12 20 371 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. * https://staging.drfop.org/files/original/7821ac6162abe595c2139897f396fecc.pdf 0bcce967fcfd627030a029c02594ff9c https://staging.drfop.org/files/original/a66e029293ca734565f6b91200071432.jpg e0ab811142f0169b690b4e8859ef14b6 https://staging.drfop.org/files/original/345a8f6d88787fb5569177c99ca4d7f7.jpg d29c0ac6eb59475dc22409206e69c298 https://staging.drfop.org/files/original/12ca9adaacb8c06c5eb20427ab64f46d.jpg 8363fe5120fc99ac33a0eb179ae273ed https://staging.drfop.org/files/original/e9d94ea851ebdbb5e0a81ae9d61b845f.jpg a108f96e990025c40ff36607bc770296 https://staging.drfop.org/files/original/27ad3e7aadc5e665c134b448e33340c5.jpg ce9577ae574f7e521bf0a6dee646d735 https://staging.drfop.org/files/original/5bc094ab41ace0120e8ba8896408edb8.jpg 8d8a73eceb72ffa43d8d319a3dfd8f8d 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_03_005.pdf Text Any textual data included in the document <h2>Bilateral Knee Disarticulation, Immediate Post-Surgical Fitting: An Unusual Case Study</h2> <h5>William Susman&nbsp;</h5> <p>There are certain specific indications for utilizing immediate Post-Surgical Fitting (IPSF) in the postoperative management of the amputee. Clinical observations have substantiated that the constant even pressure provided by the immediate application of a rigid dressing to the residual limb helps control edema, supports circulation, and immobilizes tissue, subsequently minimizing the inflammatory process within the traumatized tissues, promoting wound healing, aiding good shaping of the limb and decreasing intrinsic pain and phantom sensations.</p> <p>The attachment of a pylon and prosthetic foot to the rigid dressing either immediately after the residual limb is wrapped or within a short post-operative period has been shown to enhance the positive effects of the rigid dressing and provide additional functional and psychological benefits. The gentle compression of residual limb tissue provided by closely monitored weight-bearing promotes wound healing by further decreasing edema. Ambulation resumes with a prosthesis sooner than with more conventional post-operative management approaches. Hospital stay is shortened, resulting in a more rapid return to previous personal, social and vocational activities. The amputee experiences an almost immediate resumption of function and although he or she will most likely undergo mourning for the lost limb, the actual commencement of rehabilitation is also experienced. In addition, the patient may be told pre-surgically the sequence of post-operative events so that the immediate introduction of functional prosthetic restoration can be hopefully, although cautiously, anticipated.</p> <p>It is readily acknowledged that IPSF is not appropriate for all circumstances. Cooperation among the rehabilitation team members from prosthetics, physical therapy, surgery, physiatry, and nursing, and a shared understanding of the technical aspects and goals of treatment, as well as individual proficiency in treatment procedures are necessary. The patient's understanding of the treatment approach and a willingness to adhere to treatment protocol are also essential. Lowered standards in any one of these areas may lead to injury of residual limb tissue, pressure sores, wound infection, hematoma, or necrosis and ultimately failure of the procedure and a real physical and psychological set-back for the patient. In addition, such complications are more difficult to perceive since the wound cannot be directly observed without disruption of the rigid dressing.</p> <h3>Patient History</h3> <p>With the above general review of the clinical advantages and precautions of IPSF in mind, it may be illustrative to present a case which is representative of these aspects of this treatment approach and yet extraordinary in view of the history and personal motivation for seeking treatment. The patient was a 28 year old woman who had contracted anterior poliomyelitis at the age of 16 months. She presented with stunted lower limbs, and muscle power at both hips was below functional levels except for the ability of the Sartorious muscle to withstand moderate resistance bilaterally. The knees and ankles were essentially flaccid. Sensation throughout the lower limbs was within normal limits. No contractures were evident and upper body strength was above normal.</p> <p>The patient wore bilateral, conventional KAFO's with knee locks and both ankles set in plantarflexion. Her feet rested on approximately nine-inch cork lifts set inside the calf sections of tall leather boots. (See <a href="/files/original/a66e029293ca734565f6b91200071432.jpg"><b>Fig. 1</b></a>) The patient related that as an adolescent she increased the lift height periodically to compensate for the lack of normal lower limb growth. She displayed excellent balance and body awareness, ambulated and climbed stairs and curbs independently with axillary crutches, and was able to negotiate sitting and rising from most types of seating. She led an active life as a college instructor and graduate student.</p> <p>The patient had a history of multiple surgical procedures during her teen-age years including a spinal fusion for scoliosis, subtalar arthrodeses, transplantation of hamstring tendons to the quadriceps mechanisms, and Achille's tendon releases bilaterally. She also had a history of left patella and right tibial fractures because of falls.</p> <p>The patient had been interested in seeking elective amputation of her legs for some time. Her chief reasons were of both a physical and a psychological nature. Pain in her feet resulting from the prolonged standing teaching required, and concern over the vulnerability of her legs to fractures from falling were related. Nevertheless, her foremost concern was for her appearance. Due to the devices she used to provide height and function she always felt compelled to wear floor-length dresses and was unable to interchange footwear (see <a href="/files/original/a66e029293ca734565f6b91200071432.jpg"><b>Fig. 1</b></a> &amp; <a href="/files/original/345a8f6d88787fb5569177c99ca4d7f7.jpg"><b>Fig. 2</b></a>). She wanted greater freedom in dress and to be able to have her legs seen without embarrassment over their appearance. She also found the braces and boots cumbersome and loose on her legs. Therefore, the patient came to the clinic seeking amputation primarily for reasons of cos-mesis and self-image.</p> <h3>Pre-Surgical Management</h3> <p>The rehabilitation team's decision to recommend bilateral knee disarticulation amputations was based upon the less traumatic nature of the surgical procedure, the good weight-bearing tolerance that has been demonstrated at this level, and another factor unique to this case. Due to the diminished growth of the patient's femurs, knee disarticulations would leave the amputation level proportional in length to long above-knee amputations. This level would provide a long lever arm for prosthetic control, yet not disturb anthropometric placement of the prosthetic knee and, consequently, proportional thigh and shank length.</p> <p>The IPSF approach was selected due to the patient's psychosocial background and to avoid the abrupt prolonged change in function that can result from bilateral surgery. With IPSF the patient would have a shorter period of disruption of her social and vocational success and her proud independence in activities of daily living. It would limit her experience as a wheelchair-dependent individual since two-legged function would never be completely interrupted.</p> <p>To determine whether or not knee disarticulation prostheses would provide function comparable to her presenting situation, temporary prostheses were fabricated to simulate post-surgical restoration. Plaster quadrilateral sockets with polyvinyl chloride (PVC) thermoplastic pylons, SACH feet and shoes were used. A cut-out in the posterior wall of each socket allowed the patient's shanks to protrude in the flexed-knee position, thus mimicking knee-disarticulation amputations (see <a href="/files/original/12ca9adaacb8c06c5eb20427ab64f46d.jpg"><b>Fig. 3</b></a>). A full functional evaluation showed no deficit in the patient's function from that previously demonstrated. Her ambulation pattern remained unchanged.</p> <p>From a psychological standpoint the patient was instructed to seek psychiatric consultation to closely examine her motivations for electing this treatment and to investigate her feelings regarding the possible failure of adequate functional prosthetic restoration. In addition, the patient discussed at length with team members the pros and cons of her decision and the possible sequela of amputation surgery such as wound-healing difficulty, residual limb pain, phantom sensations, less than optimal function, and prosthetic maintenance.</p> <h3>Post-Surgical Management</h3> <p>After closure of the amputation wounds and placement of drains, stump socks were applied over the surgical dressings on both limbs. A distal pad was held in place while a plaster wrap of each residual limb was done. Each plaster socket was hand-molded to provide a quadrilateral shape and ischial seat. Supracondylar purchase and belts over the iliac crests provided suspension. Pylons were not added at this time since the PVC tubing to be used requires heating before application.</p> <p>On post-operative day (POD) #2 the surgical drains were removed. On POD #5, PVC pylons and SACH feet with shoes were applied. To control and monitor the degree of weight-bearing, a tilt table and two scales were used (see <a href="/files/original/e9d94ea851ebdbb5e0a81ae9d61b845f.jpg"><b>Fig. 4</b></a>). Two five minute-periods at ten pounds of weight-bearing were allowed initially. On POD #6 the patient was seen twice during the day and stood on scales in the parallel bars (see <a href="/files/original/27ad3e7aadc5e665c134b448e33340c5.jpg"><b>Fig. 5</b></a>). Two daily sessions were continued and weight-bearing was increased to 20 pounds on the right limb and 15 pounds on the left, being limited due to pain. Throughout this period the patient complained of phantom sensations and residual limb pain which increased markedly at night. The first cast change was done on POD #12 at which time the stitches were removed. The following day the patient began ambulation in the parallel bars with weight-bearing to tolerance. On POD #15 the patient was given a walker for bedside use and on the following day was able to ambulate independently outside the parallel bars with axillary crutches and a four-point gait, testimony to her longstanding adaptation to her physical deficits and her determination to succeed. At this time the patient was transferred from the acute care setting to an inpatient rehabilitation bed.</p> <p>Four weeks after surgery the patient was casted for her definitive prostheses. At five weeks she was fitted with the sockets and locked knees and returned to the parallel bars for ambulation training. During the sixth week, first one and then both prostheses had safety knees added. By the ninth post-operative week the patient had returned to the use of crutches and had received training in elevation activities and ambulation on different terrains.</p> <p>The prostheses were delivered at the end of the ninth post-operative week and consisted of quadrilateral total contact sockets with semi-suction and supracondylar suspension. Windows were not cut in the sockets for donning but rather a soft insert was fabricated which was compressed during donning and re-expanded within the socket to grip the femoral condyles. The patient rejected the use of any suspension belts as uncosmetic. Otto-Bock's modular endoskeletal safety knees and components, and SACH feet were used. (See <a href="/files/original/5bc094ab41ace0120e8ba8896408edb8.jpg"><b>Fig. 6</b></a>).</p> <h3>Follow-Up</h3> <p>The patient returned to her former daily interests and activities and maintained her ambulatory status. Having worn the prostheses for approximately a year and a half she returned for re-evaluation. Changes in residual limb shape due to shrinkage necessitated the fabrication of a second pair of prostheses which she currently uses.</p> <h3>Summary</h3> <p>This case well illustrates the advantages and appropriate application of the IPSF approach to amputee management. The patient was able to have both limbs amputated at once and yet hasten the rehabilitation process. The physical debilitation and psychological shock associated with such a radical intervention was minimized by her youth, determination, and cooperation with the rehabilitation team. A deeply felt desire to improve her quality of life was satisfied with minimal disruption of what was an already successful life style in the face of life-long physical difficulties.</p> Page Number(s) 5 - 7 Year 1979 Volume 3 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1979_03_005/1979_03_005-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1979_03_005/1979_03_005-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1979_03_005/1979_03_005-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1979_03_005/1979_03_005-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1979_03_005/1979_03_005-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1979_03_005/1979_03_005-6.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Bilateral Knee Disarticulation, Immediate Post-Surgical Fitting: An Unusual Case Study Creator An entity primarily responsible for making the resource William Susman  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 Text Any textual data included in the document <h2>Building A Positive Self Image In Patients</h2> <h5>Mary Point Novotny, RN., MS.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><i>"Poems are made by fools like me, but only God can make a tree. "</i></p> <p>Momentary reflection on this literary work brings into perspective the complex task of rebuilding the image of one who has lost a limb. It is a task which requires not merely the professional and technical abilities of the prosthetist, but also a personal concern for the self image of the patient.</p> <p>Body image is the constantly changing mental picture one has of his individual, body appearance. It develops through reflected perceptions about one's body and sensations originating from internal and external stimuli as the individual adapts to a kaleidoscopic variety of living activities. All too frequently body image is overlooked in the rehabilitation plans for a patient with chronic disease, disability, or surgical intervention, because physical diagnosis and mechanical advances have become paramount in our fast-paced acute care settings. The concept is so basic, it is not hard to see why it is overlooked; yet, if one begins to examine the personal effect of alterations, such as mastectomy, amputation, colostomy or stroke, we can begin to identify with the grief, anxiety and fear accompanying the loss of a body part and the ensuing alteration in functional ability.</p> <p>Research of Schilder and others has shown that since body image is primarily a psychological entity, alterations in it are extremely subjective experiences which vary in intensity, dependent on the unique characteristics of each individual, in three distinct categories. These sources of self image include:</p> <ol> <li> <p>Past experiences which are gradually built up through the years from physiologic, psychologic, and social components, organized and integrated by the central nervous system.</p> </li> <li> <p>Social interactions which include the reaction of significant others and of society to the person's body, as well as his own interpretation of that reaction.</p> </li> <li> <p>Current sensations, such as perceptions of physical appearance, alterations incurred, and images, attitudes and emotions regarding the body.</p> </li> </ol> <p>Because these components are subject to constant revision, the body image of any individual is constantly changing. Survival of a healthy self image is determined by the amount of flexibility available to adapt to new situations and one's ability to realize that the image he projects to others is the one others see.</p> <p>The loss or absence of a limb, therefore, has varying consequences dependent on the individual and his stage in the life cycle. Studies have shown that an individual is capable of incorporating a firmly-attached object, such as a prosthesis, cane, etc., into his self image. This seems to be particularly evident with congenitals fitted very early in life, before developing unilateral coordination and functional abilities. Of the acquired amputees, early fitting and functional use of the prosthesis also increases the chances of reconstructing a complete image of one's self. A juvenile amputee, up to 3 years old, is not able to consciously deal with "loss," and congenitals, up to 6 years old, generally do not perceive themselves as "different." Yet amputation in later years results in the patient undergoing the process of grief, which includes feelings ranging from denial, anger and hopelessness, to reorganization and adaptation.</p> <p>Schilder places a positive emphasis on the necessity for communication of these feelings. He believes we constantly construct, dissolve, and reconstruct our own body image as well as the body images of others. He points out that the tendency to destroy a previous body image is essential to acceptance of a new, altered image.</p> <p>This appears to be a critical area in successful care of any patient. Because most amputees and their families have limited, if any, exposure to others with similar problems, their greatest fears are of the unknown. Will amputation ruin my personal life? End my career? Leave my child handicapped and dependent? With little factual information in the areas of prosthetics and a body image distortion that has not been reconciled, the patient frequently arrives at the professional door seeking an opportunity to communicate his fears and frustrations to an individual who will, hopefully, aid in the design of a prosthesis and promise for the future. While personal style and approach vary with the needs of individual patients, certain factors should be considered in dealing with an amputee: personality type, expectations, stage of adjustment, support system, and medical conditions.</p> <p>Recent amputees, for example, would benefit from an opportunity to see and touch a prosthesis, with a complete explanation of the stages of fitting and fabrication to limb completion. Be open and honest with patients, keeping in mind that cosmesis may be a priority for some while function and durability are essential for others. While no prosthesis will ever replicate human functioning, once you determine what a patient expects to achieve through prosthetic usage, you can then fulfill his needs and likewise increase his acceptance of an artificial limb.</p> <p>Parents of a congenital amputee frequently need much more support than the child who can learn to lead a "normal" life if allowed to develop and achieve, unhampered by "concerned" adults who would treat him "special/different."</p> <p>Meeting with another amputee who has mastered life with a prosthesis can have a very positive effect on the older child or adult who is attempting to re-adjust his self image. Family members or significant others should be encouraged to be present at such meetings, as the fear of new amputees is generally in direct proportion to the acceptance reaction of those whose opinion he values most. Seeing is believing!, and once normal functioning in everyday living is explained, there will be less chance of the amputee being treated as a "handicapped" individual, which he is not.</p> <p>Lastly, bear in mind that you are a very important person in the eyes of your patient. This is because you are now the professional most heavily relied on for advice, support and adjustment in the initial period of building a new self image. So grin and bear those minor repairs, etc., keeping in mind that a well-worn prosthesis is your best measure of success. Function and form go hand-in-hand in establishing a sense of completeness in self image.</p> <p>While you may not have the power of our creator, you can surely have a part in the final design of his creations.</p> <p><b>References:</b></p> <ol> <li>Fishman, Sidney, "Behavioral and Psychological Reactions of Juvenile Amputees." Reprinted from <i>Limb Development and Deformity: Problems of Evaluation and Rehabilitation</i>, Charles C. Thomas, Publisher, 400-407.</li> <li>La Fleur, Jean and Novotny, Mary, "A Study of Human Figure Drawings by Amputee Children and Verbalization of their General Adjustment," Masters' thesis, De Paul University, 1978.</li> <li>Schilder, Paul, <i>The Image and Appearance of the Human Body</i>, International Universities Press, Inc., New York, 1950.</li> <li>Schilder, Paul "Symposium on the Concept of Body-Image," Nursing Clinics of North America, VII (December, 1972).</li> </ol> <em><b>*Mary Point Novotny, RN., MS. <br /></b>Nurse-educator for health professionals; Consultant, University of Illinois at the Medical Center, Amputee Clinic, Chicago, Illinois; has lectured across the country on body image alterations and the role of professionals in assisting patients with adjustment.</em> Page Number(s) 1 - 2 Year 1979 Volume 3 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Building A Positive Self Image In Patients Creator An entity primarily responsible for making the resource Mary Point Novotny, RN., MS. * https://staging.drfop.org/files/original/52f7d266c544d7b057ce3f61ff421222.jpeg c442d8b15660c8c79d4df71065ad319d https://staging.drfop.org/files/original/cecb22a00897ba34f840608eed75219c.jpeg 1dad83a740d94fdf8668227e6d78ec45 https://staging.drfop.org/files/original/4840e49061168dd070be6b5f910136d0.jpg bc55027014a65d697e997b2b937c2821 https://staging.drfop.org/files/original/23866a9c822d0eb399417ae71c53afde.jpg de5956ea11e10351dd0edbc4eb3964c7 https://staging.drfop.org/files/original/9654f5f19860f0e88b033d410589d261.jpg 32b34b3e40ced6807f3639dbaa1dc46a https://staging.drfop.org/files/original/208783458811d4c978eb476b9ddc2a62.jpg 1c8a4fce56522125a18f83d04e40f32b 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 Text Any textual data included in the document <h2>A Solution For Split-Size Shoes</h2> <h5>Eugenio Lamberty&nbsp;<a style="text-decoration: none;">*</a><br />John Milani&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Despite the almost daily occurrence of new concepts and improvements in Orthotics, many problems remain to be solved. A significant number of these problems result from congenital factors or acquired diseases during childhood. The severely deformed leg and foot have been of major concern, particularly when the deformed foot has been significantly shorter in length than the sound foot (<a href="/files/original/52f7d266c544d7b057ce3f61ff421222.jpeg"><b>Fig. 1</b></a>).</p> <p>In some cases the feet may vary in shoe size by as much as three or four sizes (<a href="/files/original/cecb22a00897ba34f840608eed75219c.jpeg"><b>Fig. 2</b></a>). This becomes quite expensive for the patient, who must either purchase two pairs of shoes to fit each foot properly or custom-made shoes. To reduce this financial burden and yet greatly improve cosmesis, a method of fabrication had to be found whereby the patient would be required to purchase only one pair of ordinary shoes that would be the size of the normal foot.</p> <p>A shoe filler (<a href="/files/original/4840e49061168dd070be6b5f910136d0.jpg"><b>Fig. 3</b></a>), conceived, designed and developed by the authors through the Veterans Administration Prosthetics Center, has solved this problem. This device is placed in the shoe (<a href="/files/original/23866a9c822d0eb399417ae71c53afde.jpg"><b>Fig. 4</b></a>) to take up the excess space of the shortened foot. Then the shoe insert portion of the orthosis is placed into the filler and shoe (<a href="/files/original/9654f5f19860f0e88b033d410589d261.jpg"><b>Fig. 5</b></a>). This results in a highly-cosmetic arrangement (<a href="/files/original/208783458811d4c978eb476b9ddc2a62.jpg"><b>Fig. 6</b></a>) that is also financially beneficial to the patient.</p> <h3>Method of Fabrication</h3> <p>To construct the shoe filler, proceed as follows:</p> <ol> <li> <p>Secure a SACH foot that will fit the size shoe to be worn by the patient. Ensure that the plantar surface of the SACH foot is flat, to prevent the shoe insert portion of the orthosis from rocking. An immediate post-op foot can be used.</p> </li> <li> <p>Vacuum mold the SACH foot with 1/4-inch low density polyethylene. Polyethylene is ideal since it provides good strength and flexibility.</p> </li> <li> <p>When the plastic has cooled, remove it from the SACH foot and initially trim it so that it does not protrude beyond the borders of the shoe. Refer to <a href="/files/original/4840e49061168dd070be6b5f910136d0.jpg"><b>Fig. 3</b></a>.</p> </li> <li> <p>Use standard methods and techniques to fabricate the orthosis.</p> </li> <li> <p>Place the orthosis on the patient. Then place the orthosis on the patient into the shoe and shoe filler while ensuring that the shoe filler does not hinder this process.</p> </li> <li> <p>Further trim the shoe filler along its medial and lateral sides, behind what would normally be the metatarsal heads of the sound foot. This allows the normal toe break of the shoe to function properly and thereby ensure unrestricted motions of the ankle and foot.</p> </li> </ol> <h3>Notes</h3> <p><i>To prevent the orthosis from slipping forward in the filler, the filler should curve around slightly, onto the dorsum of the foot. Refer to<a href="/files/original/4840e49061168dd070be6b5f910136d0.jpg"> <b>Fig. 3</b></a>. This trim, together with a properly laced shoe or a shoe laced with micro straps, should provide the required counterforce to prevent the orthosis from slipping forward in the filler. It is further noted that one patient, who had worn the new orthotic system for one month, required foam padding that was placed anteriorly into the filler to prevent the orthosis from slipping.</i></p> <h3>Summary</h3> <p>The design and development of a shoe filler when bracing the shortened foot is cosmetically appealing and financially beneficial to the patient who is consequently required to purchase only a single pair of ordinary shoes. In addition, fabricating the filler is a relatively simple procedure for the orthotist.</p> <h3>Acknowledgements</h3> <p>The authors would like to express their appreciation to Max Nacht, Technical Writer-Editor, VAPC, for his cooperation and assistance in preparing this article; and to Charles Berman and Anthony Morales, Photographers, VAPC, for their fine photographic work.</p> <div style="width: 400px;"><em><b>John Milani<br /></b>Orthotist-Prosthetist, Veterans Administration Prosthetics Center, 252 Seventh Avenue, New York, NY 10001<br /><b><br />*Eugenio Lamberty<br /></b>Orthotist. Veterans Administration Prosthetics Center, 252 Seventh Avenue, New York, NY 10001</em></div> <br /> <div style="width: 400px;"></div> Page Number(s) 3 - 4 Year 1979 Volume 3 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1979_04_003/1979_04_003-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1979_04_003/1979_04_003-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1979_04_003/1979_04_003-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1979_04_003/1979_04_003-4.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 5 http://www.oandplibrary.org/cpo/images/1979_04_003/1979_04_003-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1979_04_003/1979_04_003-6.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Solution For Split-Size Shoes Creator An entity primarily responsible for making the resource Eugenio Lamberty * John Milani * https://staging.drfop.org/files/original/557e23aa1d087b7c2f923c835fba0ffc.pdf ad1cf6296e80bdb87d62d1953933265f Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1979_04_004.pdf Text Any textual data included in the document <h2>Phantom Limb Pain</h2> <h5>Gustav Rubin, M.D., FACS&nbsp;<a style="text-decoration: none;">*</a></h5> <p>This article is reprinted with authors permission from the Feb. 1979 issue of "The Amp." Doctor Rubin discusses Phantom Limb Pain on a basic and objective level that is easily understandable, especially to the amputee.</p> <p>This column was prompted by a letter from John Riegel, N.S.O., of Cleveland, Ohio. Let me expand on some of the points he wanted discussed.</p> <p><i>First</i>: A definition of terms. <i>Phantom Sensation</i> is the feeling that the absent limb is still there but not necessarily painful. <i>Phantom pain</i> is the same feeling but the absent limb (or part of it) is painful. Almost every amputee experiences phantom sensation but statistically only five to ten percent have varying degrees of phantom pain.</p> <p><i>Second</i>: Some of my medical colleagues still think that this type of pain is imagined by the amputee. It is not. It is a very real pain and can sometimes be so severe and continuous as to be disabling. However, in the great majority of instances it is intermittent, although it may last for days (and nights) at a time.</p> <p><i>Third</i>: The cause and cure are unknown, just as the cause and cure of the common cold, and even cancer, are unknown. We have difficulty satisfactorily treating such ordinary conditions as chronic arthritis and severe flat feet, so the difficulty in adequately treating phantom limb pain should not be surprising.</p> <p><i>Fourth</i>: The Cause. There are many theories about the cause. None is completely explanatory. As a working basis, the theory most acceptable to me is based on the fact that there is an area in the central nervous system which is a sort of way-station for messages on the way to our consciousness where they can be interpreted, in this specific case, as pain. Signals can either go up from the absent limb, or down from the conscious part of the brain (cortex) and affect the way-station. Sometimes if an amputee talks about or thinks about phantom pain he will trigger an episode. The signals that go up can be described as either "excitatory" or "inhibitory." These terms require no explanation. The inhibitory effect is partly <i>maintained</i> by messages from the skin. If a leg is amputated then a large part of the inhibitory messages that would ordinarily come from the skin of that part will be absent. The excitation messages will dominate and pain could be experienced. A way of thinking about the effect of inhibitory messages from the skin could be exemplified by the instance of the person who bumps his shin and then <i>rubs the skin</i> over a broad area to relieve the pain. He sends skin inhibitory messages to the brain to relieve the pain.</p> <p><i>Fifth</i>: Treatments. Many different methods of treatment have been used. It is a simple fact that, when there are many ways to treat a condition, not one of them is much good. If there was one good way that would be the method used.</p> <p>Treatments attempted have ranged from the use of a freezing spray, to injections of novocaine, either locally or into the lower spine, cutting the nerves to the stump, cutting the roots of the nerves near the spinal cord, cutting the nerve pathways in the spinal cord itself, and even cutting out parts of the brain. Drugs, acupuncture, biofeedback, hypnosis, electrically stimulated implants around the nerve or in relation to the spinal cord; and even reamputation have been employed as methods of treatment.</p> <p>The most recent, and, at this writing, the most popular approach has been the use of transcutaneous electrical nerve stimulation (TNS or TENS). In contrast to many of the other previously mentioned methods it is harmless to the amputee. It is not destructive. Sometimes wrapping the stump tightly with an Ace bandage or percussing the stump will help. Putting the leg back on will often help. As one amputee said he wraps the stump and just "lies there and curses."</p> <p>If the pain in unrelieved by simple, non-destructive, non-damaging techniques, the amputee should be referred to one of the highly specialized pain centers. There are now many of these throughout the country.</p> <em><b>*Gustav Rubin, M.D., FACS <br /></b> V.A. Prosthetics Center<br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 4 - 5 Year 1979 Volume 3 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Phantom Limb Pain Creator An entity primarily responsible for making the resource Gustav Rubin, M.D., FACS * https://staging.drfop.org/files/original/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/9e60ebed5692df9e5fe07e6d4cd87a96.pdf 77971953d21518efcd4221380ba3b8a3 https://staging.drfop.org/files/original/c2545799ce5601d736f2cd4f1463a521.jpg 16fbd70081beef02a934947a081b6280 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_001.pdf Text Any textual data included in the document <h2>Introduction</h2> <p>In December of 1969 the Committee on Prosthetic-Orthotic Education of the National Academy of Sciences initiated publication of "NEWSLETTER .... AMPUTEE CLINICS" in an effort to disseminate timely information to amputee clinic teams throughout the country and to provide a vehicle for the interchange of information among clinicians responsible for the care of amputees.</p> <p>The Newsletter met with immediate success and was published every two months until 1975 when policy changes at the National Academy of Sciences precluded publication of the Newsletter .... Amputee Clinics. The final issue, Vol. VIII No. 1 has been published with a date of July 1976 after a hiatus of nearly a year.</p> <p>Because so many members of the American Academy of Orthotists and Prosthetists and their colleagues on the clinic teams that they work with have voiced regret that the forum provided by the Newsletter, no longer exists the Board of AAOP, after a study, determined that the majority of the membership were in favor of assuming responsibility for continuation of this type of publication. Therefore, the board of the AAOP has made the decision to proceed on the basis of four issues per year, initially, and to expand the coverage to include orthotics.</p> <p>It was hoped that an announcement concerning the plans of the AAOP would be made in the final edition published by the NAS, but since such could not be effected this abbreviated edition is being sent to those who in the past have received the "Newsletter-Amputee Clinics" to determine the size of the circulation that can be expected.</p> <p>Our editor for the new publication will be Mr. A. Bennett Wilson, Jr. who helped formulate the original newsletter while in his previous position as Executive Director of CPRD. Mr. Wilson is now acting Director of Training at the Krusen Research Center of the Moss Rehabilitation Hospital in Philadelphia, Pa. The editorial board will be headed by Charles H. Epps, Jr., M.D. of Washington, D.C. Dr. Epps is chief of the Juvenile Amputee Clinic at D.C. General Hospital. Mr. Robert B. Peterson, R.P.T., Supervising Physical Therapist for Hospital Services, Maryland Department of Health and Mental Hygiene and the undersigned will also reside on the board. This group plans to seek technical consultation with representatives of the Veterans Administration Prosthetic Center and the Rehabilitation Services Administration of Health, Education and Welfare on all applicable subject matter.</p> <p>We would also like to thank Mr. Anthony Staros, Director of the Veterans Administration Prosthetic Center for his assistance and guidance in planning this new publication.</p> <p>To begin, four issues per year are contemplated. The initial subscription rate will be $8.00 per year. Each issue will contain short articles on both Prosthetics and Orthotics. AAOP members will receive their copies as a service to members. Prices will be adjusted to reflect costs without profit to the AAOP.</p> <p>A subscription order blank is included in this issue for the use of those who are not members of AAOP. Your participation will help us in assuring the long term success of this publication.</p> <p><a href="/files/original/c2545799ce5601d736f2cd4f1463a521.jpg"><b>Joseph M. Cestaro: AAOP President</b></a></p> Page Number(s) 1 - 1 Year 1977 Volume 1 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1977_01_001/1977_01_001-1.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 Introduction 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/cd2773276c38e31c5de8654b32560573.pdf 87b82fb3ff0928e5a56676a56b7cbdcf https://staging.drfop.org/files/original/a78493f4da7fe644e100ca7cd8f56d1e.jpg e073105d25ced27a5e34a054493e1b9b 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 Fig. 1. Common type of fitting stool in use as early as 1915. https://staging.drfop.org/files/original/08467dd5927652e3f141a24cfd88006d.jpg 6b207b6637a053feab492dfd5671d043 https://staging.drfop.org/files/original/70ce2e00269500442488030867f39c27.jpg 89f554cdd092a9be038f0d15dd877649 https://staging.drfop.org/files/original/dccd360bb421f24a14130d0561616df2.jpg 80c4e525bbf609f14fb7e4a1ab680320 https://staging.drfop.org/files/original/7fb4c0a612ed285e0c2e9087a7e28b62.jpg 76427ad85f7535e83fe3bfd90e193887 https://staging.drfop.org/files/original/0d84a2e1a512d5f9cb9193668acd65ae.jpg bed71c0fb716d2bdf7f019f1e9eb4b37 https://staging.drfop.org/files/original/97791855ac3600156a68a12b7c972dd5.jpg 2b164807888f99334218d0f7f47b8f17 https://staging.drfop.org/files/original/da317ff46ffe02bafb48463f608f475d.jpg 6810da6531996bb2b6c2be42269f130d https://staging.drfop.org/files/original/963ad811431eb69af334aa267224b273.jpg 1e1a95fac1029fec7c7f718ecb7e4a94 https://staging.drfop.org/files/original/2841d434985c67fafb98c4d6d708fb1d.jpg 674642f0b1ea2c951c02a34b642778c3 https://staging.drfop.org/files/original/4f883a6fd1a5b6708ec59964f8f2a42b.jpg 9c29c06be2efb1a6f591ec3270228eb0 https://staging.drfop.org/files/original/c80c09227dc29bd5b10a5c5d39e6a560.jpg 44accb51743d8c7c84cfc4df44fbde0b https://staging.drfop.org/files/original/c6663fb4bff4e66ca21d755e4fd2bce7.jpg 496e66c530a145b0109ce9a5596bc33e https://staging.drfop.org/files/original/d4d6515876785c9dc32270fdd4c7af27.jpg 1a33a5ea6da53b83e55a91265fa656e3 https://staging.drfop.org/files/original/4f02159f1f7aefd8f42f385c1a097c7a.jpg 9e0b9a2c892c1167b0652e3e195a4a8c DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_020.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 20 - 28 Text Any textual data included in the document <h2>Mechanical Aids for Alignment of Lower-Extremity Prostheses</h2> <h5>Charles W. Radcliffe, M.S.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>If a prosthetic device is to give optimum service to the amputee, it must always be properly fitted, regardless of its mechanical excellence. This is especially true in the case of the lower extremity, where the prosthesis must function continually and where poor fit or alignment will lead quickly to rejection of the device by the wearer. Among prosthetists there seems to be general agreement that by far the most important factors in the success of any artificial leg relate to fit and alignment on the subject. Fit and alignment are usually considered together, since they are mutually interdependent.</p> <p>Over the years many different mechanical devices to aid in fitting and alignment of lower-extremity prostheses have been developed to help in the application of one or another particular set of alignment principles in use by individual fitters. Others of these devices are more general in application and are adaptable for use by any prosthetist regardless of the particular alignment principles he advocates. In every case, however, an attempt has been made to improve the fitting and alignment technique by adopting one definite set of principles and using a mechanical device to aid in the application of those principles.</p> <h3>Historical Background</h3> <p>In 1919 Franz Schede<a></a> wrote <i>Theoretische Grundlagen fiir den Bau von Kunstbeinen, </i>a work generally considered to be one of the first important contributions in the field of prosthetic devices. In this volume Professor Schede established for the alignment of lower-extremity prostheses a set of principles based on application of known laws of mechanics. He was particularly concerned with alignment of the joints in a lower-extremity prosthesis so as to provide sufficient stability during the stance phase. As a result of the interest in his work, there was developed the so-called "plumb-line" method of alignment, a method which, essentially, assumes that the prosthesis carries weight along a vertical plumb line, the elements of the prosthesis then being arranged using this line as a reference. Still in general use throughout Europe and the United States, this system involves the problem of determining the location of the plumb line in the socket so that it can be extended down to the foot and used as a reference. For this purpose, many mechanical devices have been used.</p> <h4>The Fitting Stool</h4> <p>One of the oldest devices to aid in the fitting of lower-extremity sockets is the common fitting stool (<b>Fig. 1</b>). This device was well known as early as 1915 and is still in general use. When it is used to aid in establishing a "weight line," wedges are employed to tilt the socket block until the desired orientation is achieved. The hydraulic fitting stool of Habermann (<b>Fig. 2</b>) is a recent refinement. It requires that the location of one point on the weight line be assumed, usually at the socket brim, and that the plumb line be drawn vertically downward from this point.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 1. Common type of fitting stool in use as early as 1915.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 2. Modern fitting stool with hydraulic height adjustment. Manufactured in Germany by Habermann.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p><i>Pivot-Point Balancing Devices</i></p> <p>In an attempt to eliminate the necessity for the assumption of one point on the weight line of the socket, various modifications of the standard fitting stool have been tried.<a></a> <b>Fig. 3</b> is a schematic diagram of a fitting stool which uses a fixed ball as the lower contact point. The point of contact of the ball locates one point on the plumb line, which is then extended upward through the socket.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 3. Point-balance fitting stool with a fixed ball as the supporting point</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>In a further refinement of this technique, introduced into this country in 1947, the plumb line is located at the intersection of two vertical planes (<b>Fig. 4</b>). The lower edge of each plane is determined by use of a triangular block giving a line contact along the bottom of the socket.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 4. Line-balance fitting stool with triangular block as a support.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>Another pivot-point balancing device (<b>Fig. 5</b>) locates a similar point near the top of the socket block by supporting the socket in a clamp which pivots about a fore-and-aft axis and allows the pivot point to be moved medially or laterally as desired. Weight is transmitted to the floor through a connecting pylon.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 5. Pylon-type fitting stand with support at a point near the top brim of the socket.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p><i>Vise-Type Fitting Stand</i></p> <p>Another school of thought in the alignment of the above-knee socket believes that establishment of a plumb line is not as important as is establishment of the proper inclination of the socket in space. In the vise-type fitting stand (<b>Fig. 6</b>) of Habermann<a></a>, the socket can be adjusted in inclination to any position desired. Once the proper inclination and height have been established, the socket is clamped rigidly in space, and the amputee "marks time" in the socket. If necessary, changes are made until the amputee is able to bear weight comfortably and to use his stump efficiently in the control of body movements. After an arbitrary plumb line has been assumed, the optimum socket orientation is incorporated into the final prosthesis.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 6. Vise-type fitting stand.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>All of these mechanical aids have helped in the so-called "static alignment" of the prosthesis, a condition which determines the stability of the artificial limb in the stance phase. The "dynamic" factors, which affect the swing phase of the prosthesis, and which account for the differences between the static and dynamic conditions in the stance phase, are adjusted as necessary after the amputee is walking on the rough leg.</p> <h4>Schneider's "Gehmaschine"</h4> <p>Hans Schneider<a></a> of Nuremberg, Germany, has long advocated the use of an adjustable leg or "walking machine." Essentially, his method is to allow the amputee to walk on a trial prosthesis (<b>Fig. 7</b>), changes being made empirically until the alignment is considered satisfactory. Then, as the optimum alignment is being duplicated in the final prosthesis, various measurements are read from the adjustable leg and a measuring stand (<b>Fig. 8</b>). It is claimed that from these measurements the fit and alignment can be duplicated in additional prostheses ordered later.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 7. Schneider's "Gehmaschine."</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 8. Schneider's alignment stand.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h3>The University of California Above-Knee Adjustable Leg</h3> <p>A study of methods for alignment of the above-knee suction-socket prosthesis was started at the University of California, Prosthetic Devices Research Project, in the autumn of 1946. As one of the first phases of investigation, two adjustable prostheses were designed and constructed. These experimental devices (<b>Fig. 9</b> and <b>Fig. 10</b>) allowed adjustment of a large number of variables, and data were collected having to do with the effect of a change in one of the many alignment variables upon the behavior of the prosthesis<a></a>. It soon became apparent that devices of this nature were not only useful as research instruments but that they might also have some practical use as limbshop tools. Accordingly, there was designed and constructed for limbshop purposes a series of models of a simplified device in- corporating only those adjustments found most important, as determined using the research devices.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 9. Experimental adjustable above-knee leg used for research at the University of California.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 10. Experimental adjustable below-knee leg (University of California).</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>The initial effort was to develop a device for alignment of the above-knee suction-socket prosthesis. Out of this work came the above-knee adjustable leg shown in <b>Fig. 11</b>. Several units of this design were used in the experimental program at the University of California and were given shop trials in the San Francisco Bay Area. They were found very useful in the alignment of above-knee prostheses in the shops and, in addition, were widely used for demonstration of alignment principles. But use of the above-knee adjustable leg was then limited because of the difficulty in transferring the optimum relationships from the adjustable trial prosthesis to the final setup.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 11. The UC adjustable leg.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h3>The UC Alignment Duplication Jig</h3> <p>To fill this need, the designers produced the Alignment Duplication Jig (<b>Fig. 12</b>), which is essentially a rather specialized set of clamps and an associated saw guide to maintain the socket, knee axis, ankle axis, and foot in a fixed position, thus permitting the temporary adjustable knee to be removed and replaced with wood, plastic, or metal structural members and joints. Three models of the alignment duplication jig were constructed and loaned, along with models of the above-knee adjustable leg, to the representatives of the Orthopedic Appliance and Limb Manufacturers Association who were then serving as the Technical Advisory Committee to the Lower-Extremity Technical Committee of ACAL. The representatives of the limb industry were unanimous in their conclusion that use of these devices offered considerable advantage to the prosthetist for alignment of all above-knee suction-socket prostheses.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 12. The alignment duplication jig.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>On the basis of the experience gained, the above-knee adjustable leg was redesigned, as shown in <b>Fig. 13</b>, and drawings for both the adjustable leg and the duplication jig were made available to the artificial-limb industry.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 13. Revised design of the adjustable leg as released to the artificial-limb industry.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>Devices similar to those shown in <b>Fig. 12</b> and <b>Fig. 13</b> are now being manufactured<a style="text-decoration: none;">*</a> and can be purchased by limbshops.</p> <h3>The UC Combination Adjustable Leg</h3> <p>Because of the acceptance of the above-knee adjustable leg during its trial period of limbshop use, the Technical Advisory Committee of OALMA recommended that a similar unit be developed for alignment of below-knee prostheses. As a result, the combination above-knee/below-knee adjustable leg (<b>Fig. 14</b>) was designed and constructed at the University of California. Its use as a below-knee alignment device is indicated in <b>Fig. 15</b>. The principal advantage of this unit over previous designs is that no tools are required in making adjustments.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 14. Combination above-knee/below-knee adjustable leg in use as a trial above-knee prosthesis</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 15. Combination above-knee/below-knee adjustable leg in use as a trial below-knee prosthesis.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h3>Use of the Adjustable Leg and Alignment Duplication Jig</h3> <p>The basic difference in the use of the University of California alignment devices, as compared with Schneider's apparatus, lies in the manner of duplication of the optimum alignment. The adjustable leg is used in much the same manner as is Schneider's device. A set of guiding principles for filling and alignment has been established, and the adjustable leg is used as a means of applying these principles to the conditions existing with a particular amputee. But the devices serve as shop tools only, and any set of principles can be applied by the prosthetist.</p> <p>In the use of the alignment duplication jig, the (assumption is made that the optimum alignment will be influenced considerably by the fit of the socket. Since subsequent sockets for a particular amputee are not apt to be exactly alike, it is considered unnecessary to try to duplicate in all later prostheses the alignment of the first. Each socket is considered as a separate alignment prob- lem, and the alignment duplication jig helps in the construction of the final prosthesis rather than as a measuring instrument.</p> <p>In the prior art of lower-extremity limb-fitting, there has naturally been the tendency to stop making adjustments as soon as the prosthesis is just "good enough," especially so when a further change would mean breaking a glued connection or resetting a joint. The principal advantage of the UC alignment equipment is that, since all adjustments in the trial prosthesis are easily and quickly made, the prosthetist can make very small changes until both he and the amputee are satisfied that the best job has been done. The alignment of a leg prosthesis is especially critical in the swing phase and during the periods of transition from stance to swing. Very small changes in alignment can have very noticeable effects upon the performance of the prosthesis at these times. Since small adjustments can be made accurately using the adjustable leg, the prosthetist is able to obtain optimum performance where that is difficult, if not impossible, to achieve by trial-and-error methods. Besides this, the adjustable leg has found considerable use as an educational aid in teaching prosthelisls the fundamentals of limb alignment in suction-socket schools and in demonstration of alignment principles before groups of orthopedic surgeons, physical therapists, and others.</p> <p><b>References:</b></p> <ol> <li>Habermann, Alfred, <i>Mechanische Hilfsmittel fur denstatischen Aufbau des Kunstbeines, </i>Medizinische-Technik, 4(3) :60 (March 1950).</li> <li>Schede, Franz, <i>Theorelische Grundlagen fur den Bauvon Kunstbeinen; Insbesondere fur den Oberschenkel-amputierten, </i>Ztschr. f. orthopad. chir., Supplement 39, Enke, Stuttgart, 1919.</li> <li>Schnur, Julius, <i>BeinbelasiungsUnie und Schwerlinie,</i>edizinische-Technik, 5(3):54 (March 1951).</li> <li>Schnur, Julius, <i>Die Aquilibral-Kontakt Prolhese,</i>rthopadie-Technik, 4(2) :36 (February 1952).</li> <li>University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Functional considerations in fitting and alignment of the suction socket prosthesis, </i>March 1952.</li> <li>War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, <i>Report on European observations, </i>Washington, 1946. <b>p.92.</b></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">By the Plastic Fibre Limb Company, Minneapolis Minnesota.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; 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">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in fitting and alignment of the suction socket prosthesis, 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>6.</b></td> <td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946. p.92.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; 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">Habermann, Alfred, Mechanische Hilfsmittel fur denstatischen Aufbau des Kunstbeines, Medizinische-Technik, 4(3) :60 (March 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>References</b></td> </tr> <tr> <td class="clsTextSmall"><b>3.</b></td> <td class="clsTextSmall">Schnur, Julius, BeinbelasiungsUnie und Schwerlinie,edizinische-Technik, 5(3):54 (March 1951).</td> </tr> <tr> <td class="clsTextSmall"><b>4.</b></td> <td class="clsTextSmall">Schnur, Julius, Die Aquilibral-Kontakt Prolhese,rthopadie-Technik, 4(2) :36 (February 1952).</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Reference</b></td> </tr> <tr> <td class="clsTextSmall"><b>2.</b></td> <td class="clsTextSmall">Schede, Franz, Theorelische Grundlagen fur den Bauvon Kunstbeinen; Insbesondere fur den Oberschenkel-amputierten, 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>Charles W. Radcliffe, M.S. </b></td> </tr> <tr> <td class="clsTextSmall">Acting Assistant Professor of Engineering Design, University of California, Berkeley; member, Lower-Extremity Technical Committee, ACAL, NRC.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> Figure 1 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-10.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-11.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-12.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-13.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-14.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-15.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-16.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-17.jpg Figure 9 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-18.jpg Figure 10 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-19.jpg Figure 11 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-20.jpg Figure 12 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-21.jpg Figure 13 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-22.jpg Figure 14 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-23.jpg Figure 15 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-24.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 Mechanical Aids for Alignment of Lower-Extremity Prostheses Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S. * 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/9e338894b1f207843da22d94280a118d.pdf 3393a872a919021256b2ab1ef2371b05 https://staging.drfop.org/files/original/4fee943f810bcedb55cf94bac3f60253.jpeg 0b6369b919b0a4c5d421fce6886e6d5e https://staging.drfop.org/files/original/6396c81100371bfe9d8ac940075631cb.jpg 023518571192ab6721498d9b4a8f7662 https://staging.drfop.org/files/original/0d2768cace046397bbf7d7040508d863.jpg 07e13ce84947e5b2f1732d2de5338794 https://staging.drfop.org/files/original/d83594653570ca96f690044f2b1d657d.jpg 8bc03b7ee87b349b287b877e8a698bc0 https://staging.drfop.org/files/original/8a3452f59a563b52f53eb6f67c8a4be4.jpg 470315d686168817996c70c6a4928ce9 https://staging.drfop.org/files/original/1f8be944e589b7eac3c9645bca1a26e8.jpg 59b8b275e0cb6ce51b166ec3ae492e31 https://staging.drfop.org/files/original/aec7299a96361a338ddc5dacbcdf4e28.jpeg cf51d6d972c19f2beaaeced91b298b2e 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_004.pdf Text Any textual data included in the document <h2>The Geriatric Amputee</h2> <h5>Florence T. Leist, P.T.&nbsp;<br /><br /><a href="/files/original/4fee943f810bcedb55cf94bac3f60253.jpeg">Fig 1: Florence Leist</a></h5> <p><i>Presented at the Annual Meeting of the American Physical Therapy Association of Md., Inc., November 13, 1976.</i></p> <p>The purpose of this presentation is to challenge each of you to become an advocate for the geriatric amputee, and to evaluate his potential on factors other than his age.</p> <p>To dispel the theory of a person being too old to use a prosthesis I would like to share a couple of real situations.</p> <p>We had a dear 77-year-old man receive his prosthesis at our clinic at Deer's Head in the spring. Last summer I met his grandson, and when I asked him how his grandfather was, he replied, "oh, he's fine now that he has his new leg. He's even courting a girl friend." Then there is the 85-year-old woman who received a new prosthesis and yet another new one at the age of 87 to enable her to continue caring for and babysitting her great grandchildren.</p> <p>This afternoon I would like to talk <em>first</em> about factors to be considered in the management of the geriatric lower-limb amputee, and then present some statistics gathered from a review of the amputees who received their prostheses through the clinic at Deer's Head Center during its first two years of operation.</p> <p>The management of the amputee can be divided into three phases:</p> <ol> <li> <p>Post amputation and/or pre-prosthetic training.</p> </li> <li> <p>Prescription.</p> </li> <li> <p>Post prosthetic training.</p> </li> </ol> <p>One of the problems we had in the management of the geriatric amputee was the scarcity of information provided by the referring physician. We sometimes got little more information than that the patient had had an amputation - not even a mention of whether it was an AK or BK, or whether it was on the right or the left.</p> <p>To help overcome this situation we developed a questionnaire to develop not only the necessary basic history, but, more importantly, information such as cardiac status and the condition of the remaining lower limb. We also included the question "is he able to increase exertion 50 per cent more than is required for normal walking or wheelchair use."</p> <p>We used the reference "On energy requirements for prosthesis use of geriatric amputee" to establish that question (Peizer, E. <i>On the energy requirements for prosthesis use by geriatric amputees, in "The Geriatric Amputee,"</i> Committee on Prosthetics, Research and Development, National Academy of Sciences, 1961).</p> <h3>Depression</h3> <p>In the pre-prosthetic period there are many apsects to consider. From our first contact with the geriatric amputee we usually get a definite feeling about his general mental status. We often find that he is depressed: his self-image has been shattered; he is suddenly unable to walk, work, or even get out of the house; he is faced with a great fear of the future. "What," he asks, "is going to happen to me and my family?"</p> <p>To help him cope with these many frightening problems, the social worker, who we feel is an important member of the team, can be of value from the beginning by helping him face reality, helping solve some of his problems, and by giving him added encouragement.</p> <h3>Range of Joint Motion</h3> <p>Loss of range of motion is more rapid in the geriatric patient because of loss of tissue elasticity. Management is to institute bed positioning and range of motion exercises and encourage freedom of movement as soon as possible. Our goal to have not more than 10 deg. of flexion contracture in hip and knee. Stretching exercises must be carried out if contractures have developed, but one must remember that the older patient tolerates stretching poorly.</p> <h3>Muscle Strength</h3> <p>There is a generalized decrease in strength with age which is compounded by the effects of surgery and forced inactivity. Management is through general strengthening exercise, but the cardiac status and other systems must be considered in planning the exercise program. Usually we must accept less than what is considered as ideal strength. The goal is that the patient be able to support himself by a walkerette or crutches.</p> <p>Often times the geriatric amputee has poor balance and is fearful of falling. He has to be encouraged to try walking with crutches or walkerette and must be well guarded to prevent failing. Ideally our highest pre-prosthetic goal is independence in walking with crutches, however, as we are more concerned with safety and realize the older person does not have the agility and balance of a younger person, walking independently with a walkerette is acceptable. Our chief concern is the safety of the patient and his ability to function. We emphasize the specific stump exercises for extension and abduction of the hip for the AK and the quadriceps for the BK.</p> <h3>Shaping the Stump</h3> <p>In the older amputee generalized soft tissue atrophy is already present and stump wrapping should be monitored carefully. The patient and his family usually lack a clear understanding for the need of stump wrapping, so clear explanations and instructions should be given to insure proper shaping of the stump.</p> <h3>Length of Time Before Prescription</h3> <p>We usually find that most new amputees are presented at our Prosthetic Clinic about 2 months post amputation. Sometimes it is more than that and once in a while less. If it has been 2 months or longer, usually there has been adequate time for reduction of contractures, an increase in strength, proper shaping of the stump, and for learning to walk with assistive devices. If the time is shorter and the patient is able to handle himself on crutches or walkerette but still lacks range of motion or has not stabilized in the shrinking process, we usually go ahead and present him at clinic. The physician in charge of the clinic at DHC has at times given a provisional prescription, stating that when the contracture has been reduced or shrinkage has stabilized the prosthetist may proceed with fabrication of the prosthesis.</p> <p>The team approach is used at the clinic at DHC. The team consists of the physician in charge, the prosthetist, the physical therapist, the occupational therapist, the social worker, counselors from the Division of Vocational Rehabilitation, the patient, and his family, whenever possible.</p> <h3>Prescription for the Geriatric Amputee</h3> <p>Usually, when a patient has worn a prosthesis previously, a prescription for a duplication of the present prosthesis is made, i.e., when a person has a plug socket or a thigh corset, it is duplicated as closely as possible. For a new amputee, we try to prescribe components to meet the criteria which we developed during our evaluation.</p> <h3>Sockets</h3> <p>Quadrilateral sockets with partial suction and valve, usually fitted with a heavy cotton sock, is the design of choice unless there is extensive soft tissue atrophy, when a 5-ply woolen sock is used.</p> <h3>Suspension</h3> <p>A hip joint with pelvic band gives greater security. Suction is generally not prescribed for the geriatric patient because he does not have the muscle strength or tone to use it. At times a "Silesian bandage," or belt, is prescribed, but the patient often has difficulty with internal rotation of the prosthesis when he pulls the "bandage" tight. We recently had to change a "Silesian bandage" to hip joint and pelvic band for a woman.</p> <h3>Knee</h3> <p>Maximum stability at heel strike is necessary for the geriatric patient. The manually locked knee joint provides this stability in ambulation. It does result in gait deviations, but safety with the geriatric patient is our chief concern. It is better to have gait deviations than no gait at all. To help overcome partially the need to circumduct or vault the prosthesis is generally made 1/2 to 1-in. shorter than the contralateral leg.</p> <p>Another knee component that is prescribed sometimes is the BOCK safety knee which provides stability through friction upon weight-bearing.</p> <h3>Foot Components</h3> <p>When a locked knee is used a single-axis foot is desirable because it permits the entire plantar surface of the foot to make contact with the floor early in the stance phase. With a person who is not a vigorous walker, such as an older person is apt to be, an extra soft heel bumper is indicated.</p> <p>When a SACH foot is used with an articulated knee an extra soft heel cushion is desirable.</p> <h3>Post-Prosthetic Training</h3> <p>Post-prosthetic training for a geriatric amputee should be considerably different from that for a young vigorous person. Balance, strength, agility, and endurance will all be reduced greatly and we must proceed more slowly. Goal setting will vary greatly from individual to individual - from limited use in the home to general activities of daily living, to return to work, from walking with no assistive device, to walking with cane or canes, crutches, or walkerette.</p> <p>We must set realistic goals for the geriatric amputee. Many of these people have not been active for a long period before amputation, and they will probably not regain vigorous strength and agility. But if we can return them to the life style to which they were accustomed then I think we have reached our goal.</p> <p>As I have said several times before, we are concerned with safety. While we would like to have a perfect gait, without any assistive device, we settle for safe gait with an assistive device. But when a 75-year-old man can climb on and run a tractor on the farm, what difference does it really make if he uses a cane? Or, if a 75-year-old woman is taking care of herself, staying by herself most of the day and performing household chores, is it so awful she uses a walkerette?</p> <p>Last year we conducted a review of the patients who received a prosthesis through our clinic during the first 2 years of its existence. The purpose of this was to ascertain whether or not the clinic was meeting the needs of the patient; i.e., were we prescribing the proper kind of prosthesis for the individual? And, we felt, this would be partially determined by the use the patient made of his prosthesis. All patients had had their prosthesis for at least a year.</p> <p>We interviewed each of these 24 patients on the day of the clinic, having them complete a questionnaire. Level of amputation, age group, and cause of amputation are given in <b>Table 1</b>. Five of these questions with the result are given in <b>Table 2</b>, <b>Table 3</b>, <b>Table 4</b>, <b>Table 5</b>, and <b>Table 6</b>.</p> <strong>Table 1. Classification of Patients</strong><br /><img src="/files/original/6396c81100371bfe9d8ac940075631cb.jpg" alt="Italian Trulli" width="368" height="158" /><br /><br /><strong>Table 2. I Wear My Artificial Limb:</strong><br /><img src="/files/original/0d2768cace046397bbf7d7040508d863.jpg" br="" width="580" height="179" /><br /><strong><br />Table 3. When I Wear My Limb It Is On:</strong><br /><img src="/files/original/d83594653570ca96f690044f2b1d657d.jpg" br="" width="602" height="134" /><br /><br /><strong>Table 4. When My Limb Is On I Can:</strong><br /><img src="/files/original/8a3452f59a563b52f53eb6f67c8a4be4.jpg" br="" width="565" height="224" /><br /><br /><strong>Table 5. When I Walk I Use:</strong><br /><img src="/files/original/1f8be944e589b7eac3c9645bca1a26e8.jpg" br="" width="571" height="127" /><br /><br /><strong>Table 6. I Need Someone To Assist Me When I Walk:</strong><br /><img src="/files/original/aec7299a96361a338ddc5dacbcdf4e28.jpeg" br="" width="566" height="74" /> <p>It was apparent to us from these statistics that we evidently were meeting the needs of the patients and that the amputees over 60 years of age function about on the same level of those under 60.</p> <p><b>References:</b></p> <ol> <li>Burgess, Ernest M., Robert L. Romano, and Joseph H. Zettl, <i>The management of lower-extremity amputations</i>, Prosthetic and Sensory Aids Service, Veterans Administration, TR 10-6, August 1969.</li> </ol> Page Number(s) 4 - 7 Year 1977 Volume 1 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-6.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Text Copy Edit Figure 7 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Geriatric Amputee Creator An entity primarily responsible for making the resource Florence T. Leist, P.T.  https://staging.drfop.org/files/original/30c31f3ab0a1bb7bf6b2fed3d44ab98e.pdf 1b4c13b6fe4572542d88a4b6b1765e21 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1977_03_001.pdf Text Any textual data included in the document <h2>"The Geriatric Amputees" - Results of the Questionnaire</h2> <p>There were twenty-three replies by mail to the questionnaire on management of lower-limb geriatric amputees that appeared in the Spring 1977 issue of the NEWSLETTER. Ten were signed by prosthetists, five came from M.D.'s and two from therapists. The remarks included on the six unsigned forms appear to have come from prosthetists.</p> <p>The raw results, question-by-question, are shown below:</p> <ol> <li> <p class="kapow"><b>Should the prosthesis weigh less than conventional prostheses?</b></p> <p class="kapow"><i>PROSTHETISTS</i></p> <blockquote> <p class="kapow">AK yes: 15, No: 1<br />BK yes: 14, No: 2</p> </blockquote> <p class="kapow">Comments made by the prosthetists:</p> <ul> <li> <p>They cannot be made too light.</p> </li> <li> <p>We use endoskeletal AK set ups and light feet as often as possible to reduce weight.</p> </li> <li> <p>Yes. Unless "conventional" prostheses are already very light. BK's should weigh between 1 1/2 - 3 lbs. and AK's from 4 1/2 — 6 1/2 lbs. Decreases energy consumption, eases suspension. Soon, however, new materials and techniques should allow all prostheses to weigh about the same. Major difference for geriatrics is not weight but socket comfort and cost.</p> </li> <li> <p>A major complaint from the geriatric patient is the weight of the prosthesis.</p> </li> <li> <p>In most cases conventional prostheses are prescribed and the geriatric patient has trouble with them usually because of the weight. But age and strength are the difference.</p> </li> <li> <p>This is debatable, each case should be considered individually. I feel that most geriatric males would prefer a conventional prothesis.</p> </li> <li> <p>As much weight as you can knock off the better. The old story of the leg being so light that in a strong wind it is hard to control, just a tale.</p> </li> <li> <p>Whenever possible, a light-weight prosthesis is desirable for geriatric patients.</p> </li> <li> <p>Patients' resources less and need for strength not important,</p> </li> <li> <p>I do not feel that this is a very major issue as far as function is concerned. Most patients complain about weight early but those who do function do not continue these complaints,</p> </li> <li> <p>It is generally desirable that prostheses be as light as possible.</p> </li> <li> <p>Light limbs seem to be tolerated much more than the heavy limb.</p> </li> <li> <p>An attempt is always made to maintain lightness in all prostheses, however, especially AK geriatrics who are fighting quite a lever arm in regard to weight.</p> </li> <li> <p>The decrease in energy out-put during ambulation is very important for the geriatric amputee. Decrease in weight decreases energy out-put which in turn decreases the stress on the cardiovascular system.</p> </li> <li> <p>Even where a geriatric has not experienced an amputation, there is loss of muscular strength. This is the primary-reason for a lighter prosthesis.</p> </li> </ul> <p><i>PHYSICIANS</i></p> <p>AK Yes: 5, No: 1<br />BK Yes: 4, No: 2</p> <ul> <li> <p>If the geriatric amputee is unable to manage the conventional prosthesis, making a lighter limb increases his difficulties when walking in a high wind or deep snow. In these cases I fit the geriatric amputee with an articulated peg leg invariably with a successful result.</p> </li> <li> <p>Initially they do quite well, however, a lighter, especially AK prosthesis would help.</p> </li> <li> <p>I think <em>all</em> prostheses should weigh less, particularly for geriatrics. The prosthetists should go to extra lengths to thin out the shell of exoskeletal limbs as thin as possible and consistent with durability. This is just not done enough with the shins of AK and BK prostheses.</p> </li> <li> <p>If there is sensory loss, a heavier prosthesis for sensory feedback may be necessary.</p> </li> </ul> <p><i>THERAPISTS</i></p> <ul> <li> <p>One therapist felt that both the AK and BK prosthesis should weigh less than the conventional and commented that "Patients seem to prefer an extremely lightweight prosthesis." The other therapist did not check any of the boxes but wrote in "Individualized Adjustment" and commented that "A neurophysiological functional evaluation should determine if the patient responds better to heavier or lighter sensory bombardment."</p> </li> </ul> <p style="margin-left: auto; margin-right: auto;"><i>DISCUSSION</i></p> <p>The great majority of clinicians seem to feel that lower-limb prostheses that weigh less than those generally available are desirable for the older patient.</p> </li> <li> <p><b>What type of knee do you generally use for above-knee cases?</b></p> <p style="text-align: center;"><i>PROSTHETISTS</i></p> <table style="border-style: none; width: 338px; margin-left: auto; margin-right: auto;" height="120"> <tbody> <tr> <td>Manual lock</td> <td>6</td> </tr> <tr> <td>Weight-bearing (Safety Knee)</td> <td>10</td> </tr> <tr> <td>Other (please specify)</td> <td>11</td> </tr> </tbody> </table> <p>Prosthetists' comments were as follows:</p> <p><i>Manual Lock:</i></p> <ul> <li> <p>Treatment for the dysvascular amputee should always be separated from geriatric amputees with other causes for amputation at Rancho, well over 90 percent of amputations are secondary to vascular problems. Manual lock knees have cut down PT time by two weeks, and, combined with an adjustable socket, have made it possible to convert nearly all of our dysvascular AK's into prosthesis wearers and more importantly, they use them.</p> </li> <li> <p>At our clinic either the adjustable AK "Rancho design" or conventional AK have locking knees.</p> </li> <li> <p>We have not been pleased with the various "safety" knees. The only really useful one is the SHS — we do not use it for geriatric patients, but it's the best.</p> </li> <li> <p>Balsa Lock knee, wherever possible, light weight foot with soft heel. Polypropylene joint and band (where stump is long)</p> </li> </ul> <p><i>Weight-Bearing (Safety-Knee):</i></p> <ul> <li> <p>The friction lock type of knee will work for 80% of the AK's.</p> </li> <li> <p>The weight-bearing knee seems to be the most easily managed by elderly amputees.</p> </li> <li> <p>Manual lock knees only when safety knee is inadequate.</p> </li> <li> <p>I prefer endoskeletal.</p> </li> <li> <p>About 90% of our geriatric patients are fitted with friction locking knees and 10% are fitted with manual locks.</p> </li> <li> <p>Aside from poorer musculature, the evidence of less proprioception illustrates that the AK geriatric has difficulty knowing where his knee and foot are. Only in extreme severe muscular weakness is a manual lock prescribed.</p> </li> </ul> <p class="kapow"><i>Manual lock &amp; Weight-bearing (Safety) Knee:</i></p> <p class="kapow">Varies with patient need.</p> <p class="kapow"><i>All three types marked:</i></p> <ul> <li> <p>Depends on needs of the patient and his ability to control the knee with his own efforts, as well as his expected level of performance.</p> </li> </ul> <p><i>Other:</i></p> <ul> <li> <p>Constant friction knee for the elderly. Not much maintenance problem. Variable gait is not an important factor. Mauch S-N-S for the younger amputee.</p> </li> </ul> <p><i>None Marked:</i></p> <ul> <li> <p>My approach is to evaluate each person individually. Our primary knee is the Bock Safety knee, relying primarily upon alignment stability and fast plantar flexion of S/A foot. I use Kolman only when absolutely necessary due to noise problems.</p> </li> </ul> <p style="text-align: center;"><i>PHYSICIANS</i></p> <table style="border-style: none; width: 390px; margin-left: auto; margin-right: auto;" height="116"> <tbody> <tr> <td>Manual lock</td> <td>2</td> </tr> <tr> <td>Weight-bearing (Safety Knee)</td> <td>3</td> </tr> <tr> <td>Other (please specify)</td> <td>0</td> </tr> </tbody> </table> <p>The physicians comments were as follows:</p> <p><i>Manual Lock:</i></p> <ul> <li> <p>Bock Geriatric. Most often. Weight-bearing (Safety) knee, seldom. Often knee lock with option to give constant friction if open, as a trial.</p> </li> <li> <p>Safety is very important. There is more energy required to operate a safety knee (Bock). I reserve it for the younger amputee.</p> </li> </ul> <p><i>Weight-Bearing Safety Knee:</i></p> <ul> <li> <p>We need a manual lock that is sturdier than the Bock geriatric knee. Ideally someone should manufacture a lock that could be placed on the outside of the prosthesis so that if patient finally confident enough with free knee after practice he could remove it.</p> </li> <li> <p>I usually use the Otto Bock Safety knee which stands use by the geriatric amputee well. However, have run into breakdown problems with this knee in my younger patients.</p> </li> </ul> <p><i>THERAPISTS</i></p> <p>The comments from the two therapists were:</p> <ul> <li> <p>Knee usually depends on patient's functional demands, equipment cost, prosthetist convenience in non-standard set-ups in that order.</p> </li> <li> <p>My training is deficient in the prosthesis — but excellent in observation of physiological response.</p> </li> </ul> <p><i>DISCUSSION</i></p> <p>Opinion on use of manual lock versus the weight-bearing (Safety) knee is slightly in favor of the weight-bearing (Safety) knee. Certainly the weight-bearing units provide more function and better appearance when they can be used. It is gratifying to find that so many prosthetists and physicians are being successful with the more functional units.</p> </li> <li> <p><b>In your opinion is the use of stubbies for bilateral AK cases desirable?</b></p> <p>PROSTHETISTS</p> <p>Yes: 7<br />No: 8<br />No experience: 1</p> <ul> <li> <p>No, Have not used them for 5 years — patients would not wear them after six months.</p> </li> <li> <p>No. We have used them, however, the cases were to prove to the patient the difficult task it is to master bilateral AK prostheses. The stubbie is a substitute but not a good one.</p> </li> <li> <p>No. Much trouble and expense for very little benefit. Most should not be fit at all. If fit, shorten slightly but include knee joints for sitting purposes. Stubbies cause problems in wheelchairs, look horrible and do not convert non-users of prostheses into users.</p> </li> <li> <p>No. In most cases the bilateral AK patient has had extensive vascular surgery and scars in abdomen and scarpas are too much of a problem.</p> </li> <li> <p>No. Most would rather sit in a wheelchair.</p> </li> <li> <p>No. We have not had the occasion to use them. Geriatric amputees, with therapy, are able to use light-weight prostheses with weight bearing knees.</p> </li> <li> <p>No. We've tried stubbies in a few cases where we thought the patient could eventually go to regular legs. A better idea is pylons — you can adjust them. No one uses stubbies permanently — a wheelchair is much more functional.</p> </li> <li> <p>No. Stubbies make patients look like "freaks", they think. Patients are more functional in wheelchairs.</p> </li> <li> <p>Yes. Only if there is a good P.T. program.</p> </li> <li> <p>Yes. To permit A.D.L. in the home — We have 2 cases of short A.K.'s who did so well they demanded full length prostheses and did fair.</p> </li> <li> <p>Yes. As temporaries to define the patient's functional potential both to him and to the clinic team.</p> </li> <li> <p>Yes. If bilateral amputation occurs simultaneously.</p> </li> <li> <p>Yes. It is a way to allow an individual independence and mobility without the problems of knee control.</p> </li> <li> <p>Yes. There are amputees that can walk with stubbies and not walk with bilateral A/K prostheses therefore it is desirable in obtaining an accurate assessment of prosthetic potential.</p> </li> <li> <p>Yes. Bilateral stubbies offer safety that no AK with knees can offer. The CG is closer to the earth, and there is less weight to be manipulated. I would recommend stubbies for the desirable active AK.</p> </li> <li> <p>No opinion. I have no experience in this area.</p> </li> </ul> <p><i>PHYSICIANS</i></p> <p>Three physicians were opposed to the use of stubbies and two felt that their use is indicated.</p> <p>The physician's comments were:</p> <ul> <li> <p>No. Stubbies are unsightly ugly things, besides (they) cost as much as prostheses. I very seldom prescribe bilateral AK prostheses to geriatric patients. The few knees I did, the prosthesis ended up in the closet. However, an occasional patient may do well, however, when the prostheses are made several inches shorter than patient's original height. Each patient is pretested with pylons.</p> </li> <li> <p>No. I do not believe in fitting bilateral AK's with vascular disease. If young and vigorous and traumatic — and candidate for limited walking with bilateral AK prostheses — should be fitted with full length.</p> </li> <li> <p>No. Not in the geriatric, but useful in young adults.</p> </li> <li> <p>Yes. Useful around the house if patient wants them. Cosmesis bad. Useful for training.</p> </li> <li> <p>Yes. I regard this as an essential if the bilateral amputee is to learn to walk satisfactorily.</p> </li> </ul> <p><i>THERAPISTS</i></p> <p>Both therapists felt that use of stubbies is desirable. Their comments were:</p> <ul> <li> <p>Yes. Stubbies are desirable to demonstrate to most patients that the amount of energy expended is usually not worth the effort, from a functional point of view.</p> </li> <li> <p>Yes. Any reasonably balanced device helps maintain balance and muscle strength. Prevention of disuse atrophy.</p> </li> </ul> <p><i>DISCUSSION</i></p> <p>The respondents were almost equally divided on the issue of stubbies, and without exception each respondent offered a comment. The comments seem to indicate that in spite of drawbacks stubbies can be used successfully in certain settings, and that a careful, thorough evaluation of this procedure is needed.</p> </li> <li> <p><b>In your opinion, is immediate postsurgical fitting of prostheses desirable for geriatric cases?</b></p> <p><i>PROSTHETISTS</i></p> <p>Eleven prosthetists felt that immediate postsurgical fitting is indicated for geriatric patients; five felt that the procedure was contraindicated, while one felt that it would probably be useful if orthopaedic surgeons performed the amputations.</p> <p>Their comments are as follows:</p> <ul> <li> <p>Yes. We only recommend a rigid dressing. Only after wound healing has been ascertained do we apply a pylon.</p> </li> <li> <p>Yes. If there is a good P.T. program; otherwise only the rigid dressing should be used.</p> </li> <li> <p>Yes. This treatment doesn't allow the geratric amputee to become comfortable in a wheelchair thus losing strength and endurance.</p> </li> <li> <p>Yes. The PT Department starts working with the patient within 24 hours and the chances are (that) contractures and depression won't occur.</p> </li> <li> <p>Yes. BK's only. AK's too much trouble for benefit accrued.</p> </li> <li> <p>Yes. Immediate fitting is good for everyone. But its hard to do — hard to supervise, takes a lot of effort so its not done.</p> </li> <li> <p>Yes. For below-knee patients who have the ability to coordinate the post surgical dressing and pylon.</p> </li> <li> <p>Yes. I feel immediate post surgical fittings minimize loss of strength which is very critical in the geriatric cases.</p> </li> <li> <p>Yes. I.P.S. fittings are desirable for any amputee, aside from trauma cases. The less muscle tone the geriatric loses the better his chances are of becoming a successful prosthetic candidate with I.P.S.F. This is possible.</p> </li> <li> <p>No. The results I have witnessed have been mostly unfavorable. Perhaps if the orthopedic surgeons did more of the amputations it would be more advisable.</p> </li> <li> <p>No. Rigid dressings for BK's should be used for 10-14 days then a temporary prosthesis for 2-4 weeks. Immediate post-surgical fittings encourage too much activity and it is too hard to control the stress the patient is placing on the wound.</p> </li> <li> <p>No. We never use immediate postsurgical fitting. Stumps should be healed before shrinkage is attempted. After stump is healed, we use laminated plastic sockets on temporary units for definitive shrinking.</p> </li> <li> <p>No. Low tolerance.</p> </li> <li> <p>(Nothing marked) It depends on the patient's prior medical history. We would not recommend it for diabetic patients.</p> </li> </ul> <p><i>PHYSICIANS</i></p> <p>Two physicians felt that immediate postsurgical fitting had a place in management of geriatric patients; two felt otherwise; and one had no experience on which to base an opinion.</p> <p>Their comments were:</p> <ul> <li> <p>Yes, <em>If</em> you have full team approach including nurses who fully understand principle. Otherwise early temporary fitting with good control of stump edema may be second best alternative. Two months is still a <em>long</em> delay.</p> </li> <li> <p>Yes. I do not feel that a differentiation need be made unless there are other conflicting medical factors, e.g. heart disease.</p> </li> <li> <p>No. But I prefer rigid dressings with early fitting when wound is fully healed.</p> </li> <li> <p>No. No benefits except psychological, and many dangers. Use of cast is OK in many cases, but adding prosthesis courts disaster.</p> </li> <li> <p>(Nothing marked) I cannot express an opinion since in our institution immediate post surgical fitting is not being done at all.</p> </li> </ul> <p><i>THERAPISTS</i></p> <p>Both therapists felt that immediate post surgical fitting is useful.</p> <p>Their comments were:</p> <ul> <li> <p>Yes, . . . but please see abstract of article to be published in American Journal of Surgery {<em>which will be publishing in a future issue. Ed</em>.). I feel that very few people now are using the prosthesis on an immediate basis, but our prospective study well documents the value of the rigid dressing in the postoperative care of the BK amputee.</p> </li> <li> <p>Yes. Normal physiology maintained at maximum potential.</p> </li> </ul> <p><i>DISCUSSION</i></p> <p>The replies to this question indicate that the use of a rigid dressing is used widely and that immediate postsurgical fitting is used more than is generally expected. Perhaps the reports on the study at Iowa will encourage others to adopt these advanced techniques. Other clinics with experience should publish results of their clinical program.</p> </li> <li> <p><b>In your opinion what is needed to improve the function of geriatric amputees?</b></p> <p>All of the respondents commented on this question.</p> <p>Their comments were as follows:</p> <p><i>PROSTHETISTS</i></p> <ul> <li> <p>The lightest prosthesis with the safety factor at the knee system (being) the main factor.</p> </li> <li> <p>A better method of suspending the AK prosthesis. Total suction does not work, rigid pelvic belt is a fair substitute, but (is) heavy. Something better is needed.</p> </li> <li> <p>Vascular surgery is often indicated but compounds our fitting problems. After several surgical procedures — physiologically and psychologically the patients require more professional service — let us all hope that more orthopedists would become more involved in amputation surgery.</p> </li> <li> <p>An adjustable BK socket that is permanent. It can be fit(ted) instead of a "temporary" and will adjust throughout the "maturing" process. (It) will save time, as patient can adjust it and since a temporary is not needed, it will save dollars. Most physicians are looking for a cheap geriatric prosthesis, although they will state "light duty" or "lightweight" or "sitting prosthesis."</p> </li> <li> <p>I believe the prosthetic components that we have now are all we need: However the P.T. program needs to be reevaluated.</p> </li> <li> <p>Better pre-op and initial post-op care.</p> </li> <li> <p>This is where the total team is so very necessary. Pre-surgical consultation, pre-prosthetic care and post prosthetic training and followup. Outpatient care for the amputee is practically overlooked by the doctors and the subsidizing agencies, the insurance companies, Medicare and Medicaid. The patient can only receive adequate care as an inpatient. Usually his funding is exhausted by the time he is ready for prosthetic fitting.</p> </li> <li> <p>A lightweight single axis foot. More training for surgeons (general and vascular) to give the patient a chance for a BK, when the problem is in the toes or ankle; also teach them how to bevel and round the tibia.</p> </li> <li> <p>Articles such as this help spread information that geriatric patients can utilize a prosthesis. Motivation is an important factor. Two days ago we fitted a 91-year-old man with a prosthesis and his initial attempts have been excellent.</p> </li> <li> <p>Lighter prostheses, greater emphasis on use of temporaries in early phase of rehabilitation.</p> </li> <li> <p>Quicker fabrication and more adjustable prostheses. We use Polysar sockets and pylons. We can make adjustments easily and get (out) the prosthesis quickly.</p> </li> <li> <p>The limiting factors in geriatric amputees are motivation, coordination, and endurance. The therapist has the best chance to do something about these things.</p> </li> <li> <p>Patient compliance and patience with the amputee.</p> </li> <li> <p>Better post-surgical physical therapy. Some method to decrease the long periods of inactivity and confinement to a bed prior to amputation.</p> </li> </ul> <p>Follow-up programs.</p> <ol> <li> <p>Successful therapy program (before and after fitting)</p> </li> <li> <p>A competent prosthetist — follow-up necessary</p> </li> <li> <p>A sound instillation of confidence to the geriatric</p> </li> <li> <p>A good exoskeletal safety knee (needs) to be developed.</p> </li> </ol> <p><i>PHYSICIANS</i></p> <ul> <li> <p>Enthusiastic team work and total care of the patient to include medical, socioeconomic and vocational aspects.</p> </li> <li> <p>Immediate referral to a rehabilitation department to teach necessary conditioning exercise, range of motion exercise to prevent contracture and stump conditioning.</p> </li> <li> <p>More interest and concern of plight of elderly person with vascular disease by surgeons in particular, but also by physicians in general. And I don't mean simply interest in the pathophysicology and surgical approaches to arteriosclerosis.</p> </li> <li> <p>Improved sensory feedback</p> </li> <li> <p>Improved training procedures</p> </li> <li> <p>Improved knowledge of what the patient <em>really </em>needs</p> </li> </ul> <p><i>THERAPISTS</i></p> <p>My concern is the bracing needed for C.V.A.'s. Our suggestion to our Medical Chief of Staff is to invite your representative to hold a seminar in our hospital.</p> <p>Generally we need to sell the success of fitting the geriatric AK from the standpoint of requiring less in terms of third-party paid institutionalization or purchased services. An AK patient on a walker is much easier to deal with than a one-legged wheelchair-bound patient. In short, we need to emphasize the 4 successes of 10 attempts, and demonstrate this success in a cost-effective manner. This is the only language cost conscious bureaucrats will understand. Additionally, many patients report positive attributes of independence in gait, so they "don't have to depend on or bother their family or friends." At the same time, we need to strive to improve our care package so as to raise the percentage of AK's who become independent with their prostheses.</p> </li> </ol> <p><i>SUPPLEMENTARY DATA</i></p> <p>To augment the data provided by the 23 questionnaires returned through the mail, prosthetists attending the instructional course in molded plastics sponsored by the American Academy of Orthotists and Prosthetists and held in Kansas City, Missouri, July 15-16, 1977, were asked to fill out the questionnaire. Forty-one did so. The results are given below:</p> <ol> <li> <p>Should the prosthesis weigh less than conventional prostheses?</p> <p>AK Yes: 41 No: 0 No mark: 0<br />BK Yes: 39 No: 0 No mark: 2</p> </li> <li> <p>What type of knee lock do you generally use for above-knee cases?</p> <table style="border-style: none; width: 402px; margin-left: auto; margin-right: auto;" height="116"> <tbody> <tr> <td>Manual lock:</td> <td>15</td> </tr> <tr> <td>Weight-bearing (Safety Knee):</td> <td>22</td> </tr> <tr> <td>Other:</td> <td>3</td> </tr> <tr> <td>No mark:</td> <td>5</td> </tr> </tbody> </table> <br /> <p>(Four people marked two places. Most of the 5 not marked made some kind of comment.)</p> </li> <li> <p>In your opinion is the use of stubbies for bilateral AK cases desirable?</p> <table style="border-style: none; width: 401px; margin-left: auto; margin-right: auto;" height="123"> <tbody> <tr> <td style="text-align: left;">Yes:</td> <td style="text-align: left;">21</td> </tr> <tr style="text-align: left;"> <td>No:</td> <td>19</td> </tr> <tr style="text-align: left;"> <td>No mark:</td> <td>2</td> </tr> </tbody> </table> <br /> <p>(One person checked both yes and no.)</p> </li> <li> <p>In your opinion is immediate postsurgical fitting of prostheses desirable for geriatric cases?</p> <table style="border-style: none; width: 400px; margin-left: auto; margin-right: auto;" height="121"> <tbody> <tr> <td>Yes:</td> <td>25</td> </tr> <tr> <td>No:</td> <td>14</td> </tr> <tr> <td>No mark:</td> <td>2</td> </tr> </tbody> </table> </li> <li> <p>In your opinion what is needed to improve the function of geriatric amputees?</p> <ul> <li> <p class="kapow">Improved knees and feet of lighter weight.</p> </li> <li> <p>In hospital prosthetic facilities so therapists and prosthetists could give combined and closer supervision to walking training, etc.</p> </li> <li> <p>Suspension in geriatrics seems to cause weight and cosmetic problems.</p> </li> <li> <p>A good pre-prosthetic program, a qualified P.T. and a well fitting lightweight prosthesis.</p> </li> <li> <p>Proper post surgical supervision and gait training with prosthesis. Lighter prosthesis that is more comfortable.</p> </li> <li> <p>A good sound Rehabilitation program: 1. Good Amputation; 2. Good prosthesis; 3. Good P.T.</p> </li> <li> <p>Simple donning procedures — less weight, uncomplicated mechanics to understand.</p> </li> <li> <p>Closer observation and good rehabilitation work after surgery so the patient will have the best chance possible of becoming self-sufficient.</p> </li> <li> <p>Reduced weight/energy consumption.</p> </li> <li> <p>Getting them in better physical condition prior to prosthetic fitting.</p> </li> <li> <p>Better physical therapy and PT follow-up.</p> </li> <li> <p>Better materials other than plaster, transparent materials perhaps, lighter weight, orthoplast possibly.</p> </li> <li> <p>More the patients can do for themselves, less care needed by other people.</p> </li> <li> <p>Feather weight prostheses, and 2) team approach management.</p> </li> <li> <p>You can put a safety knee and a two way ankle.</p> </li> <li> <p>(I don't know) I have been fitting AK prosthesis for only a year therefore the above information may not be of value due to my personal lack of experience.</p> </li> <li> <p>Lighter materials.</p> </li> <li> <p>Better communication between the doctor, therapist, prosthetist and patient.</p> </li> <li> <p>Most patients need one person, as overseer, who can control his rehab program, — a coordinator.</p> </li> <li> <p>Immediate post-operative fitting.</p> </li> <li> <p>Lighter prosthesis.</p> </li> <li> <p>Increased physical therapy, —early as possible.</p> </li> <li> <p>More lighter and durable prosthesis and exercise.</p> </li> <li> <p>Exercise.</p> </li> <li> <p>Lighter weight and a more positive attitude about age and life in the future.</p> </li> <li> <p>Proper instruction in wrapping, exercise, etc.</p> </li> </ul> </li> </ol> <p><i>DISCUSSION</i></p> <p>The supplementary data agrees remarkably well with that received through the mail, and only reinforces any conclusions that can be reached from the information supplied by the original 23 respondents.</p> <p>It seems that geriatric patients are receiving considerable attention throughout the country and while the results are good considerable refinement in devices and techniques will be welcomed. Reduction in weight of artificial legs for all levels of amputation through the lower limb seems to be indicated, and improved knee control units are needed by above-knee (and hip-disarticulation) cases. The use of stubbies certainly needs clarification, probably through a well-ordered study.</p> Page Number(s) 1 - 5 Year 1977 Volume 1 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource "The Geriatric Amputees" - Results of the Questionnaire https://staging.drfop.org/files/original/627090118e7550aef32b928f5cfc5097.pdf c7c3671e2f62151182aae56f91f5d70f https://staging.drfop.org/files/original/c7e92f6d5fe85c8d6ef8544614a97aa3.jpg e468493086048ce57199f393dee24774 https://staging.drfop.org/files/original/04ce23f2e2248f3d1d49330516618203.jpg 5ad71da0cd2407e65b1be1093f9dad0d https://staging.drfop.org/files/original/37a6c5bccac772225e463355b7ce5b99.jpg 5fdd10eb7e82869440f88ddc8281c621 https://staging.drfop.org/files/original/1df47c562dff18af23aea5737e89ad4f.jpg d057a4335966a37fed05ecf311b6fa49 https://staging.drfop.org/files/original/66602a6f594faa462098d6e7eae66228.jpg b1e3ac1eed82d64494c9acf1af76bd6f https://staging.drfop.org/files/original/beceed2ac3ba9eecfcc08cf2abe51169.jpg 9ae2a1c0df624061372096332c5fce03 https://staging.drfop.org/files/original/d308ea30b792e6fb6e57c9d43f2f66f5.jpg 8be6fb5bd0b864a1f0104a3e23affdd6 https://staging.drfop.org/files/original/5e8c8f8672d073a25e049c5a392e5ef1.jpg 5774196adae9a8c9364a6e9134b7bde9 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_029.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 29 - 39 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_02_029.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_02_029.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>Status of the Above-Knee Suction Socket in the United States</h2> <h5>Chester C. Haddan <a style="text-decoration:none;">*</a><br />Atha Thomas, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The above-knee suction socket constitutes a means of attaching an artificial leg to the stump of an amputee without necessity for the conventional pelvic band, a metal hip joint, or other types of suspension harness (<b>Fig. 1</b>). The leg is held on by the slight vacuum created in the socket each time the leg is lifted from the ground, the pressure usually being controlled by a valve installed in the lower portion of the socket. Accurate functional fit of the socket, as distinguished from the conventional "plug" fit, permits the creation of negative pressure, gives a wider range of muscular control of the leg, and provides comfort while walking or sitting. Because the conventional belt and hinge joint are eliminated, the suction socket gives the above-knee amputee more freedom and less interference with clothing. The leg feels more like an integral part of the body, a feature which tends to decrease the sensation of dead weight and to improve sense of position. Reduced piston action of the stump in the socket results in greater toe clearance during walking. No stump sock is necessary. Any adductor roll is corrected. And finally, active use of the stump muscles causes them to develop instead of becoming atrophied. For a complete discussion of the prescription, fabrication, fitting, alignment, and use of the above-knee suction-socket prosthesis, reference may be had to Bechtol,<a></a> to Eberhart and McKennon<a></a>, and to the so-called "suction-socket brochure" of the University of California.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical above-knee suction-socket leg before application of the usual rawhide finish. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Early History</h3> <p>The earliest known reference to the suction socket is in the form of a patent issued by the United States, February 10, 1863, to Dubois D. Parmelee<a></a> of New York City. Subsequent patents have been issued to George Beacock and Terence Sparham<a></a> of Brock-ville, Ontario, Canada, in 1885; to Justin K. Toles<a></a> of Stockton, California, in 1911; and to Ernest Walter Underwood<a></a> of Birmingham, England, in 1926. The fundamental principles of the Beacock and Spar-ham suction socket differed but little from those of the Parmelee method. Toles' description was basically the same but with the addition of a rubber lube and bag lining which could be inflated by air to assist in holding the socket on. The socket described by Under- wood had smooth helical grooves, which he claimed ventilated the stump as well as assisted in holding the socket in place.</p> <p>A search of the literature on above-knee suction sockets has revealed only a few articles prior to the last few years. In 1925 Muirhead Little<a></a> of England reported favorably on 11 amputees fitted with the suction socket after the design of Blatchford,<a></a> made of metal, and containing a smooth helical groove of a little more than one turn around the circumference of the socket. Some 30 cases were reported as fitted at Roehampton, England, following World War I using a metal socket with a helical groove as described by Blatchford.<a></a> It is not known whether these 30 cases included the 11 reported by Muir-head Little, but it is considered doubtful since during this period several different groups were using the suction socket in England. Use of the suction socket has been practically dormant in England since that time, although it has been revived in recent years.</p> <p>Pfau<a></a> of Berlin says the suction socket has been known in Germany for 30 years but that it was not popularized until Oesterle, in Ulm, started his work in the early '30s. Felix,<a></a> a surgeon of Diisseldorf, reported on above-knee sockets in 1941. He stated that the suction socket had been used in Germany to some extent since World War I but that it was not popularized until a satisfactory suction-socket valve had been developed in 1932. After this accomplishment, numerous selected cases were successfully fitted in Germany.</p> <p>As a result of the apparent reported success with artificial limbs in Germany, early in 1946 the Surgeon General of the United States Army sent to Europe a "Commission on Amputations and Prostheses" to observe foreign practice. One principal item of interest was the successful use in Germany of suction sockets for above-knee prostheses. Because of the favorable report<a></a> issued by the commission, the Advisory Committee on Artificial Limbs instituted, as one activity of its general plan of providing information on the best possible prostheses, a program to determine the possibilities and limitations of the suction-socket type of suspension for the above-knee leg.</p> <h3>Clinical Research in the United States</h3> <p>After extensive trials and studies in their own laboratory, workers at the University of California, Berkeley, prepared instructional material and started a nation-wide program to determine the feasibility of use of the above-knee suction-socket technique under field conditions in the United States. By September 1947, 52 subjects had been fitted in 10 widely separated localities by local prosthetists in their own shops with materials and devices normally employed but making use of supplementary information and supervision by University personnel.</p> <p>The success of this program led the Advisory Committee on Artificial Limbs, in October 1947, to recommend to the Veterans Administration the use of the suction-socket technique for above-knee amputees, its use being limited for the time being to further field tests within the VA under the direction of qualified surgeons. The recommendation was accepted and, from December 1947 through January 1949, 20 schools, each of one week duration, were held throughout the country to provide 250 orthopedic surgeons and 200 prosthetists with sufficient knowledge of the fabrication and application of the suction socket to introduce it on an experimental basis.</p> <p>By October 1949 comprehensive records had been made of over 500 cases, and ACAL felt that sufficient experience had been gained in the use of the suction socket to warrant its general application. Accordingly, a recommendation was made to the Veterans Administration, and the above-knee suction socket has since been in use routinely. The Orthopedic Appliance and Limb Manufacturers Association and the Veterans Administration, in a cooperative effort, have sponsored suction-socket schools from time to time to permit surgeons and limbfitters to gain sufficient knowledge in this field to qualify them to prescribe and fit the suction socket.</p> <h3>Surveys Of Amputee Acceptance</h3> <p>The enthusiasm with which the suction-socket above-knee leg has been accepted in the United States is indicated by the results of a number of surveys. Among them are the surveys of selected groups made by Thorndike and Eberhart <i>, </i><a></a> by Mazet, McMaster, and Hutter <i>, </i><a></a> and by Canty and Asbelle.<a></a> Results of three surveys, two by the Orthopedic Appliance and Limb Manufacturers Association, are shown in <b>Table 1</b>. The earliest data are from a University of California report<a></a> of April 1948. The 52 cases reported at that time had been carefully screened, selected, and fitted under the supervision of representatives of the Advisory Committee on Artificial Limbs. The results were carefully recorded. At the termination of this initial experimental program on April 15, 1948, of the 52 subjects fitted, 40 had been wearing their suction-socket legs routinely for 4 to 20 months. All were satisfied and had no intention of returning to the type of prosthesis worn previously. Six of the subjects, owing to improper fittings, nervous disorders, or lack of cooperation, were still alternating between the suction-socket leg and their previous legs. Six had been dropped from the program and were considered as failures.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In February 1949, the Orthopedic Appliance and Limb Manufacturers Association, in an effort to determine the extent of acceptance of the suction-socket leg in the United States, mailed questionnaires to approximately 200 limbshops. Of these, 159 shops reported. Eighty of those reporting had made no suction sockets at all; 79 shops had at that time fitted 1262 men, women, and children, with an amazingly small number of complete failures. A comparatively small group of 46 were converted to pelvic-belt-controlled legs, but many of these continued to use the suction-socket shape and some the suction valve, thus retaining many of the advantages of the suction-socket leg. The 1954 survey, also conducted by OALMA, with 72 firms reporting on 5882 cases, indicates similar conclusions. The 1954 OALMA questionnaire includes those firms reporting as few as three cases fitted and those reporting as many as 500 cases or more.</p> <p>Many of the limbshops reporting in both the 1949 and the 1954 OALMA questionnaires indicate that they have adopted the suction-socket method of fitting (that is, ischial bearing) as standard practice even though the amputee cannot actually wear the suction socket as such. Auxiliary supports, such as the Silesian bandage (<b>Fig. 2</b>), are used almost routinely by some limbshops. One of the most widely known and reputable shops in the United States reports the use of auxiliary supports on 300 out of 322 cases fitted. Another reports auxiliary supports applied in 300 out of 373 cases fitted. Another highly successful shop, in fitting 181 cases (of which 91 were children), used auxiliary supports on 90 cases. It is interesting to note that the firms reporting the largest number of cases also report the largest percentage of cases fitted with auxiliary supports.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Two forms of the Silesian bandage commonly used as an auxiliary support for the suction-socket leg, both in the United States and in Europe, particularly in Germany, where, according to Pfau, Hepp, and others <i>(13), </i>it is used almost routinely. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The surveys indicate that over 96 percent of all suction sockets fitted since the introduction of the program were fitted to stumps over 3 in. long. In the one shop that reported 90 children fitted, not a single one was fitted with a stump shorter than 3 in. It is to be noted that most of those fitted with the stump shorter than 3 in. were women; and some reported that, although they did not believe the fitting of a stump shorter than 3 in. to be practical, they were almost forced at least to attempt it because of pregnancy, a condition which precludes wearing the conventional pelvic belt.</p> <p>It may therefore be assumed that, except in very rare instances, generally it is impractical to prescribe the suction socket for stumps less than 3 in. long. A further observation is that of the large number of apparently quite successful cases of Gritti-Stokes amputations fitted, no failures whatever being reported in the case of amputation at this level.</p> <p>Another interesting feature brought out is that, while in 13 percent of the cases reported edema was present in the early stages of fitting, in only two cases did the edema persist and become a contributing cause of failure of the suction-socket leg. It is obvious from these data that, while edema may be common, it need not be considered a serious problem.</p> <p>An effort was made to determine the number of bilateral above-knee amputees fitted successfully with suction sockets, but reliable data were not obtained on this question. From the information received in the survey, however, it is believed that the number will probably be about 100, the percentage of failures being approximately the same as in the case of unilaterals.</p> <p>The overwhelming reason given for failure in the use of the suction socket comes under personality factors. An effort has been made in the surveys to obtain reliable data as to the definite reasons for failure. Personality factors are found to be predominant, with physical factors next in line, the condition of the stump third, and social and economic considerations fourth in importance. Thus tabulated, the causes of failure look about like this:</p> <blockquote><p> <i>1. Personality Factors</i><br />Unfavorable temperament<br />Poor cooperation<br />Inability to adjust<br />Discouragement<br />Lack of interest<br />Low order of intelligence<br />Insecurity<br /><i>2. General Physical Factors</i><br />Skin trouble<br />Age<br />Change in weight<br />Circulatory difficulties<br />Inability to bear weight on ischium<br />Buerger's disease<br />Overweight<br />Perspiration<br />Allergy<br />General weakness<br />Loose abduction<br />Unsocial noises<br /><i>3. Slump Characteristics</i><br />Inadequate length<br />Bone spurs<br />Interfering scars<br />Undue length<br /><i>4. Social and Economic Considerations</i><br />Insufficient time for proper fitting<br />Excessive distance from shop<br />Undue sales influence<br />Employer disapproval<br />Occupational requirement </p> </blockquote> <p>Another question asked the reporting firms was: "What percentage of above-knee amputees could, in your opinion, be fitted with a suction socket?". While the answers to this question range from a low of 30 percent of all amputees to as high as 100 percent, the average is 73 percent, a figure thought, in the opinion of the authors, to represent a realistic approach.</p> <p>Another question, asked because of the unusual amount of interest in children and the older age group on the part of the Committee on Artificial Limbs, was: "Is the socket suitable for amputees under five and over seventy?". Almost without exception the suction socket was said not to be suitable for the very young or the very old.</p> <p>Again, the question was asked: "When is the suction socket a practical approach to prosthetic fitting?". The following list of conditions, in the order of frequency with which they were mentioned, indicates the thinking prevalent among the reporting firms on this particular question:</p> <blockquote><p>Right personality factors and willingness to cooperate<br />Healthy, unscarred stump over 3 in. long<br />Under 65 years of age<br />New amputees not conditioned to suspenders or pelvic control<br />Easy access to facility<br />Good muscular reaction<br />Patient's enthusiasm<br />Good circulation<br />Good balance and coordination<br />Available training and therapy<br />Reasonable occupational demands</p> </blockquote> <h3>Factors in Suction-Socket Technique</h3> <p>Accumulated experience with fitting the suction-socket above-knee prosthesis over a period of seven years has clearly demonstrated its many advantages and its desirability over the conventional belt- or shoulder-suspended leg. On the other hand, the experience of the authors during the same period has convinced them that the suction socket is not suited for all above-knee amputees. This belief has been confirmed further by reports of survey studies previously conducted by others and by the results of the surveys reported here. In our opinion, there is considerable question as to the validity of the statement made by some to the effect that the suction socket can be used profitably by any thigh amputee who can wear the conventional type of prosthesis successfully. Experience has shown that there are certain amputees who cannot wear a suction-socket prosthesis successfully. If failures are to be avoided, all cases should be studied and screened carefully before a suction socket is prescribed.</p> <p>The factors to be considered are divided roughly into two groups, each often affecting the other-those relating to characteristics of the prosthesis itself, and those relating to the characteristics of the amputee. Chief among the mechanical considerations of the leg are alignment and socket shape. Factors relating to the amputee are the general physical and mental condition, the condition of the stump, and the condition of the opposite extremity.</p> <h4>Factors Relating To The Artificial Leg</h4> <p><i>Alignment</i></p> <p>With the suction-socket leg, which is controlled entirely by the stump muscles, alignment becomes much more critical than in the case of the pelvic-band suspension and therefore must be correct for proper control and comfort. If alignment is incorrect, there is a definite whip or rotation of the prosthesis during the swing phase. The problem of alignment has not yet been solved completely, and opinions differ a little as to what constitutes the ideal alignment of the prosthesis. Theoretically, it is desirable to incorporate as much adduction of the stump within the socket as is possible mechanically, since to do so tends to suppress body sway and to place the iliotibial band (or that portion of it which may remain intact) under tension.</p> <p>In the normal, the centers of hip, knee, and ankle joints coincide in the frontal plane with the mechanical axis of the lower extremity as a whole (<b>Fig. 3</b>). After amputation through the femur and fitting with a prosthesis, however, the body weight is no longer borne through the center of the hip joint but on the ischial tuberosity, which lies medial to the center of the hip joint. This would indicate, then, that the mechanical axis of the well-aligned above-knee prosthesis would more nearly coincide with a vertical line extending from the ischial tuberosity through the centers of the knee and ankle joints (<b>Fig. 4</b> and <b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Normal alignment in the frontal plane, showing how centers of hip, knee, and ankle joints coincide with the mechanical axis of the lower extremity as a whole. From Thomas and Haddan (14). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Forces acting on the stump and pelvis of an above-knee amputee during the stance phase. In the well-aligned prosthesis, the heel of the foot and the center of the knee should fall approximately on a vertical line (A-A') through the point of contact of the ischium (a). The tendency of the pelvis to rotate downward on the normal side owing to the body weight can be reduced by keeping the dimension (b) as small as possible. This is accomplished by an upward force through the ischium (a). Lateral rotation of the pelvis and side-sway in the shoulders and torso can both be minimized if the force in the abductor muscles (c) is sufficient to balance the body weight by lever action about the ischial seat <i>(a). </i>The stump must be anchored firmly and comfortably by pressure along the entire lateral side <i>(d). </i>Failure to do this results in discomfort at the crotch (e). From Haddan (8). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Posterior view of the above-knee prosthesis showing position of the socket in relation to the rest of the leg. The medial line (a) should be approximately vertical. The lateral line (b) is sloped downward and inward. From Had-dan <i>(8).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the sagittal plane, the weight line in the normal person is a vertical line drawn through the centers of the shoulder, hip, knee, and ankle joints (<b>Fig. 6</b>, left). After amputation and fitting of a prosthesis, however, this vertical weight line must be shifted forward in order to obtain alignment stability (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Normal posture and two postural deviations which must be compensated for in fitting and aligning the prosthesis. Left, normal; center, slight deviation from normal presenting few difficulties in prosthetic fitting; right, extreme postural abnormality which, unless corrected by postural exercises, would present almost insurmountable alignment problems. From Gocht (7). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Alignment in the sagittal plane. The stump should be oriented in the socket with several degrees of initial flexion <i>(a) </i>to allow the stump to control knee stability over the widest range of hip motion possible. The ankle may be positioned either in front of or behind the knee. The dimension (i) will depend upon the individual amputee, his age, range of motion in the stump, stump musculature, and prevailing terrain. From Haddan (8). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the amputee is young and agile, with no stump deformities and with strong and well-developed muscles in the back of the stump, the dimension <i>b </i>in <b>Fig. 7</b> may be reduced to zero. On the other hand, in the presence of flexion contracture in the stump, or weak musculature, this dimension may have to be increased to give sufficient stability. But to do so may result in the sacrifice of a normal gait and cause a tiring and awkward one. Similarly, postural abnormalities (<b>Fig. 6</b>, center and right) can make proper alignment very difficult to achieve.</p> <p>Such deviations in the weight line have upon postural stability and body alignment a biomechanical effect that is obvious. To complicate matters further, the amputee is deprived of a number of those sensory cues upon which every normal human being depends for the autonomous control of posture and motion. These include touch and pressure sensations from the soles of the feet and the never-ending bombardment of proprioceptive impulses that emanate from sensory receptors in the muscles, tendons, and joints of the weight-bearing limbs and sweep upward to the cerebellum. In the aggregate, these physiological and biomechanical deviations from normal appear formidible. Yet with proper fitting and alignment of his prosthesis, and with adequate training in the proper gait and posture, the average amputee can compensate for them to an amazing degree.</p> <p><i>Socket Shape</i></p> <p>Exactly what constitutes the most successful socket shape has not yet been fully determined owing to the many variables involved in the use of this technique. Several successful designs have been fully described in the literature <i><a></a><a></a><a></a><a></a>. </i>In these designs, weight-bearing occurs chiefly about the top posterior portion of the socket, particularly in the region of the ischial tuberosity, with a lesser amount on the gluteal muscle. The addition of a well-defined . . ischial seat reduces pis- ton action of the stump in the socket to a minimum and allows for a looser fit at the top of the socket. Incorrect shape, size, or location of the ischial seat leads to definite discomfort and frequent loss of suction, particularly when the wearer is sitting. In some very muscular stumps, the ischial seat may be reduced in size and in some cases removed entirely. Such amputees bear weight on their well-developed muscles, with the load distributed around the top portion of the socket. The socket is shaped the same except for the reduction or removal of the ischial seat.</p> <h4>Factors Relating To The Amputee</h4> <p><i>General Physical and Mental Factors</i></p> <p>A complete history and physical examination is the first step in determining the desirability of fitting the suction socket. Age is an important consideration, and as a rule elderly amputees are poor candidates for the for this reason it requires considerably more effort and muscular skill to learn to use it. If, therefore, the elderly amputee is, as is so often the case, debilitated and feeble, with muscles weak and flabby and with poor coordination and balance, he is a poor candidate for the suction socket. On the other hand, if he is strong, alert, and agile (that is, if he "appears younger than he is"), and if the stump is in proper condition and of adequate length, there is no reason why the elderly amputee cannot use a suction socket successfully.</p> <p>Experience has indicated that children as young as seven years can be fitted successfully.<a></a> The problem of lengthening and replacement as growth proceeds is no different from that with the conventional prosthesis.</p> <p>Before a suction socket is prescribed, every effort should be made to determine the psychological make-up of the amputee. All reports indicate that most failures have been due to suction socket. But old age <i>per se </i>is not a contraindication. Amputees over 70 years of age have been fitted successfully. As already noted, the suction-socket prosthesis is activated almost entirely by the muscles of the stump, and for this reason it requires considerably more effort and musulcar skill to learn to use it. if, therefore, the elderly amputee is, as is so often the case, debilitated and feeble, with muscles weak and flabby and with poor coordination and balance, he is a poor candidate for the suction socket. On the other hand, if he is strong, alert, and agile (that is, if he "appears younger than he is"), and if the stump is in proper condition and of adequate length, there is no reason why the elderly amputee cannot use a suction socket successfully.</p> <p>Experience has Indicated that children as young as seven years can be fitted successfully<a></a>. The problem of lengthening and replacement as growth proceeds is no different from that with the conventional prosthesis.</p> <p>Before a suction socket is prescribed, every effort should be made to determine the psychological make-up of the amputee. All reports indicate that most failures have been due to psychological or emotional difficulties. Learning to wear and use a suction-socket prosthesis requires cooperation, effort, patience, and perseverance. If the amputee is impatient, resentful, undependable, easily discouraged, unreasonable, or otherwise emotionally unstable, he most likely will be uncooperative and is apt to be a poor subject for the suction socket. Many failures can be attributed to the fact that the amputee is either unwilling or unable to devote the necessary time and effort to obtain a satisfactory fitting. As experience has been gained by the prosthetists, and with the additional aid of the recently developed alignment devices (page 23), the time required for construction and fitting has been considerably lessened in recent years. The interesting observation has been made that, when an amputee has to purchase his limb himself, he is likely to be much more cooperative than if he is given one by some agency.</p> <p><i>Slump Considerations</i></p> <p><i>Length. </i>Stump length is not so important a consideration as might be thought. Contour, muscle tone, and mobility are important determining factors in deciding whether or not a short stump can be fitted. Naturally, the longer the stump the better is the muscular control and the easier is the fitting and training problem. But stumps as short as 3 in. (measured from the crotch) have been fitted successfully. Usually the shorter stumps require the addition of an auxiliary suspension belt (such as the Silesian belts shown in <b>Fig. 2</b>) in order to stabilize the socket on the stump.</p> <p>End-bearing supracondylar and Gritti-Stokes amputation stumps can be fitted successfully with the suction socket, although in such cases the mechanical knee joint usually has to be placed at a level slightly below that of the opposite knee.</p> <p><i>Stump Contour. </i>With the conventional socket, a conical-shaped stump has always been considered desirable. Such is not the case with the suction socket. A stump of more cylindrical shape, with only slightly tapering sides and a fairly broad end, seems to maintain better suction and friction than does the conical or pointed stump. Most undesirable is a long, redundant, flabby mass of skin and fat extending beyond the bone end. Such a mass of tissue not only offers fitting problems but is prone to become edematous and swollen, thus making it difficult to don the leg or to remove the stump from the socket. In such cases, surgical revision is advisable before a suction socket is prescribed.</p> <p>Excessive subcutaneous fat or extreme flabbiness of stump muscles frequently results in marked changes in the contour of the stump after the suction socket has been worn for a while. Repeated modification of the socket thus becomes necessary. With excessive subcutaneous fat, the stump may shrink considerably after wearing the socket, necessitating the insertion of leather liners or even the making of a new socket. Muscles that are atrophied and flabby and of poor tone will develop and increase in size with the use of the suction socket, necessitating enlargement of the socket.</p> <p><i>Muscle Control and Strength. </i>Good muscular control and mobility of the stump are essential for successful use of the suction socket. Fixed deformities due to muscle contracture are very common in amputations above the knee, particularly in the older age group, and they not only present very serious fitting and alignment problems but also handicap the amputee in walking. Flexion and abduction deformities are the usual ones, and the shorter the stump, with resulting greater muscle imbalance, the more likely are they to occur. Once they do occur they are very difficult to correct. It is imperative, therefore, that every effort be made postoperatively to prevent such deformities. Studies in alignment conducted at the University of California<a></a> indicate that the most efficient gait with the suction-socket prosthesis is obtained by fitting the socket with the stump in adduction and slight flexion (<b>Fig. 7</b>). Severe flexion-abduction deformity of the stump makes such alignment very difficult, if not impossible, without producing marked tilting of the pelvis and excessive pressure on the stump.</p> <p>The adductor and hamstring muscles are important not only in controlling the limb but also in preventing flexion-abduction deformity by overcoming muscle imbalance. The shorter the stump, the less power remains in these muscles and the greater the tendency to deformity. It is well known that, in order for muscles to function at maximum efficiency, they must have a fixed insertion. In amputations through the thigh, the major muscles are sectioned well above their insertions, and all too often these muscles are allowed to retract upward, no attempt being made to fix their cut ends to fascia or over the end of the bone. Failure thus to fix the free ends seriously impairs muscle function in controlling the stump. In considering an amputee for a suction socket, the stump should be carefully examined to determine how well the thigh muscles are functioning and whether there are any fixed deformities. If any are present, active and passive exercises should be carried out to correct them as much as possible before the socket is fitted.</p> <p><i>Scars. </i>Deep linear scars near the socket brim may interfere with maintenance of suction. Tender, adherent scars in the weight-bearing area beneath the ischial tuberosity and over the buttocks may cause pain sufficient to prevent the wearing of a suction socket. Deep, folded, adherent, or puckered scars over the end of the stump, which so often cause difficulty with the conventional socket, rarely offer any problem with the suction socket. In fact, it has been observed repeatedly how often these scars smooth out and become more pliable after a suction socket has been worn for some time.</p> <p><i>Ulceration and Infection. </i>Open ulcers, draining sinuses, and active deep infection of the soft tissues of the stump, as well as active osteomyelitis, are definite contraindications to the use of the suction socket. With adequate surgery and use of antimicrobial drugs, these conditions can usually be eradicated readily.</p> <p><i>Bony Spurs. </i>Although in many thigh stumps bony spurs develop at the end of the femur, they rarely offer any difficulty in the fitting or wearing of a suction-socket prosthesis. Occasionally, however, a large spur will develop on the lateral side of the bone in a stump with a fixed abduction, thus producing painful pressure against the side of the socket. Relieving the socket at point of pressure, realigning the socket, or surgical removal of the spur usually solves such a problem.</p> <p><i>Skin Disturbances. </i>Skin sensitivity, irrita- tion, and infections are not uncommon in amputation stumps, and there appears to be considerable variation in the skin's resistance to pressure, friction, and irritation among individual amputees. Some are constantly troubled, while others have no difficulty. Der-matological complications are cited as a fairly common cause of failure in the use of the suction socket. Usually they can be prevented by proper hygienic care of the stump and good fitting, or else they can be relieved by derma-tologic treatment. Skin allergy and contact dermatitis, of rare occurrence with the suction socket, usually can be controlled readily. The troublesome adductor roll, with recurring "pressure boils" (suppurative hydroadenitis and folliculitis), so commonly encountered with the use of the conventional socket, rarely if ever occurs with the well-fitted suction socket. In fact, when such a condition exists with a conventional socket, and the socket is converted to a suction one, usually the roll and cysts rapidly disappear. This is one of the great advantages of the suction socket.</p> <p><i>Perspiration. </i>One troublesome problem occurs in individuals who perspire excessively and who also have a high bacterial count in their perspiration. Irritation or skin friction in such a situation leads to suppurative hydro-adenitis and furunculosis. Excessive perspiration is not uncommon when the suction socket is first worn, but it usually subsides after varying lengths of time. In alleviating these superficial skin infections, x-ray treatment is often of value. Autogenous vaccines have also been used with some success. Before any suction socket is discarded as a failure, every possible effort should be exerted to treat and eradicate such troublesome skin conditions. Some of them can be anticipated from previous history and careful examination and can be eliminated by proper treatment before the socket is fitted.</p> <p><i>Condition of the Opposite Extremity</i></p> <p>During the experimental program, and in the early suction-socket schools, abnormalities and disabilities in the opposite extremity were considered as constituting an important factor—and even as a probable contraindication—in determining the suitability of the amputee for a suction socket. Subsequent experience has shown that abnormalities in the opposite extremity, while still to be considered, are not necessarily contraindicative. Amputees with disabilities so great as to require permanent bracing of the opposite limb have been fitted successfully with suction sockets; many persons with below-knee amputations on one side are wearing above-knee suction-socket prostheses with ease and comfort on the other. In fact, in such cases the suction-socket leg appears to have several advantages over the conventional above-knee leg. Survey studies also reveal that some bilateral above-knee amputees have been successfully fitted with suction-socket prostheses. But of course it is apparent that all such cases must be selected only after a very thorough analysis of individual problems.</p> <p>Peripheral vascular disease which has necessitated amputation is in itself no contraindication to use of a suction socket, provided the opposite limb is not too seriously affected by the disease.</p> <h3>Conclusions</h3> <p>On the basis of the surveys reported upon, it appears quite definite that the suction-socket prosthesis has many advantages over the conventional belt- or shoulder-suspended leg. Approximately 75 percent of all above-knee amputees can be fitted successfully with the suction socket. Chief causes of failure, listed in decreasing order of importance, are psychological difficulties, general physical factors, stump abnormalities, and social and economic factors. Teamwork between physician, prosthe-tist, therapist, and amputee is an essential requirement in the successful fitting and wearing of the suction-socket prosthesis. Meticulous attention to fitting and alignment techniques is important, as is also adequate training.</p> <p>Research studies in gait and principles of alignment, and the development of new alignment devices and duplicating jigs, have been of great value in reducing the time involved in construction and fitting by eliminating, to a great extent, trial-and-error methods. Although many limb manufacturers in this country still do not appreciate the advantages of the suction-socket above-knee limb and make no attempt to fit it, the wide acceptance of the above-knee suction-socket prosthesis in the United States today indicates that it can no longer be considered an experimental device, its use limited to a few selected amputees. Use of the above-knee suction socket is now so prevalent that it can be safely stated—and fairly stated-that the majority of above-knee amputees can successfully be fitted with the suction-socket prosthesis.</p> <p><b>References:</b></p> <ol> <li>Aitken, G. T., and C. H. Frantz, <i>The juvenile ampu-tee, </i>J. Bone and Joint Surg., 35A:659 (1953).</li> <li>Beacock, George, and Terence Sparham, U. S. Pat-nt 329,880, November 10, 1885.</li> <li>Bechtol, C. 0., <i>The suction socket, </i>J.A.M.A., <b>146:625 (1951).</b></li> <li>Canty, T. J., and C. C. Asbelle, <i>Above knee suctionsocket prosthesis. </i>Final Technical Report No. 4, Amputation Center, U.S. Naval Hospital, Oakland, Calif., 1952.</li> <li>Eberhart, Howard D., and Jim C. McKennon, <i>Suc-tion-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>Felix, W., <i>Praktische Erfahrungen mil der Saugpro-these, </i>Ztschr. f. orthop., 72:352 (1941).</li> <li>Gocht, H., <i>Kunstliche Glieder, </i>Berlin, 1920.</li> <li>Haddan, C. C, <i>Alignment principles, </i>paper readefore a meeting of AAAS, Sec. M., Philadelphia, 1951.</li> <li>Little, E. M., <i>A new method of fitting artificial legsockets, </i>Brit. Med. J., 2:896 (Nov. 14, 1925).</li> <li>Mazet, R., P. E. McMaster, and C. G. Hutter<i>Analysis of one hundred and twenty four suction socket wearers followed from six to fifty five months, </i>J. Bone and Joint Surg., 33A:618 (1951).</li> <li>OALMA Journal, 3(3) :36 (Spring 1949).</li> <li>Parmelee, Dubois D., U. S. Patent 37,637, Febru-ry 10, 1863.</li> <li>Pfau, Heintz, personal communication.</li> <li>Thomas, A., and C. C. Haddan, <i>Amputation pros-thesis, </i>Lippincott, Philadelphia, 1945.</li> <li>Thorndike, A., and H. D. Eberhart, <i>Suction socketprosthesis for above knee amputations, </i>Am. J. Surg., 80:727 (1950).</li> <li>Toles, Justin K., U. S. Patent 980,457, January 3,1911.</li> <li>Underwood, Ernest Walter, U. S. Patent 1,586,015,ay 25, 1926. Also, British Patent 253,729, June 24, 1926.</li> <li>University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, <i>The suction socket above-knee artificial leg, </i>revised edition, April 1948.</li> <li>University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>The suction socket above-knee artificial leg, </i>3rd edition, April 1949.</li> <li>University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Functional considerations in fitting and alignment of the suction socket prosthesis, </i>March 1952.</li> <li>War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, <i>Report on European observations, </i>Washington, 1946.</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>20.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in fitting and alignment of the suction socket prosthesis, 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>1.</b> </td><td class="clsTextSmall">Aitken, G. T., and C. H. Frantz, The juvenile ampu-tee, J. Bone and Joint Surg., 35A:659 (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>1.</b> </td><td class="clsTextSmall">Aitken, G. T., and C. H. Frantz, The juvenile ampu-tee, J. Bone and Joint Surg., 35A:659 (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>19.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 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>18.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, revised edition, April 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>5.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon, Suc-tion-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></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Bechtol, C. 0., The suction socket, J.A.M.A., 146:625 (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>18.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, revised edition, April 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>4.</b> </td><td class="clsTextSmall">Canty, T. J., and C. C. Asbelle, Above knee suctionsocket prosthesis. Final Technical Report No. 4, Amputation Center, U.S. Naval Hospital, Oakland, Calif., 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>10.</b> </td><td class="clsTextSmall">Mazet, R., P. E. McMaster, and C. G. HutterAnalysis of one hundred and twenty four suction socket wearers followed from six to fifty five months, J. Bone and Joint Surg., 33A:618 (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>15.</b> </td><td class="clsTextSmall">Thorndike, A., and H. D. Eberhart, Suction socketprosthesis for above knee amputations, Am. J. Surg., 80:727 (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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 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>6.</b> </td><td class="clsTextSmall">Felix, W., Praktische Erfahrungen mil der Saugpro-these, Ztschr. f. orthop., 72:352 (1941).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Pfau, Heintz, personal communication.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Little, E. M., A new method of fitting artificial legsockets, Brit. Med. J., 2:896 (Nov. 14, 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>9.</b> </td><td class="clsTextSmall">Little, E. M., A new method of fitting artificial legsockets, Brit. Med. J., 2:896 (Nov. 14, 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>9.</b> </td><td class="clsTextSmall">Little, E. M., A new method of fitting artificial legsockets, Brit. Med. J., 2:896 (Nov. 14, 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>17.</b> </td><td class="clsTextSmall">Underwood, Ernest Walter, U. S. Patent 1,586,015,ay 25, 1926. Also, British Patent 253,729, June 24, 1926.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Toles, Justin K., U. S. Patent 980,457, January 3,1911.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Beacock, George, and Terence Sparham, U. S. Pat-nt 329,880, November 10, 1885.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Parmelee, Dubois D., U. S. Patent 37,637, Febru-ry 10, 1863.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 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>5.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon, Suc-tion-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></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Bechtol, C. 0., The suction socket, J.A.M.A., 146:625 (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>Atha Thomas, M.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Orthopedic Surgery, University of Colorado School of Medicine, Denver; member, Lower-Extremity Technical Committee, 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>Chester C. Haddan </b></td></tr><tr><td class="clsTextSmall">President, Gaines Orthopedic Appliances, Inc., Denver, Colorado; Past-President, Orthopedic Appliance and Limb Manufacturers Association; member, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-25.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-26.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-27.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-28.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-29.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-30.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-31.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-32.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Status of the Above-Knee Suction Socket in the United States Creator An entity primarily responsible for making the resource Chester C. Haddan * Atha Thomas, M.D. * https://staging.drfop.org/files/original/f4a0dba11dbd83d1386ccb0e624bc090.pdf cdd8923abdae6f28e1a9d8d1fe8755c4 https://staging.drfop.org/files/original/681863a98ef8c1b69d476ca775d584e5.jpeg ae65dd03b074faa805393f2bb2cca1eb https://staging.drfop.org/files/original/b3f368a835f52e8d59db880235d53694.jpg 64a7ad3c59294b4014476742e34ee741 https://staging.drfop.org/files/original/bd5404308943c819bbb4f8cf4312b7c3.jpg 40b7c14dc32d98e7f4de52e02a7bd7aa https://staging.drfop.org/files/original/8377ac015b32853159b839d4e215bde5.jpg ebb48fe686c96a27f8944c39a7ea1994 https://staging.drfop.org/files/original/568455a545a488a7582cc67a53f4e0ff.jpg 39633f73e9a88bef0976b0d0d921dcb5 https://staging.drfop.org/files/original/bba2f04183e22d65f8b82db57ebb81de.jpg 56a7734fbe443f9e90a5a81715258054 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1977_03_005.pdf Text Any textual data included in the document <h2>Partial Foot Amputation - A Case Study</h2> <h5>Charles H. Pritham C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Traditionally amputations through the foot have been held in poor repute for a variety of reasons<a></a>, chief among them being the equinus deformity that can result from an imbalance between the intact triceps surae and the severed anterior muscles. In addition, the poor quality of socket fit that often occurs with older styles of fabrication can be cited as a contributing factor for the low esteem in which tarsal and mid-tarsal amputations are held.</p> <p>In recent years there has been an ever increasing emphasis on more distal level of amputation for peripheral vascular disease and the advantages to be accrued. Thus, today, below-knee amputations and disarticulations at the knee have supplanted to a large measure above-knee amputations. In a similar fashion Syme's and partial foot amputations are being performed by some <a></a> to ensure the patients the advantages of full limb length, distal end-bearing, retention of proprioception, and a long lever arm. The trend has gained impetus from such improved methods of predicting successful amputation levels as Xenon Radiography, and differential pulse ratios to predict accurately stump viability <a></a> as well as such improved methods of surgical technique as fixation of the pretibial muscles for Chopart and Lisfranc amputations, heel pad fixation for the Syme's, and the use of rigid dressings for all levels of amputation <a></a>.</p> <p>It, thus, seems correct to conclude that an increasing number of partial foot amputations for vascular insufficiency will be seen by prosthetists in the years to come. The challenge to the prosthetist, therefore, is to maximize the advantages cited by using the best products of the latest available technology. One example of this can be found in the use of a modified plastic ankle-foot orthosis with a toe filler distal to the stump in those cases where stump length is adequate to ensure proper control and fit of the shoe <a></a>. Numerous variations of the basic theme exist, and are well known. Karl Fillauer has reported recently on his experience with a prosthesis that totally encompasses the stump below the malleoli and permits free motion of the ankle <a></a>. To the extent of the author's knowledge, neither of these designs have ever been subjected to formal evaluation and while experience has been gained by many prosthetists with the first design, little is known objectively about the latter. Both designs appear to work well in selected cases, but neither design appears to provide for the broadest possible distribution of pressure (or in the case of a modified AFO, the most accurate distribution) to protect the fragile, sensitive, and often partially anesthetic skin over the dorsal surface of the remainder of the foot <a></a>. The purpose of this paper is to discuss one possible solution to this problem.</p> <h3>Case Report</h3> <p>W.M. is a 62-year-old male Caucasian, who sustained a right Chopart amputation in 1972, secondary to peripheral vascular disease and necrosis of the forefoot (<b>Fig. 1</b>). He was subsequently fitted with a prosthesis which he wore until April 1977 (<b>Fig. 2</b>). The prosthesis was fabricated of polyester lamination with a posterior opening and metal reinforcing elements. Because of subsequent failure an additional steel armature was added externally, and the weight of the unit when seen by us had crept to 5 lb. 4 oz. Over the years sufficient change had taken place in contour of the stump so that W.M. was experiencing pain on the distal-lateral and anterior aspects of the stump, and he walked slowly with the use of a cane. Our initial attempt to fit the patient was made with a molded ankle-foot orthosis with a toe filler, but the patient obtained no relief from the pain, and the situation was re-evaluated.</p> <strong><a href="/files/original/681863a98ef8c1b69d476ca775d584e5.jpeg">Fig. 1.</a> W.M.'s Chopart Amputation</strong><br /><br /><strong><a href="/files/original/b3f368a835f52e8d59db880235d53694.jpg">Fig. 2.</a> W.M.'s "Conventional" prosthesis</strong><br /> <p>After due deliberation, the patient was cast in the weight-bearing position, tracings were taken of both feet and vertical reference lines drawn (<b>Fig. 3</b>). With the tracing as a guide, a proper sized SACH foot was selected for the forefoot extension to the positive model of the stump, overwhich a polyethelene form of the heel and sole could be vacuum molded. The positive model of the stump was positioned inside the polyethelene form and the tracing and reference lines were used as guides to establish proper alignment. After plaster had been poured in the form and blended into the stump model, 1/4-in. thick polypropylene was vacuum formed about the extended model and subsequently modified to establish an AFO-type of socket with maximum rigidity about the ankle and anterior lever arm. A Plastizote interface was molded to the anterior aspect of the stump model and mated to a toe filler shaped from SACH-foot heel-cushion stock.<br /><br /><strong><a href="/files/original/bd5404308943c819bbb4f8cf4312b7c3.jpg">Fig. 3</a>. Outline of feet during weight-bearing to provide references for fabrication and alignment of the molded prosthesis.</strong></p> <p>The semi-completed prosthesis was fitted to the patient so that adequacy of fit and alignment could be checked. Ambulation by the patient revealed that he still experienced some pain, which was relieved by using adhesive tape to strap the shin firmly into the prosthesis and thus distribute the pressure over a broader area. While the patient was standing, strapped in the prosthesis, splints were used to cast the limb for an anterior shell that would match properly with the posterior element. Polyethelene was vacuum formed over the model to form an anterior shell that was lined with Plastizote. The two elements were then fitted to the patient and fastened proximally with "PTB-type" buttons in a fashion identical to the tibial fracture orthosis reported by Stills <a></a>. The finished prosthesis (<b>Fig. 4</b>, <b>Fig. 5</b>, <b>Fig. 6</b>) weighed 18 ounces and fitted more loosely in the shoe than the older prosthesis. The patient reported total comfort in the prosthesis during walking and considered the vastly decreased weight an important advantage.</p> <strong><a href="/files/original/8377ac015b32853159b839d4e215bde5.jpg">Fig. 4.</a> The molded prosthesis on the patient.</strong><br /><br /><strong><a href="/files/original/568455a545a488a7582cc67a53f4e0ff.jpg">Fig. 5</a>. Lateral view of the molded prosthesis.</strong><br /><br /><strong><a href="/files/original/bba2f04183e22d65f8b82db57ebb81de.jpg">Fig. 6.</a> Three-quarter anterior view of the molded prosthesis.</strong><br /> <p><b>References:</b></p> <ol> <li>Alidredge, R. FF, and E. F. Murphy, <i>The influence of new developments on amputation surgery</i>. In: Human Limbs and their Substitutes. New York, McGraw Hill Co., Inc. 1954.</li> <li>Anderson, M. H., J. J. Bray, and C. A. Hennessey, <i>The construction and fitting of lower-extremity prostheses</i>. In: Orthopaedic Appliances Atlas. Ann Arbor, ). W. Edwards, 1960.</li> <li>Bingham, J. <i>The surgery for partial foot amputations</i>. In: Prosthetic and Orthotic Practice. London, Edward Arnold Ltd., 1970.</li> <li>Condie, D. N. <i>Biomechanics of the partial foot amputation</i>. In: Prosthetic and Orthotic Practice. London, Edward Arnold Ltd., 1970,</li> <li>El-Sharkaw, A., H. Abdel-Farrar, H. El-Hadidi, and M. Abdel-Hafez, <i>A reconsideration of tarsal amputations with a new approach to the problem of equinus deformity</i>. In: Proceedings of the International Conference, Cairo and Alexandria, Egypt, May 1- 1 1, 1972. Sponsored by Social and Rehabilitation Service, DHEW, USA and International Society-tor Prosthetics and Orthotics.</li> <li>Eillauer, K. <i>A prosthesis tor foot amputation near the tarsal-metatarsal junction</i>. Orthotics and Prosthetics 30 (3): 9-11, September 1976.</li> <li>Rubenstein, H. J., G. J. Sweeney, P. Strong, and C. Durrett, <i>A foot amputation orthosis-prosthesis</i>. Inter-Clinic Information Bulletin 14(4), April 1975.</li> <li>Rubin, G., and M. Daniso, <i>Functional partial foot prosthesis</i>. Bulletin of Prosthetic Research 10-16: 149-152, Fall 1971.</li> <li>Rubin, C, and M. Daniso, <i>A functional Chopart prosthesis</i>. Inter-clinic Information Bulletin 11(6), March 1972.</li> <li>Stills, M. <i>Vacuum-formed orthoses for fracture of the tibia</i>. Orthotics and Prosthetics 30(2): 43-55, June 1976.</li> <li>Wagner, W. <i>Instructional Course in Amputation Surgery and Post-Op Care</i>. ISPO World Congress. New York, May 1977</li> </ol> <strong>*Charles H. Pritham C.P.O. </strong><strong>Staff Prosthetist, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, 12th St. &amp;Tabor Rri., Phila., Pa. 19141<br /><br /><br /></strong> Page Number(s) 5 - 7 Year 1977 Volume 1 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-6.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Partial Foot Amputation - A Case Study Creator An entity primarily responsible for making the resource Charles H. Pritham C.P.O. * https://staging.drfop.org/files/original/d1e6d37381974afea447207e5e2dcbe4.pdf 098f55530355bceeb283da47fcc350e7 https://staging.drfop.org/files/original/0666e268b5cec1356b0b7c65cbfadb51.jpg 34526111ef1e2eb773fafce8d671b491 https://staging.drfop.org/files/original/cc9fd87e23971d5b30a0750aca41f5a3.jpg 63bf988ca05ee052c35c60bac08961ea https://staging.drfop.org/files/original/85d3b8a378a156a011e468adb5269da1.jpg 5bf92dc7bf504dcff53808541d517251 https://staging.drfop.org/files/original/227e6156213f99f0da1e50d223dee8a0.jpg 3db61f11e3ba6a4f7e34e896d5442696 https://staging.drfop.org/files/original/9a578284ee6908603aea1c033d17b00a.jpg e8da77889765cbddc376316eae272fe9 https://staging.drfop.org/files/original/2cdd2bdc87a91cc20b1bd2e2c8de8fdb.jpg bc32bfecba3ba120e95537d67188be8d https://staging.drfop.org/files/original/08887b5a399d3835a423a7465e92c363.jpg b49025384d7feb416227e5c087356179 https://staging.drfop.org/files/original/3bdc683c4fd3a3b01dd291dcc05442a7.jpg dc3f77f6a7dc6e8f10d15f57a79b4bd5 https://staging.drfop.org/files/original/baa8c678a811a389abfecf5c63ec394a.jpg fadb2fb86dfab8eae20656c2668c41bf https://staging.drfop.org/files/original/8af81fcc4e2a1200c4b3ebacefd7dcdc.jpg 71e21b708994bac32da23d1191b72f33 https://staging.drfop.org/files/original/df8f5de5f6e51604721fe6c8eac18d00.jpg daf7122151ce6dea1bd294319637ca83 https://staging.drfop.org/files/original/fc36c0b09aa6f3af1a634440b2895b0c.jpg 737f8f6f58dd6ce0aa0bafb5bc333f08 https://staging.drfop.org/files/original/f23de5b7227d292fd049b5c53370ad5e.jpg 322c5646d98f492326ba9b2ad1189f10 https://staging.drfop.org/files/original/12807becbc364793ce64139f3ed19ca0.jpg 76b2ffd63899936900e983217326addb https://staging.drfop.org/files/original/c7c004b4cacc9f9a708a3486dc137efa.jpg d1ecb9180a51ca39aec2e6a1a746c16d https://staging.drfop.org/files/original/0b96ee4588a2a50ba8ae866ee38bd212.jpg 9ce093f92ed02602e5a59abd344d72a8 https://staging.drfop.org/files/original/6dca045beee9acf9d8ca40d95e842f26.jpg 261149ab340dc088401ee1852c05995d https://staging.drfop.org/files/original/1dfabfd667493e59ce35c164c328039a.jpg d22c081e2b4704fdbf8a951a6c62136a https://staging.drfop.org/files/original/70bc99ba51deb9adc1649fc859b83790.jpg 1315b524e4b6252efd9c727af36bddc5 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_015.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 15 - 24 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_01_015.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_01_015.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Upper-Extremity Prosthetics Armamentarium</h2> <h5>Maurice J. Fletcher, Lt. Col., USA (MSC) <a style="text-decoration:none;">*</a><br /></h5> <p>The word "armamentarium" is defined as "the equipment, instruments, apparatus, or paraphernalia used by the practitioner of medicine." As applied to artificial limbs, it refers to the array of components necessary for the prescription fitting of prostheses in relationship to the site of amputation.</p> <p>In the prosthetics armamentarium, it is desirable that a complete range of components be available in order to provide satisfactory prostheses for all sites of upper-extremity amputations. A few gaps still remain in the present armamentarium of devices, but such temporary inadequacies are in the area of special cases, such as in transcarpal and fore-quarter amputations and in children's prostheses. The few remaining gaps are being rapidly filled, and supplementary components for fortifying the present armamentarium, such as additional hand sizes, are under consideration at the present time. The fact that devices now exist in each category of necessary arm components does not necessarily mean that they are the ultimate. They might even be interim devices, but they do permit prescription fitting of arm prostheses to a degree of efficiency heretofore unattainable. As a device is made available for each category of the armamentarium, improve-ments are attempted in these individual devices to increase their efficiency and useful-ness to the amputee. New models and methods of operation are being exploited in the hope of providing, eventually, even more efficient restorative prostheses. It is the purpose here to provide brief descriptions of the functions provided by the basic units of the present upper-extremity armamentarium. For a more detailed treatment of the devices and the philosophy underlying their design, reference may be had to <i>Human Limbs and Their Substitutes</i> (McGraw-Hill, in press) and to the <i>Manual of Upper-Extremity Prosthetics</i> (University of California at Los Angeles, 1952).</p> <h3>Terminal Devices</h3> <h4>APRL Model 4c Voluntary-Closing Hand and Cosmetic Glove</h4> <p>As the name implies, in the APRL voluntary-closing hand (<b>Fig. 1</b>) prehension force is obtained voluntarily by the amputee. Tension applied to a control cable closes the index and middle fingers against the thumb in a three-jaw-chuck pattern. These one-piece, hollow, metal fingers move through a 1 1/2-in. range, but since the thumb tip can be set in either of two positions 1 1/2-in. apart, objects up to 3 in. wide can be grasped. Finger angles are such that a grasped object is forced inward toward the palm. Security of grasp is further increased by the use of felt pads on the inner surfaces of the fingers and thumb. Any degree of prehensile force up to about 35 lb. can be obtained. The ring and little fingers are of cast latex and are attached so that they roughly conform to the shape of the object being handled.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. APRL model 4C voluntary-closing hand. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The actuating mechanism, shown in <b>Fig. 1</b>, consists of a cam-quadrant type of clutch which automatically locks the index finger and middle finger in place when tension in the control cable is released. Reapplication of tension automatically unlocks the mechanism, and a spring forces the fingers to the fully open position, at which point the mechanism is recocked and ready for another cycle. Backlash is eliminated in the lever system by incorporation of an auxiliary spring-and-lever system. In fact a certain amount of frontlash may be introduced into the system. The voluntary-closing type of mechanism permits fuller utilization of the potentialities of a cineplasty tunnel than any device heretofore available.</p> <p>The APRL hand is covered by a cast polyvinyl chloride glove of extremely natural appearance (<b>Fig. 2</b>). Developed especially for the APRL hand, it has been designed with particular regard to eliminating as much as possible the resistance to operation of the fingers. In order to reduce the necessarily high cost of coloring each glove on a custom basis, after careful experimentation six Caucasian and six Negroid shades have been provided. They satisfy the majority of amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. APRL model 4C voluntary-closing hanc covered with APRL cosmetic glove. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>APRL Voluntary-Closing Hook</h4> <p>The APRL voluntary-closing hook (<b>Fig. 3</b>) contains essentially the same mechanism employed in the APRL hand. One hook finger is closed against a stationary hook finger, the two designed to accommodate objects up to 3 in. in size. A control button permits the engagement of a stop to limit hook opening to 1 1/2-in. so that the hook finger does not have to move through its full range before recocking of the locking mechanism takes place. Moreover, locking action in the l 1/2-in. open position can be eliminated at the will of the amputee when this is desired for repetitive tasks. The rubber-lined, lyre-shaped, aluminum hook fingers are specially designed to provide maximum function. The smooth exterior surfaces present the least amount of friction to aid in entering pockets, while the rubber linings provide friction to aid in handling objects. Duckbill finger tips lend facility in handling small objects. By removing the fingers and reinstalling them 180 deg. from the original position, a right hook can quickly be converted to a left, or vice versa.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. APRL voluntary-closing hook in open and closed positions. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Northrop-Sierra Voluntary-Opening Two-Load Hook</h4> <p>In the Northrop-Sierra voluntary-opening two-load hook (<b>Fig. 4</b>), designed primarily for bilateral amputees, tension on the control cable causes one hook finger to open against a spring force, which in turn provides prehensile force between the hook fingers when there is no tension on the control cable. The spring force is provided by two identical coil-type springs. When both are engaged, a prehensile force of approximately 7 lb. is available at the ringer tips. When only one spring is engaged, 3 1/2 lb. of force are available.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Northrop-Sierra voluntary-opening two-load hook. Schematic diagram (above) shows arrangement of hook thumb and enclosed coil springs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The lyre-shaped fingers are the same as nose used in the APRL hook.</p> <h4>Dorrance Voluntary-Opening Hook</h4> <p>Prehension in the Dorrance hooks is provided by rubber bands which force the hook fingers together. Adjustment of the prehension force is accomplished by adding or removing bands. Hook fingers are available in many different sizes and shapes of both steel and aluminum. Dorrance hooks offer the extreme in ruggedness and simplicity. The model known as Utility #5, shown in <b>Fig. 5</b>, is very popular.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Dorrance #5 utility hook. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Length Adapters and Fairings</h4> <p>To provide a constant effective prosthetic length when terminal devices of different lengths are interchanged, as in the case of the APRL hook and hand, length adapters and fairings (<b>Fig. 6</b>) have been made available. The length adapter is simply a stud with male threads at one end and female threads at the other so that it may be inserted between terminal device and wrist unit. Also available is a plastic fairing which covers the length adapter and provides a smooth transition between the oval end section of the APRL hand and the circular section of the wrist unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Wrist fairing and length adapter for APRL model 4C hand. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Wrist Units</h3> <h4>Manual Friction-Type Wrist Units</h4> <p>Female threads receive the stud of the terminal device, the wrist-flexion unit, or the length adapter to permit attachment of these units to the arm. Compression of a rubber washer between the terminal device and the wrist unit provides sufficient friction to permit a certain amount of adjustment in the rotation of the terminal device without slippage under average operating conditions. SierraEngineering Company supplies the friction-type wrist unit in one size, 2 in. in diameter, suitable for the average adult male, while Hosmer supplies essentially the same unit in three sizes-2 in. in diameter for the average male, 1 3/4-in. in diameter for women and large children, and 1 3/8-in. in diameter for small children. All these units are designed to facilitate incorporation into plastic-laminate arms.</p> <h4>Manual Lock-Type Wrist Units</h4> <p><b>Hosmer F-M Wrist Unit</b></p> <p>Rapid interchange of terminal devices and positive locking of the terminal device in the pronation-supination plane are afforded by the Hosmer F-M (Fletcher-Motis) unit (<b>Fig. 7</b>). A serrated steel adapter with an annular groove is attached to the stud of the terminal device by threads. To connect the terminal device to the arm, the stud is forced into the wrist unit until a locking yoke and gear segment are engaged. To adjust the amount of rotation of the terminal device, the control button is depressed to the first detent, which releases the gear lock and permits rotation since the terminal device is retained by engagement of the locking yoke in the annular groove on the adapter. Further depression of the control button disengages the locking yoke and permits removal of the terminal device. A coiled compression spring attached to the end of the adapter facilitates operation of the F-M unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Hosmer F-M wrist unit, with exploded view showing arrangement of parts. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Hosmer Quick-Change Wrist Unit</b></p> <p>The Hosmer quick-change wrist unit provides essentially the same function as the F-M unit but is not quite as rugged and is more difficult to operate in some instances. The adapter and terminal device are released by rotating the forward portion of the wrist section, which disengages a detent-type lock. The quick-change unit is lighter in weight than the F-M unit and is used when weight is an important factor.</p> <h4>Northrop-Sierra Wrist-Flexion Device</h4> <p>The Northrop-Sierra Model B wrist-flexion device (<b>Fig. 8</b>), when used, is installed between the terminal device and the wrist unit. Consisting of a simple detent-type lock with three positions, it permits manual positioning and locking of the terminal device at 0, 25, and 50 deg. of flexion. Depression of a control button at the base of the unit disengages the lock to permit a change in the amount of wrist flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Northrop-Sierra model B wrist-flexion device. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Bilateral amputees find this device especially useful for working in areas close to the face and body, and some unilateral amputees have found it helpful in certain tasks necessary to their particular occupation.</p> <p>The APRL-Sierra below-elbow wrist-rotation unit (<b>Fig. 9</b>) has been developed to step up or multiply the residual pronation-supination of below-elbow amputees. A given rotation of the inner socket by the stump produces, through a planetary gear system, 2.3 times that amount of rotation in the terminal device. A locking mechanism, actuated by relative motion between the forearm and upper arm, and by which the unit is unlocked upon full extension of the forearm and locked upon flexion, is provided when desired.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. APRL-sierra wrist-rotation step-up unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Below-elbow amputees with little or no pronation-supination and nearly conical stumps have been fitted successfully with this unit, since rotation of the inner socket can be produced by rotating the humerus. In this case the lock must be provided so the stump may rotate relative to the socket upon flexion.</p> <h3>Below-Elbow Hinges</h3> <h4>Robin-Aids Flexible Hinges</h4> <p>Where no wrist-rotation step-up unit is used, the Robin-Aids flexible hinge (<b>Fig. 10</b>, bottom) is employed between the socket and arm cuff or triceps pad to impart axial stability to the entire prosthesis and yet to permit maximum use of the residual pronation-supination. The Robin-Aids hinge consists of a metal cable covered with a wrapped-wire housing and having flat terminal plates designed for firm anchoring in the plastic-laminate forearm and for fastening to the upper-arm cuff.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Below-elbow hinges. Top, Sierra insert hinge; center, Hosmer variable-ratio step-up hinge; bottom, Robin-Aids flexible hinge. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Leather-Strap Hinges</h4> <p>Nylon-coated leather straps may be fabricated in the shop and used in lieu of the Robin-Aids flexible hinge.</p> <h4>Single-Axis Hinges</h4> <p>Metal single-axis hinges specially designed for plastic fabrication are available from several manufacturers. This type of hinge is used where maximum stability is required, such as in short below-elbow cases and in heavy-duty arms.</p> <h4>Polycentric Hinges</h4> <p>Polycentric hinges may be substituted for the single-axis hinges. They are preferred by many prosthetists because less care is required in location to give the same amount of comfort to the patient. Instead of a single axis, two hinge points are provided in this unit, thereby exerting less pressure on the stump through the socket when the forearm is flexed and when some slight misalignment exists.</p> <h4>Northrop-Sierra Insert Hinges</h4> <p>Insert-type hinges might be classified as semiflexible hinges, since they provide a degree of stability somewhere between that offered by the flexible Robin-Aids hinge or the leather strap and the solid steel hinges. They are generally used on medium below-elbow prostheses where sufficient stability cannot be obtained with the flexible hinge but where the stump is long enough to provide sufficient stability so that the metal-strap hinges are unnecessary. Insert hinges are installed in "ears" on the distal end of a leather arm cuff so that the cuff may be hinged about the proximal end of the forearm socket. The method of assembly is illustrated in <b>Fig. 10</b>, top.</p> <h4>Step-Up Hinges</h4> <p><b>Hosmer MA-100 Hinges</b></p> <p>The Hosmer MA-100 step-up hinge (<b>Fig. 11</b>) was developed to permit full flexion of the prosthetic forearm when flexion of the stump is limited to 90 deg. or more. Step-up action is provided through two gears so that flexion of the stump 90 deg. results in 135 deg. of forearm flexion. The multiplication in motion results in a corresponding decrease in torque about the prosthetic forearm, and often an assistive lift is required for forearm flexion. This is accomplished by employing one of the above-elbow harnessing systems.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Hosmer MA-100 step-up hinge. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Hosmer Variable-Ratio Step-Up Hinge</b></p> <p>The Hosmer variable-ratio hinge (<b>Fig. 10</b>, center) provides approximately the same function as the MA-100 hinge but is usually preferred because the changing ratio of stump action to forearm action provided by the sliding lever system results in easier operation. This ratio in the fully extended position is 1:1.8, increases to 1:1.3 when the forearm is flexed 90 deg., and decreases to 1:1.8 at the 135-deg. position. Furthermore, because of the sliding action of the hinge, the stump does not extend as far below the forearm in flexion as in the case of the MA-100 hinge, a fact which in many instances eliminates the necessity for enlarging the sleeve of the garment covering the artificial limb.</p> <h4>Robin-Aids Stump-Actuated Elbow Lock</h4> <p>The Robin-Aids elbow (<b>Fig. 12</b>) was designed for short below-elbow cases where flexion of the forearm is limited to less than 90 deg. or for those cases where the torque about the elbow is too weak to offer sufficient stability. Full extension of the stump forces a lever into a detent on a segment about the elbow axis, locking the forearm in flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Robin-Aids stump-actuated elbow lock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Elbow Units for Above-Elbow Cases</h3> <h4>Northrop Model C Elbow</h4> <p>An alternating-type control for the locking mechanism is the prominent feature of the Northrop Model C elbow (<b>Fig. 13</b>). The first pull on the control cable drops a lever into a detent on a sector, resulting in a positive locking action about the elbow axis. The next pull on the control cable removes the locking level from the detent, thereby making the forearm free to rotate about the elbow axis. Eleven locking positions are available. In the average above-elbow case, the control cable is generally actuated by humeral extension, leaving the other hand or prosthesis, as the case may be, free. The excursion required, about 3/8-in., is so slight that after some practice most amputees are able to operate the locking unit with a motion that goes unnoticed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Northrop model C elbow unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Attachment to the upper arm is afforded by a single bolt in a turntable arrangement which permits the amputee to select at will the plane of forearm flexion and extension. A specially designed saddle for lamination into plastic is used for attaching the unit to the forearm.</p> <p>The Northrop elbow is presently available in one size only, 3 in. in diameter.</p> <h4>Hosmer Elbow Unit</h4> <p>Locking action of the Hosmer elbow unit (<b>Fig. 14</b>) is accomplished by permitting two tightly wound coil springs to wrap themselves around a shaft. Such an arrangement permits an infinite number of locking positions. Attachment to the arm and forearm and operation by the amputee follows the same pattern as in the case of the Northrop Model C.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Hosmer elbow unit, without turntable or forearm saddle attachments. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Hosmer unit is available in two sizes, approximately 2 and 3 in. in diameter. Recently Hosmer has added to its line a smaller elbow designed for children.</p> <h4>Elbow-Disarticulation Prostheses</h4> <p>The APRL-Sierra side-locking elbow hinge (<b>Fig. 15</b>) was developed expressly for elbow disarticulation and for very long above-elbow cases where insufficient room exists for the fully enclosed type of elbow unit. An alternating-type locking unit on the outside of the inner hinges permits locking and unlocking of the elbow by humeral extension, as in the case of the standard above-elbow amputee. This unit may also be used on short below-elbow cases where use of the Robin-Aids forearm-actuated lock is not feasible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. APRL-Sierra outside-locking elbow hinge. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Control Systems</h3> <p>For terminal-device operation and forearm control, Bowden-type controls, along with such parts as retainer and terminal fittings specially designed for use on artificial arms, are available from a number of sources for both the harness and cineplasty applications. This type of control system (<b>Fig. 16</b>), consisting of high-strength woven wire cable enclosed in a wrapped-wire housing, has proven infinitely more satisfactory than anything else used to date, mainly because of its resistance to stretching and its relatively high power-transmission efficiency.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Bowden-type control cable and attachments. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Below-Elbow Biceps Cineplasty Control Systems</h4> <p>Special control-system kits are available for below-elbow amputees with biceps cineplasty tunnels. The twin-cable system (<b>Fig. 17</b>), often referred to as the UCLA system, is available with either straight or ox-bow acrylic tunnel pins reinforced with a copper core. Provisions have been made for quickly attaching or removing the control cables with respect to the pin. Rapid selection of the initial tension on the muscle tunnel is made possible by the incorporation of a turnbuckle type of unit which controls the effective cable length. A single-cable system using a sheave-type equalizer and known as the APRL system is also available (<b>Fig. 18</b>). Cable-tension adjust-ment is provided by a single cable-length ad-juster installed between the sheave and the terminal device. Each of these systems is considered merely as a replacement for the shoulder-operated control system, since all other portions of the prosthesis are the same whether operated from the shoulder or from the muscle tunnel.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Twin-cable control system for below-elbow biceps cineplasty. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. APRL single-cable control system for below-elbow biceps cineplasty. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Nudge Control</h4> <p>For the shoulder-disarticulation case, in which it is impossible to provide from shoulder movement force and excursion necessary to operate the Northrop Model C or Hosmer elbow, there is available the Nudge Control, which permits the elbow lock to be controlled by chin movement. The nudge control (<b>Fig. 19</b>) is especially useful for bilateral shoulder-disarticulation cases.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Nudge control for operation of elbow lock in shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Conclusion</h3> <p>This, briefly, completes the basic items of the armamentarium of devices available for prescription fitting relative to sites of amputation. There are, however, many supplementary devices, available in the field and well known to the industry, which are used with the devices described.</p> <p>With the existence of the many devices now on the market, it is possible to custom-build prostheses to rare or irregular cases, and to increase the number of items in the armamentarium makes such custom-building more feasible. A number of improvements are constantly being made in the research establishments on existing devices, and these, of course, will be fed into the industry as they are developed to the point where they are considered commercially marketable and necessary items of the armamentarium.</p> <p>Needless to say, each existing armamentarium item is being accorded careful study by the various research groups in an effort to increase efficiency and utility. Many new devices are now in the research stage; some are approaching the transitional period; others are known to be necessary and steps have been taken to prove such devices and to production-engineer them to the point where they will be marketable from the standpoint of increased efficiency, decreased maintenance, and economics. To mention a few items, the goals sought include improved terminal devices, both hand and hook; the cosmetic glove; improved elbow-lock mechanisms and elbow mechanisms themselves; the cosmetic approach to the entire prosthesis, up to and including the shoulder; and improvement of the over-all control systems to make them more efficient and more durable than are those now available. Already existent items of the armamentarium, such as harnesses, harness materials, and fittings, have been passed by purposely in this discussion, since they are well known to the industry. The use of some of the new synthetic materials, such as nylon, orlon, and dacron webbing, is standard practice in most limbshops. These new webbings are perspiration-resistant and possess adequate strength to meet the requirements of modern prosthetic devices. New webbings of various types and structures are constantly under study and test. Steady improvement has been made in the process of weaving these materials to prevent stretching.</p> <p>It is hoped that, through the gradual improvement of all items of the armamentarium, the comfort and utility of upperextremity prostheses will be increased to the point where an amputee will continuously wear and use a prosthetic device and will no longer be considered by society as a handicapped person. It may then be realized that the amputee can perform his job as well as can the normal person. The prescription fitting of each individual case may become so precise and so efficient that there will no longer be a question as to the value of the prosthesis to the amputee in returning to his place in society. The continuous development of new items for the armamentarium, and improvement in items existing in the present armamentarium, will make available to the prosthetist a variety of components permitting the satisfactory fitting of each amputee in conformance to his own individual pattern of life and will permit the new amputee to resume many jobs without loss in efficiency.</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>Maurice J. Fletcher, Lt. Col., USA (MSC) </b></td></tr><tr><td class="clsTextSmall">Director, Army Prosthetics Research Laboratory, Walter Reed Army Hospital; member, Upper-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-010.jpg Figure 11 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-011.jpg Figure 12 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-012.jpg Figure 13 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-013.jpg Figure 14 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-014.jpg Figure 15 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-015.jpg Figure 16 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-016.jpg Figure 17 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-017.jpg Figure 18 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-018.jpg Figure 19 http://www.oandplibrary.org/al/images/1954_01_015/Jan54c-019.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Upper-Extremity Prosthetics Armamentarium Creator An entity primarily responsible for making the resource Maurice J. Fletcher, Lt. Col., USA (MSC) * https://staging.drfop.org/files/original/646807426d786878263060044f860bb5.pdf a91cea6354ddf7b14de92ba2bb2c720d Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1977_04_001.pdf Text Any textual data included in the document <h2>Partial Foot Amputation</h2> <h3>Results of the Questionnaire Survey</h3> <p>There were fifteen replies by mail to the questionnaire on management of patients with partial foot amputation that appeared in the Summer 1977 issue of the NEWSLETTER. Ten came from prosthetists, one from a physical therapist, and four from physicians.</p> <p>The answers and remarks from all but one prosthetist are given below. One prosthetist, Lewis Meitzer of Miami, Florida, took the time and trouble to write a very thoughtful letter which is printed in full after the tabulation of the questionnaires.</p> <p>Prepared by the American Academy of Orthotists and Prosthetists, 1444 N Street, N.W., Washington, D.C. 20005. Editor: A. Bennett Wilson, Jr., B.S. M.E.; Editorial Board: Joseph M. Cestaro, C.P.O., Charles H. Epps, Jr., M.D., Robert B. Peterson, R.P.T.</p> <ol> <li> <p>Do you feel that patients with partial foot amputations require prostheses that extend higher than the distal third of the tibia?</p> <ul> <li> <p><b>Certified Prosthetists</b></p> <ol> <li> <p>No. Ankle high only.</p> </li> <li> <p>The prosthesis should not be higher than maleoli.</p> </li> <li> <p>Yes.</p> </li> <li> <p>Very seldom</p> </li> <li> <p>Especially true for active people. Low activity people without deformities seem to function well with the least amount of appliance.</p> </li> <li> <p>Not in all cases, for example, we're using C. Fillauer's AC &amp; PLIC socket w/posterior (6) split for a great percentage of our partial foot amputees.</p> </li> <li> <p>No.</p> </li> <li> <p>I basically avoid terminating a prosthesis on the lower tibia. Often a shoe insert with the filler works fine. If a rigid ant. is used, I definitely do not stop at any point on the tibia.</p> </li> <li> <p>Transmetatarsal or longer - No. All others - Yes.</p> </li> </ol> </li> <li> <p><b>M.D.'S</b></p> <ol> <li> <p>If hand users.</p> </li> <li> <p>Yes.</p> </li> <li> <p>No.</p> </li> <li> <p>If full, pain free, weight bearing is possible on the remaining part of the foot - No. If not, then weight needs to be taken higher.</p> </li> </ol> </li> <li> <p><b>P.T.</b></p> <ol> <li> <p>Yes.</p> </li> </ol> </li> </ul> </li> <li> <p>Do you feel that most patients who receive partial foot amputations would function better with a Syme's amputation?</p> <ul> <li> <p><b>Certified Prosthetists</b></p> <ol> <li> <p>No.</p> </li> <li> <p>No, as long as the plantar surface can tolerate weight bearing, a partial foot is better than Syme's.</p> </li> <li> <p>No.</p> </li> <li> <p>No.</p> </li> <li> <p>Again active people and children who can possible avoid bone spurs and eventually develop an endbearing cosmetic BK. Surgery is important. Good padding over bones is very beneficial.</p> </li> <li> <p>Yes, the large majority would increase their function and be relatively pain-free.</p> </li> <li> <p>No.</p> </li> <li> <p>No. I have seen too many patients function beautifully with partial foot and only a toe filler.</p> </li> <li> <p>For P.V.D. patients a Symes amputation usually has a better chance to heal and the prosthetic fitting is better. For traumatic amputations as much length should be preserved to increase weight bearing surface and lever arm.</p> </li> </ol> </li> <li> <p><b>M.D.'S</b></p> <ol> <li> <p>Yes, but not all.</p> </li> <li> <p>Not necessarily.</p> </li> <li> <p>Yes, at least psychologically.</p> </li> <li> <p>No. A Syme's is much more radical than is often necessary and will not necessarily result in better function.</p> </li> </ol> </li> <li> <p><b>P.T.</b></p> <ol> <li> <p>Yes.</p> </li> </ol> </li> </ul> </li> <li> <p>Do you agree with the author's list of advantages and disadvantages of this amputation?</p> <ul> <li> <p><b>Certified Prosthetists</b></p> <ol> <li> <p>Some.</p> </li> <li> <p>-</p> </li> <li> <p>Yes.</p> </li> <li> <p>Yes.</p> </li> <li> <p>I feel amputation sites for children should take bony overgrowth and foreshortening into account, i.e., disarticulation rather than partial foot types.</p> </li> <li> <p>Not in its entirety, but generally speaking, yes.</p> </li> <li> <p>Yes.</p> </li> <li> <p>Some of them.</p> </li> <li> <p>Yes we do, however, prosthetic breakdown will still occur regardless which type is fitted.</p> </li> </ol> </li> <li> <p><b>M.D.'S</b></p> <ol> <li> <p>No. They are not the indication for the procedure.</p> </li> <li> <p>?</p> </li> <li> <p>Yes.</p> </li> <li> <p>Partially.</p> </li> </ol> </li> <li> <p><b>P.T.</b></p> <ol> <li> <p>Yes.</p> </li> </ol> </li> </ul> </li> <li> <p>Do you feel that the sole or shank of the shoes or prosthesis should be rigid or flexible?</p> <ul> <li> <p><b>Certified Prosthetists</b></p> <ol> <li> <p>Flexible.</p> </li> <li> <p>Flexible, to provide easy roll over the often tender distal anterior foot.</p> </li> <li> <p>Rigid to metatarsal break, flexible distal from this point.</p> </li> <li> <p>Rigid except for toe flexibility.</p> </li> <li> <p>The sole should extend the toe break past the end of the amputation, rigid slightly past this point.</p> </li> <li> <p>We think in terms of the SACH foot function using rigid soft tissue support w/flexible forefoot.</p> </li> <li> <p>Flexible.</p> </li> <li> <p>Depends on patient's gait, toe off phase especially. Generally rigid to the ball of the shoe and flexible in the toe area.</p> </li> <li> <p>Usually, a rigid shoe and/or prosthetic foot functions better. However, we do have success using a modified Winnipeg Symes Prosthesis, which is partially flexible.</p> </li> </ol> </li> <li> <p><b>M.D.'S</b></p> <ol> <li> <p>Rigid.</p> </li> <li> <p>Rigid.</p> </li> <li> <p>Do not know.</p> </li> <li> <p>It depends largely on the level of amputation, the shoe control which is achieved and the residual ankle function. In general it needs to be rigid proximal to the metatarsal heads and capable of flexing to about 15° under the metatarsal heads when loaded.</p> <p>Sometimes, e.g. when the metatarsal heads are painful or in a very proximal level amputation, it needs to be rigid throughout and with a rocker base. If there is adequate ankle function, and reasonable shoe control on the residual foot, the prosthesis should flex at the ankle too.</p> </li> </ol> </li> <li> <p><b>P.T.</b></p> <ol> <li> <p>Rigid.</p> </li> </ol> </li> </ul> </li> <li> <p>Please comment if you have experience with the "ankle-foot orthosis" type of treatment mentioned here and described by Fillauer.</p> <ul> <li> <p><b>Certified Prosthetists</b></p> <ol> <li> <p>I have been using the same basic idea for several years with good success.</p> </li> <li> <p>I have used this on one patient and he was quite pleased.</p> </li> <li> <p>-</p> </li> <li> <p>No experience.</p> </li> <li> <p>No experience. I added another approach to my repertoire.</p> </li> <li> <p>No experience.</p> </li> <li> <p>Yes.</p> </li> <li> <p>I have used the AFO with a toe filler attached a few times recently and am very satisfied with the results.</p> </li> </ol> </li> <li> <p><b>M.D.'S</b></p> <ol> <li> <p>Yes, only very limited.</p> </li> <li> <p>Yes, occasionally useful.</p> </li> <li> <p>No.</p> </li> <li> <p>-</p> </li> <li> <p>No experience.</p> </li> </ol> </li> <li> <p><b>P.T.</b></p> <ol> <li> <p>No experience.</p> </li> </ol> </li> </ul> </li> <li> <p>Would you be willing to contribute to an "atlas" or "catalog" of methods for providing prostheses for partial foot amputations?</p> <ul> <li> <p><b>Certified Prosthetists</b></p> <ol> <li> <p>Yes.</p> </li> <li> <p>Yes.</p> </li> <li> <p>Yes.</p> </li> <li> <p>Yes.</p> </li> <li> <p>Yes, although my experience is limited (which is probably the situation 90% of the time). A ready reference such as this may help us all solve the unique problems each of these amputees present.</p> </li> <li> <p>Enthusiastically.</p> </li> <li> <p>Yes.</p> </li> <li> <p>At present I have nothing new to contribute.</p> </li> <li> <p>Yes, we would.</p> </li> </ol> </li> <li> <p><b>M.D.'S</b></p> <ol> <li> <p>Yes.</p> </li> <li> <p>No.</p> </li> <li> <p>Do not feel qualified to do so.</p> </li> <li> <p>Yes.</p> </li> </ol> </li> <li> <p><b>P.T.</b></p> <ol> <li> <p>No, not enough experience.</p> </li> </ol> </li> </ul> </li> </ol> <h3>Conclusions</h3> <p>It can be seen that although there is a wide variation of opinion about partial foot amputations and prostheses, more than half of the practitioners feel that partial foot amputations can provide better function than the Syme's.</p> <p>Nearly all of the respondents would be glad to contribute to an "atlas" or "catalog" of methods for providing prostheses for partial foot amputations.</p> <p>Mr. Meltzer's letter, which follows, seems to sum up the state of the art and is reproduced here in full.</p> <p><i>September 27, 1977</i></p> <p><b>Newsletter Questionnaire</b><br />AAOP<br />1444 N Street, N.W.<br />Washington, D.C. 20005</p> <p>The following are the answers to your questions as per your request from the Newsletter Questionnaire, copy enclosed.</p> <p>NAME: Lewis N. Meltzer, C.P.O.</p> <ol> <li> <p>Do you feel that patients with partial foot amputations require prostheses that extend higher than the distal third of the tibia?</p> <blockquote> <p>It has been my experience that patients with partial foot amputations occasionally cannot tolerate the Fillauer type orthosis. Yet, for cosmetic purposes, they prefer it rather than something extending above the shoe. I have fitted a few and only succeeded with one. This is after extended trials by myself and the patient. Yet, the two who were not satisfied, preferred to wear nothing and have been lost to follow up. Several years ago I worked with polypropylene or similar AFO's with toe fillers and steel shanks in the shoe, and those seemed to work satisfactorily. I think that Mr. Pritham's idea merits trials. My only concern is cosmetic acceptance when compared to the Fillauer type.</p> </blockquote> </li> <li> <p>Do you feel that most patients who receive partial foot amputations would function better with a Syme's amputation?</p> <blockquote> <p>This seems like an ambiguous question which I feel I can only answer by saying it would depend on the individual. At the same time, all else being equal, partial foot amputation would be my choice were I to need that type of amputation as I could more easily walk without a prosthesis either around the house or at night.</p> </blockquote> </li> <li> <p>Do you agree with the author's list of advantages and disadvantages of this amputation?</p> <blockquote> <p>Yes.</p> </blockquote> </li> <li> <p>Do you feel that the sole or shank of the shoes or prosthesis should be rigid or flexible?</p> <blockquote> <p>Here, again, this would depend on the patient as I have seen patients desiring no prosthesis.</p> </blockquote> </li> <li> <p>Please comment if you have experience with the "ankle-foot orthosis" type of treatment mentioned here and described by Fillauer.</p> <blockquote> <p>The Fillauer method I have tried has included a section of Silastic R.T.V. in the anterior distal socket for comfort and total contact. This is laminated over the cast rather than after the prosthesis is made. With this, I still have had only one satisfied patient. The other two required several attempts at fitting and yet the patients were not satisfied.</p> </blockquote> </li> <li> <p>Would you be willing to contribute to an "atlas" or "catalog" of methods for providing prostheses for partial foot amputations?</p> <blockquote> <p>I would be willing, if I felt I had something specific to offer as an alternative, but I have not found it to date.</p> </blockquote> </li> </ol> <p>Sincerely,<br />Lewis N. Meltzer, C.P.O.</p> Page Number(s) 1 - 3 Year 1977 Volume 1 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Partial Foot Amputation https://staging.drfop.org/files/original/45936845c560d4d5eebd237d926562f2.pdf 0ea2670a224e26f8a1b36cd756e5f496 https://staging.drfop.org/files/original/1e3bdc3b8dc622982e576909d90687d7.jpg 4c4de5849811d644713ec7230d7d0f02 https://staging.drfop.org/files/original/abf3a4d5ce92c8133b359340480b34ab.jpg 0ceb64af346708b11b688bc9aec46035 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1977_04_004.pdf Text Any textual data included in the document <h2>Should Functional Ambulation be A Goal for Paraplegic Persons?</h2> <h5>Michael J. Quigley, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The goal of functional ambulation for paraplegic persons is a subject of long debate in virtually all rehabilitation settings. Such factors as lesion level, motivation, attitude of the clinic team, age, body build and occupation are important determinants when orthoses are prescribed for ambulatory purposes. Despite the various orthotic designs available, and the philosophies that accompany each design, the majority of paraplegic persons will either reject their orthoses or not have them prescribed.</p> <p>Personal experiences and published reports indicate that when a thoracic level lesion is present, only about two percent of patients fitted will reach the level of household ambulation. There are many reasons for this, the main one being the excessive energy expenditure needed to ambulate in an orthosis. The donning procedure for most orthoses is difficult and time consuming, and once the orthoses are on the patient they often interfere with transfer activities. In addition, crutches are needed for stability while standing and ambulating, which limits the use of the hands and arms. Other problems with standing and ambulation for paraplegic patients are the lack of bladder control while standing and obviously abnormal walking pattern.</p> <p>In this brief article, I will review some of the more pertinent articles on this subject, and then present my opinion concerning the provision of lower-limb orthoses for paraplegic persons.</p> <p>The history of the orthotic treatment of paraplegia does not go back much further than World War II, since previous to that time about 90 percent of the spinal-cord-injured persons died from genitourinary infections. The development of antibiotics to combat these infections reversed the fatality rate shortly after World War II.</p> <p>The physiological benefits of standing persons with paraplegia were first mentioned by Abramson <a></a> in 1948, who stated that an hour of standing each day will prevent osteoporosis in the lower limbs and helps to prevent urinary calculi and genitourinary infections. In 1964, Rusk, stated that "circulation and nutrition, as well as morale, are also aided by keeping the patient in the upright position for several hours each day".</p> <p>Rusk also recommended that the tenth thoracic vertebra be used as a landmark when prescribing orthoses; lesions at or superior to this level are usually given double-bar long leg-braces with a pelvic band and Knight spinal attachment (current terminology is LSHKAFO, or lumbo-sacral-hip-knee-ankle foot orthosis); lesions inferior to T₁₀ level are prescribed the same orthoses without the spinal attachment, and lesions inferior to L₁ are fitted without a pelvic band.</p> <p>Hahn <a></a> and Scott <a></a> from Craig Rehabilitation Hospital in Denver, Edberg <a></a> from Rancho Los Amigos Hospital in Downey, and Warren et al., <a></a> from the University of Washington, do not advocate the use of the pelvic band on paraplegic patients. Edberg feels that the pelvic band must apply excessive pressure against the skin to be effective, that it causes difficulty in donning the orthosis, limits flexibility and adds excessive weight. Hahn and Scott state that the two most important considerations for orthotic design for paraplegics are ease of donning and control of ankle dorsiflexion, hence the so-called Craig-Scott design KAFO (<b>Fig. 2</b>) has no pelvic band, only one thigh band, and a fixed but adjustable ankle joint.</p> <p>Hussey and Stauffer <a></a> studied the ambulatory function of 164 spinal-cord-injured patients at Rancho Los Amigos Hospital and stated that "no patient achieved any form of functional ambulation without pelvic control<a style="text-decoration: none;">*</a> and there appeared to be no effective method of bracing patients to overcome this deficit". The nerve supply for the pelvic control muscles is affected by a thoracic lesion.</p> <p>Rosman and Spira <a></a> reported similar problems in ambulating patients with thoracic lesions. In a study of 35 patients with lesions from the T₁ to T₁₁ level who were fitted with orthoses for ambulation, only one patient was ambulating out of the hospital, and five used the orthosis for standing only. The report concluded "that there is an essential difference between the 'occupation' of walking in the 'non-pressured' rehabilitation environment and walking when faced with the problems of everyday life". It further concludes that "some disabled persons with unusual strength, willpower, and motivation for walking will successfully overcome the difficulty, effort, and social strain involved in the continuous use of braces", but that "most will eventually relinquish these goals because the effort proves too great".</p> <p>Pneumatic orthoses (<b>Fig. 1</b>) were developed and first used in the United States, amid great fanfare, in 1973. Three major evaluations by Silber <a></a>, at New York's Bird S. Coler Hospital, Ragnarsson et. al., <a></a> at the Institute of Rehabilitation Medicine, New York University, and by the Committee on Prosthetics Research and Development, National Academy of Sciences <a></a> on a total of 62 paraplegic persons indicate that the orthoses were lighter than metal designs and required less energy for ambulation but severe mechanical limitations, such as donning and inflation problems, outweigh these advantages when the orthoses are used outside of an institutional setting.</p> <p>A study by Cerney, at Rancho Los Amigos Hospital, comparing energy costs for eight paraplegics walking versus using a wheelchair concluded "The average velocity for paraplegic walking was less than half of normal while oxygen uptake per minute was increased by 50 percent. These two factors combine to create an oxygen uptake per meter than is increased six times". Similar data for the same patients using wheelchairs, again compared to normal individuals, showed "only a two to six percent increase in the physiological factors and a ten percent decrease in velocity".</p> <p>Despite the poor track record I have documented, ambulation is still considered a goal for paraplegic patients in most rehabilitation settings. Obviously, the patient will fail to reach this goal in most cases, so why do most of us expend our energies in this area? I feel there are benefits to be gained by providing ambulation training. For one, nearly all new paraplegic persons believe they will walk again, and it is virtually impossible to convince them otherwise. These patients feel that they are being deprived of their chance for complete rehabilitation if they are never given the opportunity to try to walk. Psychologically, they must prove it to themselves. After these patients are convinced that walking is impractical, they will concentrate more heavily on becoming wheelchair-independent.</p> <p>A physician I worked with in Chicago told the story of an obese, bilateral above-knee amputee who wanted to be fitted with prostheses so he could walk again. They physician refused to prescribe a prostheses as he knew that the patient could never use them, and told the patient he would not be able to walk again. The patient immediately suffered a nervous breakdown in the clinic and required hospitalization. From that day on, the physician prescribed prostheses for patients with similar problems so they could convince themselves of the impracticality of ambulation and, more important, have a longer period of time to accept reality.</p> <p>A small percentage of patients do ambulate in orthoses (<b>Fig. 3</b>), especially those patients with pelvic or hip control or sensation. It is impossible to predict successful ambulators, and patients should be given a chance to succeed. Obviously, patients who lack motivation, are very obese, or who lack strength and endurance will never succeed and should be dissuaded from trying to ambulate.</p> <p>In this article I have attempted to back up my personal experiences with information from published reports, and then to justify why most paraplegics are given ambulation training despite the poor prognosis. We would appreciate your thoughts on this subject and therefore encourage you to complete the attached questionnaire.</p> <p><b>References:</b></p> <ol> <li>Abramson, S. A., <i>Bone disturbances in injuries to spinal cord and caude equina (paraplegia)</i>. J. Bone and Joint Surg. 30-A:982-987, October 1948.</li> <li>Edberg, E., <i>Bracing patients with traumatic paraplegia</i>. Phys. Ther. 47:9:818-823, September 1967.</li> <li>Hahn, Harry, Personal communication, March 1975.</li> <li>Hofstra, Peter C, <i>The clinical engineer and the spinal-cord-injured person</i>. Bull. Pros. Res. 10-22:37-40, Fall 1974.</li> <li>Hussey, Robert W., and E. Shannon Stauf-fer, <i>Spinal-cord injury: requirements for ambulation</i>. Arch. Phys. Med. Rehab. 54:12:544-547, December 1973.</li> <li>Ragnarsson, K. T., G. Heiner Sell, Margaret McGarrity, and Reuven Ofir, <i>Pneumatic orthosis for paraplegic patients: functional evaluation and prescription considerations</i>. Arch. Phys. Med. Rehab. 56:11:479-483, November 1975.</li> <li>Rosman, N., and E. Spira, <i>Paraplegic use of walking braces: a survey</i>. Arch. Phys. Med. Rehab. 55:7:310-314, July 1974.</li> <li>Rusk, Howard A., <i>Rehabilitation Medicine, Second Edition</i>. C. V. Mosby Co., St. Louis, Missouri, p. 503, 1964.</li> <li>Scott, Bruce A., <i>Engineering principles and fabrication techniques for the Scott-Craig long leg brace for paraplegics</i>. Orth. and Pros. 25:4:14-19, December 1971.</li> <li>Silber, Maurycy, Tae-Soo Chung, George Varghese, Catherine Hinterbuchner, Milton Bailey, and Nancy Hirvy, <i>Pneumatic orthosis: pilot study</i>. Arch. Phys. Med. Rehab. 56:1:27-32, January 1975.</li> <li>Warren, C. G., J. F. Lehmann, and B. J. DeLateur, <i>Use of the pelvic band in orthotics for adult paraplegic patients</i>. Arch. Phys. Med. Rehab. 56:5:221-223, May 1975.</li> <li>Cerney, Kay, R.P.T., <i>Walking and wheelchair energetics in spinal cord injury</i>.</li> <li>National Academy of Sciences, <i>Evaluation of the ortho-walk type B pneumatic orthosis on thirty-seven paraplegic patients. Washington, D.C., 1976, pp. 1-5</i>.</li> </ol> <strong>Footnote</strong><br />The Term 'pelvic control' used here refers to the ability of the abdominals to move the pelvis when body weight is on the crutches.<br /> <div style="width: 400px;"><br />*Michael J. Quigley, C.P.O.<br />Rehabilitation Engineering Center, Rancho Los Amigos Hospital, Downey, California.</div> Page Number(s) 4 - 6 Year 1977 Volume 1 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1977_04_004/1978_04_005-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1977_04_004/1978_04_005-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Needs Revision- See Trello 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 Should Functional Ambulation be A Goal for Paraplegic Persons? Creator An entity primarily responsible for making the resource Michael J. Quigley, C.P.O. * https://staging.drfop.org/files/original/a266195253e839079dde8975e42d8087.pdf c594dc2a840e8199425e981f66117aec https://staging.drfop.org/files/original/7f05ccb8586557cc7b0183cdafe725aa.jpg 63616a4cd1eb71d495e9a1972785cec8 https://staging.drfop.org/files/original/34baa4d0c9f50173d122a1fc9f03237c.jpg 17ba15b4ce63bb3be5f4808d51a3ea39 https://staging.drfop.org/files/original/1c09d56923228c1e807060fe9577bb4b.jpg c44f04d953c3e6e8897a4cd1e4634223 https://staging.drfop.org/files/original/2cc047309ed120bc63aa3b83a308d3fb.jpg 725142c35120be7cfc9eeda3881c00aa https://staging.drfop.org/files/original/616d272e127cadd9ddfd4dfa00a6ada9.jpg aecf21517233b63d0e773199af09d87e https://staging.drfop.org/files/original/d91b0ee4dc2e5f1b5d29d240c9cc5019.jpg e4c5b9f5516409a4f2feb3f7440c342e https://staging.drfop.org/files/original/ab13b0cc1721ab18b7969a2d89777bff.jpg 6dda6cc8254a02d70975f70817cf72de DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_025.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 25 - 29 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_01_025.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_01_025.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Artificial Arm Checkout Procedures</h2> <h5>Lester Carlye, M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>The story of civilization's slow but steady march of progress from the days of the Roman Empire, through the Industrial Age, and into the present Technological Age is the story of measurements. The standardization of such common units as the inch and the foot required thousands of years, but once that was accomplished, it paved the way for an almost unbelievably rapid technological advance. One need only compare the developments that have occurred since the metric system was devised in 1793 with those of all the preceding centuries. Replacement of the craftsman's personal art with clearly understood, standard methods has enhanced the lives of all of us my making simple necessities, as well as more luxurious items, available in more adequate quantities and at more reasonable prices.</p> <p>Just as mankind in general profited from measurement standardization, so can those who have lost a limb or limbs and those who devote themselves to replacing lost members. Every person concerned with the manufacture and fitting of a prosthesis-whether he be a prothetist, amputee, trainer, or representative of the paying agency-has felt the need for some set of standards to determine the worth of the prosthesis. Development of such a "yardstick of performance" was just as necessary to the advancement of the prosthetics industry as was the standardization of the inch to the Industrial Age. The so-called "checkout procedures" provide the prosthetist and other members of the clinic team with an invaluable tool for measuring the biomechanical effectiveness of all upper-extremity prostheses. Such questions as "Does this prosthesis fit as well as your last one?" or "Can you work it?" receive only a vague, often uncertain, answer, but such criteria are too often accepted as a measure of performance. One of the first steps in establishing a set of standards is to determine which variable factors can be measured accurately. In upper-extremity prosthetics, some of the measurable factors are ranges of motion with and without the prosthesis, control-system efficiencies, forces necessary to flex the forearm, live-lift of the forearm, socket stability, movement of the terminal device when locking the elbow, plus several others. Once the factors are determined, a test program must be set up and carried out. The results of such a test must first be analyzed, then a trial set of standards must be established, and finally the standards must be laboratory-tested on as great a number of amputee subjects as possible.</p> <p>To this end, a test station was established, and 29 amputees, selected at random from a mailing list, were tested. Approximately 30 tests were applied to these amputees and their prostheses. By combining the test data with research and practical experience, a preliminary set of liberal standards was drawn up. The standards were then applied to more than 70 amputees during the two-year existence of the Case Study Program at the University of California at Los Angeles. Certain modifications and refinements in the tests were made until the procedure attained present form.</p> <p>One of the prime requirements in establishing the tests was that their application be kept simple, with respect both to the equipment and to the procedures to be followed. Sufficient accuracy of measurement can be obtained with a ruler and a spring scale, and the test standards are liberal enough to allow minor inaccuracies without rejecting the prosthesis. The most important concern is, first, that all tests be applied in a similar manner and, second, that the results be compared to a universally acceptable standard.</p> <p>The tests and standards may be conveniently listed in three groups: general tests, applicable to all types of prostheses; tests for below-elbow prostheses; and tests for above-elbow prostheses.<a style="text-decoration:none;">*</a></p> <p>All tests should be performed with the amputee wearing his prosthesis. In the case of a bilateral amputee, each side should be tested separately, but the amputee should have almost complete independence of action on each side while wearing both prostheses.</p> <h3>General Tests</h3> <h4>Test No.1-Compression Fit and Comfort</h4> <p><i>Test</i>: Flex the forearm to 90 deg. (lock if AE). Push the prosthesis onto the stump while the wearer resists the push (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Test for compression fit and comfort. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Standard</i>: The amputee should feel no undue discomfort or pain when the prosthesis is forced onto the stump.</p> <h4>Test No. 2-Tension Stability</h4> <p><i>Test</i>: Straighten the prosthesis at the side (<b>Fig. 2</b>). Hook the scale over the terminal device and apply a force of 50 lb. straight down. (A force of 30 lb. is sufficient for children.) Standard: The prosthesis should not slip more than 1 in. in relation to the stump, and no part of the prosthesis or harness should fail when a 50-lb. distal load is applied.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Test for tension stability. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Test No. 3-Hook-Opening Facility (Normal Use)</h4> <p><i>Test</i>: Flex the forearm to 90 deg. (lock if AE). Have the wearer actively operate the terminal device.</p> <p><i>Standard</i>: The wearer should be able to obtain full range of terminal-device operation actively with the forearm flexed to 90 deg.</p> <h4>Test No.4-Hook-Opening Facility (At Mouth And Perineum)</h4> <p><i>Test</i>: Flex the forearm so the terminal device is near the mouth (lock if AE). Have the wearer actively operate the terminal device. Repeat this procedure with the terminal device near the perineum.</p> <p><i>Standard</i>: The wearer should be able to obtain at least 70 percent of full range of terminal-device operation actively at the mouth and perineum.</p> <h4>Test No. 5-Control-System Efficiency</h4> <p><i>Test</i>: a) Disconnect the control cable from the terminal device, and attach the scale to hook-operating lever or hand-operating cable (<b>Fig. 3</b>a). Place a 3/4-in. block between the fingers and pull until the block slips out of a voluntary-opening hook or until the fingers of a voluntary-closing hook or hand just close on the block. Note the force at this instant.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Test for control-system efficiency. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>b) Reconnect the control cable to the terminal device, and apply the scale to the T-bar. or terminal, at the other end of the control cable. Pull along the line of the harness unti. the block slips or the fingers touch, as before (<b>Fig. 3</b>b). Note the force at the instant this occurs.</p> <p>c) Multiply the force measured at the terminal device by 100. Then divide by the fora measured at the cable terminal as in the following formula:</p> <blockquote><p>Efficiency = (Force measured at terminal devices X 100)/(Force measured at cable terminal)</p> </blockquote> <p><i>Standard</i>: The control-system efficiency should be at least 70 percent.</p> <h3>Below-Elbow and Below-Elbow Biceps-Cineplasty Tests</h3> <p>All of the following tests apply to the conventional below-elbow prosthesis and to the below-elbow biceps-cineplasty prosthesis.</p> <h4>Test No. 1-Forearm Flexion</h4> <p><i>Test</i>: Compare the amputee's maximum range of forearm flexion with and without the prosthesis.</p> <p><i>Standard</i>: Active flexion with the prosthesis on should be as great as active flexion without the prosthesis.</p> <h4>Test No. 2-Forearm Rotation<a style="text-decoration:none;">*</a></h4> <p><i>Test</i>: Compare the amputee's maximum range of forearm rotation (extreme pronation the extreme supination) with and without the prosthesis (<b>Fig. 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Test for forearm rotation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Standard</i>: Active rotation with the pros-thesis on should be at least half that obtained without the prosthesis.</p> <h3>Above-Elbow and Shoulder-Disarticulation Tests</h3> <p>All of the following tests apply to the above-elbow prosthesis, and most of them apply to the shoulder-disarticulation prosthesis. Those which do not apply to the shoulder-disarticulation case are marked with an asterisk.</p> <h4>Test No. 1-Ranges Of Stump Motion*</h4> <p><i>Test</i>: Have the amputee straighten the prosthesis and lock the elbow. Then move his stump and prosthesis through the maximum ranges of flexion, extension, elevation, and rotation.</p> <p><i>Standard</i>: The amputee should be able to satisfy the following minimum requirements while wearing the prosthesis: flexion, 90 deg.; extension, 30 deg.; elevation, 90 deg.; rotation, 45 deg.</p> <h4>Test No. 2-Range of Forearm Flexion</h4> <p><i>Test</i>: Compare the amputee's maximum active range of prosthetic forearm flexion with the maximum manual range. Note the amount of initial forearm flexion built into the prosthesis.</p> <p><i>Standard</i>: The amputee should be able to flex actively to 135 deg. of forearm flexion, no more than 10 deg. of which should be due to initial flexion.</p> <h4>Test No. 3-Humeral Flexion Required to Flex Forearm*</h4> <p><i>Test</i>: Have the amputee flex the prosthetic forearm actively through its entire range using humeral flexion, and note the degrees of flexion of the humerus required to do so.</p> <p><i>Standard</i>: Humeral flexion required to flex the prosthetic forearm fully should not exceed 45 deg.</p> <h4>Test No. 4-Force Required to Flex Forearm</h4> <p><i>Test</i>: Tape the fingers of the terminal device closed and unlock the elbow. Insert the spring scale through the cable attachment, and flex the forearm to 90 deg. while holding the socket stationary. Pull along the normal line of the cable until further flexion of the forearm just starts, and note the force.</p> <p><i>Standard</i>: The force required to start flexion of the forearm from 90 deg. should not exceed 10 lb.</p> <h4>Test No. 5-Live-Lift</h4> <p><i>Test</i>: Tape the fingers of the terminal device closed and unlock the elbow. Hook the spring scale over the prosthesis at a distance of 12 in. from the elbow pivot using a leather strap if necessary (<b>Fig. 5</b>). Flex the forearm to 90 deg., and have the amputee actively resist while applying a straight-down pull on the scale. Note the scale reading when the amputee can no longer completely resist the pull and the forearm slips below 90 deg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Test for live-lift. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Standard</i>: The amputee should be able to resist actively a downward force of at least 3 lb. located 12 in. from the elbow center when the forearm is flexed to 90 deg.</p> <h4>Test No. 6-Involuntary Operation of the Elbow Lock*</h4> <p><i>Test</i>: Face the amputee and have him abduct the prosthesis 60 deg. Note whether or not the elbow lock operates. Then have him walk a short distance swinging the prosthesis in a normal manner, and note whether the elbow lock operates involuntarily or not.</p> <p><i>Standard</i>: The elbow lock should not operate involuntarily when the prosthesis is abducted 60 deg. nor during normal walking. In addition, a natural-appearing arm swing should be exhibited while walking.</p> <h4>Test No. 7-Movement of Terminal Device When Locking Elbow*</h4> <p><i>Test</i>: Have the amputee actively flex the forearm to 90 deg. Then have him actively lock the elbow. Note the movement of the terminal device as the elbow is locked.</p> <p><i>Standard</i>: The terminal device should not move more than 6 in. during active operation of the elbow lock when the forearm is flexed to 90 deg. (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Test for motion of terminal device when locking elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Test No. 8-Socket Stability During Arm Rotation*</h4> <p><i>Test</i>: Flex the forearm to 90 deg. and lock the elbow. Have the amputee abduct the prosthesis 60 deg. and rotate his stump and prosthesis. Note any slippage of the socket about the stump.</p> <p><i>Standard</i>: The amputee should be able to control the prosthesis during arm rotation, and there should be no slippage of the socket about the stump (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Test for socket stability during arm rotation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Test No. 9-Stability of Socket Against Torque*</h4> <p><i>Test</i>: Flex the forearm to 90 deg. and lock the elbow. Hook the scale over the prosthesis at a distance of 12 in. from the elbow center, using a leather strap if necessary. Have the amputee resist while pull is applied, first laterally, then medially, on the socket with a force of 2 lb. Note any slippage of the socket about the stump, or of the turntable, which may occur.</p> <p><i>Standard</i>: The amputee should be able to resist both lateral and medial pulls of 2 lb. located 12 in. from the elbow center, and the turntable should not turn with this force.</p> <h3>Conclusion</h3> <p>That the test procedure has reached a sufficient degree of refinement to be used successfully in the field is evidenced by its widespread adoption. Such agencies as the United States Veterans Administration, the State Departments of Vocational Rehabilitation of California and Illinois, and others include fulfillment of the standards as a contract stipulation. It must, however, be borne in mind that these test procedures are not to be considered as the final answer. Additions, revisions, and general improvements constitute a never-ending project in the field of prosthetics evaluation.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">This test need not be applied when the stump is only half the normal forearm length or less.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">These tests and standards may not apply in cases where atrophy, bone blocks, loss of muscles, and the like are in evidence.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Lester Carlye, M.E. </b></td></tr><tr><td class="clsTextSmall">Engineer, Artificial Limbs Project, University of California, Los Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_01_025/Jan54d-007.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 Artificial Arm Checkout Procedures Creator An entity primarily responsible for making the resource Lester Carlye, M.E. * https://staging.drfop.org/files/original/0713435cdc66e5d09afab0bd217b4263.pdf 11665dec8ad20d2b3e67e255dcf4c5e6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_001.pdf Year 1955 Volume 2 Issue 2 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_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Engineering Hope of the Handless</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The human hand, with its elaborate control system centered in the brain, is doubtless the most widely versatile machine that has ever existed anywhere. Its notorious deficiency lies in its persistent inability to create a similar machine as versatile as itself. This circumstance accounts for the fact that, while there has been from earliest times a great need for hand replacements, all attempts to produce successful hand substitutes have thus far ended in only a rather crude imitation of a very few of the many attributes of the living counterpart. For want of complete knowledge of the natural hand-brain complex, and of the ingenuity requisite even to the most modest simulation of the normal hand, artificial hands have always resembled the natural model in a superficial way only. Voltaire is said to have remarked that Newton, with all his science, did not know how his own hand functioned.</p> <p>But the science of Newton, basic as it was, is itself remote from the advanced technology of our own day. Failure in hand prosthetics, though owing in part to the difficulty of replacing any living organ with an inanimate contrivance, stems also in part from failure to apply intensively the principles of modern science generally, and of engineering in particular, to the problems of artificial-hand design. Because in general the engineering profession had not theretofore been much concerned with the development of improved artificial limbs, the hand prostheses available a decade ago represented no appreciable improvement over those to be had at the end of World War I.</p> <p>In all fields of human endeavor, the problems for which men have found tentative solutions in the past often merit the attention of the engineer of today. A new look by competent technologists usually yields gratifying results, for the solutions found by our forebears, while seemingly adequate at the time, do not reflect the progress made in the development of methods of experimental analysis, in the measurement of behavioral characteristics, in the establishment of criteria, in the development of materials, and in the evolution of forming techniques for application of the materials to the needs of man. Just so in the field of prosthetics, where the problem of matching a device to the human system is particularly acute and where, consequently, the application of new methods holds special promise.</p> <p>Perhaps the most compelling reason today for the importance of engineering in prosthetics research lies in the approach and methodology now implicit in the profession. Introduction of the requirements of man in a quantitative manner without neglect of the qualitative, subjective aspects places design on a rational basis for the first time in history. During World War II there arose the problem of designing numerous complicated systems to be operable within the limits of human capabilities. In that urgent work, a substantial number of engineers had occasion to become acquainted with certain important physiological and psychological characteristics of man, so that by the end of the war the stage was set for the impact of the engineering profession on the development of prosthetic devices, which is, after all, a unique and particularly challenging field of biomechanics.</p> <p>When, therefore, in 1945, the then Committee on Prosthetic Devices undertook to conduct basic studies toward the provision of better hand substitutes, it enlisted the services of engineers to cooperate with the medical profession and others in developing the necessary data and in applying the results to improved hand design. In the Artificial Limb Program, principal responsibility for the development of improved hand substitutes has almost from the beginning resided with the Department of Engineering at the University of California, Los Angeles Campus, and with the Army Prosthetics Research Laboratory, Walter Reed Army Medical Center. Out of this cooperative effort have now come not only new and improved devices but also, and perhaps more important, a set of criteria which lay down the basic principles of hand design toward further improvements in the future.</p> <p>Because of the importance of the hand in all human activities, because of the critical nature of adequate hand replacement in the rehabilitation of upper-extremity amputees, and also because of the rather striking advances that have been made in the design of artificial hands in recent years, this issue of Artificial Limbs is devoted entirely to a little symposium on the hand and its substitutes. The mutual cooperation of the several contributors toward a unified approach to the whole subject is typical of the cooperation that has characterized the Artificial Limb Program since its inception.</p> <p>The work in prosthetics will, it is to be hoped, serve as a pattern for further investigations jointly by the medical and engineering professions wherever developments in materials, controls, and systems in general can be brought to bear to augment human functions which an individual can himself no longer provide. One continuing problem is that of convincing able young people now studying engineering that a satisfying future exists for them in such cooperative ventures with the medical profession designed to rehabilitate the less fortunate throughout the world. Those now engaged in prosthetics development can be of great help in presenting to these young men and women the perspective of the future in such a manner that fresh engineering graduates might elect to carry forward the work now already so well under way.</p> <p>Finally, it ought to be noted that, despite the distinct accomplishments evident at this, the tenth anniversary of the establishment of the Artificial Limb Program, only the first faltering steps have been taken toward the "ideal" prosthetic hand. Structural elements and prehensile function are not enough. It remains to provide some reasonable substitute for the sensory-motor apparatus which, in the living hand, is of such consummate perfection as to beggar description. A problem like this should charge the imagination of any young engineer in search of a field of application for service. To him belongs the future in prosthetics research.</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>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, Technical Committee on Prosthetics, ACAL, NRC.</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 Engineering Hope of the Handless Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * 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.) *