 1918.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Little, E Muirhead, A lecture on a new material (duralumin) for surgical appliances, Brit. Med. J., 1:236 (1912).</td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Little, op. cit. p. 249.</td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Martin, Florent, La prothese du membre inferieur,Masson et cie., Paris, 1918.</td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart,The major determinants in normal and pathological gait, J. Bone &amp;Joint Surg., 35A(3) :543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Dorrance, D. W., U.S. Patent </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Little, op. cit. p. 8.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Little, op. cit. pp. 7-8.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, January 1954. p. 15.</td></tr><tr><td class="clsTextSmall"><b>86.</b> </td><td class="clsTextSmall">Tenenbaum, Milton, and Adele Tenenbaum, U.S.Patent 2,453,604, November 9, 1948.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Little, op. cit. pp. 6-7.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">War Department, Washington, D. C, TrainingManual 8-293, Physical therapy for lower extremity amputees, June 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Borchardt, op. cit. pp. 397, 425, 509.</td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Little, E. Muirhead, Artificial limbs and amputation stumps, H. K. Lewis and Co., Ltd., London, and Blakiston, Philadelphia, 1922.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Borchardt, op. cit. pp. 404-405.</td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Little, op. cit. pp. 6-7.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Kirk, Norman T., Amputations, a monograph from Vol. III of Lewis' Practice of surgery, W. F. Prior Company, Inc., Hagerstown, Md.,1944. Fig . 7, p. 22.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>94.</b> </td><td class="clsTextSmall">Vard, Inc., Pasadena, Calif., Subcontractor'sFinal Report [to the] Committee on Artificial Limbs, National Research Council, The development of artificial arms for amputees who have had the cineplaslic operation, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>100.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., and Robert J. Pursley,Fitting the wrist-disarticulation case, Orthop. &amp;Pros. Appl. J., September 1952. p. 17. 100. zur Verth, M., Die biologische Absetzung der menschlichenGliedmassen, Muench. Med. Wschr., 82:525 (1935).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>74.</b> </td><td class="clsTextSmall">Putti, Vittorio, Historic artificial limbs, Hoeber, New York, 1930. p. 7.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>69.</b> </td><td class="clsTextSmall">Northwestern Technological Institute, Evanston,Ill., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, 1947. pp. 1.33-1.36.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>73.</b> </td><td class="clsTextSmall">Possibilities Unlimited, Inc., Cleveland, Ohio, Possibilities unlimited, Vol. II, Issue 2, 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be recalled that with a little practice man can walk on his hands, but it is not a very comfortable behavior or one that can long be continued.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Eugene F. Murphy, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Research and Development Division, Prosthetic and Sensory Aids Service (Central Office), Veterans Administration, 252 Seventh Avenue, New York City; member, Upper- and Lower-Extremity Technical Committees, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Rufus H. Alldredge, M.D. </b></td></tr><tr><td class="clsTextSmall">Formerly Chief, Orthopedic and Prosthetic Appliance Clinic Team, Veterans Administration Regional Office, New Orleans, Louisiana; member, Advisory Committee on Artificial Limbs, National Research Council.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_03_004/fig1A.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_03_004/fig2.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Prosthetics Research and the Amputation Surgeon Creator An entity primarily responsible for making the resource Rufus H. Alldredge, M.D. * Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/8c7a6970296e60cde98fb2b926104479.pdf e0922ee3443a9fb4e8fe43481878f21c https://staging.drfop.org/files/original/683dddbeabe8a01b0c8e7067bc596ecf.jpg 271073242017918d8370a864251ad0eb https://staging.drfop.org/files/original/373393b245d73849895b4181a127430b.jpg ff274eca7b23aa261109f9258b2e7c0e https://staging.drfop.org/files/original/32cd3103345077afd83b7af5dc7abc05.jpg 6f53d9444bd5c4976b690cd3cdf3bf39 https://staging.drfop.org/files/original/326f0da3a571622d5e2f89a4f1fbf8f7.jpg 3a46e2005501e0890e80e9d19c88297b https://staging.drfop.org/files/original/6c37ae42905af01a9e9460d43bd3553f.jpg 8ee9df44430899e5ec2be193ff06157c https://staging.drfop.org/files/original/5a8831a6307c5d66cdbc2c2d334b473e.jpg b8b6d65bc61c774c998c966b4b8d9776 https://staging.drfop.org/files/original/65a169d989d02cea39b0c321f258efa3.jpg cd8f75e9cfe0960fb6bf27afce0ba348 https://staging.drfop.org/files/original/70bcb435ec1c123bf2b535fb68b27738.jpg c78dfaf4d86b2f73a6a2a70f5a64a7d7 https://staging.drfop.org/files/original/161398ae7cc34eeac4871900abe93df6.jpg eff0bd44c9f395dd53ae74ecc0ba4242 https://staging.drfop.org/files/original/7d80433608eed4a89c5fc22dd07055ef.jpg 35b33774ed1a270b804361dc81f05bff https://staging.drfop.org/files/original/a0ca2656198d3d989f5e474a37b95dcf.jpg 5b4d98e6150520153b45e30d3431bfd4 https://staging.drfop.org/files/original/d36951552083714c2c80fb0e9b8d7005.jpg 4842a3d61f9e2e5c58c5c7946f2da9ff https://staging.drfop.org/files/original/f174327fa60278c7a99afa8d8f592ac1.jpg ae8b6b1631695f54693e660a689337b2 https://staging.drfop.org/files/original/fc107ec87d21c63b7439534a3f554f07.jpg 53c791fbf64feffd8cab5c141c9f8606 https://staging.drfop.org/files/original/0b1833b99f21a9bef0babbe75f155aa2.jpg e95fdcb37adc9e7a6f249f62be244e39 https://staging.drfop.org/files/original/f68c9b3da10bd6494c265eebd460e66a.jpg a16093ae85b8381722948051554431eb https://staging.drfop.org/files/original/20291c2668b999b54c80a68aba5da376.jpg f24be81cd11ca69b05949e0d02eedc9c https://staging.drfop.org/files/original/b6606c9f4e7dceb4aa02b5b6dd8582e0.jpg 3df58f3eed4f318cf1971b56f5d402c4 https://staging.drfop.org/files/original/91e23f3a95ec0103ee52beb7c5d5eb14.jpg 965674dd0925c9b4d2a55098c963a7f7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_03_047.pdf Year 1954 Volume 1 Issue 3 Page Number(s) 47 - 76 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/1954_03_047.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_03_047.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Prosthetics Research and the Engineering Profession</h2> <h5>Renato Contini, B.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>In the establishment of any program in prosthetics,<a style="text-decoration:none;">*</a> whether it be a program devoted to research on and development of new and improved devices, or whether it be a program for the dissemination of knowledge in the application of these devices, guidance must come primarily from the medical sciences. In any such program, one can appreciate the role of the physician, either the surgeon involved in the amputation or the physiatrist concerned with the physical rehabilitation of the patient. To a lesser extent perhaps, the role of the physical and occupational therapist, in implementation of the prescription established by the physician for medical rehabilitation or re-education, also is generally appreciated.</p> <p>Since there can be no prostheses without a limbmaker, the role of the prosthetist cannot be underestimated. Certain attempts at the fabrication of artificial limbs may be traced back to the time of the Roman Empire. Several ingenious devices made during the sixteenth century (<b>Fig. 1</b> and <b>Fig. 2</b>) still are in existence. The major impetus, however, was received as a result of the Napoleonic Wars, of the War between the States, and of the Franco-Prussian War. Improvements in medical practice had by then made it possible to save a much larger number of men who had lost limbs than had been possible earlier. There thus developed a well-defined craft which reached its peak during World Wars I and II and which established with the medical profession a working relationship directed toward the fabrication of acceptable prosthetic devices.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Iron hand of Goetz von Berlichingen, a.d. 1509. From Faries,<a></a> by permission. See also Thomas and Haddan.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Leg of Ambroise Pare, a.d. 1561. From Faries,<a></a> by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To the efforts of these three professional groups - medicine, therapy, and limbmaking - there have been added in more recent rehabilitation programs the efforts of the social worker, of the psychologist, of the psychiatrist, and of the counselor in vocational guidance, the over-all purpose being to return the amputee to a more successful and better-adjusted position in society. The organization and functions of a modern prosthetics clinic team, as most usually accepted, have been fully and ably described by Bechtol.<a></a> </p> <p>Important as is the role of each of these disciplines, the progress that has been made in prosthetics in recent years may be attributed, in large measure, to the interest the problem has aroused in a substantial number of engineers. The role of engineering in a prosthetics program is not as yet well understood or fully appreciated by the general public. We speak of the role of engineering, rather than of the role of the engineer, because we are concerned more with the application of certain basic physical principles than with the particular individual who applies them. When these principles are well understood and applied by the physician, therapist, or prosthetist, each will function better in his own role. Unfortunately, in our present system of education no provision is made for imparting the basic principles of engineering in courses of instruction for any of these other disciplines. As a consequence, until recently such advances as were made in prosthetic devices came about primarily as a result of much trial and error rather than as the outcome of a planned approach.</p> <p>Any program directed to the development of new prosthetic devices may be divided into three major stages. The first is concerned with basic research. Second is the translation of knowledge gained in the basic research stage into a specific design for a particular device. And third is the application of the device to the amputee and the evaluation of functional gain. But of course a program does not necessarily proceed in such an orderly fashion. Before a device is finally accepted for general application, it may be necessary, and in fact it often is, to retrace the sequence not once but many times in order to gain additional information and understanding. We shall consider later the role of engineering in each of these stages.</p> <h4>The Background</h4> <p>Man performs activities in a variety of ways controlled by physical law. The manner in which he does so has thus interested scientists since the time of Leonardo da Vinci (1452-1519), who made the first systematic study of human movements and described them in his <i>Note on the Human Body.</i> <a></a> In 1679-1680, Borelli,<a></a> a pupil of Galileo, published <i>De Motu Animalium, </i>the first treatise which applied the sciences of physics and mathematics to human and animal activity. The mathematicians and physicists of the eighteenth century - Bernoulli, Euler, and Coulomb - tried to develop rational mathematical formulae for determination of the capacity of human work.</p> <p>The number of investigators increased greatly in the nineteenth and early twentieth centuries, and the two World Wars gave still greater impetus to research in the general field of human locomotion and activity. In Germany, France, England, Russia, and the United States, with different objectives perhaps but directed toward the same general problems, Fischer,<a></a> Fick,<a></a> Gilbreth,<a></a> Amar<a></a>, Martin,<a></a> Schlesinger,<a></a> Schede,<a></a> Bernshtein <a></a>, Steindler,<a></a> Elftman,<a></a> Henschke and Mauch ,<a></a> and the groups at the University of California<a></a> and at New York University<a></a> have studied human performance. Each, individually or as groups, contributed to the increasing knowledge both in the general areas of human activity and in the specific application of this knowledge to prosthetics.</p> <p>From the time of Leonardo, almost every investigator in this field either was primarily a physical scientist, or, if not, had a very intimate knowledge of physics and mathematics. In the later period particularly, the major contributors to the increasing knowledge of human performance have been engineers, physical scientists, or anatomists and physiologists with training in the physical sciences. A more comprehensive review of the investigators in this field is that of Contini and Drillis .<a></a> </p> <h4>Basic Research in Human Motions</h4> <p>In the design of any structure or mechanism, for whatever purpose, the engineer usually proceeds from a set of established specifications. These specifications may describe the function of the device, the space it may occupy, the activity it must perform, the forces which may be applied to it and which it must withstand, the chemical and physical damage to which it may be subjected, the working life expected of it, how often it should be overhauled or maintained, and what it may cost. To design a prosthetic device properly, similar specifications should be prepared. Some of the requirements for a satisfactory prosthesis may be developed from known data, that is, from information obtained empirically over extended periods of time and from the experience of countless amputees. Other information, however, and perhaps the more important in the design of prostheses, can come only after systematic experimentation. To supply this information, then, is the purpose of the program in basic research.</p> <p>Every human movement takes place in time and space and is controlled by external and internal forces and by the mass of the parts involved. The internal forces are generated in the muscles and transmitted through the limbs to tools, controls, instruments, or other objects. The external forces are those of gravity, inertia, ground reaction, and air resistance. When the body is at rest, the external and internal forces are in equilibrium; when it is in motion, the resultant of these forces has some value other than zero.</p> <p>Of course human movements may be observed and the pattern of movement described subjectively. But unless these movements can be recorded and measured precisely, no true understanding of the movement can be had, nor can repeated movements be compared objectively in the same individual or between different individuals. As technology has moved ahead, engineering knowledge has made it possible to develop instruments and techniques for recording and measuring movements and the forces which affect these movements. Although it would be interesting, as an historical aside, to review the methods used by earlier investigators, it is more profitable to describe some of the recent developments.</p> <h4>Methods of Measurement</h4> <p>The invention of photography in the middle of the nineteenth century, and the subsequent improvements in photographic techniques, have made it possible to record motions and displacements exactly (<b>Fig. 3</b>). The development of motion-picture photography, of interrupted-light photographic techniques, and of a combination of the two as obtained in the gliding cyclogram has made it possible to measure not only displacement but also the rate and change in rate at which movements occur. By these techniques, then, we can obtain displacement, velocity, and acceleration. Once these quantities are known, and when the mass of the total moving body or of its segments can be obtained by other measures, the forces acting on the body, the energy costs, and the power requirements can all be computed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Walking with 75-lb. load. Subject photographed synchronously from three points of view. Time intervals: 0.075 sec. From Muybridge<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Motion-Picture Photography</i></p> <p>Of the photographic techniques mentioned, motion-picture photography is used perhaps most universally. By mechanical or electromechanical means, a light-sensitive film is transported at a known, fixed rate past a lens and shutter. The film-transport mechanism is synchronized with the shutter so that a picture is taken each time the film is advanced one frame. The speed at which pictures are taken may be varied between sequences to suit the particular need, and the shutter speed may be varied to stop the action down to the smallest fraction of time consistent with the particular apparatus and with the object being photographed.</p> <p>With conventional motion-picture equipment, frequencies of up to 128 frames per second have been photographed, action being stopped down to the order of one five-hundredth of a second. Within these limits most human activities may be photographed adequately. A timing device - in effect a large clock, driven by a synchronous motor, and with the dial subdivided into hundredths of a second - permits measurement of the variability in time between frames and in exposure time (<b>Fig. 4</b>). Sometimes x-ray and motion-picture photography have been combined. By this means it is possible not only to record the motion of a limb but also to observe any relative motion between the activating skeletal structure and the external surfaces.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Typical motion picture of walking. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although this method of motion recording has been used extensively, and even though it may be quite adequate for some measurements, it has certain disadvantages which detract from its general usefulness. In the reduction of data, for example, each frame must be registered in two of the three major coordinate axes, some point being maintained as a control. The location of each moving segment must be determined from a constant frame of reference, a matter which introduces possible sources for error. And it has been found that the transport mechanism does not always respond at the same rate, so that the interval of time between frames, on which the computations depend, may not always be constant.</p> <p><i>Interrupted-Light Photography</i></p> <p>When the activity to be recorded is not a repetitive one, as in jumping, or is repetitive but progresses along a linear axis, as is the case with the walking pattern of a leg amputee, interrupted-light photography can be used. In this system the film is stationary in the camera. The lens shutter is kept open, while a slotted disc, driven at the desired speed by a synchronous motor through a gear or pulley system, rotates before the shutter in such a way as to admit and exclude light alternately. The speed at which the disc rotates and the number of slits in the disc together determine the time increment between exposures. The width of the slit (that is, the size of the angle included in the slit) and the rotation speed of the disc determine the time of exposure. In the studies conducted at New York University in conjunction with the Veterans Administration's Prosthetic Testing and Development Laboratory, the disc rotates 20 revolutions per second and the slit is 14 degrees wide, so that the exposure time is of the order of one five-hundredth of a second and each revolution results in one exposure (<b>Fig. 5</b>). These conditions are optimum for the particular application, but they can be modified for other applications. In the system developed by the Prosthetic Devices Study, Research Division, New York University, working with the VA's PTDL, the light is supplied by a single photoflood bulb and is returned by reflective tape, such as <i>Scotch-lite, </i>which marks the points to be photographed. Similar results might be achieved with an open lens and a strobe-flash source of light.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Typical stick diagram of walking. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The obvious advantage of this system is that it provides a complete pattern of a total movement, such as the forward progression of an amputee for two or three strides, all of which may be recorded on one film. Reduction of data is greatly simplified, since the measures of vertical and horizontal displacement are taken directly from a single set of axes. The error then is only that which the operator may make in measuring. The time increment is as constant as permitted by the variation in speed of a synchronous motor.</p> <p><i>The Gliding Cyclogram</i></p> <p>When the motion to be recorded is repetitive in limited space, the interrupted-light method cannot readily be employed, for the pattern of points cannot then be distinguished as to occurrence in time. To overcome this difficulty, Bernshtein<a></a> in Russia and Drillis<a></a> in Latvia developed the gliding cyclogram. This method is similar to that previously described except that here the film is transported across the field at a constant rate but at one that may be varied to suit the particular activity being recorded. Under these circumstances, the position of any point can be identified both in space and time. Even if, in a repetitive motion, a point on a moving segment is returned to an original position, the image in the initial and succeeding instances will be displaced on the film by the distance the film has been transported in the elapsed time increment. If, for example, a point were moving in a circular path, its locus would appear on the film as a cycloid. Although this method increases the amount of work to be done in data reduction,<a style="text-decoration:none;">*</a> suitable graphic shortcuts reduce this work differential to a minimum. As will be apparent (<b>Fig. 6</b>), the gliding cyclogram has special advantages in recording the motion of arm activities, many of which are repetitive and overlapping.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Gliding cyclogram of the axe stroke in woodcutting. From Drillis.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>The Tachograph</i></p> <p>Although each of these methods permits the measurement of displacement, velocity, and acceleration, other methods of instrumentation give direct measurement of velocity and acceleration in certain situations. Velocities along one axis may be measured with a tachograph, a device consisting of a fine cable connected to a moving body, continuing in a closed loop, and driving the rotor of a generator (<b>Fig. 7</b>). Since the voltage is proportional to the angular velocity of the rotor, which in turn is proportional to the velocity of the body, the voltage generated is a direct measure of the linear velocity.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The tachograph - a system for recording linear velocity. From an NYU report.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>The Accelerometer</i></p> <p>Another electrodynamic device, the accelerometer, measures accelerations directly. Essentially, this instrument consists of a small, compact mass supported by a spring device. When the mass is suddenly accelerated, its inertia deflects the spring by an amount dependent upon the acceleration and the spring constant. By suitable means, such as by differential transformers, the deflection is converted into a change in voltage proportional to the displacement and thus proportional to the acceleration imparted to the accelerometer. More recently, accelerometers have been devised employing strain gauges (see below).</p> <p><i>Direct-Recording Force-Measuring Devices</i></p> <p>Displacement and velocity permit us to describe a motion; acceleration and mass permit us to compute the forces which affect the motions. Sometimes it is possible and desirable to measure forces directly. A number of such force-recording devices have been made possible by technological advancement in the past 20 years.</p> <p><i>The Strain Gauge. </i>The strain gauge, which has been used in innumerable applications, is such a device. Essentially, it consists of a fine wire of known cross-sectional diameter and electrical resistance, arranged in a packet (not unlike a <i>Band-Aid</i>) so that it may be attached directly to some structural element. When the structural element is stressed, it either elongates or shortens, depending upon whether it is in tension or in compression. The filament of the strain gauge follows the structural element to which it is attached, and its cross-sectional area is reduced or increased, with consequent stretching or compression along its length. The electrical resistance is thus increased or decreased from the normal or zero-load position. By suitable electrical magnification and instrumentation, and with proper initial calibration, instantaneous changes in load can be measured and recorded.</p> <p><i>The Capacitor. </i>Another device for measuring loads or forces directly is the capacitor, a small capsule consisting of a dielectric material between two layers of electrical conducting material. When a voltage is applied across a capacitor, an electric charge is stored. The capacitance of the unit varies directly as the area of the surface plates and inversely as the thickness of the dielectric. When pressure is applied across the faces of the capacitor, the thickness of the dielectric is reduced and the capacitance is changed.</p> <p>Pressure gauges based on this principle have been developed at the Franklin Institute.<a></a> In these instruments, the construction is loose so that appreciable changes in spacing between the plates, and hence in capacitance, occur with changes in loading. Springiness is achieved by impressing a waffle pattern of indentations into the steel discs which serve as the plates of the capacitors. The gauge is used as one arm of a bridge circuit in which a high-frequency signal is supplied and the unbalance is amplified and recorded on an oscillograph. The degree of unbalance is calibrated in terms of load on the gauge.</p> <p><i>Other Force-Recording Devices. </i>Still other techniques for the measurement of loads have been used widely. For example, the principle of equal distribution of pressure in pneumatic and hydraulic systems has resulted in the development of various types of pressure gauges. The property of springs - leaf, helical, or torsion types - in maintaining, within certain limits, a direct ratio of load to deflection has been used in other force-measuring units. Still other devices have been developed making use of other known physical phenomena to obtain data desired in specific problems.</p> <h4>Experimental Adaptations</h4> <p>Many of these principles, techniques, or devices have been applied in the basic research program to obtain the data needed to develop new and better prostheses. The same applications also have been used to evaluate the prostheses on the amputee, and in some instances special adaptations of certain of these principles have been used as aids in amputee training. Some of the more important experimental units merit further elaboration.</p> <p><i>The Lower Extremity</i></p> <p>In 1945 the Prosthetic Devices Research Project at the University of California, Berkeley, initiated a program of basic research directed toward the gathering of information on locomotion, both in normal subjects and in leg amputees. It was desired to obtain data on the individual factors which contribute to the pattern of human gait - the displacements of the head, arms, and torso; the displacements and rates of displacement of the thigh, shank, and foot; the moments at the hip, knee, and ankle joints; the pressure at the point of ground contact; and the shift in apparent point of pressure application. Using the techniques already described, the engineers participating in this program developed a variety of ingenious devices.<a></a> </p> <p>To record the displacements of the segments of the body, motion-picture techniques were adopted. The appropriate control points on the body were identified by targets, in some instances the motions of small magnitude were magnified by target extensions, and in other instances the pattern of locomotion was photographed at intervals varying up to 3000 per second. To obtain the components of motion along the three axes of space, a glass walkway and tilted mirror were used. By this expedient, side and plan pictures were taken simultaneously on one film, thus minimizing the time required for reduction of data and also reducing the possibility of error as compared to the use of two synchronized cameras. From these photographs the motions of the leg segments, heel and toe rise, degree of knee flexion, phasing of the step, and all other desired details could be analyzed. Forces during the swing phase could be determined, as could also the moments at the joints.</p> <p>To measure ground reaction, two force plates were designed using strain gauges in various combinations to measure vertical, fore-and-aft, and lateral components of foot pressure at ground contact. Through appropriate electronic combinations, the strain pickup also could give the apparent instantaneous center of pressure and the torsional moments exerted by the rotation of the foot at ground contact. In a similar study conducted by the Research Division, College of Engineering, New York University, the same elements, strain gauges, and structural beams were combined in another variation of the force plate.<a></a> Both the UC and the NYU force plates represented a refinement of those conceived and used by Elftman,<a></a> who, in his earlier studies in human locomotion, had used springs and dial gauges to record components of forces.</p> <p><i>The Upper Extremity</i></p> <p>The University of California at Los Angeles, through its Engineering School, was entrusted with basic research in the upper extremity. To study the range of movement required by arm prostheses in the performance of selected daily activities, a photographic procedure was established. A subject was placed within an enclosure composed of vertical, horizontal, and lateral grids. Two mirrors permitted views in the horizontal and lateral planes (<b>Fig. 8</b>). When the subject was photographed, the motion of the targets on the joints could be pictured simultaneously in all three planes, together with the coordinate grids, thus permitting rapid data reduction. An ingenious mannikin enabled the duplication of motions photographed for further study of particular combinations of angular displacement of segments.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Three-dimensional grid system for analyzing motions in the upper extremity. From an NRC report.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Adaptations to Evaluation</i></p> <p>It is difficult to indicate clear boundaries between the basic research and the evaluation stages in the Artificial Limb Program, for many of the tools used to obtain basic data also are useful to the group at New York University engaged in the evaluation of prostheses. These techniques and others now being used in the evaluation program are discussed later (page 65). As the measuring and recording instruments become more generally applied, scientists other than engineers will become equally proficient in their use. When the need arises, the engineering profession undoubtedly will produce even more refined devices for measuring more complex performances.</p> <h4>Prosthetics Design</h4> <p>Important as is the role of engineering in the development of instrumentation and equipment for basic research in human motion, it is in the second stage of any prosthetics program - the design of the prosthetic device - that the engineer is pre-eminent. Among the many factors he must consider in the design of a prosthetic device we may include safety, function, control, efficiency, appearance, comfort, simplicity, and durability. These features can scarcely be assigned any order of importance; since they are all interdependent, the design usually must end up as a compromise.</p> <p>Safety, function, control, efficiency, and appearance require a knowledge of the means - mechanical, pneumatic, hydraulic, or electrical - by which the desired performance can be accomplished and also a knowledge of the forces available, of the forces applied, and of the proper distribution of masses in the device. Comfort requires a knowledge of the limits and distribution of pressure that can be tolerated by body tissues and vessels without damage and without distress to the amputee. Simplicity and durability, both important in the cost and maintenance of the device, require a knowledge of the breakdown that may occur owing to perspiration and body acids, continuous use, temperature changes, and abrasion and chemicals from external sources and, in addition, knowledge as to what materials and combinations of materials may be used to minimize such deterioration.<a style="text-decoration:none;">*</a></p> <p>This kind of problem is the true test of engineering. All the physical sciences which contribute to the substance of engineering may be called upon in evolving the final product. The mechanical engineer contributes his knowledge of mechanisms - cams and gears and linkages, which together may reproduce a motion. With the hydraulic and electrical engineer, he devises means for the operation or control of the prosthesis, for damping a swing, or for magnifying the power available within the amputee. The metallurgical engineer develops the alloys which go into the joints and prescribes methods of treatment to bring out the maximum qualities desired - strength or ductility or resilience or wear. The chemical engineer makes available the new synthetic substances which so handsomely replace the natural substances heretofore the only materials available. Plastics, whether they be the strong, structural resins used in the lamination of shanks and arms,<a></a> or whether they be the plastics used for cosmetic purposes,<a></a> have radically changed the appearance, weight, and sanitary properties of prostheses.</p> <p>The design engineer must combine all this knowledge into the most effective whole. He must bring to the job all of the experience and ingenuity he possesses so that the ultimate product will not only produce the desired function, be strong enough, and last an adequate period but will also be relatively inexpensive and simple enough to be maintained locally with a minimum of special tools. The making of artificial limbs can now be based on well-established scientific principles; it can cease to be empirical and can become a branch of engineering and medical activity. But without the necessary technical skills, progress in prostheses will return to the trial-and-error system from which it has so recently emerged. Some of the specific problems to be solved, and the methods for their solution, which have occurred in the design of upper- and lower-extremity prostheses, deserve to be discussed in some detail.</p> <h4>The Lower Extremity</h4> <p>The scientific basis for lower-extremity prostheses is provided by biomechanical investigation of the functions of the lower limb in human locomotion. Man is an erect biped, that is, he has two supporting limbs and the mass of his body is carried in a vertical plane. The human body, then, may be represented as an upper mass upheld by two supporting columns. The upper mass consists of the head, arms, and trunk. The supporting columns are the two lower limbs. Of complex character, they each consist of three segments, superposed and movable on each other. To meet the needs of standing, the three movable segments form a quasi-rigid column by virtue of their superposition.</p> <p>The standing position includes standing on both feet and standing on one foot, as in the stance phase during locomotion when the weight is borne on one foot only. The vertical line passing through the center of gravity of the body passes behind the line connecting the centers of the two hip joints and in front of the axes of the knee joints. Extension of the trunk relative to the thigh and of the thigh relative to the shank is thus maintained by gravity and limited by powerful ligaments. The two lower limbs therefore remain rigid with a minimum use of active muscle groups. But locomotion demands that the lower limbs be composed of movable, superposed segments. This requirement appears irreconcilable with the demands imposed by the standing position, but the natural arrangement of the lower limbs meets both requirements. Mobility of the hip and knee joints is essential in performing a normal step, a motion which can be divided into four alternating phases, two phases of support on both feet and two phases on each foot alternately.</p> <p>During single support on one foot, the supporting leg bears the weight of the body while the other swings in the sagittal plane like a pendulum suspended from the trunk. Since the two lower limbs are of precisely the same length, the swinging leg must become shorter than the supporting one, or else the swinging foot would drag on the ground. Shortening of the swing leg is effected by flexion of the thigh on the trunk, of the shank on the thigh, and of the foot on the shank.</p> <p>The geometry of the hip joint, and particularly that of the knee and ankle joints, is very complex. Not all authorities are in agreement as to the movements of the segments of the lower limb in flexion and extension, but enough is known to provide information as to how stability and mobility are provided both in standing and in walking. In the manufacture of artificial legs, it is desirable to reproduce insofar as possible the static and dynamic characteristics of the sound limb.</p> <p><i>The Above-Knee Case</i></p> <p>With notably rare exceptions, the design of artificial legs proceeded along a fairly well-defined pattern. Generally, until the middle of the nineteenth century, and now still so in many underprivileged countries, it was considered adequate to supply the leg amputee with a peg-leg. For above-knee amputations, it consisted of a pylon supported below a pad, corset, or socket, which in some fashion was attached to the stump or suspended from the shoulders. For below-knee amputees, the stump was flexed and the peg-leg attached below the flexed knee.</p> <p>Such an artificial leg satisfied completely one of the two functions of the normal leg. It provided a column which, together with the sound leg, allowed the individual to stand erect. It also enabled the wearer to walk, although, since there was no knee joint, it affected the amputee's gait considerably. In the swing phase, the wearer was required to raise the hip on the amputated side in order to swing through; in the stance phase he necessarily had to vault over the pylon. Although such a device is simple, strong, inexpensive, and quite serviceable, the amputee is subjected to excessive stress during walking, his gait is asymmetric and unnatural, his performance in walking is inefficient, and his physical appearance is far from cosmetic.</p> <p>Next in order of development was the so-called "conventional" leg (<b>Fig. 6</b>, page 11). In general, this prosthesis was made to look like the sound leg, that is, it possessed some cosmetic appearance. The knee was hinged and could be flexed, although in the earlier devices a knee lock was provided to assure stability in standing. The foot was attached to the shank with either a rigid or a jointed ankle.</p> <p>This order of devices had many advantages over the peg-leg, but it introduced other problems. Because of the knee hinge, it was possible to sit or kneel or to perform in a more natural manner other activities requiring knee flexion. Moreover, because of the knee joint, when not provided with a knee lock, the amputee was able to walk with a better gait. Knee flexion permitted a certain amount of leg shortening in the swing phase, thus reducing the amount of hip elevation required to clear the ground. But the knee and ankle joints introduced instability in the stance phase, particularly at heel contact. The free-swinging leg resulted in an exaggerated back swing and forward swing with a pronounced shock at each stop. Later compromises were effected by setting the knee bolt forward of the weight line of the body, by addition of check straps to decelerate the shank at toe-off and to provide some assistance at the beginning of the forward swing, by introducing friction devices at the knee bolt, by a combination of both, and by limiting ankle motion through the use of bumper blocks.</p> <p>With minor and individual exceptions, this was the general state of development at which the above-knee prosthesis had remained until the end of World War II. As a result of the research initiated thereafter, engineers began to devote time to the application of old and new knowledge to the design of lower-extremity prostheses. Among the features which had been demonstrated as desirable were flexion at the knee but with some stabilizing control at the time of heel contact and immediately thereafter, some measure of support in an emergency situation such as in stubbing the toe, a controlled swing of the leg, an ankle joint which would permit rotation in a horizontal plane as well as in the sagittal and transverse planes and yet not be so flexible as to increase instability, and a toe-lift device for ground clearance in the swing phase. All this was to be accomplished without substantially increasing weight, sacrificing durability, or increasing initial and maintenance costs of the device. By combining known engineering principles with newly developed materials, a substantial gain was achieved in the above-knee prosthesis, with consequent improvement in the performance of many leg amputees.</p> <p>The U.S. Navy above-knee leg <a></a> developed at the U.S. Naval Hospital, Oakland, California, is an example of such an improved prosthesis. Controlled swing with terminal deceleration was achieved by the use of friction devices which come into operation in the last portion only of the forward and backward swings. New plastics and molding techniques provide a much more natural appearance. New methods of bonding rubber and a new method of attaching the foot to the shank allow for greater flexibility at the ankle without serious problems of instability.</p> <p>Proper application of mechanical and hydraulic engineering principles have resulted in two improved devices, the Stewart-Vickers and the Henschke-Mauch hydraulic legs, both for above-knee amputees. The Stewart-Vickers leg (<b>Fig. 9</b>) provides some resistance to knee flexion and hydraulic damping or deceleration at the terminal portion of the forward and backward swings. By a controlled cycle of operation of valves and cylinders, it provides coordinated hip-knee-ankle flexion in the swing phase so that adequate ground clearance is obtained, gives to the gait a more natural appearance, and apparently results in less effort on the part of the amputee. Whenever it has been tried by an amputee, it has generally resulted in favorable acceptance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The Stewart-Vickers hydraulic leg incorporating knee lock, swing-phase control, and coordinated motion between ankle, shank, and thigh. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Henschke-Mauch leg,<a></a> which most nearly duplicates the swing pattern of the sound limb, has been designed to provide stability at heel contact, both at the beginning of the stance phase or in the event of a sudden forward acceleration as in stumbling. A carefully designed, pendulum-type valve controls the passage of hydraulic fluid within a cylinder, the added stability being maintained long enough for the amputee to regain his balance but not long enough to impede knee flexion in the stance phase or to increase the risk of a fall. By other valving arrangements the hydraulic cylinder also controls the leg in the swing phase by providing adjustable constant friction in the full cycle plus terminal deceleration.</p> <p>The human knee joint flexes by a combination of rotation and sliding, so that a simple, single-axis joint cannot duplicate the relative positioning of the tibia and femur. A number of attempts have therefore been made to duplicate this articulation in so-called "anatomical" knees by means of various complex mechanical devices, of which one is the four-bar linkage. In <b>Fig. 10</b>, links <i>AD </i>and <i>BC </i>attach thigh to shank. Links <i>AB </i>and <i>CD </i>are formed by the shank piece and the thigh piece, respectively. <i>A </i>is the center of rotation of the ankle; <i>K </i>is the center of rotation of the knee; <i>H </i>is the center of rotation of the hip joint. The locus of the instantaneous center of rotation of the knee is 0-5-10-20-30-45-90, the centers being at the point of intersection of projections of the links <i>AD </i>and <i>EC. </i>Each number indicates the angle of knee flexion which places the instantaneous center at the point shown. As extension takes place, the effect is as if the shank were lengthened and the thigh shortened, a feature which aids stability in the stance phase and reduces the force required to start flexion at the beginning of the swing phase.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Polycentric knee based on a four-bar linkage. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the design shown, maximum elevation of the center of knee rotation occurs prior to full extension, so that initial knee flexion at toe-off is difficult. An improved design, with maximum knee elevation at full extension, is to be found in the University of California four-bar-linkage knee <a></a>. It attempts to simulate the path of the instantaneous centers of rotation of the knee joint so as to provide maximum stability and maximum flexibility at the proper times in the walking cycle.</p> <p><i>The Below-Knee Case</i></p> <p>It is this complex articulation of the knee joint that poses a major problem in the design of an adequate below-knee prosthesis. Since the below-knee amputee retains his natural knee, and since each individual knee follows an individual pattern in flexion, it has thus far been impossible to provide between the thigh corset and the below-knee socket an articulation that will not introduce some displacement between the stump and the socket.</p> <p><i>Methods of Suspension</i></p> <p>The suspension of the above- or below-knee prosthesis has been another area for research and design. Above-knee prostheses had been suspended either by shoulder harness or by some sort of pelvic band. The former did not maintain an adequate positioning between the stump and the socket, since by its very nature it could not adjust to the varying relationship between the shoulder and the leg in different activities. Although the pelvic band retained the leg more securely, it in turn imposed an artificial restriction on possible thigh movements, especially rotation and abduction.</p> <p>A novel method of suspension by suction was patented by Parmelee<a></a> in 1863, but the idea apparently was abandoned in this country although it continued to be used occasionally in Europe. Increasing experience with the suction socket in Germany after 1933 brought it to the attention of medical and engineering scientists in other countries, including the United States. After World War II, in a coordinated program sponsored by the Veterans Administration and directed by the Advisory Committee on Artificial Limbs of the National Research Council, all aspects of suction-socket suspension were studied carefully. The results of this study proved the merits of the suction-socket method of suspension, and it is gradually being adopted for all above-knee prostheses<a></a> where the limbmaker is certified to make such a socket and where there are no medical contraindications. A similar method of suspension is being worked out for below-knee prostheses with increasing evidence of success.</p> <h4>The Upper Extremity</h4> <p>The upper limb is the limb of contact. It consists of three segments - the hand, the forearm, and the arm. Of these, the hand is the most highly differentiated and the most important, since the essential upper-extremity function is grasp, which is mobile and variable in quality, power, and duration. Although its primary function is that of prehension, the hand is also one of our major sense organs. Through it we sense temperature, pressure, surface quality, and the shape of objects. For the blind it serves as substitute for the eyes by providing a sense for discriminating form and texture and, together with the forearm and arm, for determining spatial relationships. The forearm and arm serve merely as mobile attachment for positioning the hand in space. Since most of the hand movements and its different articulations are dependent on arm and forearm muscles, they provide a reserve of active power for hand activation. A detailed analysis of the functional mechanism of grasp <a></a> furnishes the basis for construction of the more scientifically conceived artificial hands.</p> <p><i>The Mechanism of Prehension</i></p> <p>The natural grasp and manipulation are wholly dependent upon the muscular action controlling movement of the fingers. The nature of muscular action therefore determines the nature of the grasp, and the two properties governing the mechanical phenomena of muscular function are contractility and elasticity. Contractility of the muscle is controlled at will. It can be graduated voluntarily in power, extent, and duration, so that the fingers can be closed firmly or gently, as in holding a tool or an egg, or partially or wholly, as in holding a book or a sheet of paper (<b>Fig. 11.</b>). Similarly, the fingers can be moved or closed for very short or very long increments of time, as in fingering the violin or in holding a telephone receiver. Muscle normally is in a state of tone, which may be defined as the property possessed by muscle of preserving, either by voluntary or by reflex action, a state of contractility. This contractility may be long or short in duration, greater or less in extent, strong or weak in power. By means of muscle tone, the hand can be kept in a convenient position for long periods of time.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Twelve basic types of grasp. After Schlesinger.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since the hand is so important in everyday activities, and since its functioning is so complex and so dependent for mobility on the two other segments of the upper limb, surgical and orthopedic treatment of the upper-extremity amputee is extremely important in restoration of functional loss. It should be directed toward preservation of the maximum amount of natural mobility. Since it is not yet possible to create artificial muscle, it is necessary to reproduce as well as possible by indirect processes the effects of normal muscle action on the fingers. Prostheses for this purpose are successful in such proportion as the mechanical effects produced approximate those of the natural limb.</p> <p><i>Substitute Power Sources</i></p> <p>Until the present, and even now with all the currently available technology, the most adequate substitutes for the lost muscle activators are muscular substitutes, self-powered agents which induce the movement of the artificial fingers by means of artificial tendons, that is, by control cords. The latter are, as a rule, attached by some appropriate means to the shoulder on the amputated side or on the normal side or both. The movement produced by them is thus entirely dependent upon the shoulder group of muscles. Improvements in surgical techniques<a></a> and extensive research in muscle physiology<a></a> recently have reawakened interest in the use of cineplastic procedures to provide other muscle motors (<b>Fig. 12</b>). Both the biceps and pectoral muscle groups have been used for this purpose.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Below-elbow biceps cineplasty control system. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since the action of the controlling muscles must continue for such periods as required for the particular grasp function concerned, the muscular substitute can become heavily burdened. It is therefore absolutely necessary to arrange for release of the muscular substitute once the fingers have been placed in the appropriate position. This is achieved by mechanisms which produce in the artificial fingers the same effect as that produced by muscle tone in the natural fingers.</p> <p><i>Prior Art in Upper-Extremity Prosthetics</i></p> <p>Although the basic concept of an artificial arm and its terminal device has not changed materially from that of the first arms made many years ago, recent technological developments in materials of construction and a better application of known mechanical principles have together resulted in arms of improved appearance and greatly improved function. As in the artificial leg, the materials most commonly used for the artificial arm and forearm have been wood and leather. Control was achieved by shoulder harness operating through control cords, usually leather, connected to the terminal device, which was usually a split hook, that is, a pair of iron or steel fingers bent in the shape of a hook and so hinged as to close on each other. For different applications the shape of the hook was modified as appropriate. Since in general the closed position required for grasping an object is of longer duration than is the open position for approaching the object, opening was effected by the shoulder muscles and closing was brought about by some spring or elastic medium. Cosmetic appearance was neglected or, in those few cases where it was attempted, a passive hand was the usual result.</p> <p>To return to the arm amputee some measure of productive capacity, there were devised a great many one-function terminal devices, each intended for some particular occupational need (<b>Fig. 13</b>). Such "tools" could be inserted and attached to the distal end of the artificial arm. The practice was predominantly European, and we see in their "armamentaria" hooks, rings, hammers, knives, brushes, and a multiplicity of other designs intended to enable the amputee to function in his customary occupation as smith or carpenter or metal worker .<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Typical occupational-aid terminal devices, all European. The screened boxes indicate the devices recommended for the various activities. From a German report.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Present-day technology and a formal approach to the design of both arms and terminal devices has since effected vast improvements in upper-extremity prostheses. Although most of the newer designs have been described in detail in available literature,<a></a> it is appropriate here to review these developments in a very general way as they relate to engineering practice.</p> <p><i>New Arm Substitutes</i></p> <p>The developments in plastics and in methods of fabrication have resulted in greatly improved arms. By proper lamination, molding, and coloring, arms and forearms can be made lighter, stronger, and with much better cosmetic value.<a></a> Shoulder caps for high above-elbow amputations and for shoulder disarticulations (<b>Fig. 14</b>) can be molded successfully to provide a good base for attachment of the prosthesis. Similarly, plastics of a different character and with other molding methods produce the flexible artificial gloves which cover the active hand to provide natural appearance.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Shoulder-disarticulation harness. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With regard to elbow and wrist articulation, basic research had indicated the desirability of certain ranges of arm motions.<a></a> To provide the necessary mobility, multipositioning elbows and wrists have been devised. The use of ratchet mechanisms, friction clutches, and alternator devices enable the above-elbow amputee to position the forearm by voluntary control through the shoulder harness. Wrist units have been designed both for positioning the terminal device in flexion and rotation and for quick disengagement of the terminal device.</p> <p><i>New Hand Substitutes</i></p> <p>The improvements effected by sound engineering approach are particularly evident in the terminal device (<b>Fig. 15</b>). Since control resides in the shoulder muscles, it appears logical that voluntary control should be available for closing the fingers rather than for opening the device. Such an arrangement, characteristic both of the APRL hook and of the APRL hand,<a></a> permits some measure of control of the force applied. An alternator mechanism provides for alternate opening and closing of the fingers, locks the fingers in the closed position with the desired pressure, and thus relieves stress on the shoulder muscles while an object is held. The extent of opening of the fingers can be set in either of two positions, depending upon the particular operation being performed, and in repetitive operations the lock can be eliminated, thus reducing the amount of work to be done by the shoulder muscles. The development of these voluntary-closing devices has, moreover, permitted the more successful fitting of cineplasty cases.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Types of grasp possible with the natural hand and those available in various designs of artificial hands. After Schlesinger.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For other situations, where an amputee may prefer a voluntary-opening hook, the Northrop two-load hook<a></a> is available. Using springs rather than elastic bands, it permits the fingers to close with either one of two available spring loads. The hook fingers of this terminal device as well as of the APRL hook were shaped in accordance with the findings of basic research into the frequency of hand prehension patterns.<a></a> </p> <p><i>Harnessing</i></p> <p>The whole technique of harnessing has undergone extensive revision as a result of applied engineering principles.<a></a> One feature concerns the fact that the power available at the shoulder should be transmitted to the terminal device with a minimum of loss, that is, with maximum efficiency. Replacing the older leather thongs is the Bowden cable adapted from the aircraft industry. The cable is attached to the harness, directed along the arm by an appropriate number of suitably located cable-housing retainers, and ends at the terminal device. In this circuitous path are friction losses owing to passage of the cable through its housing, especially at points of flexion around joints. Proper selection of points of load application, however, and judicious design of various components make it possible to reduce frictional losses to a minimum (<b>Fig. 14</b> and <b>Fig. 16</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Below-elbow figure-eight harness. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The successful harnessing of cineplasty cases requires the intelligent use of applied mechanics and biomechanics.<a></a> The terminal device and the control system by which it is operated must be adapted both to the end-uses desired by the amputee and to the physiological characteristics of his muscle motor.</p> <p><i>External Power Sources</i></p> <p>A more or less radical departure in the design of upper-extremity prostheses has been the application of engineering science to the utilization of external power sources for activation of arms and terminal devices. Although pneumatic and hydraulic applications have been attended with little success, the development of miniature, compact, and powerful electrical components has made it possible to develop an electrically actuated arm.<a></a> Elbow flexion, wrist rotation, and prehension can all be operated electrically, but thus far it has not been possible to develop completely suitable methods of control. The individual components, such as the electric elbow lock, may, nevertheless, have useful application in more conventional arms.<a></a> Study of such possible applications is now under way. There can be little doubt that, in some future study, with even newer materials and more advanced methods, externally powered arms, discretely controlled and respondent to the will of the amputee, may be developed.</p> <h4>Techniques of Evaluation</h4> <p>The real merit of a prosthesis cannot be judged solely on the basis of mechanical and cosmetic elegance of the design or by the number of functions it incorporates. It can be evaluated in true perspective only when it is fitted to the amputee and when his over-all performance with and acceptance of the device is appraised. In the Artificial Limb Program, the Prosthetic Devices Study, Research Division, College of Engineering, New York University, has been charged with the evaluation of prosthetic devices. To conduct this work, the roster of personnel includes physicians, psychologists, physiologists, therapists, and engineers, and the evaluations consider both the subjective and objective aspects of the biomechanical relationship.</p> <p>Although in much of ordinary engineering practice the objective evaluation of a mechanism is the only valid criterion, in prosthetics practice, because of the close relationship between the human and mechanical elements, the importance of subjective evaluations cannot be discounted.<a></a> As has been demonstrated repeatedly, what appears to be a very distinct and sound advance in a prosthesis may not in fact be acceptable to the amputee. A proper understanding of the attitudes of amputees, how they are affected by their own experience and by the characteristics of a device, and how these factors can be translated into the design is altogether necessary. The psychologist therefore has an important role in the evaluation process. So, too, the therapist, trained to observe human performance, and with a knowledge of the physiology and function of the human organism, can render a sound opinion with respect to the relative merits of various amputee-prosthesis combinations.</p> <p>But these methods of evaluation are subject to all the limitations of personal judgment. The experience and acuity of the particular observer, the relationship between the observer and the amputee, and other individual factors will in some way affect the evaluation. To a certain extent these variables are controlled by a comparison and correlation of judgments of different observers, but even under the most favorable conditions there may always be areas of disagreement as to what has been observed.</p> <p>When positive criteria of performance with a prosthetic device can be established, it becomes very important to be able to measure and record accurately those factors which constitute the criteria. Instrumentation and methods developed on the basis of engineering knowledge provide the tools for obtaining objective data. They enable the investigator to compare the performance of a particular amputee with different prostheses, of a given amputee with the same prosthesis at different times, or of different amputees wearing identical prostheses. The recording instruments and techniques available can record more rapidly, more accurately, and more permanently than can any human observer. All the devices useful in the basic research program are equally useful in the evaluation program.</p> <h4>The Lower Extremity</h4> <p><i>Symmetry in the Walking Pattern</i></p> <p>In establishing criteria for the evaluation of lower-extremity prostheses, it has been postulated that the pattern of normal locomotion is symmetrical and, therefore, that the behavior of the normal side may be the legitimate measure of performance of the affected side. That is to say, the more nearly the amputee achieves a symmetrical pattern of locomotion the better the prosthetic device and the better the adjustment to it. Further, it is assumed that, in the performance of activity, the human organism adjusts itself to perform at a minimal level of stress. The measure of performance of normals, then, can be a guide to the relative merits of amputee-prosthesis combinations. Such criteria as stability in the erect position, variability of stride time, and other biomechanical factors may be used as indices of performance. Lacking proper instrumentation, no objective evaluations of this character could be made.</p> <p><i>Energy Costs</i></p> <p>The investigations of Hettinger and Muller<a></a> indicate that the walking cadence favored by a normal human being is usually that which requires the minimum expenditure of energy. Deviations from this optimum cadence require increasing amounts of energy. Psychologists indicate that, in a repetitive operation which may be performed at varying tempos, the average person will perform the operation with least deviation at some one tempo best suited to him. On the strength of these two premises, the variations in stride time at different cadences were recorded and curves plotted (<b>Fig. 17</b>). The assumption is made that the nearer the curve of the affected leg approaches that of the normal leg, and the nearer the two curves approach those of a normal subject, the better the prosthetic device. Such data can be taken with the tachograph (<b>Fig. 18</b>), force plates, and interrupted-light photography.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Variability in stride time. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Velocities in level walking at normal speed (from tachograph records). <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 19</b> represents a typical plot of vertical load versus time during ground contact from heel contact to toe push-off. By means of stick diagrams and force-plate records, this over-all curve may be resolved into one for heel-contact impact and another for toe push-off momentum. When the separation is correct, the area C should be equal to the area <i>D. </i>Used in conjunction with other criteria, these curves give useful information regarding the effect of a prosthesis on the amputee's gait.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Components of vertical force. Normal speed, level walking, mean of eight subjects.<i>Double-Support Time (delta t)</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Marey and Demeny<a></a> determined that the time of double support in the walking cycle is inversely proportional to cadence. The NYU studies indicate that it is also related to the ratio of swing-phase time to stance-phase time <i>r </i>and that, moreover, at optimum cadence the stance-phase time in normals is approximately twice the swing-phase time. A criterion was established that, given the relationship between double-support time and cadence, plotted against a family of curves for varying ratios of swing-phase time to stance-phase time, that amputee-prosthesis combination was best which enabled the amputee group more nearly to approach the normal group.</p> <p><b>Fig. 20</b> shows the average trend line for a group of normals and for a group of above-and below-knee amputees. From the equation indicated, a series of hyperbolas may be plotted for varying values of <i>r. </i>The observed double-support times for normals, for below-knee amputees, and for above-knee amputees at three different speeds were plotted, and straight lines were fitted to these observed points. A line for double-support time crosses each of the hyperbolas at two points. The mean abscissa of these points indicates optimum cadence. Since a deviation from this optimum causes an increase in energy consumption, the increase in the value of <i>r </i>can be used as an indicator of higher energy requirement. The validity of this criterion appears to be borne out, since the below-knee group, having more of their natural limbs, more nearly approach the normals. Again, such data can be obtained only because adequate instrumentation, force plates, tachograph, and camera are available.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Analysis of optimum cadence. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Vertical Stability</i></p> <p>Stability in the erect position is used as another criterion.<a></a> The normal individual keeps himself erect by the interaction of muscle and skeletal groups responding to sensory cues. In the amputee some of the normal cues have been destroyed and new ones, such as pressure on the stump, or pain, have been introduced. Besides this, the amputee has fewer muscle groups available with which to compensate for the effect of external forces tending to throw him off balance. Because the human anatomical structure is not truly rigid, the equilibrium of a normal erect subject will be disturbed by a force of lower magnitude than that which will unbalance a rigid body of the same general mass distribution and with the same general support base (<b>Fig. 21</b>). Since the amputee cannot compensate for the effect of unbalancing forces as readily as can a normal, and since in fact poor alignment or fit of the prosthesis may exaggerate the unbalancing effect, the measure of stability is highly important.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. The base of support. <i>C </i>represents the center of the support base. Shaded areas show the contact zones of feet and ground. The small trapezoid defines the limits of travel of the projection of the center of gravity. <i>P </i>represents the mean of all the readings of center-of-gravity projection. The distances <i>d1, d2, d3, </i>and <i>d4 </i>are the respective distances from the center <i>P.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Three methods are used for obtaining information on stability. In one, the subject is placed in a known position on one force plate and the center of the base of support on the force plate is determined geometrically. The extent and frequency of deviation in the sagittal and transverse planes are recorded simultaneously (<b>Fig. 22</b>). Mean values of recorded oscillations determine the location of the center of pressure, which at the same time is also the projection of the center of gravity on the force plate. Distances measured from the center of pressure of the axis of each foot give an indication as to how the body weight is distributed between the two legs.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Record of stability in standing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since the reduction of force-plate data alone is not sufficient for the purpose of determining stability constants, a simple device, the stability platform shown in <b>Fig. 23</b>, has been fabricated for imposing upon a subject known accelerations and recording that one at which he is unbalanced. The support base is known, the center of mass of the subject vertically above the platform can be established, the acceleration when the platform is suddenly released can be controlled by the known weights in the suspended basket, and thus it can be determined at what acceleration the subject is unbalanced. Stability trapezoids for normals and for above- and below-knee amputees (<b>Fig. 24</b>) have been prepared on the basis of available data. It will be noted that thus far only four positions have been recorded - accelerations tending to unbalance the subject in the forward, rearward, right, and left directions. No positions along intermediate axes have been studied, but it seems likely that, if more positions were measured, the envelope would assume some oval shape. This criterion too seems validated by results, since, although there are differences between individual amputees as well as between normals, as a group the below-knee amputees more nearly approach the normal group.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. The stability platform. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Stability polygon; mean values in percent of <i>g. Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Another simple device which has been used to corroborate acceleration data is the inclined platform. A kymograph records the increasing angle of tilt, and the recording is interrupted when the subject topples.</p> <p><i>Standardization of Fit and Alignment</i></p> <p>It is not amiss at this point to mention two devices, developed at the University of California, which are indispensable in the evaluation procedures. The alignment devices for above- and below-knee prostheses and the transfer jig<a></a> are tools useful in assuring that different prostheses on the same amputee are alike in physical dimensions and positioning, and they make it possible to measure the effects of known changes in position or alignment in the same prosthesis. A third device, developed at the Prosthetic Testing and Development Laboratory of the Veterans Administration, makes it possible to duplicate sockets, a matter of importance when shanks requiring different sockets are needed. The internal contours of the socket can be maintained and their effect on changes in performance thus minimized.</p> <p><i>Measurement of Force Distribution</i></p> <p>Engineering knowledge makes it possible also to study special characteristics of a device or of a method of fitting. In evaluating the relative merits of the "soft" and hard sockets for below-knee amputees, three new techniques have been evolved. It is desirable to observe changes which occur in the stump as a result of wearing the socket. Accordingly, there has been devised a jig which will hold the amputee in a given position while an impression or cast is made of his stump. Since a rigid pattern of posture is thus imposed, the impression or cast reflects only physiological changes over a period of time. The contours of the stump are then obtained by using a contour tracer or perigraph, also developed for this special purpose. Small variations in contours at known levels can be recorded and compared.</p> <p>The second technique involves the use of the capacitance gauges previously described. In a study at New York University, in cooperation with the Prosthetic and Sensory Aids Service of the Veterans Administration, they have been applied in an attempt to answer once and for all the question among limb-makers as to the proper distribution of forces within a below-knee socket. Several gauges are attached at points of particular interest on the stump of a below-knee amputee (<b>Fig. 25</b>). The subject then walks at different speeds for a distance of 30 to 40 feet while the unbalance of the gauge bridges is recorded. In this way, simultaneous indications of pressure are obtained at six points on the stump. Although it is still too early to make a general statement, it is evident that great differences exist in the forces exerted by the stump on the socket wall at different points. A composite record of the forces involved during a single stride (<b>Fig. 26</b>) shows the relative magnitudes of forces at a number of points. The maximum observed pressure was 65 lb. per sq. in. at the relatively insensitive patellar tendon. Eventually it is intended to map the total stump contact area for pressure distribution during different phases of the walking cycle.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Experimental arrangement for pressure measurement using capacitors. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Typical oscillograph record of forces in walking. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In addition to the research applications of the pressure gauge, it is likely to find use in the routine fitting of sockets. For this purpose, gauges would be attached to the stump at critical points, such as weight-bearing areas, sore spots, or relieved areas, when a new socket were tried on. A meter reading would give the magnitude of the pressure at the points in question and would tell objectively whether the pressure were excessively concentrated or well distributed when the subject stood or walked.</p> <p>The third technique specially developed makes use of the strain gauge also described previously. By means of this instrument it has been possible to attack the problem of determining the relative distribution of body weight between the sidebars and the socket of the below-knee amputee. In the experimental procedure developed, modified sidebars (<b>Fig. 27</b>) are substituted for the original ones of the test subject. So constructed that the subject's gait is unaffected by the substitution, these modified sidebars permit the mounting of the strain gauges so as to simplify determination of axial and bending strains. In the test procedure, wires are run from the gauges on the bars to a recording oscillograph by means of an eight-conductor cable. Stick diagrams and force-plate records are taken simultaneously with the recording of the dynamic sidebar strains (<b>Fig. 28</b>). Thus, at any particular instant, the position of the leg in space, the forces it exerts on the ground, and the strains in the sidebars all are known. From the knowledge of the axial sidebar loads, plus some logical assumptions and some simple kinematic relationships, the components of socket load along the axis of the shank and normal to the shank axis can be found. At the present time, runs have been made on two test subjects, one unilateral and one bilateral, both wearing conventional wooden sockets.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Conventional sidebar (left) and experimental modification for measurement of bending forces. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Axial load on sidebars. Body weight, 250 lb.; cadence, 120 steps per minute. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Upper Extremity</h4> <p>Engineering techniques have been employed in the evolution of upper-extremity prostheses also, though not to the same extent. The refinements in lower-extremity prostheses are such as to require discrete, fine, and rapid measurements, while those in the upper extremity are comparatively gross and subject, in many cases, to visual observation and judgment. Moreover, the increased performance with the newer arms and terminal devices can be appreciated quite readily by both the amputee and the observer. In the upper extremity, therefore, the employment of measuring devices is required only in those special situations where human observations fail.</p> <p><i>Control Systems</i></p> <p>The efficiency of an upper-extremity control system, from the point of load application at the harness to the point of pressure applied by the terminal device, cannot be obtained other than with measuring instruments. For such measurement, the strain gauge, applied to appropriately designed devices, can be used to measure the pressure at the tips of the fingers or the force applied at any point along the cable of an actuating system. In the course of some of the NYU studies, a channel-shaped structural element was designed in such a way that it could be inserted as a link in the cable system at different points along the cable. Tension in the cable causes deflection in the elements, and the extent of deflection is recorded as a change in voltage through strain gauges cemented to the crossbar of the channel.</p> <p><i>Finger Forces</i></p> <p>A similar principle has been used for measuring hook-finger pressures. Elements resembling tuning forks were designed, the beams being so shaped as to accommodate different grasps. Strain gauges cemented to the crossbar measure the bending stress in the fork, the stress being proportional to the pressure applied by the amputee at the tips of the hook fingers. With knowledge of the linkages involved in the system, it is possible to determine what harness combination is most efficient.</p> <p>At the Army Prosthetics Research Laboratory, a "grip" meter has been developed for the purpose of measuring normal grips and the grips that can be achieved by amputees with artificial hands. The grip is resisted by a spring calibrated to be read directly on a dial gauge.</p> <p><i>Range of Stump Motion</i></p> <p>During the course of development of the electric arm, an unusual instrument was developed by Alderson<a></a> to measure the range of motion of the various muscle groups which later were to actuate the controls of the electric arm. The <i>simul"arm"ator </i>permits the designer and fitter to estimate the range of control available to the amputee in the various muscle groups - biceps, triceps, pectoral, etc., and to allow for this range in designing the control switches of the prostheses.</p> <h4>The Future in Prosthetics Evaluation</h4> <p>As more and more improvements are incorporated into upper- and lower-extremity prostheses, the relative merit of one prosthesis as compared to another will become more and more difficult to evaluate without appropriate instrumentation and recording. The development of recording and measuring devices must therefore keep pace with the combinations to be evaluated. Hence the engineer must continue to function in his role in the evaluation phase of the program.</p> <h3>Conclusion</h3> <p>The contributions of engineers and the role of engineering in all stages of prosthetics design and application now have been well established. But this turn of events could scarcely have materialized without the cooperation of the Government. The program established by the U.S. Congress,<a></a> supervised by the Veterans Administration, and coordinated by the Advisory Committee on Artificial Limbs of the National Research Council assured a continuity of operations - of research, design, and evaluation - in which engineers and engineering groups could become interested.</p> <p>Theretofore engineers had been interested in prosthetics in a desultory fashion only, and engineering principles had been applied only to the extent that that knowledge was available to the individual limbmaker concerned. Engineers have brought to the Artificial Limb Program a curiosity as to the physical principles involved in human performance and an appreciation of the scientific method in approaching the problems. They have contributed their knowledge of measurement and of instrumentation to obtain necessary data, they have translated the results into terms of new needs, and they have applied their knowledge of materials and of mechanisms toward the fulfillment of those needs.</p> <p>It cannot be expected that the present program, born of World War II and under the pressure of veterans' demands, will continue indefinitely. And yet it may be anticipated that more and more amputees will continue to need truly functional artificial limbs. Records indicate that annually there arise from disease and other natural causes - industrial and traffic accidents and accidents in the home - many times more amputees than were produced in all Service-connected activities throughout World War II. And these include the weak and the old and the very young, not alone the average, healthy male represented by the veteran amputee. As in all science, the problems which yet require solution are much more numerous than are those already solved. Programs must therefore be established which will be broad enough in scope and long enough in duration to attract engineers. The limb industry must continue to upgrade itself, to create the positions which require engineering skills, and to offer commensurate rewards. Rehabilitation agencies and all those groups interested in the welfare of the disabled should consider how the role of the engineer and of the physical scientist can be integrated into their work.</p> <p>As an alternative it has been suggested that a cross-discipline should be evolved, with courses of instruction available to the engineer, the physician, and the rehabilitation specialist to enable each to understand each other's problems. Such a curriculum in biotechnology could offer the engineer instruction in physiology and psychophysiology useful as well in applications other than prosthetics. It could offer the physician and rehabilitation specialist instruction in the physical sciences, instrumentation, and measurement. For such an integrated course of instruction there are already precedents. Physicians have studied engineering for a better understanding of orthopedics. Engineers have studied the physiology of human activity to develop better operational methods in industry. In Europe, particularly in Germany, Russia, and the Scandinavian countries, a whole new science of "work physiology" or "work science" is being developed. In England the Ergonomics Society brings together physiologists, psychologists, and physical scientists interested in the problems of human performance, and their contributions are having effect on the design of equipment and operational processes. A scientist from whatever field, trained in biomechanics, can bring to a prosthetics program a much greater appreciation of the problems to be solved. He will be better equipped to evaluate the solutions that will be offered. But it seems inevitable that the solutions in their final development will be offered only by the engineer.</p> <h4>Acknowledgments</h4> <p>In the preparation of this article a number of people were exceptionally helpful. Special mention needs to be made of Rudolf Drillis, of the Prosthetic Devices Study, New York University, who provided much of the raw data and who was of particular assistance in review and discussion of the technical aspects of the material. Martin Koenig and Seymour Kaplan, both also of the staff of PDS-NYU, supplied the sections on capacitors and on be-low-knee sidebars, respectively. Various other members of the PDS-NYU staff read critically several sections of the manuscript. The Prosthetic Testing and Development Laboratory of the U.S. Veterans Administration supplied a number of the photographs, and George Rybczynski worked up all of the line drawings from rough sketches. To all these, and to others not mentioned specifically, sincere thanks are extended.</p> <p><b>References:</b></p> <ol> <li>Alderson, Samuel W., <i>The electric arm, </i>Chapter 13 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Alderson Research Laboratories, Inc., New YorkCity, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on <i>Research and development of electric arms and electric arm components, </i>1954.</li> <li>Alldredge, Rufus H., Verne T. Inman, HymanJampol, Eugene F. Murphy, and August W. Spittler, <i>The techniques oj cineplasty, </i>Chapter 3 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Amar, Jules, <i>Le moleur humaine et les bases scientifiques du travail professionel, </i>H. Dunod, Paris, 1914.</li> <li>Amar, Jules, <i>Organisation physiologique du travail,</i>H. Dunod et E. 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Chir., Supplement 39, Enke, Stuttgart, 1919.</li> <li>Schlesinger, G., <i>Die Mitarbeit des Ingenieurs bei der</i><i>Durchbildung der Ersatzglieder, </i>Verein. Deutsch. Ingen., Berlin Ztschr., 61:6 (1917).</li> <li>Steindler, Arthur, <i>Mechanics of normal and pathological locomotion in man, </i>Charles C Thomas, Springfield, Ill., 1935.</li> <li>Taylor, Craig L., <i>Control design and prosthetic</i><i>adaptations to biceps and pectoral cineplasty, </i>Chapter 12 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Taylor, Craig L., <i>The biomechanics of the normal and of the amputated upper extremity, </i>Chapter 7 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Technical Institute, Charlottenburg, Report of theSpecial Commission for Accident Prevention, <i>Merkblatter der Prufungsstelle fur Ersatzglieder, </i>Berlin, 1916-1917.</li> <li>Thomas, A., and C. C. Haddan, <i>Amputation prosthesis, </i>Lippincott, Philadelphia, 1945.</li> <li>University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs, </i>1947. Two volumes.</li> <li>Wagner, Edmond M., <i>Contributions of the lower-extremity prosthetics program, </i>Artificial Limbs, May 1954.</li> <li>Wagner, Edmond M., and John G. Catranis, <i>New</i><i>developments in lower-extremity prostheses, </i>Chapter 17 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Wilson, A. Bennett, Jr., <i>The APRL terminal devices,</i>Orthop. &amp; Pros. Appl. J., March 1952.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Public Law 729, Eightieth Congress, Second Session,Approved June 19, 1948.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New YorkCity, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Kaplan, S., Determination of dynamic loads and strains in below-knee artificial limbs, unpublished report, Prosthetic Devices Study, New York University, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. p. 20.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Drillis, R., Investigations on stability, unpublishedreport, Prosthetic Devices Study, New York University, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Marey, E., Mouvement, G. Masson, Paris, 1894.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Marey, E.-J., and G. Demeny, Eludes experimentales de la locomotion humaine, Compt. rend. Acad. d. sc, 106:544 (1887).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Hettinger, Th., and E. Muller, Der Einfluss des Schuhgewichtes auf den Energieumsatz beim Gehen und Lastenlragen, Arbeitsphysiol., 15:33 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,(report to the) Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alderson, Samuel W., The electric arm, Chapter 13 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New YorkCity, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alderson, Samuel W., The electric arm, Chapter 13 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New YorkCity, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prostheticadaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, January 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Schlesinger, G., Die Mitarbeit des Ingenieurs bei derDurchbildung der Ersatzglieder, Verein. Deutsch. Ingen., Berlin Ztschr., 61:6 (1917).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prostheticadaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, January 1954.</td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., The APRL terminal devices,Orthop. &amp;Pros. Appl. J., March 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Leonard, Fred, and Clare L. Milton, Jr., Cosmetic gloves, Chapter 9 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, January 1954.</td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr.,New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Technical Institute, Charlottenburg, Report of theSpecial Commission for Accident Prevention, Merkblatter der Prufungsstelle fur Ersatzglieder, Berlin, 1916-1917.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Borchardt, M., et al., eds., Ersatzglieder und Arbeit-shilfen, Springer, Berlin, 1919.</td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Schlesinger, G., Die Mitarbeit des Ingenieurs bei derDurchbildung der Ersatzglieder, Verein. Deutsch. Ingen., Berlin Ztschr., 61:6 (1917).</td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Technical Institute, Charlottenburg, Report of theSpecial Commission for Accident Prevention, Merkblatter der Prufungsstelle fur Ersatzglieder, Berlin, 1916-1917.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, HymanJampol, Eugene F. Murphy, and August W. Spittler, The techniques oj cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Schlesinger, G., Die Mitarbeit des Ingenieurs bei derDurchbildung der Ersatzglieder, Verein. Deutsch. Ingen., Berlin Ztschr., 61:6 (1917).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Borchardt, M., et al., eds., Ersatzglieder und Arbeit-shilfen, Springer, Berlin, 1919.</td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Schlesinger, G., Die Mitarbeit des Ingenieurs bei derDurchbildung der Ersatzglieder, Verein. Deutsch. Ingen., Berlin Ztschr., 61:6 (1917).</td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon,Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United States, Artificial Limbs, May 1954. p. 29.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Parmelee, Dubois D., U.S. Patent 37,637, February10, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Wagner, Edmond M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Wagner, Edmond M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Catranis, Inc., Syracuse, N.Y., Subcontractor'sFinal Report to the Advisory Committee on Artificial Limbs, National Research Council, Improved artificial limbs for lower extremity amputations, June 1954.</td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Wagner, Edmond M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954.</td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Wagner, Edmond M., and John G. Catranis, Newdevelopments in lower-extremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Leonard, Fred, and Clare L. Milton, Jr., Cosmetic gloves, Chapter 9 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A report on prosthesis development, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">In press as of this writing is a large collaboration on the general subject of deterioration prevention. Prepared by the Prevention of Deterioration Center, National Research Council, under the joint editorship of Glenn A. Greathouse and Carl J. Wessel, and titled Deterioration of Materials - Causes and Preventive Techniques, it is to be available this autumn from the publishers, Reinhold Publishing Corporation, New York. Many of the techniques described may find application in the field of prosthetics.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Committee on Artificial Limbs, National Research Council, Washington, D. C, Terminal research reports on artificial limbs [to the Office of the Surgeon General and the U.S. Veterans Administration] covering the period from 1 April 1945 through 30 June 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Elftman, H, The measurement of the external force in walking, Science, 88:152(1938).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">New York University, College of Engineering,Research Division, [Report to the] Special Devices Center, Office of Naval Research (Contract No. N6onr-279), Investigations with respect to the design, construction, and evaluation of prosthetic devices, June 1, 1949. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Eberhart, H. D., and V. T. Inman, An evaluation of experimental procedures used in a fundamental study of human locomotion, Ann. N. Y. Acad. Sci., 51:1213(1951).</td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Frank, Wallace E., and Robert J. Gibson, New pressure sensing instrument, J. Franklin Inst., in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,(report to the) Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Drillis, R., Investigation on axe and woodcutting,Latvijas Lauksaimnieks, Riga, 1935. In Latvian.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Since a constant valueâ€the distance the film is transported in an increment of time must always be subtracted from the measured horizontal displacement of a point.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Drillis, R., Chronocyclographische Arbeitsstudien, inPsychophysiologische Arbeiten, 1A, Riga, 1930.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Bernshtein, N., Die Kymocyclographische Methode der Bewegungsunlersuchungen, in Hndb. d. biol. Arbeitsmethoden, Lief. 263., Urban und Schwar-zenberg, Wien, 1928.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Muybridge, Eadweard, The human figure in motion,Chapman &amp;Hall, London, 1901.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Contini, R., and R. Drillis, Biomechanics, Appl.Mech. Rev., 7:49 (1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">New York University, College of Engineering,Research Division, [Report to the] Special Devices Center, Office of Naval Research (Contract No. N6onr-279), Investigations with respect to the design, construction, and evaluation of prosthetic devices, June 1, 1949. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Henschke, Ulrich K., and Hans A. Mauch, The improvement of leg prostheses, The Military Surgeon, 103(2) :135 (1948).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Elftman, H, The measurement of the external force in walking, Science, 88:152(1938).</td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Elftman, H., The force exerted by the ground in walking, Arbeitsphysiol., 10:485 (1939).</td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Elftman, H., The basic pattern of human locomotion, Ann. N. Y. Acad. Sci., 51:1207(1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Steindler, Arthur, Mechanics of normal and pathological locomotion in man, Charles C Thomas, Springfield, Ill., 1935.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Bernshtein, N., et al., Investigations on biodynamics of locomotion, Vols. 1 and 2, Moscow, 1935 and 1940. In Russian.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">Schede, Franz, Theoretische Grundlagen fur den Bau von Kunstbeinen; Insbesondere fur den Ober-schenkelamputierten, Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Schlesinger, G., Die Mitarbeit des Ingenieurs bei derDurchbildung der Ersatzglieder, Verein. Deutsch. Ingen., Berlin Ztschr., 61:6 (1917).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Martin, Florent, Artificial limbs, International Labour Office, Geneva, 1925.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Amar, Jules, Le moleur humaine et les bases scientifiques du travail professionel, H. Dunod, Paris, 1914.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Amar, Jules, Organisation physiologique du travail,H. Dunod et E. Pinot, Paris, 1917.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Gilbreth, Frank B., and Lillian M. Gilbreth, Motion study for the handicapped, G. Routledge and Sons, Ltd., London, 1920.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Fick, R., Handbuch der Anatomic und Mechanik der Gelenke unter Berucksichtigung der bewegenden Muskeln, G. Fischer, Jena, 1904-1911. Three volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Fischer, O., Theoretische Grundlagen fur eine Mechanik der lebenden Korper, mit speziellen Andwendungen auf den Menschen, B. G. Teubner, Leipzig and Berlin, 1906.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Borelli, Giovanni A., De motu animalium, Romae,1679. Two volumes. To be found in Pathologie de chirurgie, Vol. 2 of 3 vols., by Jean Baptiste Ver-duc, Paris, 1727.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Leonardo da Vinci, On the human body, C. D.O'Malley and J. B. DeC. M. Saunders, eds. Schuman, New York, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Bechtol, Charles O., The prosthetics clinic team, Artificial Limbs, January 1954. p. 9.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Faries, John Culbert, Limbs for the limbless, Institute for the Crippled and Disabled, New York, 1934.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>55.</b> </td><td class="clsTextSmall">Thomas, A., and C. C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Faries, John Culbert, Limbs for the limbless, Institute for the Crippled and Disabled, New York, 1934.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">A prosthetic device may be defined as one which attempts to restore, in function or appearance or both, any portion of the external human anatomical structure that has been impaired or removed owing to injury or to some degenerative process. In the broadest sense,therefore, artificial eyes and false teeth, as well as braces and artificial limbs, are prostheses. In the more commonly accepted sense, however, prosthetic devices usually refer to artificial arms and legs. The present discussion isconcerned with the role engineering must take in the development, fabrication, and application of artificial limbs.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Renato Contini, B.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Research Coordinator, College of Engineering, New York University; member, Upper- and Lower-Extremity Technical Committees, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Prosthetics Research and the Engineering Profession Creator An entity primarily responsible for making the resource Renato Contini, B.S.M.E. *