13 20 371 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? 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_01_038.pdf Text Any textual data included in the document <h2>The Rancho Syme Prosthesis with the Regnell Foot</h2> <h5>Michael J. Quigley, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Sam E. Hamontree, CP.&nbsp;<a style="text-decoration: none;">*</a><br />Joe Antorietto&nbsp;</h5> <p>The Syme amputation has been with us since 1842, when James Symes developed it for three reasons, "(1) the risk to life will be smaller, (2) a more comfortable stump will be afforded, (3) the limb will be more seemly and useful for ambulation."<a></a> Since then, the major improvement in the surgical technique has been the introduction of the two stage Syme amputation,<a></a> which was developed to increase the success rate in dysvascular and infected patients. Wagner further refined the technique at Rancho Los Amigos Hospital, and increased his success rate to 95% by the use of Doppler ultrasound to determine adequate blood flow.<a></a> Wagner also advocates removing the flares of the tibia and fibula during the second stage to narrow the distal end and provide better cos-mesis.</p> <p>The advantages of the Syme level of amputation are many (<b>Fig. 1</b>), but the design of the prosthesis has been a constant challenge for prosthetists (<b>Fig. 2</b>). The Syme level amputee is typically more active, walks at a faster pace, and expends less energy than the below-knee amputee;<a></a> for these reasons the demands on the prosthesis are greater. Breakage of Syme prostheses has been a constant problem, especially with prosthetic designs that have openings (medial opening, posterior opening, etc.). Syme prostheses that have no openings must allow enough room for the bulbous end of the leg to pass through, giving a "stovepipe" appearance to the leg. In addition, the "no opening" designs had other advantages, i.e., the silastic bladder expandable wall design was not durable and tended to delaminate, the full insert type added additional bulk to the prosthesis, and the removable pad design needed constant adjustment.</p> <p>The Rancho expandable wall prosthesis eliminates many of the problems inherent in other designs. This prosthesis was first described in the AAOS Atlas of Limb Prosthetics although fabrication was not detailed at that time. The Rancho expandable wall prosthesis incorporates the following features:</p> <ol> <li> <p><b>Strength</b>—The "no opening" design laminated to the Regnell foot provides maximum strength and durability.</p> </li> <li> <p><b>Expandable liner</b>—A durable elastic window sewn in a thin flexible inner liner eliminates problems with silastic or Pe-lite™ inserts, which will tear or add excess bulk.</p> </li> <li> <p><b>Cosmesis</b>—No buckles or straps are required. No line or seam at ankle joint. Bulk is kept to a minimum with thin wall thickness.</p> </li> <li> <p><b>Ease of adjustment</b>—Although the expandable inner is bonded in place permanently, it can be left unbonded for the first month of wear to allow for adjustments.</p> </li> <li> <p><b>Can accommodate large distal ends</b>—Two expandable windows can be made in the flexible liner to allow for large distal ends.</p> </li> </ol> <h3>Negative Impression Procedure and Measurements</h3> <p>The plaster negative impression is taken in the conventional manner. Reliefs are made over the bony prominences by the use of 1/8" padding before the impression is taken. The circumferences of the distal end and the narrowest part of the ankle should be compared. Maximum cosmesis is attained when the malleoli have been trimmed and the largest circumference at the distal end is about 3/4" greater than the smallest ankle circumference.</p> <p><i>Fabrication</i></p> <p>After the necessary modifications are made to the positive model, measure the M-L at the distal end, then move the calipers proximally until the model has the same M-L. This will determine the length of the elastic panel (<b>Fig. 3</b>). If the circumference of the distal end is 1 1/4" or greater than the narrowest part of the model, two elastic panels will be necessary.</p> <strong>Figures 3A &amp; 3B. Measure distal end with M-L calipers and move proximally until the same M-L is found to determine the length of polyethylene panels and the buildup needed on the inner socket.</strong><br /> <p>To allow space for the elastic panel, polyethylene "inserts" (<b>Fig. 4</b>) are cut to the length determined above, and are inserted between two nylon stockinettes for the expandable liner. The polyethylene inserts are laminated into the nylon using a 80% flexible, 20% rigid resin.</p> <strong>Figure 4. A: Medial/lateral polyethylene inserts are inserted between the two points made by the calipers. B: Inserts are laminated into expandable bladder using 80% flex and 20% rigid.</strong><br /> <p>The PVA bag is left on the lamination and a polyurethene foam buildup is made over the lamination (<b>Fig. 5</b>); this is then measured and shaped down to 1/4" less than the circumference of the distal end. A PVA bag is pulled over the foam and an outer shell of 6 nylon is laminated using rigid (90-10) resin (<b>Fig. 6</b>). After the resin sets, a hole is drilled in the distal end and the outer lamination is forced off the model using compressed air (<b>Fig. 7</b>). The polyurethene foam buildup and PVA bag are then removed from the inner lamination.</p> <strong>Figure 5. Foam buildup which results in the void necessary for the expandable bladder to open, allowing the patient to don the prosthesis.</strong><br /><br /><strong>Figure 6. Laminated outer shell over the expandable bladder with the foam buildup.</strong><br /><br /><strong>Figure 7. Bladder being pulled out of the laminated outer shell.</strong><br /> <p>Remove the polyethylene inserts by drilling small holes in the center of each end and slitting the outer nylon with a razor (<b>Fig. 8</b> and <b>Fig. 9</b>). Most of the laminated nylon covering the outside of the polyethylene sleeve is removed, leaving a 1/4" overlap to hold the stitching for the elastic panel. A single vertical razor slit is made on the inside of the liner to allow expansion. Use the polyethylene sleeves as patterns to cut out one-way stretch elastic. The proper elastic for this procedure, called grip-net, is difficult to find, as it must have a heavy durable weave and comes in a wide roll (8" or greater).</p> <strong>Figure 8. Drilling holes at widest proximal and distal points to properly position the slit in the bladder for the elastic panels.</strong><br /><br /><strong>Figure 9. Slit the lamination with a razor vertically to connect the drill holes. The polyethylene panels are used to determine the shape and size of the elastic panels that have been trimmed to size and are to be inserted into the bladder.</strong><br /> <p>The elastic panels are temporarily taped in place and then sewn in place in a long arm patcher sewing machine (<b>Fig. 10</b>). The liner may have to be folded and/or lubricated with silicone to allow the machine to reach the end of the insert. The prosthesis is now ready for static alignment on the Regnell foot (<b>Fig. 11</b>).</p> <strong>Figure 10. The elastic panels are inserted; it helps to tape them in temporarily at the proper width in preparation for sewing in the elastic</strong><br /><br /><strong>Figure 11. Outer socket and inner expandable socket with elastic panels sewn in place.</strong><br /> <p>The Regnell foot is an external keel design specifically suited for Syme prostheses because the distal end of the socket can be placed very close to the floor: a thin sole and heel cushion take little space under the prosthesis. No ankle bolt is needed, and the finished laminated external keel provides good cosmesis. The toe break is located and designed to allow for more optimum A-P alignment of the socket, resulting in smoother functional rollover and more cosmetic shaping.</p> <p><i>Static Alignment</i></p> <p>Static alignment can be set up by either sinking the socket into the keel of the foot, or by cutting off the top of the foot with a bandsaw, leaving only the amount equal to the leg length discrepancy (<b>Fig. 12</b>). The socket is then sunk into the block cut-off of the foot and tack glued to the prosthesis (<b>Fig. 13</b>). The second method allows the prosthetist easier M-L and A-P and toe-out adjustments by simply moving the block on the prosthesis and regluing. Dynamic alignment is achieved in the usual manner.</p> <strong>Figure 12. Socket is set into the block, aligned, and glued to the Regnell foot.</strong><br /><br /><strong>Figure 13. Lateral view of static aligned prosthesis ready for fitting.</strong><br /> <p><i>Finishing</i></p> <p>Following dynamic alignment, the socket is shaped to blend into the foot and roughed up. All soft parts of the foot are taped off and the final lamination of 2 nylon is made. The sole of the foot is not removed during lamination (<b>Fig. 14</b>). The lamination is then trimmed away, leaving the sole and toe break free (<b>Fig. 15</b>).</p> <strong>Figure 14. Following dynamic alignment with the patient, the socket is shaped to the foot and made ready for finishing of the outer prosthesis. Two nylons are used with rigid laminate with the sole in place and taped off.</strong><br /><br /><strong>Figure 15. The finished, laminated prosthesis. Expandable liner must be permanently bonded to the outer socket at same point, but can be left separate initially to allow for adjustments.</strong><br /> <p>The expandable liner is inserted into the outer shell. If no adjustments are anticipated, the liner is bonded to the outer shell at the proximal border with sealing resin.</p> <h3>Summary</h3> <p>The Rancho expandable wall Syme prosthesis, when used with a Regnell foot, provides a very practical solution to the problems existing in other Syme prostheses. Many of the durability and cosmesis problems have been eliminated. Whenever possible, prosthetists should encourage physicians to perform more Syme level amputations, and to try to achieve less bulky distal ends when these amputations are performed.</p> <h3>Acknowledgments</h3> <p>The prosthesis described here was developed in response to the needs of Richard Voner, CP., of Orthomedics and William Wagner, M.D., of Rancho Los Amigos Hospital, Downey, CA.</p> <p>The fabrication procedure was developed by Ortho-medics Central Fabrication, which also provided the fabrication photos.</p> <strong>Figure 16. Syme patient holding expandle liner.</strong><br /><br /><strong>Figure 17. Syme patient pulling on the liner. Note the expansion of the elastic panels; normally this would not be seen as the liner would be bonded to the outer socket.</strong><br /><br /><strong>Figure 18. Patient standing on the finished prosthesis.</strong> <p><b>References:</b></p> <ol> <li>Syme, J. "Amputation at the Ankle Joint," <i>London Edinburgh Monthly J. Medical Science</i>, 2, 1843, p. 93</li> <li>Harris, R.I. "Syme Amputation," <i>J. Bone and Joint Surgery</i>, 38B, 1956, p. 614.</li> <li>Spitther, A.W., J.J. Brennen, and J.W. Payne, "Syme Amputation Performed in Two Stages," <i>J. Bone and Joint Surgery</i>, 55A, 1973, p. 568</li> <li>Wagner W., "The Syme Amputation," <i>AAOS Atlas of Limb Prosthetics</i>.</li> <li>Waters, R.L., J. Perry, D. Antonelli, and H. Hislep, <i>Energy Costs of Walking of Amputees, The Influence of Level of Amputations</i>.</li> <li>Voner, R,, "The Syme Amputate: Prosthetic Management," <i>AAOS Atlas of Limb Prosthetics</i>, pp. 334-340.</li> </ol> <em><b>*Sam E. Hamontree, CP. </b> Sam E. Hamontree, CP., is Executive Vice President of Orthomedics, 2950 E. Imperial Hwy., Brea, California 92621.</em><br /><br /><em><b>*Michael J. Quigley, C.P.O. </b> Michael J. Quigley, C.P.O., is President of Oakbrook Orthopedic Services, Ltd., 1 South 224 Summit Avenue, Oakbrook Terrace, Illinois 60181.<br /><br /><br /></em> Page Number(s) 38 - 40 Year 1988 Volume 12 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Needs Revision- See Trello Figure 6 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-14.jpg Figure 15 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-15.jpg Figure 16 missing Figure 17 missing Figure 18 missing Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Rancho Syme Prosthesis with the Regnell Foot Creator An entity primarily responsible for making the resource Michael J. Quigley, C.P.O. * Sam E. Hamontree, CP. * Joe Antorietto  https://staging.drfop.org/files/original/1191469674a4152e921228b656aa1dfe.pdf d08f2c16efeb47cb114ce1f919ffdaed Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_04_210.pdf Text Any textual data included in the document <h2>Orthotic Management of the Surgically Stabilized Spine in Quadriplegic and Paraplegic Patients</h2> <h5>Michael MacMillan, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />E. Shannon Stauffer, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Daryl G. Barth, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Recent developments in the diagnosis and understanding of spinal dysfunction have affected both surgical and orthotic management of post-traumatic spine instability. The diagnosis of spinal instability has been clarified by clinical study of its natural history and by application of advanced imaging techniques.<a></a> Biomechanical studies have defined the role of each vertebral component in maintaining structural stability.<a></a> Surgical techniques and instrumentation for treating this problem have also evolved rapidly. These advances have resulted in an improved approach toward operative management of spinal instability. First, because the outcome of spinal injury can be more accurately predicted, surgery can be elected earlier for disorders that certainly would fail with nonoperative management. Surgery systems are available which maximize their effect in both obtaining and maintaining optimal spine positions. These reliable instruments have allowed surgeons to apply operative stabilization to a wider range of spine problems. Therefore, the orthotist is presented with an increasing number of patients who have undergone surgical stabilization and require postoperative immobilization. The purpose of this paper is to review the rationale for surgical treatment of traumatic spine disorders. This review will identify both the neurological and mechanical factors which must be addressed. Some of the instrumentation systems available and a few of their advantages and disadvantages will be examined. Finally, five separate areas of the spine will be identified and the special orthotic considerations in each region reviewed.</p> <p>The primary concern in all injuries to the spine is the neurologic status of the patient. There are three general categories of neurologic injury for which reduction and stabilization of the spine improves recovery.<a></a> The first group includes the Brown-Sequard, anterior cord, and posterior cord syndromes. These are collectively known as incomplete cord syndromes. Stabilization of the spine in the presence of these lesions can significantly improve neurologic recovery in a majority of cases. The second class of neurologic injury which is benefited by stabilization is nerve root compression at the cervical level. The recovery of a single nerve root at the cervical level dramatically improves the function of the patient for the rest of his life. This recovery can be facilitated by stabilization. The final lesion helped by internal fixation is the progressive neurological deficit. Often motion at a site of neurologic damage aggravates the injury. Surgical stabilization can reduce irritation and promote recovery. Thus, irrespective of the integrity of the spine, surgery can be indicated for neurologic conditions alone.</p> <p>However, loss of structural integrity can itself be an indication of operative treatment. If an area of bony disruption has resulted in significant deformity or has compromised the spine's ability to resist further deformity, surgical stabilization may be indicated. Authors have established guidelines for angulations and displacements to define this instability, but in all cases the final diagnosis of instability is largely clinical.<a></a> Pain at an area of compromised stability may also be an indication to reduce and stabilize a lesion. However, again the final determination is made on clinical grounds.</p> <p>If internal fixation of the spine is indicated, the subsequent step is the selection of an instrumentation system and postoperative immobilization method for that patient. In dealing with quadriplegic and paraplegic patients, a major concern is skin insensitivity. Although postoperative cast immobilization provides the most rigid support and protection, it also presents the highest risk for skin and wound complications. It is generally agreed that orthoses which can be removed once or twice a day for skin inspection are best suited for neurologically impaired individuals.<a></a> The dilemma the surgeon faces is how to mobilize the patient as soon as possible after surgery, yet not use the rigid protection of casts. The solution to this problem has been the development of more rigid internal fixation systems for the spine.</p> <p>Ultimately, the characteristics of the spinal column disruption determines the choice of instrumentation. Flexion, compression, and distraction are the three major mechanisms of spinal injury. Rarely does one force occur totally independent of the others. Usually one force is predominant with variable effect of the other two. The instability resulting from each of these forces, the instrument techniques used to counteract each of the deforming forces, and finally how the postoperative orthosis is also used to counter the mechanism of injury will be discussed.</p> <p>Fractures which result primarily from flexion often involve crushing of the vertebral body anteriorly and distraction of the posterior elements. Generally speaking, instrumentation systems to correct this problem rely on three-point bending to reduce the fracture and maintain position. The Harrington system uses a single hook at either end of a rod to effect leverage against the kyphus and create an extension force. A long rod is required for this, so that excessive force is not generated under the single hook. In order to shorten the length of the rod and improve fixation, other systems have developed methods for attaching the rod to every segment over which it passes. The Luque, Wisconsin, and Cotrel-Dubosset instruments are examples of this segmental type fixation. These systems have three advantages over Harrington rods. By fixing the rod to each segment over which it passes, the large leverage force necessary to reduce the deformity is evenly distributed over several segments. This reduces pull-out failure. Because this force is distributed evenly, it is possible to reduce the total number of segments stabilized by the rod, thus preserving spinal motion segments. And finally, these segmental fixation systems are significantly more stable, which helps promote bony fusion of the injured segment. Another method of obtaining three-point reduction while improving instrument fixation is the use of transpedicular screws for placement of the hardware. This system uses a short plate placed over the vertex of the kyphus, and then screws placed through the plate are firmly anchored to the uninjured vertebra above-and-below the fracture. As the screws are tightened, the kyphus is slowly reduced. These devices involve the least number of normal vertebral segments to achieve reduction. They are exemplified by Steffee and Roy-Camille plates.</p> <p>The segmentally fixed rods and transpedicu-larly anchored plates described above have excellent immediate stability. The major requirement of the postoperative orthosis is to reduce the stress on the implant by preventing repetitive forward bending of the patient. Orthotic requirements for Harrington rods systems are more demanding. With only single hook attachment, Harrington rods require an orthosis which generates a supplementary three-point bending force to reduce the possibility of hook pull-out. Because there are multiple unfixed segments where fusion is expected to occur, postoperative mobilization should be rigid enough to prevent non-unions from rotation and side-bending movements.</p> <p>In fractures where axial compression is the major deformity, the vertebral body can burst both anteriorly and posteriorly. To reduce the fracture, an instrumentation system capable of distracting vertebral segments is chosen. Again, Harrington rods can be used in this situation. They have a hook in one end that can be ratcheted against the rod to distract and pull apart the segments above and below the crushed vertebra. Segmental wiring alone is ineffective in reducing vertebral body burst fractures. However, many surgeons first use Harrington rods to counteract the compressive force, then use wires attached to the rod at every level to get the advantages of segmental wiring. This combination is lightly referred to as "Harri Luque." Plates anchored to the spine with transpedicular screws are incapable of generating a distracting force. An experimental Swiss system attaches a threaded distractor to the spine with screws and can be used to distract burst-type fractures.</p> <p>Orthoses cannot effectively counteract an axial load, or the results of the compressive mechanism of injury. Therefore, the orthosis is used exclusively to protect the implants from stress while the bone graft is consolidating. Again, the orthosis is most clearly indicated when Harrington rods are the only instruments maintaining the reduction. These single hook rods are subject to dislodgement if excessive bending or torsional forces are encountered.</p> <p>The loss of structural integrity resulting from distraction injuries has different implications in the diagnosis and treatment of this instability. While flexion and compression forces generally cause anterior bony collapse, distraction injuries tend to cause posterior ligament disruption. Since the injury is a traumatic tearing of ligaments and discs, the instrumentation is used to compress or pull the separated segments together. In the thoracolumbar spine, hooks enclose the vertebrae above and below the site of injury and are connected by a threaded rod. Turning of the rod slowly approximates the hooks and reduces the deformity. However, this type of injury predominantly occurs in the cervical spine. In this location, wires are usually used to draw the separated segments together. Because of the ineffectiveness of ligamentous healing, bone graft fusion is used in conjunction with internal fixation.</p> <p>Postoperative orthotic management in this situation is more complementary than supplementary. Whereas the internal fixation stabilizes in flexion, it offers little resistance to extension. Therefore, the orthosis should emphasize stability in extension.</p> <p>For the sake of completeness, orthotic management after anterior spinal decompression and fusion should also be mentioned. When this procedure is performed, most of the affected vertebra is removed and replaced with a block of iliac bone graft. Present anterior spine instrumentation uses a threaded rod attached to the spine with screws to afford stability. Control of motion in all planes by the orthosis is required in this clinical situation.</p> <p>The previous section dealt with the indications and techniques of spinal internal fixation, with emphasis on the role of postoperative orthotic management. Next, five regions in the spine and some specific orthotic requirements for each will be identified. Particular emphasis will be placed on whether a specific injury requires an orthosis to restrict or only to reduce intervertebral motion. When an orthosis restricts intervertebral motion, less than ten percent of normal motion is possible at that segment with the orthosis in place. An orthosis which restricts motion is used when either no or minimal internal fixation is used to provide stability. When up to 30% of motion at an intervertebral segment is possible while wearing an orthosis, the orthosis is said to only reduce intervertebral motion and not restrict it. A reduction orthosis is indicated to protect inherently stable fractures or spines internally stabilized secondary to surgery.</p> <p>The first anatomic area to be discussed is the upper cervical spine. In this area, instability can result from fractures of the atlas, from fractures of the odontoid process, and from disease processes such as rheumatoid arthritis and tumors. Orthoses generally are inadequate in restricting intervertebral motion between the occipito-atlanto-axial segments. Therefore, for virtually any upper cervical disorder requiring restriction of intervertebral motion, application of a halo and vest is indicated.<a></a> One possible exception is the SOMI brace, which can be used to effectively restrict instability from ruptures and attrition of the transverse ligament of the atlas.<a></a></p> <p>The second anatomical area is the lower cervical spine. This extends from C3 through T1. Restriction of motion in this region is required in at least three situations. One is a flexion injury which compresses the vertebral body anteriorly and disrupts ligaments posteriorly. A second need for restriction is for extension injuries which avulse both the anterior longitudinal ligament and the intervertebral disc. A final situation is postoperative management of lower cervical fusions in which no internal fixation is used. In these situations, a cervicothoracic four-poster device should be used. If only reduction of intervertebral motion is required, then application of a Philadelphia collar is all that is necessary. The usual clinical situation needing reduction of intervertebral motion is immobilization after posterior cervical stabilization with wires.</p> <p>The third anatomical region lies between T3 and T10. The thoracic region possesses the most inherent stability of the entire spine. For this reason, the bracing requirements are minimal. If no internal fixation is performed, the stabilization afforded by the thoracic cage need only be supplemented by a thoracolumbosacral orthosis (TLSO) to ensure maintenance of position. Segmental type operative fixation is especially suited for the thoracic spine. When this is performed, often no postoperative orthosis is required. Postoperative immobilization is still required in the thoracic spine when Harrington instrumentation is employed.</p> <p>In the fourth region, the thoracolumbar junction, the use of orthotic management is dependent on whether or not surgical stabilization is performed and if so, which instruments are used. In this area, from T11 through L3, the typical fracture occurs from a combination of flexion and compression forces and is termed a "burst" fracture. Nonoperative management of this lesion relies on bracing to create an extension moment to reduce the amount of collapse during healing. Operative treatment has a combined goal: to reduce and hold the fractured segments while leaving mobile as many normal lumbar segments as possible. For this reason either segmentally attached rods or transpedic-ularly applied plates are used in this area. Since these systems possess significant inherent stability, the TLSO provides effective postoperative immobilization. This orthosis has been demonstrated to be effective for the upper lumbar spine.<a></a></p> <p>The final anatomical area, the lumbosacral spine including L4, is least subject to traumatic fractures. It does, however, present some interesting challenges to obtaining effective immobilization. Operative treatment in this area should also preserve as many mobile lumbar segments as possible. With L4 fractures, the lumbosacral articulation can often be maintained. However, the more rare L5 fractures usually require fusion to the sacrum. Because of the need for short but extremely rigid spinal instrumentation, systems using transpedicular fixation are favored for lumbosacral fusions. Although this fixation method is rigid, the high stresses at the lumbosacral junction dictate that external immobilization be used, especially if two level fusions are attempted. The TLSO has almost no ability to immobilize the lumbosacral motion segment. Therefore, the use of a one-half spica cast is recommended for use after lumbosacral surgery.<a></a></p> <p>In summary, the role of orthotics in the postoperative management of spinal instability is critical. Because the lack of normal sensation precludes the use of casts in quadriplegics and paraplegics, the proper fabrication and application of an orthosis is essential. Knowledge of the original fractures forces, as well as an understanding of the principles of operative stabilization, can assist the orthotist in managing the postoperative immobilization of the injured spine.</p> <p><b>References:</b></p> <ol> <li>Denis, F., "Spinal Stability as Defined by the Three-column Spine Concept in Acute Spinal Trauma," <i>Clin Ortho</i>, 189, 1984, pp. 65-76.</li> <li>Sances, A., J.B. Myklebust, D.J. Mainman, S.J. Larsen, J.F. Cusick, R.W. Jodat, The Biomechanics of Spinal Injuries. CRC Critical Reviews in Biomedical Engineering 11(1), 1984, pp. 1-65.</li> <li>Stauffer, E.S., "Neurologic Recovery Following Injuries to the Cervical Spinal Cord and Nerve Roots," <i>Spine</i>, 9(5), 1987, pp. 532-3.</li> <li>White, A.A., M.D. Panjabi, I. Posner, W.T. Edward, W.C. Hayes, "Spinal Stability: Evaluation and Treatment," <i>AAOS Instructional Course Lectures Volume XXXIV. The Spine</i>. Chapter 23. CV Mosby, St. Louis-Toronto-Princeton, 1985.</li> <li>Dickson, J.H., D.R. Harrington, W.D. Erwin, "Results of Reduction and Stabilization of the Severely Fractured Thoracic and Lumbar Spine, "<i>J Bone and Joint Surg,</i> 60A(6), 1978, pp. 799-805.</li> <li>Bradford, D.S., B.A. Akbarnia, R.B. Winter, E.L. Seljeskog, "Surgical Stabilization of Fracture and Fracture Dislocations of the Thoracic," <i>Spine</i>, 2(3), 1977, pp. 185-196.</li> <li>Johnson, R.M., D.L. Hart, E.F. Simmons, G.R. Ransby, W.O. Southwich, "Cervical Orthoses," <i>J Bone and Joint Surg</i>, 59A(3), pp. 332-339.</li> <li>Fidler, M.W., "The effect of four types of support on the segmental mobility of the lumbosacral spine," <i>J Bone and Joint Surg</i>, 65A(7), 1983, pp. 963-7.</li> </ol> <em><b>*Daryl G. Barth, C.P.O. </b> Daryl G. Barth, C.P.O., is Assistant Director of Orthotic and Prosthetic Services for the Division of Orthopaedics and Rehabilitation at Southern Illinois University School of Medicine.</em><br /><br /><em><b>*E. Shannon Stauffer, M.D. </b> E. Shannon Stauffer, M.D., is Professor of Chairman of the Division of Orthopaedics and Rehabilitation at Southern Illinois University School of Medicine.</em><br /><br /><em><b>*Michael MacMillan, M.D. </b> Michael MacMillan, M.D., has a Spinal Fellow with the Division of Orthopaedics and Rehabilitation at Southern Illinois University School of Medicine in Springfield, Illinois.<br /><br /></em> Page Number(s) 210 - 214 Year 1987 Volume 11 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Orthotic Management of the Surgically Stabilized Spine in Quadriplegic and Paraplegic Patients Creator An entity primarily responsible for making the resource Michael MacMillan, M.D. * E. Shannon Stauffer, M.D. * Daryl G. Barth, C.P.O. * https://staging.drfop.org/files/original/3ec7888cee2f851b5ad939cfc35e9698.pdf fa3c522ca3dfd7e1953c8cf88f054613 https://staging.drfop.org/files/original/2616f512f3d92ac4e805d79a4a8c64e8.jpg 6cd68ef1007dbe4d5d6544411ccf6f4f https://staging.drfop.org/files/original/d371115128acfc7dc1bd1659a5ceb2f1.jpg 8deb734fb9677fc2cf23fb2b9da7508a https://staging.drfop.org/files/original/e917b8732cef50461c1b681f0c7ecf1b.jpg e7deb03a7c60d3420be551312817837d https://staging.drfop.org/files/original/e1cf8112df2a1bb2aaf97e8332e6283c.jpg 00d0af6d0e569c08eb99f6c8a0b9bfb9 https://staging.drfop.org/files/original/c47154226c8b4249202c0177d968f9e4.jpg 788be41c8c242497efb0357b9909d3bd https://staging.drfop.org/files/original/d2df4f38ae19ba6c1560527a9c637a97.jpg 789ef1b71b6b7f3880aa1cc1b897b13b https://staging.drfop.org/files/original/425550a68b616b6cce5a9eeb50c3fc1b.jpg 11e3639315fd4c06d8fd6f7599c446ed https://staging.drfop.org/files/original/c00b05fc2d9be2f9a1cbf792263fab16.jpg 468d623d117056703073eb6525cb72bd https://staging.drfop.org/files/original/f7ef05f73d6d3e5119b1b1a3ea3df648.jpg 0f90542403702a924a2c605a62d317aa https://staging.drfop.org/files/original/62f30434ecf0464e8a03a8e7566f1fee.jpg e87645ad72adee68b98015e48c906e9d Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_04_159.pdf Text Any textual data included in the document <h2>Commercial Options for Positioning the Client with Muscular Dystrophy</h2> <h5>Michael Silverman, CO.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Before the advent of modern medicine, progressive weakening of the musculature was thought to be due to disorders of the nervous system. Early researchers thought the problem was with the nerves somehow being unable to activate the muscles, which in turn caused the muscles to atrophy. It wasn't until the late nineteenth century that researchers began to understand that these problems were due to the muscles only, without involvement of the nerves.</p> <p>In 1861, Guillaume-Benjamin-Amant Duchenne, a Bolognese sea captain's son, published the first description of the severe childhood form of muscular dystrophy now known by his name. Specifically, Duchenne noted that the disease ran in certain families, and he clearly defined pseudohypertrophy (false overdevelopment) of the calf muscles as one of the disease's symptoms. It was thirty years later that Wilhelm Erb described the underlying clinical features of the various forms of progressive muscular dystrophy and outlined four subvarieties. "Some of the observed features included symmetrical muscle wasting, progression, abnormal gait, a development of charcter-istic body deformities. Erb was the first to see that these symptoms were disorders of muscle tissue, not of nerves, and he hazarded to guess that they were due to a complex nutritional disturbance."<a></a></p> <p>Over the last few decades, many categories of muscular dystrophies have been designated. Some, such as Myasthenia Gravis, are controllable with simple medication and do not require special devices other than lightweight orthoses. Others, such as Duchenne muscular dystrophy, are progressive and require increasing amounts of specialized equipment to make the disability as manageable as possible. In this paper, the development of specialized seating for clients with muscular dystrophy, as well as new systems on the market today, which can help to make these clients remain as functional as possible for as long as possible, will be reviewed. Below are listed some of the major types of muscular dystrophy whose treatment will often require specialized seating.</p> <blockquote> <p><b>Duchenne</b><br />(<i>Pseudohypertrophic</i>)</p> <p>Rapid, ultimately involving all the voluntary muscles. Death usually occurs within 10-15 years of clinical onset.</p> <p><b>Werding-Hoffmann</b><br />(<i>Infantile Spinal muscular atrophy</i>)</p> <p>The earlier the onset, the more rapid the course. Respiratory failure and/or infection usually cause death.</p> <p><b>Kugelberg-Welander</b><br />(<i>Juvenile spinal muscular atrophy</i>)</p> <p>Variable, but usually very slow. Most patients live to old age.</p> <p><b>Amyotrophis Lateral Sclerosis</b><br />Rapid, leading to death usually within three to five years.<a></a></p> </blockquote> <p>There are no easy rules for seating the client with muscular dystrophy. The pattern and severity of weakness varies from client to client and is usually changing so that each client has to be looked at for his individual needs. With the early onset of Werdnig-Hoffmann, specialized seating can be used to help with the prevention of deformities. These children tend to be very floppy. The positioning system will make them easier to handle and put them in a position where they can use their arms and hands to explore the world around them.</p> <p>The pre-adolescent onset of Duchenne muscular dystrophy will often times lead to extreme curvatures of the spine unless the client is properly managed in a positioning system or orthosis. The advantage of using a positioning system in place of an orthosis is usually that of comfort. The positioning system should provide greater comfort to its user than the use of a wheelchair with a sling seat and back. The orthosis can be a source of discomfort to the user and, for this reason, is likely to be left in the closet. "This tendency for the brace to be uncomfortable is understandable because of deformity is a collapsing type of scoliosis and the patient lacks the muscle power to pull away from a painful pressure area."<a></a> With degenerative forms of muscular disease, <b>the most important thing a positioning system can do for the client is to aid in increasing his function, allowing him to continue with normal activities of daily life for as long as possible.</b></p> <p>The client with Amyotrophis Lateral Sclerosis (ALS) presents a whole new set of problems for the clinician. Because of the age of onset and rapid progression of the disease, the clinician does not usually have to worry about the prevention of deformity. But these same problems make it nearly impossible to design a positioning system that will provide these clients with comfort and function for any reasonable length of time. Clients with ALS tend to prefer less contoured systems, and require adjustable reclining mechanisms for comfort.</p> <p>Once the decision has been made that a positioning device may be beneficial, certain questions must be considered and information about the clients' family and home environment must be obtained. Then methods of transportation must be looked into. What is the prognosis of the clients condition? Is the client out with the family occasionally or most of the time? Are the outside conditions rural or urban? What are the client's favorite activities? What are the families needs? Does the family have, or will they be getting, a van which would allow the client to be transported in his or her positioning system? How close is the roofline to the clients head while seated in their standard wheelchair? Is powered mobility needed now or in the future?</p> <p>An overall clinical evaluation should be made and the results of these tests should be available before any positioning decisions are made. A complete physical and functional evaluation of the client is necessary to determine the extent of the weakness and whether there are any contractures present. Orthopedic considerations add another dimension and may require the input of a surgeon to determine if releases are possible to aid in good long-term positioning. (A consideration with Duchenne muscular dystrophy is the question of a possible spinal fusion.) Any deformities which are present must be noted, as their severity will help further narrow the options for positioning the client. Slight flexion contractures of the hips or knees should not pose a problem for a successful positioning system. However, extension contractures of the hips or ankles could be more of a problem. Remember that a positioning system can serve a preventative role in reducing the formation of contractures and deformities, but the positioning system cannot be used to correct these situations. If correction is needed, it is best done on the operating table before the seating system is provided.</p> <p>The seating system should allow the client enhanced abilities when using the system. The extremities also need to be looked at in relation to function. Arms must be free if independent mobility is possible. Strength must be tested to determine if ultralight bases would be of benefit. The wheelchair is as much a part of the seating system as a headrest or foot support. There are many types of wheelchairs on the market today and the initial evaluation is critical in determining what type wheelchair would best serve the client. For the purposes of this paper, we will concentrate on positioning solutions only.</p> <p>When deciding on the best position in which to seat a client with muscular dystrophy, it is necessary to start with the pelvis and achieve a neutral position to provide a stable base of support. Standard sling seats provide an unstable surface for sitting, as the pelvis will not sit level and forces a lateral compensatory curve up the spine (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-01.jpg"><b>Fig. 1</b></a>). The pelvis should be in midline and should not be allowed to slide laterally by blocks built into the positioning system. A 90 degree position of hip flexion is desired, and in some cases, a back-to-seat angle of less than 90 degrees may be beneficial, especially when introducing increased lordosis into the spinal section. An anteriorly wedged seat will help to achieve a proper hip angle, while assisting to maintain the client in the seating system. The object is not to immobilize, but to stabilize the pelvis.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-01.jpg">Figure 1.</a> A person with abnormal tone becomes more a asymmetrical when seated on a hammock type surface. (A. Bergen and C. Colangelo, "Positioning the Client with CNS Deficits," 1985, p. 7).</strong><br /> <p>To complete the base of support for the upper body, the clinician must properly position the lower extremities. An abductor (wedge) will help to position the legs slightly apart giving a wider base of support (be careful not to bring the legs any wider apart than the diameter of the hips.) When using an abductor, keep it away from the groin and make sure it is of the flip-down or removable variety if a urinal is being used. Sometimes the clinician may wish to use an abductor as a reminder of the proper placement of the client in the positioning system, especially when there may be multiple care givers. The knees and ankles should be at 90 degrees unless contractures are present. In many cases, the knees may have to be extended slightly in order to clear the front casters of the wheelchair. The feet should always be supported so as to complete the stable positioning of the pelvis. As you can see, a great improvement in seating can be made just by replacing the sling seat upholstery with simple plywood and foam componentry (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-02.jpg"><b>Fig. 2</b></a>).</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-02.jpg">Figure 2.</a> A firm sitting surface provides a base for symmetrical sitting. (A. Berger and C. Colangelo, "Positioning the Client with CNS Deficits," 1985, p. 7)</strong><br /> <p>Now, the clinician is ready to work his way up the spine. The trunk must be held in midline, as close to natural shape as possible to allow better head control. In older clients, the natural shape of the spine includes forward curves at the neck and lumbar region of the spine. For the floppy client, as well as those with a scoliotic deformity, lateral trunk supports are usually required. Usually with scoliosis, the pads are placed under the apex of the curve on the convex side and under the axilla on the other side. The third point of the pressure system is the pelvis held in with good lateral positioners (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-03.jpg"><b>Fig. 3</b></a>).<a></a></p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-03.jpg">Figure 3.</a> Transverse loading in seating the patient with scoliosis (rear view).</strong><br /> <p>With clients who have flexible spines, many different approaches to positioning are used. For the small child with spinal muscular atrophy, allowing the spine to shape into a gentle C-curve may promote the best head position. Increasing the lordosis with these clients may help to push them out of the chair and cause their heads to fall backward. In the case of adolescent clients with Duchenne muscular dystrophy, increasing their lumbar spinal extension may actually help with the prevention of lateral curvature, as well as promote good head positioning. To understand this idea, one must first understand the mechanism of the spinal collapse in the client with Duchenne muscular dystrophy.</p> <p>The first sign of spinal instability as demonstrated by roentgenograms (x-rays) is the appearance of a long thoracolumbar curve of less than 10 degrees sent in patients who are ambulating with the aid of long leg braces. During the early wheelchair bound stage, the curves lose their flexibility. They also involve fewer vertebral segments, primarily in the lumbar spine, without axial rotation in curves of less than 20 degrees of lateral curvature as measured by Cobb's method. Rotation in the upper segment of the curve, which generally extends over the bodies of T10 to L3, is followed with maximal rotation at L2 of an estimated 5 degrees. Vertebral rotation then increases at a faster rate than the lateral displacement. Once rotation reaches 15 degrees and the lateral curve 30 degrees, both parameters increase rapidly.</p> <p>Mr. Jan Koreska and his group at the Hospital for Sick Children in Toronto, Ontario have done many studies of the spine which suggest that if lateral displacement of the lumbar spine is not prevented, axial rotation follows, and by this time conservative bracing is unlikely to succeed since structural failure has already occurred.<a></a> They also found that the posterior facets and ligaments of the lumbar spine appear to be responsible for the linear alignment of the lumbar spine. The influence of the posterior facets on the upper lumbar spine appears to be less significant because their resistance to axial rotation is reduced.</p> <p>"Some 80 percent of the children develop a collapsing type of scoliosis." The observation of 62 spines of boys by the Hospital for Sick Children yielded consistent results. "A few patients' spines gradually became very stiff and somewhat hyperextended over a period of years. When this happens, the patient will be a good sitter for a long time. The more usual pathway involves moving gradually from a straight spine to a rapidly steady progression into a severe kyphoscoliotic."<a></a></p> <p>The first seating system developed specifically for prophylactic use by clients with Duchenne muscular dystrophy was developed in the mid 1970's. This specially designed seat was effective in limiting the progression of spinal curves to less than one degree per month in 13 out of 16 patients. The thought was, if spinal deformity could be maintained until skeletal maturity was achieved, good spinal alignment could be maintained. Clients whose curves progressed to greater than 35 degrees would usually ultimately require surgery.</p> <p>The Toronto Spinal Support System (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-04.jpg"><b>Fig. 4</b></a>) is made of a fiberglass shell, lined with custom carved ethafoam, upholstered with a modified urethane foam and a tricot double knit covering. Headrests, arm rests and leg supports are attached to the fiberglass shell. The unit is meant to be inclined backward a minimum of 15 degrees. The pelvis is snugly fitted and the thoracolumbar junction extended, while the back has lateral guides to promote midline sitting. "The snug fit gives the spinal column a stable base (the pelvis), and the extension of the thoracolumbar region reduces the mobility seen when the interarticular facet joints at this level are opened up in flexion. The 15 degree backward tilt reduces the load on the spine every time the patient leans back, while the foam lining makes it comfortable and acceptable to the patient."<a></a></p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-04.jpg">Figure 4.</a> The Toronto Spinal Support System.</strong><br /> <p>Conclusions from the group in Toronto over the last few years show that, although spinal deformity is not absolutely prevented, development is slowed, prolonging the period of trouble free sitting. This slowing down of the development of the spinal deformity takes place at a time when spinal growth is rapid, making the introduction of the system at a young age before puberty of utmost importance. A 10 year follow-up to the development of the Spinal Support System (SSS) sponsored by the Muscular Dystrophy Association of Canada was completed in late 1983. Following are some of the more significant findings.</p> <ol> <li> <p>The Spinal Support System has made a significant contribution to the management of individuals with Duchenne muscular dystrophy across Canada. Improvement of user comfort is the attribute most consistently stated. The SSS development has been particularly well received by parents.</p> </li> <li> <p>The SSS in its originally conceived design does not arrest the progression of spinal deformity. However, reduction in the rate of progression of deformity (1/3 to 1/2) was reported by the participating clinics.</p> </li> <li> <p>From the clinical data available, it was not evident that any one single feature of the SSS is the key to the improvement of spinal management; but rather suggests that there is a combination of multiple interrelated factors involved.</p> </li> <li> <p>There is no clear evidence supporting the hypothesis that extension of the lumbar spine is the key contributor to the lateral stabilization of the spine.</p> </li> <li> <p>Lack of easy adjustment for growth or change of spinal alignment creates serious delays or the postponement of the necessary revisions.</p> </li> <li> <p>Although biomechanically advantageous, the 15 degree recline of the backrest necessitates that the child lean anteriorly and away from the posterior supporting surfaces when participating in functional activities or seeking head stability. Only rarely were children observed or reported as using the back and head rest as intended by the designers.</p> </li> <li> <p>The use of prefabricated modular components which results in relatively easy assembly is viewed as a very positive feature of the design concept.</p> </li> </ol> <p>The overall experience with the Spinal Support System was pretty well summed up in a follow-up study completed by a review committee in 1983. "Most of the principles obtained from the SSS study in Toronto have included the importance of the incorporation of a lumbar lordotic pad to maintain the lumbar and thoracic spine in a lordotic position. The concept is, if the spine is going to become fused or rigid spontaneously, it will adopt a stiff extended alignment rather than collapsing kyphoscoliosis. However, this is the exception rather than the rule. There is no orthotic or seating system in use today, including the Spinal Support System, that will prevent the majority of these children (approximately 90 percent) from developing a collapsing kyphoscoliosis. Even in the few cases (perhaps 10 percent) in which the result is a stiff extended spine, the contribution of the seating system towards that outcome is probably only minimal. Surgery is serious; it must be offered to the patients and parents with full knowledge of potential complications. The patient's pulmonary reserve must be sufficient to withstand the surgery and the disease. The rationale for surgical intervention may be difficult to accept by the parents when the effects of non-surgical intervention are not yet readily evident. If successful, the surgical intervention will stabilize the spine, making the seating problems easier for the management team. However, even when surgical stabilization is undertaken, appropriate seating systems are required since the patient still requires pelvic support, upper and lower limb alignment and support, head support and mobility. Generally, the Spinal Support System has addressed the problem of development of scoliosis in muscular dystrophy patients. It has decreased the rate of progression, as shown in several studies. However, this may be detrimental to the patients general health because of the progression of the decreased pulmonary reserves. That is, the management team may be lulled into a "wait and see mode," only to find out later that the reduced vital capacities have shifted the balance of risk towards non-surgical management, whereas early surgical intervention would have been the treatment of preference. The use of the modified Spinal Support System in conjunction with early surgical stabilization of the spine may be useful.<a></a></p> <p>The Spinal Support System was a pioneering development at a time when there were virtually no commercially available seating systems or components. Today, the interest in specialized seating is booming, and commitment by manufacturers has led to a variety of systems and components. In this next section, some of the newer systems on the market and how they are used as tools for positioning different types of clients will be reviewed. Also, current methods of seating and their ability to correct a corresponding level of orthopedic deformity will be considered.</p> <p>In a case where there is no, or very little, orthopedic deformity, that does not present positioning problems; the standard wheelchair should still be modified with a rigid seat insert or off the shelf wheelchair cushion over a rigid base. The normal folding wheelchair with a sling seat and back does not provide a stable base of support for the pelvis. It is alright when used temporarily, but if it is to be used for any length of time, a firm seat insert is mandatory. Sitting on a sling seat causes the hips to internally rotate, which contributes to abduction and usually an oblique pelvis. This causes a compensatory spinal curve. The client with muscular dystrophy will have differential muscle weakening in the spinal musculature and will almost always assume this position in due time. Therefore, for anyone sitting in a wheelchair for more than just quick trips, the addition of a rigid seat is mandatory.</p> <p>Most wheelchairs can be ordered from the factory with a rigid seat of either the drop-hook variety or attached with a special folding mechanism. A firm seat can also be made as a separate piece meant to be placed on an existing wheelchair seat. Those wheelchairs with attached non-removable rigid seats tend to make the folded chair unruly and increase the weight. The separate variety is preferred, but because it is removable, it is often left behind. This problem is usually alievated with the drop-hook seat. After removing the seat upholstery, these cushions have special hooks which clip on to the seat rails with clamps. (The wheelchair then can not be used if the seat is left behind.)</p> <p>The base of the seat cushion is usually plywood, at least 3/8". On top of the wood, different foams can be used. Preferably, a high density urethane which will not bottom out over time. In Chicago, we make three or four-inch cushions of two different types of T-foam or Sun-Mate foam, which have special weight distribution properties. On the first layer, we use one to two inches of firm Sun-Mate for the base and two inches of medium-to-soft foam on top of that. The cushions are then upholstered with a thin flexible vinyl surface. The vinyl takes away some of the properties of the Sun-Mate foam but protects the open cell structure against water damage.</p> <p>Where problems with either boney prominences or an already oblique pelvis are envisioned, the Jay Cushion will provide a stable surface while accommodating these deformities. The Roho cushion provides excellent pressure relief but may not provide enough stability and encourage leaning. The Roho is best used where pressure relief is the main concern and stability is not a problem, as with paraplegics. This is why an overall clinical evaluation is important as well as an understanding of available products. There are many other commercially available seating cushions on the market, and they must be in stock and tried on the client to determine if one will better fit the clients needs than another. A good place to see all of what is commercially available in this field is at the National Home Health Care Expo in Atlanta.<a></a> The show is always in late fall or early winter and is free.</p> <p>For the moderately involved clients with muscular dystrophy, there are also many choices available. More likely, they are the type of clients seen. When not in bed, these clients spend almost all of their time in a wheelchair and are in the early to moderate stages of deformity or contracture. Moderate levels of deformity or contractures are measurable but not enough to create seating or functional problems.</p> <p>The most widely used method of manufacture for seating devices today is using plywood and foam technology. Here, there is a seat and back section, with body supports, pelvic supports, and leg supports bolted on. Many clinicians combine the linear plywood technology with custom carving of blocks of foam (usually ethafoam) to give a custom contoured look. The advantage of the contoured system is that they provide a larger area of contact between the seating system and the client. The Toronto Spinal Support System mentioned earlier is just an advanced version of this method, utilizing component parts such as a preshaped fiberglass shell instead of plywood. It was also one of the first systems to have head rests, arm rests and leg supports specially designed as part of the seating system.</p> <p>Today, it really makes little sense to make an entire seating system from scratch with so many commercially available components on the market. Many companies will actually make the entire seating system based on measurements of the individual client. For componentry and/or complete systems of the non-molded variety, some of the leading systems include those manufactured by Scott Therapeutics, Freedom Designs, Miller's, CRD, Gunnell, and CP seat by Pin Dot Products. Of the contoured modular systems, there is the Winnipeg system, the Otto Bock MOSS System (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-05.jpg"><b>Fig. 5</b></a>) and the Pin Dot Modular Seating System (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-06.jpg"><b>Fig. 6</b></a>).</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-05.jpg">Figure 5.</a> The M.O.S.S. system from Otto Bock.</strong><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-06.jpg">Figure 6.</a> Pin Dot Modular seating system.</strong><br /> <p>These systems are all designed for "moderately involved" clients who have minimal deformities only, with no rotational deformities. Rotational deformities become more and more evident as lateral deformities increase, and the linear systems (or those contoured with preformed cushions) becomes less and less effective.</p> <p>The next group with rotational as well as lateral deformities are designated the high moderates or low severe. Two new systems developed recently by the University of Tennessee Rehabilitation Engineering Program work well for this category. The Foam-in-Place seating system (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-07.jpg"><b>Fig. 7</b></a>) uses a plastic module with an elastic bladder which fits into the chair, and liquid polyurethane foam is measured, mixed and injected into the empty bladder while the client is properly positioned on a pre-ischial strap. The foam rises and within minutes sets up and forms a customized seat or back cushion. Because the foam takes on the exact contours of the individual, it is possible to accommodate difficult rotational deformities. The difficulties with this system are that the client is forced to sit on a 2 inch wide strap, and be perfectly positioned in a chair while the foam is mixed, injected and set up (about 5 minutes). Even though the foam can shape to the most severely involved, only the high moderates can support themselves or be supported in the proper position under these conditions. Foam-in-Place may be better used for seat cushions only, as they are easier to form and more consistent in their results.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-07.jpg">Figure 7.</a> Foam-In-Place seating system.</strong><br /> <p>It is important to remember that all of the systems described here should not be thought of as complete systems only, but also as various components. The best way to produce an individualized seating system is to use some of the various components of each system in the best way possible to give the desired result for the individual client. Adrienne Bergen, O.T.R., a pioneer in this field, has used the word "eclectic" to describe those devices made from a variety of components from various companies, and it allows her to best fill her clients needs in the most economical manner.</p> <p>The Bead Seat is another new development from Douglas Hobson's group at The University of Tennessee Rehabilitation Engineering Program, which uses essentially the same componentry of the Foam-in-Place seating system. The difference between the two systems is the filling or "stuffing" in the cushions. In the Foam-in-Place system, there is a liquid foam which sets up and forms while the person is suspended over the empty shell. The Bead Seat's "stuffing" is a mixture of a fast setting epoxy and polystyrene pellets (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-08.jpg"><b>Fig. 8</b></a>). The epoxy will set up two hours after the introduction of the catalyst, locking the lightweight pellets into the form desired. The form is made while the whole system is under vacuum using the dilation method.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-08.jpg">Figure 8.</a> Side view of Bead Seat Technology.</strong><br /> <p>Dilation is a molding technique used for more than three decades and consists of an airtight bag filled with pellets and attached to a vacuum pump. When the vacuum is introduced into the system, the bag compresses against the pellets and holds whatever shape it has prior to the introduction of the vacuum. To change the shape, air is introduced into the bag, loosening the pellets' structure and allowing a change in shape.</p> <p>The Bead Seat system depends on the vacuum to hold the shape until the epoxy sets up, creating a mechanical bond between the styrene pellets. Once the epoxy has set, the vacuum can be removed and the positioning system completed. The advantage of the Bead Seat over Foam-in-Place is that there is more time available to mold and remold the system, while simulating the finished system, to attain the desired shape. The extra time available for shaping with the Bead Seat allows it to be used with more severely involved clients than Foam-in-Place. This advantage of extra time is also a disadvantage when compared to the Foam-in-Place system, since it takes longer to produce the finished product. Also, when finished, the Bead Seat has a harder surface compared to the flexible surface of the Foam-in-Place cushion. This harder surface may be an advantage with positioning, but a disadvantage when pressure relief is the objective. Bead Seat, as well as Foam-in-Place, will accommodate rotational deformities but may not be durable enough for the long-term needs of the larger clients because of the plastic framework. For lighter clients (under 100 pounds), the Bead Seat will easily accommodate the severely involved. Another limiting factor of both the Foam-in-Place and Bead Seat systems is that only a headrest system and a simple 90 degree legrest are available as options for customizing the systems, as they are designed to be used with the accessories in the existing wheelchair and this may not be enough for the most severely involved clients.</p> <p>When dealing with the severely involved, the traditional orthotic approach is the vacuum-formed plastic or Gillette style seating system. Using this system, a mold is taken of the individual by placing the client prone on a table with the hips flexed to 90 degrees. The mold is taken using either the dilation method or with plaster bandages. This method of taking an impression is a problem. The mold (or measurements) should always be taken while the client is simulating the final seating position. The effect of gravity on the client cannot be felt when the client is molded in a prone position, and the client's shape may be completely different when upright. It is easy to straighten a client's spine when prone on a table; the problem is that the client may not be able to tolerate this corrected position for long periods of time when upright. This applies especially to the client with muscular dystrophy, who may not have the muscle strength to pull away from a sore area. When one is dealing with a client in the severely involved category, the idea is to correct as much flexible deformity as possible, while making the positioning system as comfortable as possible so the client will be able to use the system for long periods of time during the day.</p> <p>Other difficulties with the traditional orthotic approach include the time needed to fabricate the finished system and the inability to adjust the system once it is finished. These problems are the same as those encountered when making a sophisticated seating system out of plywood and foam. With the traditional orthotic approach, the finished mold is filled, smoothed and corrected. Over the finished mold, a layer of foam is vacuum formed, then a layer of polypropylene is added. The plastic shell is then trimmed out, set in a box to form a base so it sits in the wheelchair at the desired angle, and upholstered. Time is valuable, and today most private facilities cannot profitably produce seating systems in this manner.</p> <p>Today, because of the large amount of commercially available componentry, systems do not have to be made this way. Is anybody still hand forging knee joints? Today seating is where orthotics was in the late 50's or early 60's, at the advent of commercially available componentry.</p> <p>Two newly developed systems work especially well for the severely involved clients: the Contour-U seating system (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-09.jpg"><b>Fig. 9</b></a>) and the Matrix seating system. Contour-U utilizes the same dilation technology as the Bead Seat, but molds are taken on a specially designed molding frame with rubber seat and back bags filled with polyethylene pellets. Once a mold is taken of the individual in the proper position, plaster splints are worked into the mold to give a positive impression of the client. The molds are then turned into flexible upholstered cushions on a central fabrication basis, designed to eliminate the shop time needed for fabrication. The finished seat and back cushions snap into aluminum hardware, which also has the ability to be angularly positioned (both back-to-seat angle and recline orientation) and adjusted for length. This system accepts a wide variety of accessories designed to accommodate even the most severely involved client properly. The system is not labor intensive but can be expensive, especially when used with the many accessories available.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-09.jpg">Figure 9.</a> Contour-U seating system.</strong><br /> <p>As clinicians, knowledge of patient priorities should be uppermost. Don't use Contour-U when a Bead Seat will do. Don't use a Bead Seat where a Jay cushion will do the job. Think eclectically for the patient. Contour-U cushions with plywood and simple componentry can be used to create an inexpensive, custom molded seating system. For another client, a Bead Seat molded back and a Foam-in-Place seat may be the best solution.</p> <p>Another advancement in seating developed in Vancouver and now manufactured in England is the Matrix system (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-10.jpg"><b>Fig. 10</b></a>). The Matrix takes an altogether different approach by providing a flat sheet of locking ball joints which can be contoured to almost any shape and locked into that position by individually tightening the ball joints.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-10.jpg">Figure 10.</a> Matrix seating system.</strong><br /> <p>Essentially, a sheet of material into which tucks can be taken and contours formed, Matrix can be fabricated to position somebody in any position desired. A nice feature of the Matrix is that it can be loosened and reshaped when necessary. Also, where growth is expected, the matrix can be extended by just adding a row or two of modules. The disadvantage of this system is in the time required to produce the finished product. Anywhere from 15 to 25 hours is necessary, which puts it into the same category as traditional orthotic seating systems. Fortunately, Matrix fabrication is also available on a central fabrication basis.</p> <p>Some may consider the Matrix unattractive, but its high tech design also makes it airy, lightweight, and waterproof. The Matrix fits in well with the eclectic approach, as pieces of the material may be used for a custom head rest or arm trough when needed, making a whole system out of material unnecessary, unless preferred for the client.</p> <p>These are brief descriptions of some of the newer systems on the market today. Information is available from the manufacturers to learn the benefits and weaknesses of all these systems (see suppliers list). The idea is to best provide the client with a product which, individually, does what is required for the most economical price. Having a variety of systems at our disposal, as well as the ability to custom fabricate components when necessary, will allow us to provide the best service to our clients and establish our facilities as specialists in this expanding field.</p> <p>In Chicago, we have done just this by establishing the Chicago Seating Institute. At the facility, we specialize in proper positioning of clients, while providing various styles of seating systems, wheelchairs, and environmental controls. In the future, we hope to expand our field of expertise to include communication devices as well. Over the last few years, the development of the specialized seating side of our business has increased our volume from 12-15 clients a year in 1981 to 150-200 clients a year today. In no other area of our business could we have expected to see a ten fold increase in the number of clients seen, even with the same commitment made as we've done for specialized seating. The field of specialized seating is up and coming, not only for the orthotist, but the prosthetist and other allied health professionals as well.</p> <p>Unfortunately, traditional education for specialized seating is not available. However, there are some programs and seminars offered, with increasing frequency in the past few years. Watch the upcoming issues of the American Orthotic and Prosthetic Association Almanac, or contact The Association for the Advancement of Rehabilitation Technology (RESNA) at Suite 700, 1101 Connecticut Avenue, Washington, D.C. 20036; (302)857-1199. Historically, as with orthotics and prosthetics, the best and only real way to learn is to learn by doing. See your clients, and learn from making systems for them. This hands-on method is the best teacher for seating because you can watch the clients expression to know if they are comfortable. The "cookbook" approach with easy rules just doesn't work here since people do not demonstrate this reflex or that reflex, this deformity or that deformity, but a hodgepodge of various reflexes, deformities and contractures. Add to this differing age groups, backgrounds, living conditions, and mental abilities, and the cookbook method becomes impossible. Have a variety of solutions at your disposal. Think of the client as an individual. This education will help you understand your clients discomforts and needs. With the help of a therapist, decide on realistic attainable goals. With this in mind, there are many ways to achieve the desired results of functional (where possible) and comfortable (always possible) seating for clients.</p> <h3>Suppliers</h3> <p>BEAD SEAT<br />Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618. (Developed by The University of Tennessee Rehabilitation Engineering Program.)</p> <p>CP SEAT<br />Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618. (Second generation of the MPI seating system developed by The University of Tennessee Rehabilitation Engineering Program.)</p> <p>CONTOUR-U SEATING SYSTEM<br />Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618.</p> <p>CRE<br />Creative Rehabilitation Equipment, 513 NE Schuyler, Portland Oregon, 97212.</p> <p>FOAM-IN-PLACE SEATING SYSTEM<br />Carapace, Inc., P.O. Box 45040, Tulsa, Oklahoma 74147.</p> <p>FREEDOM DESIGNS<br />Freedom Designs, Inc. 18165 Napa #8, Northridge, California 91324.</p> <p>GILLETTE SEATING SYSTEM<br />Gillette Childrens Hospital, Orthotic Department, Minneapolis, Minnesota.</p> <p>GUNNELL<br />Gunnell Manufacturing, 221 North Water Street, Vassar, Michigan 48768.</p> <p>JAY CUSHION<br />Jay Medical Ltd., 805 Walnut, Boulder, Colorado 80302.</p> <p>MATRIX SEATING SYSTEM<br />Pin Dot Products, 2215, West Belmont, Chicago, Illinois 60618. (Developed by Clinical Engineering Designs, Kingston upon Thames, England.)</p> <p>MILLER'S<br />Miller's Rentals and Sales, 284 East Market Street, Akron, Ohio 44308.</p> <p>MOSS (Modular Orthotic Seating System)<br />Otto Bock Industries, 4130 Highway 55, Minneapolis, Minnesota 35422.</p> <p>PIN DOT MODULAR SEATING SYSTEM<br />Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618.</p> <p>ROHO CUSHION<br />Roho, Inc. P.O. Box 658, Belleville, Illinois 62222.</p> <p>SCOTTIE SEATING SYSTEM<br />Scott Therapeutic Designs, 430 Robertson Lane, San Jose, California 95112.</p> <p>TORONTO SPINAL SUPPORT SYSTEM<br />The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario.</p> <p><b>References:</b></p> <ol> <li>Ogg, Elizabeth, "Milestones in Muscle Disease Research," Published by the Muscular Dystrophy Associations of America, Inc., 1971.</li> <li>Muscular Dystrophy Associations of America, Inc., "Chart of Differential Diagnostic Characteristics of the Primary Diseases Affecting the Neuromuscular Unit."</li> <li>Gisbon, D.A. and Koreska, J., "The Management of Spinal Deformity in Duchenne's Muscular Dystrophy," <i>Orthopedic Clinics of North America</i>, Vol. 9, No. 2, April, 1978, pp. 437-450.</li> <li>Letts, M. and Rang, M., "Seating the Disabled," <i>Atlas of Orthotics</i>, American Association of Orthopedic Surgeons, p. 468.</li> <li>Koreska, J. and Robertson, D., "Biomechanics of the Lumbar Spine and its Clinical Significance," <i>Orthopedic Clinics of North America</i>, Vol. 8, No. 1, January, 1977, pp. 121-133.</li> <li>Gibson, D.A. and Koreska, J., "The Management of Spinal Deformity in Duchenne's Muscular Dystrophy," <i>Orthopedic Clinics of North America</i>, Vol. 9, No. 2, April, 1978, p. 439.</li> <li>Gibson, D.A. and Koreska, J., "The Management of Spinal Deformity in Duchenne's Muscular Dystrophy," <i>Orthopedic Clinics of North America</i>, Vol. 9, No. 2, April, 1978, p. 440.</li> <li>Hobson, D., Desrosier, F., Beauchamp, R., and Martel, G., "The Spinal Support System and Other Approaches to Specialized Seating for Duchenne Muscular Dystrophy Patients-A Review Report," The Muscular Dystrophy Association of Canada, November, 1983.</li> <li>National Home Health Care Expo, Atlanta, Georgia. Call (305)773-2222 for details.</li> </ol> <p style="width: 400px;"><em><b>*Michael Silverman, CO. </b> Michael Silverman, CO., is with Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618.</em></p> <div style="width: 400px;"></div> Page Number(s) 159 - 170 Year 1986 Volume 10 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Commercial Options for Positioning the Client with Muscular Dystrophy Creator An entity primarily responsible for making the resource Michael Silverman, CO. * https://staging.drfop.org/files/original/d926666429d9f2cdaf83ae21fe646c4f.pdf fc83de5564adb8c10840e56fc70c62ee https://staging.drfop.org/files/original/3b5e2b430dabd8baf145e6318ad9a8ac.jpg 01ae62dacd8de2696172979a524bc346 https://staging.drfop.org/files/original/c3618fa7bba7b72cca5c7f35c50ccebf.jpg 6ffb262220815834326298815ce4703a https://staging.drfop.org/files/original/6e60ab4bfaa6a84d3cd16563dd3a1b00.jpg b7d55619ad69dca45bb140cb75b7ff3d https://staging.drfop.org/files/original/6cef018bad60db66a6ccacad7eaa8947.jpg 5567ec543d1d62d47c68c307b1277865 https://staging.drfop.org/files/original/720bdb4a059cfeabf344aa1141a372ae.jpg 6858cb4c2244e6b253e500666c4e1865 https://staging.drfop.org/files/original/92e2ffc11c03bf7e45ccd8ceb1d94c1a.jpg 9c8423654d6cb14560a481688f433867 https://staging.drfop.org/files/original/7ccbc9292d966c3628e96d4de8252295.jpg 829221dd8b8b0904dfb59d0079def2c8 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_02_061.pdf Text Any textual data included in the document <h2>The Susceptible Insensate Foot</h2> <h5>Mitchell E. Kalter, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Richard L. Jacobs, M.D.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>Patients with limbs which are both insensate and functionless often are best treated with amputation to improve hygiene, functional potential with prosthetics, and often cosmesis. There exists, however, a large population of patients whose lower extremities are insensate, but remain functional. Because of continued functional demands, and the loss of important protective mechanisms, breakdown of the delicate articulations occurs resulting in neuropathic arthropathy.</p> <p>While there are a multiplicity of disease states associated with neuropathic arthropathy, there are certain general principles and characteristics inherent in the final common pathway of the Charcot joint. In years past, neuro-syphillis was the major cause. Nowadays, diabetes mellitus is by far the most common cause.</p> <p>This article will explore some of the historical aspects, causes, pathophysiology, clinical manifestations, and principles of treatment as they relate to neuropathic arthropathy of the susceptible insensate foot.</p> <h3>Historical Aspects</h3> <p>Jean Martin Charcot, at La Salpetriere in 1868, first called attention to "ataxic" forms of arthropathy associated with neurological diseases, the most commonly recognized cause being tabes dorsalis.<a></a> Charcot attributed the acute and destructive arthropathy to the loss of certain "neurotrophic influences" ncessary to support the normal joints.<a></a></p> <p>Charcot's contemporaries, Volkmann and Virchow, disagreed with this "trophic," or what was known as the "French" theory.<a></a> They argued that the arthropathy was due to continued mechanical stress and trauma on an insensitive biological structure.<a></a> These stresses continued in the absence of normal protective reflexes, which inevitably lead to a cycle of injury, inflammation, further injury, and finally instability and joint destruction. The end result, now the "Charcot joint."</p> <p>This basic process was gradually recognized in an ever broadening horizon of disease entities. Myelitis and syringomyelia were recognized as causes in 1875 and 1892 respectively.<a></a> It was not until 1936 that Jordan described neuropathic arthropathy in the diabetic,<a></a> now the most common cause of Charcot joints.<a></a></p> <h3>Etiologic Factors</h3> <p>The myriad of conditions which can produce Charcot joints is well outlined elsewhere.<a></a> The three most common causes are diabetes mellitus, tabes dorsalis, and syringomyelia.<a></a> The prevalence of neuropathic arthropathy in diabetes is only 0.1% to 0.5%, as compared to tabes dorsalis and syringomyelia which are 5% to 10% and 25%, respectively.<a></a> The almost epidemic numbers of diabetics makes them the largest group seen clinically, however.</p> <p>Various theories have been espoused, such as Charcot's "neurotrophic" theory, Volk-mann's "mechanistic" theory, and "neurovascular" theories.<a></a> Each stresses some aspect of the observations made in the neuropathic ar-</p> <p>thropathy process. Certainly, "trophic" nerves have never been proven.<a></a> Mechanical trauma most certainly has a major role in the process, as is noted by many authors.<a></a></p> <p>The basic concept of the mechanical theory is the blunting or eliminating of pain and proprioceptive information received from the involved body part. This dampens the afferent input for both conscious and nociflexive response patterns which have evolved to protect the extremity from intolerable mechanical stresses, and thus avoid injury.<a></a> The loss of proprioceptive and fine sensory input leads to ataxic gait patterns which further increase mechanical stresses.</p> <p>The spectrum of sensory deficit can be from an apparently normal sensory examination, to complete anesthesia.<a></a> Patients can experience pain, but it is invariably much less than expected for the degree of trauma and distortion of bone and soft tissues.<a></a> When pain does occur, it is usually secondary to severe posttraumatic inflammation of richly innervated synovial and pericapsular structures.<a></a> Joint proprioception, which normally inhibits hypermo-bility, is diminished, or absent, allowing instability to develop and progress.<a></a></p> <p>Attempts to explain the rapidity of the process and bony reabsorption, seen especially in the diabetic patient,<a></a> have been made with the "neurovascular" theory.<a></a> This theory states that an abnormal "neurovascular reflex"<a></a> increases blood flow, resulting in bony washout, and hyperemic distensible soft tissue supports, all of which predispose the joint to a destructive process with normal stresses. The high incidence of objective autonomic dysfunction in diabetics lends some support to this theory.<a></a></p> <p>As stated by Hurzwurm and Barja,<a></a> ". . . a more plausible explanation is that all of the above theories play a role . . . ," but to different degrees in each patient.</p> <p>Simply, relatively minor fractures in an otherwise normal foot or ankle can lead to rapid Charcot arthropathy if neuropathy is present.<a></a></p> <p>One can think about the insensate foot like the insensate mouth after our friendly dentist mercifully relieves pain. If we insist on eating before the anesthetic wears off, despite his instructions, we can induce a "Charcot mouth." We will have pain for our indiscretion within several hours. The patient with neuropathy will continue to "chew away," oblivious of the damage he creates.</p> <h3>Clinical Features</h3> <p>The foot is the most commonly affected part of the appendicular skeleton.<a></a> However, it should be noted that different distributions of skeletal involvement can be seen, such as primarily upper extremity involvement with syringomyelia. The spine, knee, and hip may also be involved.<a></a> Why one joint in an insensate extremity is involved, while other joints remain normal, has remained unanswered.<a></a></p> <p>Patients commonly present with the chief complaint of swelling, deformity, or mal perforant ulcers.<a></a> Pain may or may not be present, but is usually dependent upon presence of acute inflammation.<a></a></p> <p>As described by Charcot and Volkmann,<a></a> the process of joint disruption begins with a period of swelling, erythema, local hyperemia, and effusion. This acute phase presentation is a manifestation of a normal acute inflammatory response to injury. If the injury is not perceived, the already edematous and hyperemic tissues receive continued trauma, recurrent inflammation, and poor, inadequate healing occurs. This eventually, if unchecked, leads to progressive soft tissue and bony deformity,<a></a> more characteristic of the chronic phase. An important distinction must be made between acute inflammation and infection, as both can present with the same local findings of swelling, erythema, and increased skin temperature. In the Charcot joint, however, laboratory studies, such as the white blood and differential counts and sedimentation rate, are normal; and importantly, there are no systemic manifestations such as fever or signs of sepsis.<a></a></p> <p>Usual deformities include increasing flat foot to complete arch collapse, ankle and hindfoot valgus (or varus), and forefoot external rotation and eversion.<a></a> Mal perforans ulcers are formed intradermally, under heavy callous, caused by abnormal weight bearing.<a></a> A 50% association of diabetic mal perforans with neuroarthropathy has been described,<a></a> usually occurring at the metatarsophylangeal joint level.</p> <p>Patterns of joint involvement have been described in the diabetic. Primary ankle and subtalar joint patterns are frequent, with mid-tarsal joints most frequently involved.<a></a> Tarsometatarsal and metatarsophalangeal involvement have each been described in up to 30% of cases<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-1.jpg"><b>Fig. 1A</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-2.jpg"><b>Fig. 1B</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-3.jpg"><b>Fig.1C</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-4.jpg"><b>Fig. 1D (1)</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-5.jpg"><b>Fig. 1D (2)</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-6.jpg"><b>Fig. 1E</b></a>, and <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-7.jpg"><b>Fig. 2</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-1.jpg"><strong>Figure 1A. Initial evaluation of a 54 year old female diabetic. Normal AP, lateral, and oblique views of the left foot.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-2.jpg"><strong>Figure 1B. At age 59 years, the lateral view is still normal.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-3.jpg"><strong>Figure 1C. Only ten months later, lateral view of same foot shows advanced Charcot changes of the ankle, subtalar, and metatarsalphylangeal joints.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-4.jpg"><strong>Figure 1D. AP view.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-5.jpg"><strong>Figure 1D. Oblique view.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-6.jpg"><strong>Figure 1E. AP and mortise views of the ankle at the same time as 1C and ID.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-7.jpg"><strong>Figure 2. The right foot of same patient in Figure 1. Lateral, oblique, and AP views show mid-tarsal, tarsal-metatarsal, as well as interphylan-geal Charcot joint changes—a different pattern of joint involvement in the same patient. Elements of bone fragmentation, joint subluxation and dislocation and bone formation are represented.</strong></a><br /> <p>Radiological characteristics of neuropathic arthropathy progress from debris at the articular margins and periarticular calcifications, to diffuse bony fragmentation which can coalesce to larger fragments and large osteophytes.<a></a> Later changes include bony marginal sclerosis in attempts to reform articulations<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-7.jpg"><b>Fig. 2</b></a>).</p> <p>Pathologic examination reveals bone and cartilage fragments in the synovial tissues, and fibroblastic reaction with some round cell infiltrates in ligamentous and capsular soft tissues.<a></a></p> <p>Circulatory status may be good in the Charcot foot,<a></a> but it is crucial to establish the diagnosis of vascular compromise on first evaluation as this can drastically affect treatment and outcome, especially in the diabetic.<a></a></p> <p>Neuropathic arthropathy can be the presenting problem with previously undiagnosed diabetics.<a></a></p> <p>Complicating factors in the clinical course are spontaneous fractures, which can hasten the degenerative process; deformity, which can be quite rapid in syringomyelia, tabes dorsalis, and with varus deformities; and soft tissue injury, predominantly neurotrophic plantar ulcers.<a></a></p> <h3>Treatment</h3> <p>Treatment follows from the recognition that the extremity is injured; and is likely to have continued trauma because of the neuropathy. Early recognition should allow curtailment of the progression, but because of the 'nature of the beast', there is often significant arthropathy at presentation.</p> <p>Control of neuropathy, if this is possible, should be a primary consideration. This should be followed by attention to soft tissue injuries, or skin ulcerations which may require local debridement.<a></a> Evaluation of circulation is also part of the initial evaluation,<a></a> with necessary vascular intervention performed if this is a concomitant problem.</p> <p>Cast immobilization to decrease edema, allow bony and soft tissue healing, and avoid or correct deformity, has been advocated by many authors.<a></a> Prolonged immobilization is essential to allow healing and stabilization.<a></a> Casting should continue until the local temperature has returned to that of the uninvolved or inactive side. It can then be assumed that the acute repair process has abated, and progression to supportive and protective orthoses is possible.<a></a></p> <p>Because of the potential for rapid progression, periodic x-rays must be obtained to assess progression which may alter therapy<a></a> (Compare <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-2.jpg"><b>Fig. 1B</b></a>&nbsp;and <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-3.jpg"><b>Fig.1C</b></a>).</p> <p>The indications for orthopaedic surgical intervention include unacceptable deformity, making shoeing difficult; bony prominences, causing ulceration; concomitant infection, requiring debridement and drainage; and deformities with a high likelihood of progression (i.e. varus).<a></a> "Bumpectomies," decompressive fusions of digits, Keller bunionectomies, and subtalar or ankle debridements and fusions are some of the more commonly indicated procedures.<a></a> Total joint arthroplasty has no place in the neuropathic patient as it will inevitably be disrupted by the same process that destroyed the natural joint.<a></a></p> <h3>Conclusions</h3> <p>The major problem of the insensate foot is its susceptibility. Ataxia, secondary to neuropathy, imparts abnormal stresses and trauma to an extremity no longer able to detect injury. The neuropathy is usually irreversible, so defensive measures must be taken to control the process of joint destruction. Well fit ankle and foot orthoses to support unstable joints and redistribute weight bearing forces more evenly are the next line of defense once cast immobilization has controlled the injury reaction and allowed healing. Surgery is useful to correct unacceptable or unstable deformities and relieve skin pressures.</p> <p>By understanding the patient's perceptions, and the pathophysiology of the Charcot foot, we can provide treatment to prolong the functional life and avoid the complications of the insensate foot.</p> <p><b>References:</b></p> <ol> <li>Curtiss, P.H., "Neurologic Diseases of the Foot," <i>Foot Disorders: Medical and Surgical Management</i>, Editor N.J. Giannestras, Lea &amp; Febiger, Philadelphia, 1973, pp. 500-503.</li> <li>Delano, P.J., "The Pathogenesis of Charcot's Joint," <i>American Journal of Radiology</i>, 2:56, August, 1946, pp. 189-200.</li> <li>Donovan, J.C. and J.L. Rowbotham, "Foot Lesions in Diabetic Patients: Cause, Prevention, and Treatment," <i>Joslins's Diabetes Mellitus</i>, 12th Edition, Editors A. Marble, et al., Lea &amp; Febiger, Philadelphia, 1985, pp. 732-736.</li> <li>Herzwurm, P.J. and R.H. Barja, "Charcot Joints of the Foot," <i>Contemporary Orthopaedics</i>, 3:14, March, 1987, pp. 17-22.</li> <li>Jacobs, R.L., "Neuropathic Foot in the Diabetic Patient," <i>Foot Science</i>, Editor M.E. Bateman, W.B. Saunders Co., 1976, pp. 235-253.</li> <li>Jacobs, R.L. and A.M. Karmody, "The Charcot Foot," <i>The Foot</i>, Editor M. Jahss, W.B. Saunders Co., 1982, pp. 1248-1265.</li> <li>Kristiansen, B., "Ankle and Foot Fractures in Diabetics Provoking Neuropathic Joint Changes," <i>Acta Orthopaedics Scandanavia</i>, 51, 1980, pp. 975-979.</li> <li>Locke, S. and D. Tarsy, "The Nervous System and Diabetes," <i>Joslin's Diabetes Mellitus</i>, 12th Edition, Editors A. Marble, et al., Lea &amp; Febiger, Philadelphia, 1985, pp. 665-685.</li> <li>Mooney, V. and W. Wagoner, "Neurocirculatory Disorders of the Foot," <i>Clinical Orthopaedics</i>, 122, January-February, 1977, pp. 53-61.</li> <li>Podolsky, S. and A. Marble, "Diverse Abnormalities Associated with Diabetes," <i>Joslin's Diabetes Mellitus</i>, 12th Edition, Editors A. Marble, et al., Lea &amp; Febiger, Philadelphia, 1985, pp. 843-866.</li> <li>Salter, R.B., "Degenerative Disorders of Joints and Related Structures," <i>Textbook of Disorders and Injuries of the Musculoskeletal System</i>, Williams &amp; Wilkins Co., Baltimore, 1970, pp. 219-220.</li> </ol> <p><em><b>*Richard L. Jacobs, M.D. </b> Division of Orthopedic Surgery at Albany Medical College, Albany, New York</em></p> <p><em><b>*Mitchell E. Kalter, M.D. </b> Division of Orthopedic Surgery at Albany Medical College, Albany, New York<br /><br /><br /></em></p> Page Number(s) 61 - 66 Year 1988 Volume 12 Issue 2 Figure 1 FIG 1A http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-1.jpg FIG1B http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-2.jpg FIG 1C http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-3.jpg FIG 1D-1 http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-4.jpg FIG 1D-2 http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-5.jpg FIG 1E http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-6.jpg Figure 2 FIG 2 http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-7.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Susceptible Insensate Foot Creator An entity primarily responsible for making the resource Mitchell E. Kalter, M.D. * Richard L. Jacobs, M.D. * https://staging.drfop.org/files/original/9dbe52f7fdd35578cf5246376f655c2a.pdf a3efeb93b0ab8f0a71f9da3dd1aae1cc https://staging.drfop.org/files/original/49c519d9cfc114bc2adb3d22a688c55c.jpg 019d282606c1c336d88f88bb227ae5f9 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_02_074.pdf Text Any textual data included in the document <h2>Post-polio Syndrome: An Overview</h2> <h5>Neil R. Cashman, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Irwin M. Siegel, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Jack P. Antel, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Poliomyelitis was a dreaded disease in developed countries, affecting tens of thousands of children and adults during each of the epidemic years up to the mid-1950s. The polio virus is a small RNA virus whose only natural host appears to be man. The vast majority of exposed persons develop either an inapparent infection or a non-specific flu-like illness (non-paralytic poliomyelitis). Secondary invasion of the brain and spinal cord is associated with infection and death of motor neurons, with loss of innervation to muscle fibers, and consequent muscle weakness and atrophy. Postmortem studies show that muscle weakness in poliomyelitis is clinically apparent only when more than half of the corresponding motor neurons are destroyed.<a></a> Frequently, muscles can be reinnervated by healthy neighboring motor neurons by a process of axonal sprouting. Thus, partial or complete recovery of muscle bulk and strength can occur, in which subnormal numbers of motor neurons support increased (up to 8-fold) numbers of muscle fibers.<a></a> It is estimated that about 250,000 people in the United States have survived paralytic poliomyelitis and are alive today.<a></a></p> <p>Recently, it has become clear that some patients who had paralytic poliomyelitis may develop new complaints after decades of stable function.<a></a> These new symptoms have been designated the "post-polio syndrome" (PPS) or "late sequella of poliomyelitis." Although some reports of new weakness following polio can be found in the medical literature since 1875,<a></a> recent epidemiologic studies indicate that new symptoms are common, occurring in approximately 25 percent of patients with antecedent paralytic poliomyelitis.<a></a> If this estimate is correct, over 50,000 persons in the U.S. are at risk of developing PPS. From published reports, the mean latency of onset has been calculated to be 36 years.<a></a> Thus, an increasing incidence of new cases will probably continue into the early 1990s, reflecting the last epidemics of the mid-1950s.</p> <p>The risk of developing PPS appears to correlate with severity of the original poliomyelitis. Thus, a patient with four-limb involvement and a history of respiratory dependence during his polio is more likely to develop new symptoms than a patient with one-limb involvement.<a></a> The severity of the original onset of polio also seems to predict the latency of developing the syndrome; severely affected patients may develop new symptoms after only 10-20 years, whereas mildly affected patients are more likely to exhibit extended delays in time of onset of PPS.<a></a></p> <p>What causes PPS? Why should a patient who has had stable function for decades develop new symptoms? At the present time, there is little definitive data on this subject. Early conjecture focused on a possible reactivation of the polio virus which had remained latent in the nervous system since the original infection. However, there appears to be little or no evidence for inflammation in post-polio patients; spinal fluid is without the cells, protein, and immunoglobulin which characterize other nervous system viral infections. Some investigators have suggested that the normal attrition of neurons with aging may trigger the post-polio syndrome when superimposed on previous static damage of polio.<a></a> However, aging-related loss of neurons in the spinal cord normally begins at about age 60<a></a>; the onset of PPS most commonly occurs 30 years after polio and does not correlate with chronological age of the patient.<a></a> Weichers and Hubbel<a></a> and Dalakis, et al.<a></a> have suggested that motor units grossly enlarged by reinnervation in recovery from poliomyelitis may begin to experience peripheral disintegration with the passage of time. Our own data support this hypothesis in part; late denervation is most common in muscles with the greatest degree of reinnervation. However, we find that group atrophy, a putative indicator of motor neuronal disease (and not terminal axonal degeneration), is also common in patients with prior poliomyelitis.<a></a></p> <p>Although a bewildering variety of new symptoms are recognized as occurring in PPS,<a></a> most new complaints appear to be subsumed under the three major problems of new pain, new weakness, and fatigue (<b>Table 1</b>). Some investigators have theorized that new muscle atrophy and weakness constitutes a separate syndrome, "postpoliomyelitis progressive muscular atrophy" or PPMA.<a></a> In this scheme, other symptoms of PPS, such as pain and fatigue, are thought to be manifestations of a separate "musculoskeletal" syndrome due to chronic strain of muscles and joints that have been forced to bear weight in an unnatural fashion.<a></a> Common orthopedic deformities in patients with poliomyelitis include knee valgus, varus, and recurvatum, as well as ankle equinus.<a></a> However, new weakness can result in new joint instability, and new joint problems may interfere with efficiency of movement. Although a symptomatic approach to separate complaints of PPS patients is warranted, there is little scientific data that supports a division of sub-syndromes of PPS at present. We have found that even patients without new symptoms have evidence of an ongoing neuromuscular disorder.<br /><br /><strong>Table 1</strong><br /><img src="/files/original/49c519d9cfc114bc2adb3d22a688c55c.jpg" /></p> <p>New pain is the most common symptom in PPS based on our experience (<b>Table 1</b>) and is a frequent complaint in other series as well.<a></a> We have evaluated patients experiencing pain in conjunction with an orthopod experienced in neuromuscular disease. Several causes of pain are commonly identified in PPS patients. Perhaps the most common cause is insertional tendonitis and/or bursitis from chronic overuse and strain of muscle groups with subnormal strength. Palpation of tendons and bursae at common sites of involvement, such as the pes tendon at the medial knee and the trochanteric bursa, will often reveal profound point tenderness consistent with this syndrome. A trial of rest and non-steroidal anti-inflammatory agents may induce remission in this remitting/relapsing syndrome. For certain local sites, a steroid injection may be useful; weight reduction and readjustment of weight-bearing (through retraining and/or orthotic devices) may also produce long-range benefits. Degenerative arthritis, found most often in weight-bearing joints (where walking aids are used, the joints of the upper extremities may indeed become weight-bearing), may also respond to the same regimen. Nerve compression syndromes characterized by pain and paraesthesias, secondary to positional or repetitive stress, should also be considered in the differential diagnosis of pain in PPS patients.</p> <p>Another type of pain, unrelated to joint "wear and tear" is muscle pain. This occurs frequently during or after exercise and may be associated with cramps, fasciculations, or intense local fatigability. This may be related to muscle substitution and/or overwork in denervated muscle, and may ultimately be associated with permanently increased weakness.<a></a> Treatment of this muscle pain includes avoiding the circumstances which induce it. Rest, orthoses, or even intermittent wheelchair use should also be considered to reduce the load on overworked muscle. Medications which reduce muscle cramps (quinine, diphenylhydantoin) may increase weakness and should be avoided.</p> <p>Fatigue is also a common complaint in PPS patients, occurring in over 60 percent of our series (<b>Table 1</b>). Two types of fatigue are reported by patients: generalized fatigue requiring rest or sleep, and local muscle fatigue. Local muscle fatigue is most common in muscles previously severely affected by polio and is often associated with cramps and fasciculations. Local fatigue may be a manifestation of ongoing muscle denervation and is also reported by patients with classic denervating diseases such as amyotrophic lateral sclerosis.<a></a></p> <p>Generalized (systemic) fatigue is common in PPS, but may also be a symptom of a variety of other states, including medical conditions such as diabetes mellitus, cardiopulmonary dysfunction, and thyroid disease. Depression ("low energy") may also lead to systemic fatigue. Once medical and psychiatric diseases have been ruled out, systemic fatigue in PPS may be a symptom of widespread neuromuscular junction transmission defects. We have found that patients with fatigue and marked increased jitter in single-fiber electromyography (an indicator of defective neuromuscular transmission) respond to agents which enhance neuromuscular transmission, such as the anticholinesterase pyridostigmine (Mestinon). Rest, ambulatory aids, and activity planning may also alleviate generalized fatigue.</p> <p>New weakness is the third major component of the "post-polio triad" (<b>Table 1</b>). When new weakness occurs with new muscle atrophy, PPS patients are thought by some investigators to suffer from a specific syndrome of post-poliomyelitis progressive muscular atrophy (PPMA).<a></a> It has been suggested that evidence of ongoing denervation (fibrillations and positive waves on EMG, increased jitter on single-fiber EMG, and atrophic muscle fibers on muscle biopsy) are diagnostic for this syndrome.<a></a> However, we have found that electrophysiologic and muscle biopsy evidence of denervation is as common in polio patients who are not having new symptoms, as in patients who have clinically defined PPMA.<a></a> Moreover, evidence of denervation is most severe in muscles which show the most signs of old polio.<a></a> Thus, late denervation appears to be a concomitant of massive monophasic antecedent denervation and not a sign of new disease. In addition, we found that although 14 out of 15 patients who complained of new atrophy also reported new weakness, only about one-half of patients who reported new weakness noted new atrophy.<a></a> Thus, the relationship of atrophy to weakness is not clear.</p> <p>New muscle weakness may put extra stress on a previously borderline compensated muscle, producing pain, cramping, and an "overwork myopathy," with accelerated weakness as an end result.<a></a> It has been estimated that a partially denervated muscle graded "good" must work two and a half times as hard as a normal muscle to accomplish the same task.<a></a> We caution patients with new weakness to reduce activity. Exercise programs must be undertaken with extreme caution, and exercise should never be performed to the point of pain or muscle cramps. We advise patients to exercise limbs not previously affected by polio or, if this is impossible, participate in a carefully graded program in a therapeutically heated pool. One should exercise enough to prevent atrophy of disuse, but not enough to cause damage from overuse. High repetition, low resistance exercises are favored, as well as stretching and isometric drills. Orthotic devices, including the ankle-foot orthosis and knee-ankle-foot orthosis, may provide support for certain critically weakened muscle groups, although adequate function of other muscle groups (e.g., knee and hip extensor function for an ankle-foot orthosis) is a prerequisite for effective use. Wheelchair use should also be considered, sometimes only intermittently, as prolonged activity may predispose the patient to osteoporosis or venous thrombosis. Training in effective transfers, efficient movements, etc. by the physical and occupational therapist may also be useful, as can home help aids such as a shower chair and raised toilet seat.</p> <p>Limb weakness may result in new joint instability, which in turn may be associated with new pain and increasing deformity. It has been noted, for example, that floor reaction with knee hyperextension serves a knee-locking function when the quadriceps is weak.<a></a> However, profound degrees of weakness can provide a "positive feedback" situation where posterior knee ligaments are subjected to more torque stress, leading to further stretching.<a></a> A knee-ankle-foot orthosis (fit with a posterior offset knee hinge) may prevent progressive joint damage in this situation.</p> <p>Pulmonary complaints may occur in patients with previously weakened diaphragm, intercostals, abdominal, or accessory muscles. Frequently, a patient with previous paralytic poliomyelitis, involving muscles of respiration, will have borderline respiratory compensation for decades and will undergo precipitous respiratory failure later in life.<a></a> Increasing scoliosis, aspiration pneumonia, gradual loss of motor units with aging, and other factors may contribute to respiratory insufficiency. Respiratory symptoms (daytime somnolence, snoring, dyspnea, etc.) must be sought in all patients, particularly those with a history of respiratory involvement with polio. Baseline spirometry is also obtained in patients attending clinics. Muscle relaxants and medications which suppress respiratory drive should be avoided. Vaccines (pneumonia and flu vaccines) and cessation of smoking are also important in patient management. New respiratory muscle weakness may also present as sleep apnea, which may respond to medication (e.g., protripty-line), or may require night time oxygen or mechanical ventilation. Pulmonary complaints should always be evaluated and treated in conjunction with a pulmonary physician versed in neuromuscular diseases.</p> <p>The prognosis of the post-polio syndrome depends upon the symptoms experienced by the patient and upon individual (as yet uncharacterized) differences in disease progression. General health care measures (proper rest, nutrition, weight management, etc.) as well as psychosocial support are important. Inflammation in joints and muscles may be managed well with the treatments cited above. At least some patients with PPS fatigue respond to anticholinesterase medications. Progressive weakness, with or without atrophy, is the least responsive symptom of PPS. Respiratory complaints, particularly, should be considered seriously. Fortunately, weakness progresses slowly (about one percent per year according to a recent study),<a></a> and plateaus in function are observed. Although rapid progression of weakness does occur in some PPS patients, other diagnoses such as medical illnesses or superimposed neurologic and orthopedic problems must be considered.</p> <p>A common complaint of post-polio patients is that health professionals do not understand or even believe their new symptoms. Although a breakthrough of understanding on PPS may not occur in the immediate future, it is the responsibility of all health personnel to listen carefully to patients with new problems and provide the best care possible. Specific symptomatic treatment should be made available where appropriate. The patient who has been rehabilitated from the effects of acute polio must now be helped to accept the activity aids and lifestyle modifications necessary to ameliorate his "second disability."</p> <h3>Acknowledgments</h3> <p>This paper was based on our experience at the University of Chicago Post-Polio Clinic, which was made possible by the fruitful collaboration of R. Maselli, R. Wollmann, R. Roos, E. Salazar, F. Brown, E. Nichols, R. Simon, P. Heidkamp, and R. Martia. We thank C. René de Cotret for preparing the manuscript.</p> <p><b>References:</b></p> <ol> <li>Sharrad, W.J.M., "Correlation Between Changes in the Spinal Cord and Muscle Paralysis in Poliomyelitis", <i>Proceedings of the Royal Society of Medicine</i>, 40, 1953, p. 346.</li> <li>Cöers, C, and Woolf, A.L. <i>The Innervation of Muscle: A Biopsy Study</i>, Blackwell Scientific Publications (Oxford), 1959.</li> <li>Halstead, L.S., and D.O. Weichers, "Introduction," <i>Late Effects of Poliomyelitis</i>, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. xv-xx.</li> <li>Codd, M.B., D.W. Mulder, L.T. Kurland, CM. Beard, and W.M. O'Fallon, "Poliomyelitis in Rochester, Minnesota, 1935-1955: Epidemiology and Long-term Sequelae: A Preliminary Report," Late Effects of Poliomyelitis, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. 121-134.</li> <li>Jubelt, B. and N.R. Cashman, "Neurologic Manifestations of the Post-Polio Syndrome," <i>Critical Reviews in Clinical Neurobiology</i>, in press.</li> <li>Halstead, L.S., D.O. Weichers, and CD. Rossi, "Late Effects of Poliomyelitis: A National Survey," <i>Late Effects of Poliomyelitis</i>, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. 11-31.</li> <li>Tomlinson, B.E. and D. Irving, "Changes in Spinal Cord Motor Neurons of Possible Relevance to the Late Effects of Poliomyelitis," <i>Late Effects of Poliomyelitis</i>, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. 57-70.</li> <li>Weichers, D.O. and S.L. Hubbell, "Late Changes in the Motor Unit After Acute Poliomyelitis," <i>Muscle and Nerve</i>, 4, 1981, pp. 524-528.</li> <li>Dalakis, M.C., G. Elder, M. Hallett, et al., "A Long-term Follow-up Study of Patients with Post-poliomyelitis Neuromuscular Symptoms," <i>New England Journal of Medicine</i>, 314, 1986, pp. 959-963.</li> <li>Cashman, N.R., R. Maselli, R.L. Wollmann, R. Roos, R. Simon, and J.P. Antel, "Postpoliomyelitis Syndrome: Evidence of Ongoing Denervation in Symptomatic and Asymptomatic Patients," <i>Proceedings of the Second Annual Symposium on the Late Effects of Poliomyelitis</i>, Symposia Foundation (Miami, FL), in press.</li> <li>Maynard, F.M., "Differential Diagnosis of Pain and Weakness in Post-polio Patients," <i>Late Effects of Poliomyelitis</i>, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. 33-41.</li> <li>Tomlinson, B.E. and D. Irving, "The Number of Limb Motor Neurons in the Human Lumbosacral Cord Throughout Life," <i>Journal of Neurological Sciences</i>, 34, 1977, pp. 213-219.</li> <li>Clark, D.R., J. Perry, and T.R. Lunsford, "Case Studies-Orthotic Management of the Adult Post Polio Patient," <i>Orthotics and Prosthetics</i>, Vol. 40, No. 1, 1986, pp. 43-50.</li> <li>Bennett, R.L. and G.C. Knowlton, "Overwork Weakness in Partially Denervated Skeletal Muscle," <i>Clinical Orthopedaedics</i>, 12, 1968, pp. 22-29.</li> <li>Mulder, P.W., E.H. Lambert, and L.M. Eaton, "Myasthenic Syndrome in Patients with Amyotrophic Lateral Sclerosis", <i>Neurology</i>, 9, 1959, p. 627.</li> <li>Perry, J., "Orthopedic Management of Post-polio Sequellae," <i>Late Effects of Poliomyelitis</i>, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. 193-206.</li> <li>Ringel, S.P. and R.J. Martin, "Respiratory Complications and Their Management in Neuromuscular Disorders," <i>Interdisciplinary Rehabilitation of Multiple Sclerosis and Neuromuscular Disorders</i>, F.P. Malone, J.S. Burks, and S.P. Ringel, J.B. Lippincott Co. (Philadelphia), 1985, pp. 211-227.</li> </ol> <em><b>*Jack P. Antel, M.D. </b> Jack P. Antel, M.D. is Professor of Neurology and Neu-rologist-in-Chief at the Montreal Neurological Institute.</em><br /><em><b><br />*Irwin M. Siegel, M.D. </b> Irwin Siegel, M.D. is an Associate Professor in the departments of Orthopaedic Surgery and Neurological Services, Rush-Presbyterian-St. Luke's Medical Centre, Chicago, IL; Chairman of the Department of Orthopaedic Surgery at Louis A. Weiss Memorial Hospital in Chicago, Illinois; and Director of Muscular Dystrophy Clinics of the above facilities.</em><br /><em><b><br />*Neil R. Cashman, M.D. </b> Neil R. Cashman, M.D. is an Assistant Professor of Neurology at the Montreal Neurological Institute, 3801 University Street, Montreal, Quebec H3A 2B4, CANADA. He developed and directed the University of Chicago Post-Polio Clinic 1985-86.<br /><br /><br /></em> Page Number(s) 74 - 78 Year 1987 Volume 11 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 1 TABLE 1 http://www.oandplibrary.org/cpo/images/1987_02_074/1987_02_074-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Post-polio Syndrome: An Overview Creator An entity primarily responsible for making the resource Neil R. Cashman, M.D. * Irwin M. Siegel, M.D. * Jack P. Antel, M.D. * https://staging.drfop.org/files/original/78226bca3eceb612d7d8db7908b1afea.pdf 17ea92cb6ada6610f2fbaf86eea54a0f https://staging.drfop.org/files/original/261df725d54dd7f063e4c1480fe2b3d3.jpg e794ee1f0b5fff92c69ded224bd3aa44 https://staging.drfop.org/files/original/5dfcfa64de6eb114dc3fd23266ad039f.jpg 154d7c1efbfef010c8ffd5299e701802 https://staging.drfop.org/files/original/26f6f61c5da43145a36acf58b1b84714.jpg 710d554f2eca75d9ec64650b02660da0 https://staging.drfop.org/files/original/11c9646efd2d9c0d69c2c465b47da84c.jpg d2191235871cd29462432969c2b36907 https://staging.drfop.org/files/original/db60e11c55d82008b2c099fe8ebda7ea.jpg 92cd2270b0e64d666d64407d4727ea18 https://staging.drfop.org/files/original/52834292f43677d81a9dc47f6f0f8db8.jpg da920604014ba63f1c778df76f95429d https://staging.drfop.org/files/original/f25fe005117d51ad9f0f54b235e228b3.jpg 2b8bb51f1b1e51f6d17abf901bde4539 https://staging.drfop.org/files/original/77e0f06a236e310a84838dc1ae8ea654.jpg b54a96a32abe60f41a30de18539467e7 https://staging.drfop.org/files/original/717dfa7fc8a884e6add25d763cbec268.jpg ac4508fff3afb9d1e91dc55704c0ecd5 https://staging.drfop.org/files/original/9833ca023913ff88aa0624da3d7d60eb.jpg ee895b1e9c8002f8f13bd6e78e37fcef https://staging.drfop.org/files/original/016bae82750ffc63db29627f435b81be.jpg 49366f88c3c52085520c43c8c7d454eb https://staging.drfop.org/files/original/7aec942c558625876ab59a8cbfa191da.jpg 2d09d1494909a8173317549ba8eaaff0 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_02_068.pdf Year 1970 Volume 14 Issue 2 Page Number(s) 68 - 80 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_02_068.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_02_068.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A New Approach to Patient Analysis for Orthotic Prescription- Part I: The Lower Extremity</h2> <h5>Newton C. Mccollough III. M.D. <a style="text-decoration:none;">*</a><br />Charles M. Fryer. MA. <a style="text-decoration:none;">*</a><br />John Glancy, CO. <a style="text-decoration:none;">*</a><br /></h5> <p>There is little question that the field of orthotics has taken a back seat to prosthetics in modern times, and perhaps for good reason. The needs of the amputee are more immediate and obvious, and the wars of the past thirty years have yielded untold numbers of young men in their prime whose productivity depended upon satisfactory functional restoration of their missing limbs. Medicine, engineering, and the prosthetic profession have responded to the needs of the amputee through extensive research and development, widespread educational programs, improved fabrication and fitting techniques, and better delivery of services. The field of orthotics remains in comparative disarray with more limited, though no less sophisticated, research activities, few educational endeavors, and little improvement upon local fabrication and delivery services over the past fifty years.</p> <p>Much of the blame for this rather distressing state of affairs must be laid to the physician, whose approach to orthotic prescription has been somewhat less than scientific. More often than not, little thought is given to analyzing specific biomechanical defects present in an extremity with the aim of translating them into an appropriate mechanical substitute. Even when this is done, all too often the device that is prescribed impairs to some degree the normal biomechanical functions which coexist in the same extremity. For example, a long leg brace prescribed for genu recurvatum may also limit normal functioning of the subtalar joint. Much of the physician's casual approach to orthotic prescription stems from a relatively sparse education in orthotic principles, but an even greater deficiency is the failure to relate well-known biomechanical principles to the mechanical substitute, or orthosis. Therein lies the trap, for without this awareness, prescriptions will continue to reach the orthotist calling for simply a "short leg brace" or a "long leg brace," and thus there is no stimulation for new or improved design criteria for orthotic components and systems.</p> <p>There is little doubt that the great advances which have been made in prosthetics in recent years have resulted primarily from a systematic appraisal of normal human posture and locomotion, with resultant attempts to duplicate not only the missing anatomy but also the biomechanical functions of the extremity. The problem in orthotics is somewhat different: specific functional losses must be substituted for in the presence of intact anatomy, and the variety of functional losses which may be present in a given extremity necessitates correspondingly varied design criteria. It is apparent, therefore, that an initial step in developing a rational approach to orthotic design and prescription would be some means of systematically analyzing the biomechani-cal losses in an impaired extremity. Once properly identified, these losses could then be matched against specific components or component systems to substitute for the functions lost. In addition, such an analysis might point up certain areas or functions for which truly satisfactory components are not available, and thus it might serve as a stimulus for future design and development.</p> <p>Recognizing the need for a more organized and systematic approach to orthotic prescription as a part of current efforts to revise volume 1 of the <i>Orthopaedic Appliances Atlas, </i>the Committee on Orthotics and Prosthetics of the American Academy of Orthopaedic Surgeons appointed an ad hoc committee for the development of a lower-extremity analysis form. In essence, this article represents a report of that committee, whose work commenced two years ago. During the development of the form, workshops were held periodically with the parent committee, together with representatives of the American Orthotic and Prosthetic Association, the Veterans Administration Prosthetics Center, and the Committee on Prosthetics Research and Development of the National Research Council. The form underwent periodic revision as it was applied to patients with a variety of disabilities, utilizing several clinics. The most recent and final application of the lower-extremity analysis form was in conjunction with the Workshop Panel on Lower-Extremity Orthotics held at Rancho Los Amigos Hospital in Downey, California, in March 1970. Its applicability to the evaluation of lower-extremity disability is now felt to be such as to warrant description for more widespread usage.</p> <h4>Lower-Extremity Analysis Form</h4> <p>The form consists of four pages of appropriate size for insertion into the patient's hospital chart. The first page <b>Fig. 1</b> contains spaces for patient data, including the diagnosis and a summary of major impairments existing in one or both extremities. At the bottom of the first page there is a legend for symbols to be used on the extremity diagrams. The second and third pages <b>Fig. 2</b>,<b>Fig. 3</b> contain skeletal outlines of the right and left lower extremities, respectively, in the sagittal, coronal, and transverse planes. Overlying the major joints are shaded areas, representing the normal ranges of joint motion within a circle divided into thirty-degree segments. Similar smaller circles overlie the mid-shafts of the long bones for diagraming angular, rotational, or translational deformities of the femur and tibia. The fourth page <b>Fig. 4</b> includes spaces for summarizing the functional disability, and for orthotic recommendations based upon this summary.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Front sheet of patient analysis form, including summary of major impairments and legend. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Second page of patient analysis form, with diagram of right lower extremity. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Third page of patient analysis form, with diagram of left lower extremity. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Fourth page of patient analysis form provides space for summary of patient's functional disability and for the orthotic recommendation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Instructions for Use</i></p> <p>Most of the "Major Impairments" portion of the form is self-explanatory. "Abnormal bone and joint" conditions may include such entities as osteoporosis, Paget's disease, and coxa vara. "Muscle" may be normal, flaccid, or spastic, but a space is provided for description of rarer disorders such as muscular dystrophy and fibrosis of muscle. Under the heading of "ligament," check boxes are provided to indicate abnormal laxity of the major ligaments of the knee and ankle. The sections on "sensation," "skin," and "vascular" impairments cover considerations which may influence orthotic design, and are self-explanatory.</p> <p>"Balance" is either normal or impaired, and if impaired, the following definitions are applicable: "mild" impairment is compatible with independent ambulation; "moderate" impairment is compatible with ambulation utilizing external support; and "severe" impairment indicates the need for maximal support or personal assistance in ambulation.</p> <p>"Extremity shortening" is recorded as follows: ischial tuberosity to sole of heel, ischial tuberosity to medial tibial plateau, and medial tibial plateau to sole of heel.</p> <p>In leg-length discrepancies exceeding one-half inch, X-ray studies of leg length may be indicated, and an appropriate space is provided for this measurement.</p> <p><i>Legend and Extremity Diagrams</i></p> <p>Two terms must first be defined:</p> <ol> <li><i>"Translatory motion"</i> is motion in which all points of the distal segment move in the same direction, with the paths of all points being exactly alike in shape and distance traversed <b>Fig. 5</b>.</li><li><i>"Rotary motion"</i> is motion of a distal segment in which one point in the distal segment or in its (imaginary) extension always remains fixed <b>Fig. 6</b>.</li></ol> <p>The symbols described in the legend are used in conjunction with the right-and left-extremity diagrams according to the following rules:</p> <ol> <li><b>Recording motion:</b> The degrees of rotary motion or centimeters of translatory motion are to be obtained from passive manipulation, and are to reflect passive (not active) motion at the site being examined. In the lower extremity, joints are to be observed during weight-bearing, and if the degree of joint excursion is greater under conditions of loading than under passive manipulation, this figure is diagramed rather than the smaller figure (e.g., recurvatum of the knee). <ul><li><i>Translatory motion:</i> Linear arrows horizontally placed below the circle indicate the presence of (abnormal) translatory motion at one or more of the six designated levels of the lower extremity listed on the left side of the form. The head of the arrow always points in the direction of displacement of the distal segment relative to the proximal segment. Linear arrows vertically placed on the right side of the circle indicate(abnormal) translatory motion along the vertical axis at the site indicated.</li> <li><i>Rotary motion:</i> Normal ranges of rotary motion about joints are preshaded on the diagram. Abnormal rotary motion, either as limited or excess motion, is indicated by double-headed arrows placed outside and concentric to the circle, to indicate the extent of available motion present in the affected joint. In certain instances, it may be more meaningful to use two double-headed arrows in order to describe the range of motion to either side of the neutral joint axis, rather than a single arrow which describes the total range of motion present. If one head of an arrow fails to reach the preshaded margin, limitation of joint motion is denoted. Conversely, if one head of an arrow projects beyond the preshaded margin, excess motion is designated. Numbers in degrees are placed adjacent to the arrows to indicate the arc described. In addition, radial lines drawn from the center of the circle and passing through its perimeter at the tips of the double-headed arrow are to be used for more graphic representation of the arc of available motion. At sites where rotary motion does not occur (e.g., fracture site, or knee joint in the coronal plane), the presence of abnormal rotary motion is similarly designated by a double-headed arrow with adjacent numerical value in degrees.</li> <li><i>Fixed position:</i> Double radial arrows indicate a fixed joint position, and describe in degrees the deviation from the neutral joint position. Horizontal or vertical double arrows indicate a fixed joint position in a translatory sense, and the extent of abnormal translation is indicated in centimeters adjacent to the arrow (e.g.,subluxation of the tibia in a hemophiliac knee).<br /></li></ul></li><li><b>Muscle dysfunction: </b> <ul><li><i>Flaccid muscle:</i> Flaccid muscle is designated as such under the section on major impairments. Muscle-group strength, not individual muscle strength, is determined by conventional means on the examining table, and the letter grade corresponding to volitional force is recorded adjacent to the skeletal outline at the proper location for each muscle group. The letter grades correspond to the standard muscle-grading system used in poliomyelitis. No symbol is used if muscle strength is normal.</li> <li><i>Spastic muscle: </i>Spastic muscle is designated as such under the section on major impairments. It is further identified in the legend as "SP." The letter grade (e.g., SP_MO) for muscle-group tone, not individual muscles, is to be placed adjacent to the skeletal outline at the proper location for each muscle group. Spastic-muscle estimates are to be made with the patient in the functional position for the lower extremity, i.e., observation during standing and walking. The subletter grades for spastic muscle are as follows:<br /> "M" indicates a mild degree of spasticity;<br /> "MO" indicates a moderate degree of spasticity sufficient for useful holding quality;<br /> "S" indicates severe spasticity, obstructive in terms of function.<br /> In certain instances, muscle groups in a patient with spastic paralysis may be more appropriately graded according to volitional force, e.g., dorsiflexion of the foot in a hemiplegic.<br /></li></ul></li><li><b>Recording fracture or bone deformity: </b> All translatory or rotary motions at the fracture on the shaft of a long bone are diagramed on the circle located</li></ol> <p>The technique of completing the analysis forms for specific lower-extremity disabilities is shown in <b>Fig. 7</b>,<b>Fig. 8</b>,<b>Fig. 9</b>,<b>Fig. 10</b>,<b>Fig. 11</b>,<b>Fig. 12</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Record for patient with left hemiplegia. Information given on front sheet includes spastic muscle picture with inversion deformity of foot, mild loss of proprioception, venous stasis in left leg, and mild impairment of balance. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Diagram of patient E.L.'s left lower extremity. Muscles which are not normal are designated by letter grade. Muscles which are not spastic clinically and which possess volitional control are designated by conventional letter grading. The diagram illustrates presence of good hip flexors, extensors, and abductors, good knee extensors, fair knee flexors and foot invertors, poor foot dorsi flexors, zero foot evertors, and mild calf spasticity. There is 15° of hyperextension at the knee, and the heel cord is tight, limiting dorsiflexion of the foot to neutral. The presence of edema from the knee to the foot is also noted at the mid-shaft of each bone. The actual fracture site is indicated by the fracture symbol. All bony deformities such as valgus angulation of the shaft are likewise diagramed on the circle located at the center of the shaft, regardless of the position of the angular deformity. The location of the angular deformity is designated by circling the appropriate level on the left side of the chart. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Summary of the patient's functional limb disability, and the orthotic recommendation based upon that summary. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Record for patient with residual poliomyelitis affecting his left lower extremity. Information given indicates flaccid paralysis with severe atrophy, laxity of the medial collateral ligament of the knee, and 1 3/4 in. shortening of the left lower extremity. In addition, the patient had an old supracondylar fracture of the femur and a previous triple arthrodesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Diagram of patient W.S.'s left lower extremity. In addition to showing the letter grades for muscle-group strength, the diagram also shows 20° of hyperextension at the knee, 15° of valgus instability of the knee, 15° of external tibial torsion, limitation of dorsiflexion at the ankle, abnormal inversion and eversion at the ankle, and a fixed position of the subtalar joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Summary of patient W.S.'s functional limb disability, and the orthotic recommendation based upon that summary. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Discussion</h4> <p>The stated purpose of developing a patient analysis form of this type is to organize a systematic approach to orthotic prescription. In addition, through stimulation of a careful appraisal of biomechani-ical faults in a given extremity, it may also serve as a basis for identifying certain areas in need of new or further design and development. It is also viewed as a valuable teaching tool for students of orthotics at both the technician and physician levels. Most importantly, it may serve as a common ground upon which both the orthotist and the physician can meet to work out satisfactory solutions to bracing problems. (Sample copies of the form are available from the CPRD office).</p> <p>As a further step in making such an analysis form more meaningful to orthotists and physicians, a list of available lower-extremity orthotic components is currently being compiled in such a way as to categorize these components by their biomechanical function. Ideally then, one might diagra-matically plot the biomechanical losses present in a limb and then select a mechanical device from the appropriate category to substitute for the lost function. In this way, the orthotic prescription can evolve as a carefully thought-out combination of specific components to create a suitable orthotic system for the deficient limb.</p> <p>A revitalized approach to orthotics is urgently needed. According to a recent estimate, there are 3,370,000 orthotic patients in the United States as opposed to 311,000 amputees, or ten times as many patients who need orthoses as need prostheses <i>(1). </i>Little that is new has been done for many of these patients until very recently. Several research centers in the United States and Canada are engaged in sophisticated and promising orthotic research. Unfortunately, by and large, the products of this research have not yet reached the masses of handicapped people. Stimulation of new approaches to mechanical design at the local level must be achieved through close and meaningful collaboration between physician and orthotist. It is hoped that the material presented in this article will be an initial step toward that goal.</p> <p>Work is currently being done on a similar approach to the upper extremity and the spine. These areas will be the subjects of future reports.</p> <h4>Acknowledgements</h4> <p>The authors wish to express special appreciation to Dr. George T. Aitken, former chairman of the American Academy of Orthopaedic Surgeons Committee on Prosthetics and Orthotics; Dr. Robert Keagy; Mr. A. Bennett Wilson, Jr.; Mr. Anthony Staros; and Dr. Edward Peizer for their specific contributions to this work.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> FIg. 5. "Translatory motion": motion in which all points of the distal segment move in the same direction, with the paths of all points being exactly alike in shape and in distance traversed. In all three examples, the pathways between original position "A" and final position "B" of four arbitrarily selected points in each figure are each exactly alike in direction, form, and distance traversed. Note that the long axes of the figures also remain parallel throughout the "translation" from A to B. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. "Rotary motion": motion of a distal segment in which one point in the segment, or in its (imaginary) extension, always remains fixed. The axis "O," in each of the three examples, represents a point in the figure (or as in "III" in its imaginary extension) that always remains fixed in position when the body "rotates" from position "A" to position "B." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Committee on Prosthetics Research and Development, <i>Report of the Seventh Workshop Panel on Lower-Extremity Orthotics of the </i><a><i>Subcom.it-</i></a><i>tee on. Design and Development, </i>National Research Council-National Academy of Sciences, March 1970.</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>John Glancy, CO. </b></td></tr><tr><td class="clsTextSmall">Orthotic Division, Indiana University Medical Center, Indianapolis, Ind. 46207.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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 M. Fryer. MA. </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetic-Orthotic Center, Northwestern University Medical Center, Chicago, Ill. 60611.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Newton C. Mccollough III. M.D. </b></td></tr><tr><td class="clsTextSmall">Assistant Professor of Orthopaedics, Associate Director of Rehabilitation, University of Miami School of Medicine, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-07.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-08.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-09.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-10.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-11.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-12.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-05.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-06.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 New Approach to Patient Analysis for Orthotic Prescription- Part I: The Lower Extremity Creator An entity primarily responsible for making the resource Newton C. Mccollough III. M.D. * Charles M. Fryer. MA. * John Glancy, CO. * https://staging.drfop.org/files/original/54dae95f148a182054379dab02968d3b.pdf 8910c8603388bad0090b5916a7fc8ef7 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_002.pdf Text Any textual data included in the document <h2>Guest Editorial: Thoughts On The Amputee Clinic Team</h2> <h5>Newton C. McCollough, III, M.D.&nbsp;</h5> <p>The Amputee Clinic team as we know it today, evolved during World War II when the Surgeon General of the Army established a number of Amputee Centers within Army Hospitals to upgrade the management of these patients. Impetus to this multidisciplinary approach was given by the Veterans Administration in 1948 when suction suspension was introduced for the above knee amputee and a protocol was developed establishing the Amputee Clinic Team which initially comprised the physician, the prosthetist and the therapist.</p> <p>Since that time as a more holistic approach to disability developed the team has been enlarged in most clinics to include the occupational therapist, social worker and vocational specialists among other disciplines.</p> <p>The clinic team approach is comprehensive and unquestionably has resulted in superior management of patients with limb loss over the past thirty years. However, recently questions have been raised regarding the efficiency of such a clinic and whether or not a more streamlined approach is desirable from the standpoint of the logistical management of relatively large numbers of patients. The impersonal nature of such a clinic has also been impugned in recent years, and some have felt that the patient may actually be intimidated by such a host of professional personnel.</p> <p>Several years ago, at the University of Miami, a compromise approach to amputee management was undertaken. All new patients and patients with identifiable medical problems (including skin breakdown) were seen in the traditional setting with the physician as the amputee team leader in clinic. Routine follow-up visits and problems which were purely prosthetic in nature were seen in "prosthetic clinic" by the prosthetist and therapist with a prosthetist as the team leader or clinic chief. Other clinic personnel including physicians were available for these clinics but were not necessarily in attendance. This approach was far more efficient in terms of man hours and in many ways more practical than imposing the traditional approach upon all patients at every clinic visit.</p> <p>Two major drawbacks to this system of care slowly became apparent and currently we have resumed the traditional approach to all patients. The first difficulty encountered was that many routine prosthetic visits were also accompanied by concurrent medical problems which could not be identified before the patient was actually seen. Of course, the patient could be referred to the next "full team clinic" but this resulted in undue delay of treatment. Psychological or vocational problems though less frequent were also concurrent in some patients. Secondly, in a major teaching hospital, the education of residents, interns and students suffered from this approach. The critical analysis of prosthetic problems in relation to alignment, gait, suspension, etc. was lost upon students in the absence of interchange between prosthetist, physician and therapist. Additionally, innovative techniques in prosthetic management not infrequently result from discussions involving the prosthetist and physician and the presence of all team members in clinic greatly enhances this aspect of the amputee program.</p> <p>In conclusion, I now feel that the multidisciplinary clinic team approach is sound and has no equal in the educational sphere. Spinoffs from the dialogue created may enhance prosthetic research and thus ultimately patient care. Efficiency in this sytem is less than ideal, but the benefits are greater in the long run. Suitable precautions must be taken to avoid "depersonalization" of the amputee in the multi-disciplinary environment and it is encumbent upon each team member to insure that the clinic experience is a rewarding one for the patient.</p> Page Number(s) 2 - 3 Year 1979 Volume 3 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 Guest Editorial: Thoughts On The Amputee Clinic Team Creator An entity primarily responsible for making the resource Newton C. McCollough, III, M.D.  https://staging.drfop.org/files/original/3dc12ac74d007b30cd9ac2192ac0215c.pdf 5d7beccc83e107ade0d0749486469958 https://staging.drfop.org/files/original/a0a401a9b25d17513105126cb0e22659.jpg 0fcc33c1d8a6f3816a522919abb35777 https://staging.drfop.org/files/original/44c99f5d58723ecaa4e79eaf87cf3981.jpg 892fb6ec39817908bb4edc85e61acf13 https://staging.drfop.org/files/original/3ef2a0fe19537ad158c472f2949df71b.jpg 55a4929f1a78ab78e33373d5ea6ce3f9 https://staging.drfop.org/files/original/3612577ff647fd7ecd02f0df52948026.jpg 08f3fa9b0f6f0385168f6e324ceda5a0 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_02_028.pdf Year 1968 Volume 12 Issue 2 Page Number(s) 28 - 35 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_02_028.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_02_028.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>Some Considerations in Management of the Above-Knee Geriatric Amputee</h2> <h5>Newton C. McCollough, III, M.D. <a style="text-decoration:none;">*</a><br />Augusto Sarmiento. M.D. <a style="text-decoration:none;">*</a><br />Edward M. Williams, M.D. <a style="text-decoration:none;">*</a><br />William F. Sinclair, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>The gradual increase in the life span of people in the developed countries of the world has resulted in a tremendous increase in the number of amputees in the older age, or "geriatric," group. A survey by Glattly in 1962 <a></a> showed that approximately 52 per cent of all amputees fitted with prostheses for the first time were over 50 years of age. Of these patients, 82 per cent had had amputations as a result of disease, 2 per cent because of tumor, and 16 per cent because of trauma. Most of these, of course, were lower-extremity cases.</p> <p>As short a time as 10 years ago, only a relatively few geriatric amputees were provided with limbs, and not much attention was given to the special problems of older patients. However, it has now been demonstrated that, with expert care, older amputees can be fitted with functional prostheses and that the results obtained are well worth the extra efforts required. The below-knee case obviously presents fewer problems as a rule than does the above-knee case, but though surgeons are now saving more and more knee joints there will always be a certain number of above-knee cases that require attention.</p> <p>Just as in the case of younger amputees, geriatric patients should be fitted as soon as possible. The longer the patient goes without a prosthesis, the greater the possibility for the development of contractures, edema, and other undesirable conditions. If the patient is not provided with a prosthesis immediately after the amputation, he should be fitted with a preparatory prosthesis as soon as he is seen by the clinic team.</p> <p>When treating the geriatric amputee, the clinic team must keep in mind constantly that the patient's potential is far from that of an otherwise healthy person, and certain compromises must be made if optimum results are to be achieved. The primary factors to be considered are condition of the skin, muscle tone and strength, coordination and balance, and energy potential.</p> <h3>Anatomical and Physiological Factors</h3> <p>Skin loses its turgor and becomes more fragile as age increases, and although it does not necessarily become more sensitive to the touch it does become more subject to abrasion and breakdown. This is true especially for the below-knee amputee but also demands special consideration when fitting and training the above-knee patient, and every effort is made to limit relative motion and pressure between the socket and stump.</p> <p>The older a person becomes the more likely he is to collect a fair number of scars, some of which may become supersensitive. The patient who has had an amputation secondary to vascular occlusion may well have scars present in the femoral triangle or abdominal scars from previous sympathectomies (<b>Fig. 1</b>). Particular care must be given to socket fit and suspension in order to avoid undue pressure and abrasion of these scarred areas. The presence of abdominal or inguinal hernias must likewise be taken into consideration and appropriate relief given if necessary.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Sensitive scars in the inguinal area secondary to vascular reconstruction may require modifications in the quadrilateral socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Subcutaneous atrophy occurs in the elderly patient and may present difficulties with socket fitting. The loss of fatty tissue padding often gives rise to complaints of extreme discomfort in areas subjected to high pressure, such as the ischial tuberosity and the laterodistal end of the femur. It may also complicate socket fitting, because flabby tissues tend to roll and therefore provide less stability. Muscles also tend to atrophy with age and, in addition to becoming weaker, have correspondingly less tone and less bulk, as any surgeon knows who has operated through the muscles of an elderly patient. Loss of muscle tone and bulk further decreases the soft tissue padding over bony prominences and may contribute to socket discomfort. Loss of definition of muscle groups leads to loss of stump contour and hence less stability between socket and stump. The decrease in muscular strength which accompanies atrophy results in less strength for actuating the prosthesis; hence, the weight of the artificial limb becomes an extremely important factor.</p> <p>Coordination and balance definitely are affected by the process of aging and rapidly become impaired when any degree of cerebral arteriosclerosis is present. Studies have shown that vestibular function decreases steadily after 50 years of age and, in addition, there is a general slowing of reflex motor action to proprioceptive stimuli which is irreversible. <a></a> The prosthesis, therefore, must be modified frequently to provide increased stability.</p> <p>The energy expenditure in the elderly above-knee amputee has been studied only recently, and is highly significant in the management of this class of patient. Miiller and Hettinger showed that energy expenditure was 25 per cent greater in above-knee amputees than in normal people. <a></a> Bard and Ralston gave a figure of 20 per cent greater energy expenditure in the above-knee amputee over the normal person. <a></a> Later, Ralston studied 17 above-knee amputees, all over 50 years of age, and found that the average energy expenditure was 55 per cent greater than for a normal elderly person. <a></a> He further demonstrated that a normal subject walking at a comfortable speed consumed 580 cc. of oxygen per min., whereas the same subject at maximum walking speed consumed 715 cc. of oxygen per min. This figure coincided almost exactly with the figure of 700 cc. of oxygen per min. consumed by above-knee amputees walking at a slow speed. The average pulse rate in these elderly amputees walking at slow speed was 110 per min. From these studies it is obvious that energy expenditure is greatly increased when an elderly person must use an artificial limb instead of his own.</p> <p>The use of crutches without a prosthesis has been used in the past as a criterion for prescribing prostheses for the elderly. However, this not only demands more energy from the patient than the prosthesis itself, but also demands more balance and coordination, and therefore the use of this criterion has been discontinued. Many patients who are not able to use crutches without a prosthesis can achieve some functional activity with a prosthesis. Use of a temporary, or preparatory, prosthesis (<b>Fig. 2</b>) offers the best index to future function. <a></a> This is to be distinguished from a pylon, which has no articulated knee joint and no prosthetic foot. The temporary, or preparatory, prosthesis has a completely formed, quadrilateral, total-contact socket on an adjustable knee with a positive knee lock, an aluminum shank, and an articulated SACH (solid-ankle, cushion-heel) foot.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. A typical temporary above-knee prosthesis for determining the feasibility of a permanent prosthesis for the elderly amputee. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Socket Design</h3> <p>Hall has reviewed the principles which led to the development of the quadrilateral socket as we know it today: <a></a></p> <ol> <li>Actively functioning muscles should have relief.</li><li>Stabilization forces should be applied where no functioning muscles exist.</li><li>Functioning muscles should be placed at slightly greater than rest length for maximum power.</li><li>Properly applied pressure is well tolerated by neurovascular structures.</li><li>Force is best tolerated if it is distributed over the largest available area.</li></ol> <p>For these reasons, the quadrilateral socket is relieved anterolaterally for the functioning rectus muscles and postero-laterally for the functioning gluteus maxi-mus muscle; it is flattened along the lateral wall to provide the greatest surface area for the forces of abduction and along the posterior wall to provide a similar large area for the forces of extension, and is molded snugly into Scarpa's triangle to keep the ischial tuberosity displaced posteriorly on the ischial seat.</p> <p>Although it may seem like fitting a round peg into a square hole, the quadrilateral socket has provided the most satisfactory union between stump and prosthesis ever achieved for the above-knee amputee, because its shape permits proper function of the muscles which move the stump. At the same time, the forces generated by this muscular activity are distributed over relatively large areas.</p> <p>This is in contradistinction to the "plug-fit" socket which was used formerly and which did not take properly into consideration muscle action and the forces generated. The plug-fit socket, seemingly more compatible because it provides a round hole for a round peg, allows the ischium to slide inside the socket brim and the weight to be borne chiefly on the gluteal muscle mass and adductor region. Because the weight is borne chiefly by the soft tissues and because the socket is of a conical shape, there is a wedging effect of the stump in the socket and the distal tissues are pulled tightly over the end of the femur, frequently causing pain or stump breakdown. Stability about the long axis is poor because of its round cross section. In addition, the forces of abduction are distributed over relatively small areas as the femur is pushed out against the lateral wall.</p> <p>The use of the plug-fit socket has been largely abandoned today, but some of its features are useful at times for the geriatric amputee, particularly when pressure is to be avoided over Scarpa's triangle because of a femoral bypass graft or because of inadequate circulation. In some geriatric patients there is justification for modifying the quadrilateral shape in the direction of a rounded or plug-fit shape, retaining, however, certain characteristics of the quadrilateral socket.</p> <p>The quadrilateral socket is not made to a rigid pattern but is modified from a typical pattern in various ways to accommodate individual stumps. If the rectus femoris is unusually large, it may be accommodated by further relief. The same is true for the hamstring and gluteal groups. If the gluteal muscles are underdeveloped or atrophied, less relief can be given. In the elderly, because of tissue atrophy, ischial weight bearing is often uncomfortable and the posterior wall may be modified to distribute the load over the gluteal group. If it is necessary to have the Scarpa's-triangle area free from pressure, this can be accomplished by relief in this area, allowing the ischium to slide into the socket over a properly contoured posterior brim.</p> <p>We must also reconcile ourselves to the fact that, as much as we delight in rehabilitating the geriatric amputee to an ambulatory status, he will, nevertheless, spend much of his time sitting, and certain socket modifications must be made to provide comfort during prolonged periods of sitting. The thickness of the posterior wall may be decreased so that pressure neuropathy of the sciatic nerve does not develop, and the anterior brim may be lowered so that excessive pressure does not develop in the region of the femoral neurovascular bundle or the anterior superior iliac spine.</p> <p>There appear to be no contraindications to the fitting of total-contact sockets to the elderly above-knee amputee. With total contact, not only are the tissues supported evenly and edema and skin breakdown prevented, but a greater proprioceptive and kinesthetic sense is developed, a condition of even more importance to the geriatric amputee than it is to his younger counterpart. Total contact, however, is not as important with pelvic suspension as it is with suction suspension, and it is difficult to maintain, particularly when stump socks are used.</p> <h3>Suspension</h3> <p>There is uniform agreement that suction provides the best suspension available. Suction suspension, however, has a limited use in the geriatric amputee because of the exertion required in donning the prosthesis and the fact that many elderly patients have a limited ability to bend forward.</p> <p>The pelvic band is in wide use, but it has disadvantages. It is apt to create excessive pressure about the lower abdomen when the patient is sitting. It must be well padded to prevent the development of excessive pressure over the iliac crest and over any scarred areas on the abdomen. The location at the hip joint is critical.</p> <p>The preferred method of suspension in the elderly above-knee amputee is the Silesian bandage or one of its modifications. When used with the quadrilateral total-contact socket, it provides comfortable suspension and gives good stability. It may be modified to include a shoulder strap, or may be modified further to incorporate an elastic webbing band from the posterior portion of the belt to the posterior wall of the socket to act as a hip-extensor aid. <a></a></p> <p>The inability of most elderly above-knee amputees to don a suction socket properly has led to the development of a split-socket type of appliance at the University of Miami Prosthetic Laboratory (<b>Fig. 3</b>). In this type of prosthesis the intimate fit of the suction-type socket is obtained, yet it is donned easily by the geriatric amputee. [A complete description of the split-socket type of appliance will be published in the Spring 1969 issue of <i>Artificial Limbs.</i>-Ed.]</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The double-wall above-knee suction socket with anterior opening developed by the University of Miami Prosthetic Laboratory for easy application in the older amputee. The flexible inner socket is jointed to the outer by a lateral Velcro strap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Alignment</h3> <p>The above-knee socket, in general, is adducted at least 5-10 deg. to restore the normal position of the femur and place the abductor muscles at their optimum functional length. Adduction of the socket also has the effect of narrowing the base of gait, an important factor in energy conservation. <a></a> If the abductor muscles are not placed in their optimum position of function, if the socket is abducted too far, or if the prosthetic foot is located too far laterally, the center of gravity of the body must shift over the supporting leg in order to gain sufficient stability during walking. Conversely, if the adduction of the socket is sufficient to hold the femur in a normal position of adduction and to keep the abductor muscles at their optimum length, these muscles will act to stabilize the pelvis with a minimum amount of contraction while dissipating the force of stabilization by femoral pressure against the lateral wall of the socket. This ideal cannot always be achieved in the elderly patient and the socket sometimes has to be aligned in the neutral or slightly abducted position in order to gain the required stability, at the expense of increased energy consumption.</p> <p>Aligning the socket in some degree of flexion increases the power of hip extension and voluntary knee stability. In general, the above-knee socket should be aligned in some degree of flexion, usually by 5 deg. in excess of the maximum amount of hip extension that can be obtained by the amputee while standing on his good leg without producing excessive lordosis. The amount of flexion will vary from 5 to 35 deg., depending on the length of the stump and the amount of hip-flexion contracture present. Alignment of the socket in flexion is limited by the length of the stump, and in the longer stump is minimal. As socket flexion is increased, the knee bolt must be moved somewhat more posteriorly in order to retain the same alignment stability at the knee. <a></a></p> <p>Although adduction of the socket is quite efficient because there is very little excursion of the femur outward toward the lateral wall of the socket in walking, flexion is not nearly so efficient because the large posterior muscle mass allows considerable backward shift of the femur in the soft tissues prior to its exerting significant pressure on the posterior wall. This has been documented by the senior author in a cineradiography movie of above-knee stumps in sockets (<b>Fig. 4</b>). Because of this backward excursion of the femur in the soft tissues as the thigh is extended, it is felt that the femur should be set in the maximum amount of flexion consistent with cosmesis to give greater voluntary control of extension to the knee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Frames from a cineradiography film of an above-knee stump in the socket. <i>Left, </i>The femur displaces posteriorly in the soft tissues a considerable distance before effective force can be transmitted to the posterior socket wall to stabilize the knee. <i>Right, </i>The limb is at heel strike prior to hip-extensor thrust. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the elderly patient with less voluntary control and deficiencies of balance and coordination, even a long stump may require the alignment characteristics of the medium or short stump.</p> <h3>Stability of the Knee Joint</h3> <p>Knee stability is usually achieved by a combination of voluntary control by the hip extensors and alignment of the knee axis so that it is posterior to the weight-bearing line (so-called alignment stability), or by a lock or brake. Voluntary control of knee extension is usually diminished in the geriatric amputee because of muscular weakness and poor coordination, and often an increased amount of alignment stability is necessary. This alignment stability, in combination with a single-axis constant-friction knee, the most standard type, is generally sufficient. However, there may be instances in which additional stability during weight bearing is necessary, and this can be provided by the use of a unit, such as the Bock Safety Knee, which gives a braking action during weight bearing. The chief disadvantage of this type of unit is the added weight of the mechanism.</p> <p>For the elderly amputee with extreme instability and insecurity, such as a bilateral amputee, or one in whom there is a severe flexion contracture, some type of positive knee lock is usually necessary. The knee is locked in extension throughout all phases of gait, producing obvious gait deviation, but as someone once said, "an abnormal gait is better than no gait at all," which would otherwise be the case.</p> <p>Hydraulic knee units can be used successfully by the elderly above-knee amputee, and offer many advantages when the amputee has sufficient muscle power to handle these necessarily heavier limbs. The chief advantage of the hydraulic unit in geriatric patients is that it allows more anterior placement of the knee joint without sacrificing stability, and less energy is consumed in hip flexion to initiate the swing phase of gait. The other primary advantage of the hydraulic knee unit, that of permitting rapid walking by faster and more reliable knee extension, is frequently lost on geriatric amputees as they usually walk with a slow, purposeful gait.</p> <p>Until recently it has been a most difficult task to provide the knee-disarticula-tion and long above-knee stumps with adequate swing-phase control. DuPaCo recently introduced a set up so that the DuPaCo "Hermes" unit can be used with these long stumps.</p> <p>Stability at heel strike is extremely important to prevent buckling of the knee or jack-knifing, which may occur in the elderly above-knee amputee with insufficient hip-extensor power. The less resistance to plantar flexion, the more stability there is at heel contact and shortly thereafter. Locating the foot anteriorly with respect to the knee also increases stability during the period just after heel contact.</p> <p>The SACH foot is generally satisfactory for use by geriatric amputees, although in cases where weight is a real consideration a wooden foot with an aluminum ankle joint can be lighter than the SACH feet available commercially. For the elderly amputee the heel should be relatively soft in order to act as a shock absorber and enhance stability of the knee at heel contact. A single-axis wooden foot in which the softness of the plantar bumper can be varied can give greater stability than even the softest SACH heel available. However, excessive stability results in unnecessary expenditure of energy.</p> <p>The foot must occasionally be outset more than usual to enhance lateral stability in the elderly. This again is another example of obtaining stability at the expense of increased energy consumption, for outset of the foot requires a greater lateral shift of the center of gravity in walking.</p> <h3>Ambulation</h3> <p>While it is desirable to return all elderly above-knee amputees to an ambulatory status, it is often not practicable. Nearly all bilateral above-knee amputees over 50 years of age will find the wheelchair an easier and more practical means of locomotion than the use of prostheses. One must carefully evaluate the patient in terms of strength, endurance, balance, and coordination prior to prescribing a prosthesis. The patient and his family or, more likely, the government will be saved unnecessary expenditure by proper selection of patients for fitting. Often, one must accommodate the patient's own desire to find out for himself whether or not he should be relegated to the wheelchair permanently. In the true geriatric amputee, once ambulation has been achieved it is best to continue the use of some type of external support, depending upon the patient. Usually a cane or single crutch on the opposite side will be sufficient support for the elderly amputee. In some extreme cases a walker may be used, which admittedly makes for poor gait pattern, but this is preferable to no gait at all. The use of external support not only gives increased mechanical stability but also provides the amputee with additional proprioceptive feedback from the terrain on which he is walking, thus leading to better balance. In determining the functional capacity of the bilateral amputee in the older age group, the use of "stubbies" is strongly recommended and the patient should graduate to nonarticulated pylons with increasing height, to a preparatory prosthesis, and, finally, to a permanent prosthesis. Needless to say, the bilateral above-knee patient must always use external support when walking, and a wheelchair should be considered the primary mode of locomotion.</p> <h3>Summary</h3> <p>In order to provide optimum function in the elderly above-knee amputee, one must consider thoroughly certain anatomical and physiological characteristics of the patient which may indicate the necessity for modifications of the standard prosthesis. The characteristics are individual and vary greatly from one elderly amputee to another, but include skin condition, condition of the subcutaneous tissue, muscle strength and tone, coordination, and general factors relating to energy consumption. Modifications based on these factors may then be made in the prosthesis to ensure optimum functional performance. These modifications may include changes in socket shape and alignment, changes in the suspensory apparatus, provisions for increased stability at the knee, and provisions in the ankle to ensure over-all stability. In every instance an attempt should be made to provide the amputee with a minimum prosthetic weight. The future level at which the amputee will function can best be anticipated by the initial use of a temporary, or preparatory, prosthesis.</p> <p><b>References:</b></p> <ol> <li>Anderson, M. H., John J. Bray, and C. A. Hennessy, <i>Prosthetic principles-above knee amputations</i>, Charles C Thomas, Springfield, El., 1960.</li> <li>Bard, Gregory, and H. J. Ralston, <i>Measurementof energy expenditure during ambulation, with special reference to evaluation of assistive devices</i>, Arch. Phys. Med., 40, October 1959.</li> <li>Birren, J. E., <i>Age changes in speed of simple responses and perception and their significance for complex behavior</i>, Old age in the modern world, E. and S. Livingstone, London, 1955, pp. 235-247.</li> <li>Glattly, Harold W., <i>A preliminary report on theamputee census</i>, Artif. Limbs, 7:1:5-10, Spring 1963.</li> <li>Hall, Cameron B., <i>Prosthetic socket shape as related to anatomy in lower extremity amputees</i>, Clin. Orthop., 37:32-46, November-December 1964.</li> <li>Muller, E. A., and T. Hettinger, <i>Arbeitsphysiologische Untersuchungen verschiedener Ober-shenkel-Kunstbeine</i>, Ztschr. f. Orthop., 81: 525, 1952.</li> <li>Radcliffe, Charles W., <i>Functional considerationsin the fitting of above-knee prostheses</i>, Artif. Limbs, 2:1:35-60, January 1955.</li> <li>Radcliffe, Charles W., Norman C. Johnson, and James Foort, <i>Some experience with prosthetic problems of above-knee amputee</i>, Artif. Limbs, 4:1:41-75, Spring 1957.</li> <li>Ralston, H. J., <i>Some observations on energy expenditure and work tolerance of the geriatric subject during locomotion</i>, in <i>The geriatric amputee</i>, NAS Publication 919, 1961.</li> <li>Staros, Anthony, <i>The temporary prosthesis for the above-knee amputee</i>, in <i>The geriatric amputee</i>, NAS Publication 919, 1961.</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>7.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Functional considerationsin the fitting of above-knee prostheses, Artif. Limbs, 2:1:35-60, January 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Anderson, M. H., John J. Bray, and C. A. Hennessy, Prosthetic principles-above knee amputations, Charles C Thomas, Springfield, El., 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Norman C. Johnson, and James Foort, Some experience with prosthetic problems of above-knee amputee, Artif. Limbs, 4:1:41-75, Spring 1957.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Hall, Cameron B., Prosthetic socket shape as related to anatomy in lower extremity amputees, Clin. Orthop., 37:32-46, November-December 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Staros, Anthony, The temporary prosthesis for the above-knee amputee, in The geriatric amputee, NAS Publication 919, 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Ralston, H. J., Some observations on energy expenditure and work tolerance of the geriatric subject during locomotion, in The geriatric amputee, NAS Publication 919, 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bard, Gregory, and H. J. Ralston, Measurementof energy expenditure during ambulation, with special reference to evaluation of assistive devices, Arch. Phys. Med., 40, October 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Muller, E. A., and T. Hettinger, Arbeitsphysiologische Untersuchungen verschiedener Ober-shenkel-Kunstbeine, Ztschr. f. Orthop., 81: 525, 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>3.</b> </td><td class="clsTextSmall">Birren, J. E., Age changes in speed of simple responses and perception and their significance for complex behavior, Old age in the modern world, E. and S. Livingstone, London, 1955, pp. 235-247.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Glattly, Harold W., A preliminary report on theamputee census, Artif. Limbs, 7:1:5-10, Spring 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>William F. Sinclair, C.P. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edward M. Williams, M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Augusto Sarmiento. M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Newton C. McCollough, III, M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_02_028/1968_02_028-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_02_028/1968_02_028-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_02_028/1968_02_028-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_02_028/1968_02_028-04.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 Some Considerations in Management of the Above-Knee Geriatric Amputee Creator An entity primarily responsible for making the resource Newton C. McCollough, III, M.D. * Augusto Sarmiento. M.D. * Edward M. Williams, M.D. * William F. Sinclair, C.P. * https://staging.drfop.org/files/original/128a4ee02ba99ec2b2f3383ebf4c5ee1.pdf 1d58a741d5b899bf3165aaee4a30b867 https://staging.drfop.org/files/original/2d1139a7a8b381922d685cedf6c247d6.jpg b1b7bf385524209a364b2a5d706e69f1 https://staging.drfop.org/files/original/0b625e54797b43090410315f51bb8d4d.jpg 5a4a4b7273c3c08e58009c0f1d7ac1c4 https://staging.drfop.org/files/original/6af1f53cf4a83727f1442c98daaf6325.jpg e59a5dce109a736b1220cea93df1d532 https://staging.drfop.org/files/original/ef39aec52d3f6f89d396d8de9b904348.jpg 43eb5113c3c8357bc66c5661da85c546 https://staging.drfop.org/files/original/43f4c2cfada99345789b214972118bb4.jpg 53c3f83b5e1afba21df1b455a5cf3d6b https://staging.drfop.org/files/original/cf564e482b2e846fe2bf016c153528c5.jpg 16165f4e12ab933aa6a4134f395ceaf4 https://staging.drfop.org/files/original/94ddb01505c6fd91d498912976af3048.jpg 9f4e4824217f753bbfc090061b775b86 https://staging.drfop.org/files/original/c3e6400840337b90c6265d9fdb31ba05.jpg 6c5c72cce2507fd840d11e5b01c72499 https://staging.drfop.org/files/original/5fe4651c4989ad661077ef728ce3dfc2.jpg f4589d3c099abf5c832d2f368ac04110 https://staging.drfop.org/files/original/c95654d14fbc139044f4f2c1d95cf838.jpg 02cf0e94fb1afe4a88464f018b0407b3 https://staging.drfop.org/files/original/50f3d635111e4062bd949a25d13d93b8.jpg f7f75243050a5c11088831cc5677c2d1 https://staging.drfop.org/files/original/defb3aa2f95589f1d808e5bbcdb5f068.jpg 92e2681beb7f96b1aafc78a0ee712bde https://staging.drfop.org/files/original/18540ad87543021e8ea0daf13b66a934.jpg 884df0195a3f5e4beba928039b604b8f https://staging.drfop.org/files/original/973afd8b16f8e2b86200850467e47aa9.jpg da85192551a55f89ecb5f68fbfba2f86 https://staging.drfop.org/files/original/8f08a4840fdbccaad732de3cf86c6656.jpg aa1650fd1dee2a737800610dea67e78e https://staging.drfop.org/files/original/b29824f38251a82718c4ee9151c706c1.jpg 0493e10fdd34899b9d3d60972263341f https://staging.drfop.org/files/original/babc4d6089681d0e63053e41f2891aad.jpg 45827d84a72fd1e1c6c812877bbfa404 https://staging.drfop.org/files/original/b80b8ef48cb874db384cb2177426b857.jpg 644927a521638fa7a65d2a0059ca0925 https://staging.drfop.org/files/original/6be0ab9c948daa999fee159e98b18731.jpg ff93ed94477dc598a4d1bdf910d8f292 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_01_057.pdf Year 1958 Volume 5 Issue 1 Page Number(s) 57 - 72 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/1958_01_057.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_01_057.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>Studies of the Upper Extremity Amputee II. The Population (1953-55)</h2> <h5>Norman Berger, M.S. <br /></h5> <p>The number of upper-extremity amputees examined during the "Survey Studies" conducted by New York University probably represents the largest sample of a single type of disabled individual any research group has thus far had the opportunity to study. The size of the sample (1630 cases) offered a unique opportunity for assessing the status of the upper-extremity amputee on a nationwide basis during the years 1953-55 just prior to the widespread introduction of the devices and techniques promulgated by the Artificial Limb Program. The information that will allow us to form a picture of the arm-amputee population during those years is presented in the following pages under the headings:</p> <blockquote><p><em>General characteristics.</em> This section presents identifying data (such as age, height, weight, and educational level) as well as some general findings concerning causes of amputation, amputee types, and amputee vocations.</p> <p><em>Stump characteristics.</em> Here are found data concerning the strength and range of motion of various stump movements, characteristics basic to the control and use of a prosthesis.</p> <p><em>Extent of use of prostheses.</em> Under this heading is presented information dealing with the extent and type of prosthetic use in the common activities of daily living, data which permit inferences concerning the functional value of prostheses.</p> <p><em>Prosthetic components.</em> This section presents a description of the prostheses worn by arm amputees throughout the country.</p> </blockquote> <p>Within this outline, the data gathered are presented, where applicable, by amputee type, an arrangement which permits comparison of attributes between below-elbow, above-elbow, shoulder-disarticulation, and bilateral arm amputees.</p> <p>One should note at the very outset that this entire study deals with male amputees only. No female patients are included anywhere. It will also be noted that the tables and graphs which present the data contain a varying number of cases. Owing to such limitations as the fact that some amputees were not wearing their prostheses or could not remember details about their prosthetic experience, full information was not available for each case. Accordingly, the totals approximate, but are usually somewhat less than, 1630.</p> <h3>General Characteristics</h3> <p>Below-elbow amputees only slightly outnumber above-elbow amputees in the general population. This observation may be somewhat surprising in view of the widespread belief that below-elbow amputations occur much more frequently than do other types. Apparently, the latter is not the case, and it would therefore be unwise to direct research and development toward the one area at the expense of the other. The relative infrequency of shoulder disarticulations and of bilateral arm amputations also is noteworthy. (<b>Fig. 1</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Classification of arm amputees is based on stump length expressed as a percentage of the length of the same arm segment on the sound side. For example, a below-elbow amputee whose stump measures 6 in. from medial epicondyle to end and whose sound forearm measures 12 in. from medial epicondyle to ulnar styloid has a remaining stump length of 50 percent. The system of classifying arm amputees is thus based on percentage categories, each category indicating a progressively greater amount of loss of function. Because the remaining percentage of the length of the corresponding normal arm segment is an indication of the amount of functional loss occasioned by the amputation, the figure is an important one. (<b>Fig. 2</b>)</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 the NYU survey, the number of amputees in each category was as indicated in the accompanying charts. Nearly half (45 percent) of all below-elbow amputations fall in the medium below-elbow range, while more than half of the above-elbow cases (66 percent) fall in the standard above-elbow category. Extremely short stumps tend to outnumber extremely long types in both above- and below-elbow cases. Of the below-elbow stumps, 10 percent are very short as compared to 8 percent that are wrist disarticulations; in the above-elbow group, 12 percent are shoulder disarticulations as compared to 7 percent that are elbow disarticulations. (<b>Fig. 3</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A very substantial portion of the amputees contacted during the survey studies were veterans whose amputations were service-connected and who were receiving prosthetic treatment through the Veterans Administration. This preponderance of veteran amputees should be borne in mind, since it may tend to affect the data in some respects. (<b>Fig. 4</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the large number of veterans in the sample, it is not surprising that over half of the amputations were caused by combat injuries. Aside from wartime casualties, most upper-extremity amputations result from trauma, less than 5 percent being either of congenital origin or due to disease.</p> <p>The average age of the group (<b>Table 1</b>) is 36 years, but in view of the large number of veterans in the sample it is difficult to say whether this age distribution is representative of the entire amputee population. It is likely that significant numbers of cases in the older age groups are not included in these data.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 2</b> and <b>Table 3</b> give respectively the heights and weights of the subjects studied. <b>Table 4</b> gives the residence of the subjects by state.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Almost four out of five of the amputees in the survey group were married (<b>Table 5</b>). There has been speculation about a possible relationship between the extent of handicap and marital status. In this regard, the following breakdown may be of interest: (<b>Fig. 5</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>While there is some indication of a trend in these figures, their significance must await additional data bearing on this point.</p> <p><b>Table 6</b> presents the educational level of the subjects, but here again the data may be biased by the fact that a large portion of the group was eligible for educational benefits through the Veterans Administration or State Vocational Rehabilitation Divisions. The effect of these influences on the data cannot be assessed without further study.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Amputation in the upper extremity apparently results in a definite occupational shift primarily away from agricultural and other forms of manual labor at all levels of skills and toward managerial, clerical, sales, and office work. Prior to amputation, professional-managerial, clerical, and sales jobs accounted for 14 percent of the sample's vocations, while agricultural, skilled, semiskilled, and unskilled jobs accounted for 64 percent. In contrast, the former groups of jobs include 41 percent of the postamputa-tion occupations (an increase of 27 percentage points), and the latter groups include 27 percent (a decrease of 37 percentage points).</p> <p>Another marked shift occurs in the rate of unemployment. Whereas only 1 percent of the group was unemployed prior to the loss of an arm, 19 percent were not gainfully employed when seen at amputee clinics.</p> <p>It is interesting to note that those amputees who were employed were occupied in a wide variety of jobs including agricultural and skilled vocations. This fact leads us to speculate as to the reasons for these occupational shifts. Are these trends actually caused by the physical inability of the amputee to perform and compete, or are there perhaps other social or psychological reasons for the occupational shift? Doubtless, a combination of factors is operative, but the relative importance of each is still unknown. (<b>Fig. 6</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Stump Characteristics</h3> <p>The stump characteristics with which we are concerned in this section are strength and range of motion. Information about these characteristics was obtained through gonio-metric measurements and standard muscle-testing techniques.</p> <p>In general, the below-elbow amputee retains somewhat more range of pronation than of supination (<b>Table 7</b>). The average amount of residual pronation in the entire sample is 38 deg., the average amount of supination being 33 deg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Besides retaining somewhat more range of motion in pronation than in supination, the below-elbow amputee tends to have somewhat greater strength of pronation (<b>Table 8</b>). The strength of pronation was rated good or excellent in 57 percent of the cases while 51 percent were rated good or excellent in supination. (<b>Fig. 7</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Of the total group, 75 percent were able to flex their elbows actively to an angle of 130 deg. or more (<b>Table 9</b>). Among below-elbow amputees, then, approximately three out of four cases retain a normal amount of elbow flexion on the side of the amputation. On the other end of the scale, however, it should be noted that a significant number of amputees have a restricted range of motion and require special prosthetic or medical attention in order to achieve a more normal flexion angle. Whereas somewhat more than 50 percent of the cases had good or excellent strength in pronation and supination, 90 percent had equivalent strength ratings in elbow flexion (<b>Table 10</b>), as would be expected since amputation through the forearm interferes less with the muscles and joints related to elbow flexion than with those related to pronation and supination.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When wearing a prosthesis, the above-elbow amputee rarely has occasion to move his stump beyond an angle of 80 deg. either in elbow flexion or in abduction of the humeral stump. On this basis, the majority of above-elbow amputees have more than adequate range of motion for present conventional prostheses. The data indicate that 94 percent of the cases had 80 deg. or more of flexion; 91 percent had 80 deg. or more of abduction (<b>Table 11</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The motion of extension at the shoulder joint is used primarily in locking and unlocking the prosthetic elbow. To perform this operation, an extension range of 40 deg. is more than adequate. In our sample, 82 percent of the cases could achieve an extension angle of 40 deg. or more.</p> <p>The majority of above-elbow amputees have no significant problem with regard to the strength of motions at the shoulder joint. In the total group, 90 percent of the cases had good or excellent strength in flexion, 81 percent had good or excellent strength in extension, and 90 percent had good or excellent strength in abduction (<b>Table 12</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Extent of Use of Prostheses</h3> <p>In assessing the extent of prosthetic use, information was obtained as to the length of time the prosthesis was worn, if at all, and as to the specific activities for which it was used in dressing, eating, work, and recreation. These data permit inferences to be made concerning the usefulness of the prosthesis in everyday life.</p> <p>A surprisingly large portion (62 percent) of the amputees indicated that they were prosthesis wearers at the time of the survey, but this figure may be deceivingly high because of the large number of veterans in the sample. Moreover, the term "present wearer," while it indicates daily wear, does not indicate the actual amount of time the prosthesis is worn. Some of these "present wearers" may use the prosthesis only a short time each day. Further information bearing on this point is to be found in the accompanying chart dealing with the number of hours per week the prosthesis was worn. (<b>Fig. 8</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is perhaps more informative to notice how the wear status varies with increasing severity of loss. While 75 percent of the below-elbow amputees were classified as present wearers, this figure drops to 61 percent for the above-elbow amputees and to 35 percent for the shoulder-disarticulation cases. Clearly there are considerably fewer unilateral arm amputees wearing prostheses as the level of amputation moves proximally.</p> <p>The same trend is found among amputees who had worn prostheses before but who had given them up and were nonwearers at the time of the survey. Among the below-elbow amputees, 9 percent were nonwearers although they had had previous prosthetic experience. Among the above-elbow amputees, this figure rises to 21 percent and reaches 35 percent among the shoulder-disarticulation cases.</p> <p>From these data, the inference is inescapable that, while the below-elbow prosthesis was a fairly widely worn device, the prosthetic replacement for the above-elbow case and that for shoulder disarticulation left more to be desired.</p> <p>A significant portion of those amputees who wear prostheses apparently use them full-time, i.e., 80 or more hours per week, which is about the equivalent of 12 hours a day, every day. In this respect there are, however, significant differences among the several amputee categories. For example, 71 percent of the below-elbow amputees were full-time wearers. But for the above-elbow and shoulder-disarticulation groups, this figure drops to 53 percent and 54 percent, respectively. Among bilaterals the figure rises to 88 percent; the bilateral is obviously more dependent on his prosthesis than is the corresponding unilateral amputee.</p> <p>The conclusion that the amount of wear decreases significantly as the level of unilateral amputation becomes higher is reinforced by the data pertaining to the percentage of amputees who wear their prostheses for relatively short periods each week. A wearing time of less than 40 hours per week was reported by 11 percent of the below-elbow group, 20 percent of the above-elbow group, 27 percent of the shoulder-disarticulation group, and 6 percent of the bilaterals. Judging from these data, individuals with amputations above the elbow do not receive sufficient value from their prostheses to wear them consistently.</p> <p>We come now to a consideration of the degree of actual use to which arm prostheses are put by those who wear them. The activities listed in the four accompanying charts have two important characteristics. First, they are extremely common, being performed several times daily by almost every active individual. They are an inescapable and integral part of normal daily life. Secondly, they are bimanual in nature, either requiring two hands directly or else necessitating the use of one hand while the other is occupied in an auxiliary role. For these reasons, the use or nonuse of the prosthesis in these activities can properly be considered an indicator of the value of the replacement.</p> <p>We have already seen that some amputees had never worn a prosthesis and that others had given one up after some trial period. While the situation is quite complex, these facts point out that, at least for a certain number of amputees, the prosthesis did not offer sufficient functional advantage to compensate for any inconvenience or discomfort involved in its use. But what of those amputees who did wear their appliance? Did they use their artificial arms to assist in the accomplishment of these common activities? (<b>Fig. 9</b>)</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 the activities of dressing, we find that 42 percent of the below-elbow amputees did use their prostheses in tying shoe laces and in holding up the trousers while the sound hand adjusted buttons, zippers, or belts. This figure, however, is considerably reduced in the case of the above-elbow amputee and is even smaller for the shoulder-disarticulation cases. The information can be summarized by saying that, first, significantly less than half of those amputees who wear arm prostheses use them in dressing activities and, second, that use of an arm prosthesis in dressing decreases markedly the more proximal the level of amputation. (<b>Fig. 10</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although it is customary for the normal person to use a knife and fork in cutting food, apparently most arm amputees adopt some other method. It should be recalled that the use of two hands for eating activities is mandatory in only a few instances, such as in cutting tough meat or in buttering bread. The amputee can try to avoid these situations, can receive help from another person, or can use a special tool such as a combination knife-fork. At any rate, it seems clear that, in the area of eating, the prosthesis was not of great functional value to the sample group. The highest rate of use was only 23 percent (among the below-elbow and the bilateral subjects, who reported holding a fork in the prosthesis). (<b>Fig. 11</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Light grasp is differentiated from heavy grasp not only by the weight of the object but also in that precision is the essential feature of the former while strength of grip is paramount in the latter. Holding papers and writing implements are examples of light grasp; handling tools exemplifies heavy grasp. The word "support" is here used to indicate holding an object up, as in carrying a topcoat, not by grasping but by placing a terminal device or prosthetic forearm underneath it. "Weight" implies holding an object down in the fashion of a paperweight, again without grasping. (<b>Fig. 12</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As regards work activities, the data on use of an arm prosthesis present much the same picture as we have seen in connection with dressing and eating. The majority of the group still report no use of their prostheses, and again the amount of use at work declines at the higher amputation levels. It is interesting to note, however, that in this area there is much less decrease in use among above-elbow and shoulder-disarticulation amputees than is the case in the other two areas (dressing and eating). That is to say, the above-elbow and shoulder-disarticulation prosthesis was used more often for work tasks than for eating or dressing. This may be accounted for by the social and competitive pressures in job situations, or perhaps by the fact that work tasks are extremely varied as compared to the restricted number and type of activities in dressing and eating.</p> <p>As for activities involved in recreation, the number of amputees reporting use of the prosthesis for grasp of heavy objects is more than double the number reporting light grasp. This reversal of the data dealing with use of the prosthesis at work raises a number of questions. Does the amputee find himself placed in jobs whose demands are quite light physically? And, if so, is this a real or an imagined limitation, since apparently the amputee is able to and tends to do heavier activities for his own recreation than he does on the job? It may be that there is an existent prejudice, not in accord with the facts, concerning the kind of activity that an arm amputee can perform. Such a misconception, on the part either of the amputee or of other persons such as vocational counselors, could lead to placement in jobs requiring activity levels lower than those which the amputee is capable of producing. (<b>Fig. 13</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Prosthetic Components</h3> <p>In this section we are concerned primarily with the types of prosthetic equipment worn by arm amputees throughout the country just prior to the research studies. For convenience, we shall deal first with those prosthetic components that are common to all prostheses and then proceed to components that are specific to below-elbow and to above-elbow arms.</p> <p>At the time of this survey of upper-extremity amputees, the voluntary-opening Dorrance No. 5 was by far the most widely used hook. Over 32 percent of the group wore it. In all, the Dorrance hooks, of which there are numerous types, were worn by 70 percent of the subjects, the No. 8 and the No. 7 following behind the No. 5 in popularity. Other hooks that had a fairly widespread use were the APRL voluntary-closing hook (10 percent of all the amputees) and the Trautman hook (9 percent).</p> <p>The three hands that had been most widely dispensed were the Miracle (31 percent of the group), the APRL (24 percent), and the Becker (21 percent). In addition to the relative numbers of the various types of hands, it is interesting to note that 84 percent of the sample used active hands as compared to 16 percent who wore passive hands. Also, as one would expect, the total number of hands worn (728), while quite high, is substantially less than the total number of hooks (1010). Many amputees owned both a hand and a hook. (<b>Fig. 14</b>, <b>Fig. 15</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is clear that at the time of the survey the great bulk of arm amputees (70 percent) used friction wrist units. The positive-locking type of wrist unit was worn by 20 percent of the group, and approximately three out of four of these units were of the Hosmer WD-400 type. The proportion of positive-locking wrists remained fairly constant in all groups except that of the bilaterals, who would be expected to have difficulty in operating this unit. Among the arms worn by bilaterals, only two were equipped with positive-locking wrists.</p> <p>The remaining 10 percent of the sample wore the quick-change Dorrance "Butterfly" type of wrist, which is essentially a friction unit with provision for quick interchange of terminal devices.</p> <p>Considering the group as a whole, plastic sockets were used most extensively. Forty-three percent of the subjects wore this type as compared to 37 percent who wore sockets made of leather, 12 percent whose sockets were made of wood, and 9 percent with fiber sockets. Since plastic is the standard socket material today, it is interesting to note that 57 percent of the entire group did not wear plastic sockets at the time of the survey.</p> <p>There was, however, considerable variation among the below-elbow, above-elbow, and shoulder-disarticulation groups. The leather socket was used by a substantial portion of the below-elbow population (47 percent) but by smaller segments of the above-elbow and shoulder-disarticulation groups (23 percent and 35 percent respectively). Approximately half of this latter group (above-elbow and shoulder disarticulation) wore plastic sockets. (<b>Fig. 16</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is interesting to note that at the time of the survey there was still fairly prevalent use of wood for the above-elbow socket (19 percent of the cases) and of molded leather for the shoulder-disarticulation socket (35 percent of the cases). The data also indicate that over 79 percent of the below-elbow and over 86 percent of the above-elbow sockets were of single-wall construction. Double-wall sockets, which have many functional and cosmetic advantages, were not in general use. (<b>Fig. 17</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The harnesses worn by arm amputees at the time of the survey present quite different pictures in the below-elbow and above-elbow groups. The bulk of the below-elbow population (63 percent) used standard figure-eight harnesses, and an additional large group (25 percent) wore a single axilla loop. These two types of harnesses differ only in that the axilla loop does not contain the front suspension strap (commonly in the form of an inverted F) of the figure-eight harness. The other major style of below-elbow harnessing is the chest strap and shoulder saddle, which was worn by 12 percent of the sample.</p> <p>Turning to the above-elbow population, we find the situation reversed. Fifty percent of this group wore a shoulder saddle and chest strap, while another 24 percent wore the same harness plus an axilla loop to which the control cable was attached. Thus, three quarters of the above-elbow sample had shoulder saddles and chest straps as their basic suspensory harness. The remaining one quarter of all above-elbow amputees wore figure-eight harnesses, either with or without the over-the-shoulder strap. (<b>Fig. 18</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The most universally used elbow joint was the poly-centric rigid joint. It was found in 57 percent of the below-elbow arms (<b>Table 13</b>). If we add to this figure the three other types of rigid hinges listed in the accompanying table, we find that 70 percent of the below-elbow sample wore rigid elbow joints. The remaining 30 percent wore flexible or semi-flexible joints.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Beginning with the triceps pad, a relatively small section of leather located on the posterior side of the humerus, each type of upper-arm cuff is progressively larger. The half cuff covers approximately half of the upper-arm circumference, the full cuff completely encircles the arm, and the three-quarter cuff is between these two in size.</p> <p>A principle generally agreed upon is that the less cuffing used the more comfortable and convenient is the prosthesis, provided that stability and control are not impaired. It is noteworthy, therefore, that the smallest cuff, the triceps pad, was worn by only six percent of the cases. The half and full cuffs were worn almost exclusively (48 and 41 percent of the sample, respectively).</p> <p>Almost all of the half and full cuffs were worn with one or two billets. One of the factors accounting for the large number of full cuffs and supportive billets, which contrasts markedly with present practice, may have been the previously noted prevalence of the axilla-loop harness, which has no front suspension strap.</p> <p>Slightly more than half of all above-elbow amputees did not use automatic, harness controlled elbow units, which are considered standard equipment today. Of this group, 42 percent were manual locks operated by the remaining sound hand, while the remainder (12 percent) wore Fitch-type elbows, which do not contain a locking mechanism. (<b>Fig. 19</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Of the slightly less than half who did wear harness-operated elbow-locking units, 25 percent used Hosmer units (primarily the E-300 elbow) and 21 percent used Sierra units (the Model C elbow).</p> <h3>Summary</h3> <p>The past five years have witnessed a rapid change in the field of upper-extremity prosthetics, partly as a result of the education program and of the studies reported in this issue of Artificial Limbs. As a step in the measurement of the progress that has been and will be made, the survey studies were designed to provide a baseline describing the state of upper-extremity prosthetics prior to the introduction of new techniques, devices, and concepts of amputee management. (<b>Fig. 20</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To establish this baseline, information has been presented about a sample of 1630 amputees observed during the years 1953-55. The character and status of the entire upper-extremity amputee population in 1953-55 can reasonably be inferred from these data. The extremely large number of all types of male amputees who participated, the nationwide scope of the survey, the inclusion of wearers and nonwearers, and the wide variety of occupations represented make for confidence in the accuracy with which the state of the art has been depicted.</p> <p>The primary limiting factor in these data is the large number of veterans among the group, which undoubtedly influences the results. In addition, the data tend to characterize those amputees who reside in urban areas or within a 100-mile radius of the major metropolitan centers where the participating clinics were located. Hence it is likely that the rural resident is not fully represented.</p> <br /> Figure 1 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-12.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-13.jpg Figure 3 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-14.jpg Figure 4 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-15.jpg Figure 5 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-17.jpg Figure 6 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-18.jpg Figure 7 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-19.jpg Figure 8 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-21.jpg Figure 9 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-22.jpg Figure 10 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-16.jpg Figure 11 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-23.jpg Figure 12 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-20.jpg Figure 13 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-25.jpg Figure 14 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-26.jpg Figure 15 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-24.jpg Figure 16 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-27.jpg Figure 17 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-28.jpg Figure 18 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-29.jpg Figure 19 http://www.oandplibrary.org/al/images/1958_01_057/tmp4F8-30.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 Studies of the Upper Extremity Amputee II. The Population (1953-55) Creator An entity primarily responsible for making the resource Norman Berger, M.S.  https://staging.drfop.org/files/original/1af135b4046fb2db501ded967f727ab2.pdf a4ca54acbda5984b15304cd6f7f016f5 https://staging.drfop.org/files/original/228e86e9452aa08be3bd9351e6c31dd0.jpg 5ccce9aaa2c5fa279985a74d639717be https://staging.drfop.org/files/original/c3df5a9743aed351dd319f2fb7e5112b.jpg a6f33c8ff187dab14eaff25dfafeecc3 https://staging.drfop.org/files/original/d5917e7f85a5a4c742cd2881c5d8c622.jpg 7b428b86fa69aeaa6a00da502d9b8c5b https://staging.drfop.org/files/original/d7d878173bbf5ec95e330af715e05b3a.jpg 3fc75ef8e1cadc253917ec7678b04d21 https://staging.drfop.org/files/original/da2a87a3ffef9f0eaf6e00bce461aede.jpg b746ec00689aa36b9d45c21f1587efca https://staging.drfop.org/files/original/54cbbe5693ea9e29ee0aab4eeb74d355.jpg f68af07a7951cc4830b6396717efbbcb https://staging.drfop.org/files/original/c865c0387c4ee04978be8c5707188774.jpg b2accc827111018a5ac53834cf59ac5a https://staging.drfop.org/files/original/ec3a3830c510a3a5beeeceb61f8ec202.jpg 9ef1d7fba1b6d89801277060612ca699 https://staging.drfop.org/files/original/85aee9dd4f8c9ffb71f4f4f600f45426.jpg 3ba2d1b34f53dbd76ad7069fbc2847d3 https://staging.drfop.org/files/original/e9760a32a1177547755bd80d61b859d0.jpg 0e658181df75e5a68bafb70e7e89cb7a https://staging.drfop.org/files/original/e83bead762c305b477ce5472b0c2c660.jpg cfe681da6e99338852c5c85b9aa8a8cf https://staging.drfop.org/files/original/efcb14dbaa8a3571f79a5c522cbfc587.jpg b7a17d0b20c308b84db4cb71383ed647 https://staging.drfop.org/files/original/063f9cc82fc0b22d33d5afc3b26ab2f8.jpg c0c7f6254ff24cb2489895ad919e66c5 https://staging.drfop.org/files/original/d9aef5c99b9e68a90850d61c434ee8fb.jpg 302927b6d2390d85826ddc3c38ea28fc https://staging.drfop.org/files/original/d1a8faaf3cedc688656a9fdf13e1d6b1.jpg e86b096968e144fb105e347fca51cc98 https://staging.drfop.org/files/original/bae29461b9316b470b68481ef53c0e67.jpg 3a177550c19df8561c721d998a50b471 https://staging.drfop.org/files/original/cf3f68b62ba311b841de515c0ad9727c.jpg 378c97c7ad10e652d2a03009da51411b https://staging.drfop.org/files/original/1739de25d66a546b4f81d95b07a9cd81.jpg 74e052d9003c72e4bb39645dfb2f587f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_01_001.pdf Year 1968 Volume 12 Issue 1 Page Number(s) 1 - 13 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_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>The Acceptance and Rejection of Prostheses by Children With Multiple Congenital Limb Deformities</h2> <h5>P. J. R. Nichols M.A., D.M. (Oxon), D.Phys.Med. <a style="text-decoration:none;">*</a><br />E. E. Rogers, M.A.O.T. <a style="text-decoration:none;">*</a><br />M. S. Clark, M.A.O.T. <a style="text-decoration:none;">*</a><br />W. G. Stamp, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Children with severe multiple congenital limb deformities associated with thalidomide are numerically few. <a></a> Because of the severity of this disability, the associated deformities, and the psychological trauma to both parents and child, the thalidomide tragedy has served as a catalyst to study the congenital amputee in depth. There is still controversy concerning the appropriate prosthetic and rehabilitation program for these children, but the attention this tragedy has focused on other less-involved children perhaps will reap benefits far beyond our expectations. <a></a></p> <p>The possible factors associated with acceptance or rejection of appliances may be inherent in the appliance, or they may arise from the child's own frustration, the parental reaction, <a></a> or other environmental factors. Retrospective studies of children who attend the Nuffield Orthopaedic Centre for prosthetic management and a review of the relevant literature have been carried out in an effort to establish a pattern of management and to delineate topics for future research.</p> <h3>Scope of the Study</h3> <p>During the past four years, 50 children with congenital amputations and limb deformities have attended the Disabled Living Research Unit at the Nuffield Orthopaedic Centre. Approximately half were deemed not to need prostheses or appliances at this time.</p> <p>This article reviews 21 children with multiple congenital limb deformities who have been under continuous care for prosthetic management and general rehabilitation for four years. All the deformities were presumed to be due to thalidomide, and the lesions were characteristically bilateral (<b>Table 1</b>). Thirteen of the children have been fitted with upper-limb prostheses only, four with lower-limb appliances only, and four with both upper-and lower-limb appliances (<b>Table 2</b>). Henkel's classification <a></a> was used; other classifications are used in various parts of the world. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Each child has been fitted with appliances on more than one occasion. In considering acceptance or rejection of prostheses, attention has been focused on the type of prosthesis provided rather than actual numbers. A satisfactory design may well be repeated in different sizes or, after rejection of one type, a different pattern may be tried. On average, each child has passed through three stages of prosthetic management, but the number of prostheses made and supplied is in considerable excess of this (<b>Table 2</b>). The classification of type of prosthesis fitted is given in <b>Table 3</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Some children had only conventional prostheses, and others only powered upper-limb appliances. The majority, however, started with conventional appliances and then "graduated" to the powered ones.</p> <h3>Criteria for Prosthetic Management</h3> <h4>Upper-Limb Appliances</h4> <p>The fitting of upper-limb prostheses at the Disabled Living Research Unit was governed by various factors. In the early stages, the demands of the parents and the availability of materials and appliances were the most dominant factors. As this was a disability incurred by a man-made drug, the parents felt that they had the right to have the best treatment available. For the first year or so the Unit was dependent upon the availability of material and parts from within the United Kingdom, those imported from Germany, or what could be made locally.</p> <p>When the children's rudimentary arms were long enough to grasp objects bilaterally, to reach the mouth, and to be within the child's vision, then an appliance was not considered appropriate. <a></a> But when both arms were absent, or the rudimentary arms were so short that they could not achieve the basic function of feeding, artificial arms were fitted. However, these children were also deliberately encouraged to use their feet to enable them to acquire sensory perception of texture, temperature, etc., as well as dexterity in movement and achievement of toilet management. <a></a></p> <p>The fitting of the upper-limb appliances attempted to follow the normal behavioral patterns. A cosmetic appliance fitted during the first few months of life helped them to get used to wearing such appliances and learn sitting balance.</p> <p>In order to give the child some form of bilateral grasp, "pat-a-cake" appliances were fitted when the child was approximately one year old. These were the first type of appliances to be powered by compressed carbon dioxide, and were actuated bv body movement (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The first powered upper-limb appliances known as "pat-a-cakes" were fitted at the age of about one year. These are no longer issued. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The next stage was the introduction of wrist rotation and externally powered hooks or hands, fitted as the materials became available and the needs of the child demanded (<b>Fig. 2</b>). <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Child with bilateral amelia who was issued an appliance giving powered prehension and wrist rotation with passive elbow and shoulder movements. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Lower-Limb Appliances</h4> <p>A child's development is directly dependent on the vertical positioning of spine. Sitting, standing, and walking at the normal age are important for the child's normal development. Therefore, it is important that babies with amelia or short dysmelia of the lower extremity sit up at the normal age of sitting; that is, at the age of six months in a "flowerpot" (<b>Fig. 3</b>), and at about one year they should be given some form of legs for mobility (<b>Fig. 4</b>). <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Child with lower-extremity amelias placed in a "flower-pot" at the normal age of sitting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Some form of mobility should be provided during the child's second year. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The type and height of the lower-limb appliances issued to the children depended on the degree of competence and confidence in balance (<b>Fig. 5</b>). The children were supplied appliances with "shoes" as soon as was practicable; in any case, before they commenced formal schooling.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The type and height of a lower-limb appliance depend upon the child's competence and balance. Whenever possible, the height should be kept within the lower limits of normal growth. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Coping with appliances for all four limbs imposes a considerable physical and intellectual strain on small children. The physical maneuvers necessary to walk with bilateral lower-limb appliances are often considerably restricted by the presence of upper-limb appliances. The children's activities and needs should be balanced and the training program phased to allow the children to obtain practice with both sets of appliances separately and together. For some children, upper-limb appliances are an aid to balance, whereas for others these appliances are an impediment.</p> <h3>Method</h3> <p>The children and parents were interviewed, schools were visited, and all available records and reports were reviewed. These records include functional activities of daily living, simple objective tests of skill, and school reports. The extent of the activities covered included those featured in other simple follow-up studies. <a></a> All children were seen by a clinical psychologist.</p> <p>In the analysis, notation was made of:</p> <ol> <li>The children's preferences.</li><li>The parents' preferences.</li><li>The amount of cooperation from the child.</li><li>The amount of cooperation from the parent.</li><li>The amount of cooperation from the school and teachers.</li></ol> <p>Concerning mechanical aspects, comments were recorded concerning:</p> <ol> <li>The weight of the appliance.</li><li>Delay in supply of the appliance.</li><li>Delay in supply of spare parts.</li><li>Speed of response of the appliance.</li><li>Limitation of reach.</li><li>Limitation of other movements.</li></ol> <p>Physical reactions noted included heavy perspiration (associated with the weight of the appliance), skin rashes, soreness from the harness, and restriction of the child's body movement.</p> <h3>Definitions</h3> <h4>Appliances</h4> <p>The appliances have been grouped into: conventional upper limbs; powered upper limbs; lower limbs; and then classified according to their functional features (<b>Table 2</b> and <b>Table 3</b>).</p> <h4>Acceptance And Rejection</h4> <p>"Acceptance" of prostheses by children is often more passive than active. "Acceptance" of an appliance in this study means that the child uses the appliance for most of the day for various activities; for example, feeding, writing, or playing. "Acceptance" in this context does not necessarily indicate that the child prefers the appliance to his own limbs. Almost invariably, the children prefer to use their own body and residual limbs for most manipulative activities.</p> <p>"Total rejection" implies complete refusal to wear the appliance. Some children have to be persuaded to wear the appliances even for short periods each day, but will do so with encouragement; this usually means periods of half an hour. This condition is termed "partial rejection"; it could equally well be termed "partial acceptance."</p> <h3>Results</h3> <h4>Acceptance And Rejection Of Conventional Upper-limb Appliances</h4> <p>Undoubtedly, conventional appliances for this group of children have a poor record of acceptance. Of those fitted before the age of two years, 14 children fitted with 14 bilateral appliances rejected the appliances on nine occasions (64 per cent), whereas acceptance was recorded in five cases (36 per cent) (<b>Table 4</b>). But it is difficult to assess correctly whether a child of this age has accepted or rejected an appliance, as the observer's judgment is likely to be very subjective.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It was noted, however, that after the age of two years conventional appliances were totally rejected.</p> <h4>Acceptance And Rejection Of Powered Upper Limbs</h4> <p>Thirty-nine powered upper-limb appliances were fitted on 13 children, and were rejected on 27 occasions.</p> <p>The acceptance of the powered upper-limb appliances in this series is 25 per cent in children under four years of age and 38 per cent in those over four years (<b>Table 5</b>). Acceptance increased considerably when the powered hand was introduced.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>However, partial rejection (or partial acceptance) occurs for 50 per cent of appliances, and total rejection of powered appliances has not occurred in children over four years of age.</p> <h4>Acceptance And Rejection Of Lower-limb Appliances</h4> <p>Seventeen lower-limb prosthetic appliances have been fitted on eight children; 13 of these were accepted, one partially rejected, and only three totally rejected. Ultimately, <i>all </i>lower-extremity prostheses were accepted.</p> <p>One child rejected appliances during her second year, because any type of appliance restricted her mobility and she was able to progress well by crawling. One child rejected, when, at the age of five years, he was fitted with appliances and he found them cumbersome and restrictive. This child has now accepted caliper appliances. Another child preferred the ski-type of appliance rather than those with shoes, because the latter kept on breaking and she had little confidence in them.</p> <p>The swivel walkers were made according to the design principles described by Motloch and Elliott <a></a> (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Swivel walkers are a distinct improvement over previous lower-limb appliances. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>None of the swivel walkers fitted has been rejected. They are a distinct improvement over any previous appliance. The full details are given in <b>Table 6</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Acceptance And Rejection Of Appliances According To Age</h4> <p>Acceptance and partial acceptance are clearly related to increasing age (<b>Table 7</b> and <b>Table 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Major Reasons For Rejection Of Upper-limb Appliances</h4> <p>There were many recorded reasons for rejection or partial rejection, and for each child there were usually several contributory reasons.</p> <p>When these were grouped together and all the different appliances were considered, it was found that the commonest cause for rejection was the mechanical inefficiency of the prostheses (76 per cent); the next most common cause of rejection was the child's preference for using his or her own residual limbs. In a relatively few cases, the lack of cooperation of parents or child was a major reason for rejection (<b>Table 9</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Change From Rejection To Acceptance</h4> <p>It is even more interesting to analyze the major factors that lead from a rejection to an acceptance (<b>Table 10</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Family Environment</h4> <p>The problem of parental cooperation is partly reflected in the families' general environmental background. Although the numbers are small, the review indicates that the better-educated, middle-class families are more likely to help their children accept appliances (<b>Table 11</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Clinical Psychologists' Assessment</h4> <p>All the children in this series were of at least average intelligence, with three being distinctly above average. Two children of average intelligence developed aggressive tendencies and for a period would use their artificial arms almost entirely as weapons. Their aggression finally diminished after starting at normal primary schools.</p> <p>Psychological testing was unable to delineate specific features helpful in predicting acceptance or rejection of appliances. Perhaps if the testing had been more comprehensive and more frequent, trends might have been exposed. However, the simple clinical psychological appraisal reflected the acknowledged situation rather than helping to elucidate the underlying motivation toward acceptance or rejection of prostheses. <a></a></p> <h4>School</h4> <p>In this series, 13 children attended normal state schools, five attended day schools for the physically handicapped, and two were at residential schools for the physically disabled. One child was undergoing orthopaedic treatment during the period covered by this survey. From this small series, acceptance for upper-limb appliances was higher for children attending normal state schools than for children at special schools for the physically handicapped (<b>Table 12</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Discussion</h3> <p>The birth of a child with a congenital limb deformity is a domestic crisis and the parents need urgent help and advice on the total management of the child. The crisis intervention <a></a> is a critical function of the management team, but the personal approach and careful handling are also essential. <a></a></p> <p>That there should be complex factors interacting to produce acceptance or rejection of the appliances is understandable. Goldner and Titus <a></a> noted that they have been uniformly unsuccessful in the upper-extremity amelia and phocomelia, particularly when the condition occurred bilaterally. It was only when external power was added that they were able to make significant progress. This experience has been true of other authors. <a></a></p> <p>The outstanding findings in this study are that therapists, parents, and children partake in a mutual learning process, and very close cooperation between all concerned is essential for good rehabilitation. <a></a> Brooks <a></a> emphasizes the importance of recognizing situations which are known to produce adverse reaction and aptly refers to this as "crisis intervention." Each stage of the child's development must be watched, <a></a> and the value of the appliances should be frequently reassessed.</p> <p>Many children have deformities which at first do not seem to need surgical or prosthetic intervention. However, as the child develops, function and environmental features change, and there is a need for continuity of supervision and repeated clinical and functional reappraisal. The need for aids to daily living, special aids, or, indeed, surgical management may become relevant at any stage of the child's development. <a></a> Although surgery of the upper limbs should be approached with caution during infancy, arteriograms indicate that the blood supply, even in single-digit phocomelia, is likely to be adequate for major reconstructive surgery to be contemplated in later life. <a></a></p> <p>Objective records of activity, writing, and performing other prearranged tasks which can be timed, or for which some degree of accuracy can be charted, are of more value than a "clinical impression" or answers to a questionnaire. <a></a> This study has employed simple tests which can be timed, and from which "learning curves" can be constructed. <a></a></p> <p>The assessment of a child's function is more than simple assessment of activities of daily living in a therapeutic environment. Assessment must be in "real life" terms, and the children, the teachers, and the parents need to be integrated into the assessment and therapeutic team. This is well illustrated by the comprehensive evaluation of a functional cosmetic hand carried out by New York University. <a></a></p> <p>The teacher does not need to be particularly orientated toward the physically handicapped. The children in this study often appear to do better at normal schools than at special schools for the physically handicapped, unless they have all four limbs severely involved; and very often a normal school near home would seem to be more appropriate than a school for the physically handicapped that is located further away. Estimation of intelligence should be an accepted method of evaluation of all children prior to entrance into school, and psychological evaluation may be of significant help. <a></a></p> <p>However, it may be necessary to adapt the child's physical environment, so that he is not penalized by unsuitable classroom furniture or unduly physically fatigued. This can usually be overcome by relatively simple devices.</p> <p>Gouin-Decarie <a></a> compared thalidomide children to the average population and found the mean I.Q. to be 98. Along with a delay in speech, there was retardation in development of the child's perceptual concept of space and movement.</p> <p>The design and fitting of prosthetic devices for children with multiple limb deformities and the subsequent training and resettlement of the children at home and school are complex activities involving engineers, technicians, prosthetists, therapists, school teachers, social workers, and, not the least, the children and their parents. The establishment of objective and valid criteria for evaluating patient performance in the very young is difficult. The fact that the children are constantly changing as they grow and develop should emphasize the importance of reassessing goals of achievement as well as anticipated attainment.</p> <p>There are three major factors of influence: the personality of the child, the parental influences, and the therapeutic unit managing the child. <a></a></p> <p>Brooks and Shaperman <a></a> devised a "Prosthesis Adjustment Scale" based on the child's use of the prosthesis-the applied use, maintenance, and acceptance. In their experience with the below-elbow congenital amputee, acceptance was interrelated with wearing, use, and skill of applied use. Although they emphasize that the fitting of a unilateral congenital below-elbow amputee before the age of two tends to result in full-time wearing and good acceptance of the prostheses, they also note that the category most closely related to early fitting is full-time wearing. Although indoctrination for full-time wearing is possible for single amputees, it is much more difficult to accomplish for multiple amputees.</p> <p>The almost complete acceptance of lower-limb appliances from an early age reflects the point that if the appliance fulfills a real need, even if inefficiently, the appliance will be accepted.</p> <p>In the case of upper-extremity appliances, there is a definite improvement in partial acceptance and a dramatic improvement with the development of more reliable appliances, less subject to mechanical failure (note the change from P.3. to P.4. in <b>Table 5</b>).</p> <p>In this review, no differentiation has been made between mechanical failure, troubles with control mechanisms, or power packs. Interestingly enough, in this series there was no particular problem relating to the supply and recharging of the gas cylinders. As more function is derived from gas-powered appliances, the supply problem will increase and probably limit the use of this type of appliance. <a></a></p> <p>Brooks and Shaperman <a></a> also note that the acceptance of a prosthesis is closely related to the ability to communicate, and that good communication between parents and child (that is, good family relationships) is probably the major factor in establishing acceptance of appropriate prostheses. Thus the home environment is critical, and in certain circumstances this may be the determining factor. <a></a> In this series, the age of four appeared to be the "watershed." At this age, children can begin to understand the reasons for continuing to use appliances and become at least partially cooperative. They also tend to start to attend nursery school at this age. Children with severe multiple limb deformities may be educated in normal schools or special schools for the physically handicapped, depending upon their clinical or their social needs. <a></a></p> <p>The decision to remove the child to a residential school for the physically handicapped is a major one, and not necessarily associated with improvement in physical function or acceptance of suitable appliances. In this study, it has been noted that normal state schools have accepted these severely disabled children as a personal challenge and have usually gone to great lengths to encourage the children in their rehabilitation, collaborating closely with the hospital therapists and prosthetics departments. By treating the children in this way, they have been permitted, indeed encouraged, to face up to many of the normal challenges and experiences of school life. This seems to have helped the children to be integrated into community living.</p> <p>In this series, a small number of children with limb deformities in special schools for the physically handicapped are not so adapted to their disability as those at normal schools, and prosthesis acceptance is relatively poor. The atmosphere of the schools for the physically handicapped is often more protective and necessarily geared to the most incapacitated. Furthermore, some of these schools have many children who are on the borderline of being educationally subnormal. Appliance training in these schools is usually the responsibility of the physical therapist and not the teachers, and the teachers are reluctant to divert individual attention to appliance training in the presence of more disabled children who are unable to use appliances, for example, victims of cerebral palsy. However, children with severe mobility problems, as well as severe upper-limb dysmelia, may find the special equipment, adapted environment, slower tempo, and special staff of particular help.</p> <p>As a group, these children achieve remarkable levels of manipulative skills using their residual upper limbs, chin, shoulder tips, feet, and mouth. The wearing of an upper-limb prosthesis frequently hampers these skills while only providing a much cruder form of function. However, there has been no experience here in fitting a single multifunctional arm balanced with a cosmetic prosthesis, and there are certain advantages in this approach. <a></a> For children with absent or deformed legs, almost any form of lower-limb appliance gives them an immediate advantage in standing, achieving reasonable height, and—as a bonus—walking short distances.</p> <p>As a general experience, it can be said that patients must obtain an immediate advantage from the appliance for it to be accepted. It is the immediate postfitting phase which appears to be of greatest importance. If the appliance looks unfinished, if the technicians have to make numerous adjustments in the fittings, if it is uncomfortable or scratchy, if mother's face registers horror at the appearance—all these factors have a long-term effect out of proportion to their immediate import. If the antagonistic features even slightly outweigh the advantages, then acceptance is unlikely, or at best partial, and becomes more a matter of deference to authority, or, for children, part of a game rather than a true integration of the appliance into the body image. The immediate advantage gained must outweigh all the antagonistic factors. If this occurs, the patient will persist through further stages of fitting, training, and redevelopment.</p> <p>The swivel walkers are a striking example. These appliances were used experimentally at first because earlier caliper-type lower-limb appliances were breaking so frequently that the children were continually frustrated. The swivel walkers were both more reliable and more immediately efficient, and acceptance was immediate and universal.</p> <p>Cosmesis is often a motivating force in acceptance of any appliance. <a></a> In this series, there was a marked improvement in acceptance on the introduction of a powered hand in preference to a hook (<b>Table 5</b>) even though function might be less. The change from 25 per cent to 75 per cent acceptance associated with the use of a powered hand accentuates the urgent need for a sophisticated, cosmetically acceptable, functional terminal device. This confirms the experience of New York University. <a></a> Children were also pleased when ordinary shoes could be fitted to their lower-limb appliances.</p> <p>Frequently, however, it is the mothers' dominant influences which lead to cosmetic acceptance overriding function, whereas fathers are often more likely to be interested in function. In one instance, a powered prosthesis was frequently returned nonoperational because a father repeatedly attempted to improve its functions. Another father, often at home because of shift work or lack of work, spent many hours training his son to use his upper-limb prostheses.</p> <p>However, acceptance associated with cosmesis might occasionally extend to a pathological acceptance, and there is one child with bilateral upper-limb, unequal-length phocomelia, who insists on wearing a single upper-limb prosthesis in spite of the fact that it prevents him from undertaking many functions he could perform with his two phocomelic limbs. The initial supply was largely at the insistence of the parents, and in retrospect probably should have been refused.</p> <p>One problem that was very unsettling for both child and parents was the involvement of more than one clinical center. Usually, this was due to geographical circumstances. The clinicians near the child's home were unable to provide certain facilities; for example, experienced training, or appropriate surgery or prosthetic devices. Furthermore, in some instances, there was a separation between the provision of upper-limb appliances and lower-limb appliances. In all instances, this diversification of clinical control and lack of unified approach led to difficulties in management and was, not infrequently, a contributory factor in rejection of appliances.</p> <h3>Conclusions</h3> <p>The object of any critical reappraisal of clinical management is to improve the treatment of patients in the future. On the basis of this study, it is possible to lay down some broad general principles for the management of children with congenital limb deformities.</p> <p>In the initial stages, the parents' attitudes are dominant; therefore, early confident collaboration is essential. The parents should have faith in the doctors and should have a clear understanding of the individual responsibilities of the members of the pediatric and prosthetics team, which may vary according to local facilities. The child should be under frequent review by the same clinical team. Each member of the team—pediatrician, prosthetics consultant, therapist, technician, social worker, and psychologist-has contributions to make at all stages.</p> <p>For severely disabled children, introduction to adapted clothing, aids to daily living, and training activities must be tailored to fit the individual child's expected development, and independent activities should, wherever possible, match the accepted "stepping stones" of child development.</p> <p>Lower-limb deformities should be treated by appropriate surgery and prosthetics so that independent mobility is achieved as early and as efficiently as can be matched with normal progress. The size of the appliance should match natural growth as nearly as possible.</p> <p>Upper-limb appliances present a more complex problem. Most children will alternate between accepting and rejecting appliances, depending on their development and needs.</p> <p>Early fitting, at perhaps 12 to 18 months (or even earlier), has some relevance in that it accustoms the child to a somewhat uncomfortable appliance. But the child is unlikely to accept formal training in the use of a sophisticated appliance until more than four years of age. Once schooling starts, training in the use of an appropriate appliance should be part of formalized education, and this demands close collaboration between therapists and teachers, particularly in the school surroundings.</p> <p>The prosthetists and technicians must be prepared to adapt and redesign frequently as the child's needs change. They must accept the need for adequate cosmesis even at an early age. Rejection of appliances must never be regarded as "naughty" or "ungrateful," but as part of natural development. Gentle insistence on regular training sessions may well tide a child over until in later years he understands and appreciates the need for the appliance and can make a reasonable personal decision regarding design and use.</p> <p>There is an urgent need for the development of mechanically reliable, cosmetically acceptable, and functionally sophisticated upper-limb appliances.</p> <p>This development of an awareness of the most suitable design and the appropriate uses of upper-limb prostheses should be the outcome of close understanding between the child, parents, doctors, teachers, and therapists.</p> <h3>Summary</h3> <p>A group of 21 children with multiple limb deformities associated with thalidomide who have been supplied with various upper- and lower-limb prostheses is described. The acceptance and rejection of the appliances are analyzed according to age, family background, and the type of appliance.</p> <h3>Acknowledgments</h3> <p>The powered upper-limb appliances and the swivel walkers were designed and made in the Research Workshops at Mary Marlborough Lodge.</p> <p>Other appliances were made in the Orthopaedic Workshops of the Nuffield Orthopaedic Centre or supplied by the Ministry of Health in various limb-fitting centers.</p> <p><b>References:</b></p> <ol> <li>Aitken, G. T., and C. H. Frantz, <i>Management of the child amputee</i>, Instructional Course Lecture, Amer. Acad, of Orthopaedic Surgeons, 17:246-295, 1960.</li> <li>Brooks, M. B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, <i>Crisis intervention</i>, Inter-Clinic Information Bull., Vol. IV, No. 11, September 1965.</li> <li>Brooks, M. B., and J. Shaperman, <i>Infant prosthetic fitting</i>, Amer. J. Occup. Ther., 19:6, November and December 1965.</li> <li>Burtch, R. L., <i>A study of congenital skeletal limb deficiencies</i>, Inter-Clinic Information Bull., Vol. II, No. 7, May 1963.</li> <li>Buttrup, E., <i>Parents of child amputees</i>, Prosthetics International, Vol. 2, No. 1, 1964.</li> <li>Campbell, E. I., and J. C. Bansavage,<i> The psychological and social factors related to successful prosthetic training in juvenile amputees; a preliminary study</i>, Inter-Clinic Information Bull., Vol. III, No. 12, October 1964.</li> <li>Fishman, Sidney,<i> Studies of the upper-extremity amputee; VIII. Research implications</i>, Artif. Limbs, Autumn 1958, pp. 117-127.</li> <li>Fishman, Sidney,<i> Amputee needs, frustration and behavior</i>, Rehab. Lit., Vol. 20, 1959.</li> <li>Fishman, Sidney, and Hector W. Kay, <i>Acceptability of a functional-cosmetic artificial hand for young children, Part 1</i>, Artif. Limbs, Spring 1964, pp. 28-43.</li> <li>Frantz, C. H., and R. O'Rahilly,<i> Congenital skeletal limb deficiencies</i>, J. Bone Joint Surg. (Amer.), 43:1202-1224, December 1961.</li> <li>Friedmann, L.,<i> Special equipment and aids for the young bilateral upper-extremity amputee</i>, Inter-Clinic Information Bull., Vol. IV, No. 6, April 1965.</li> <li>Gesell, Arnold L., et al.,<i> Infant and child in the culture of today; the guidance of development in home and nursery school</i>, Harper, New York, 1943.</li> <li>Gillis, Leon,<i> Thalidomide babies; management of limb defects</i>, Brit. Med. J., September 8, 1962.</li> <li>Goldner, J. L., and Bert R. Titus,<i> An experience with externally powered prostheses for children</i>, Inter-Clinic Information Bull., Vol. VII, No. 2, November 1967.</li> <li>Gouin-Decarie, T., <i>The mental and emotional devel- opment of the thalidomide children and the psychological reactions of the mothers</i>, Inter-Clinic Information Bull., Vol. VII, No. 4, January 1968.</li> <li>Hall, C. B., M. B. Brooks, and M. F. Dennis, <i>Congenital skeletal deficiencies of the extremities</i>, J.A.M.A., 181:590 599, August 1962.</li> <li>Hall, C. B., <i>Corrective surgery for infant hands</i>, Inter-Clinic Information Bull., Vol. IV, No. 8, June 1965.</li> <li>Hall, C. B., <i>Recent concepts in the treatment of the limb-deficient child</i>, Artif. Limbs, Spring 1966, pp. 36-51.</li> <li>Haslam, E. T., Joan Hayden, and Jean Dutro, <i>The habituation of a congenital quadruple amputee</i>, Inter-Clinic Information Bull., Vol. VI, No. 9, June-July 1967.</li> <li>Hebert, B., <i>The psychologist and congenital physical anomalies, Inter-Clinic Information Bull.</i>, Vol. VI, No. 4, January 1967.</li> <li>Henkel, L.,<i> Das Fehlbildungsmuster der Dysmelie</i>, 17 Tagung der Gesellschaft fur Orthopadie in der D.D.R., Postam-Babelsberg, 1968.</li> <li>Her Majesty's Stationery Office Publication, <i>Deformities caused by thalidomide</i>, 1964.</li> <li>Hunter, J. M., David Subin, and A. J. Plank, <i>Some observations on upper extremity prosthesis applications</i>, Inter-Clinic Information Bull., Vol. IV, No. 8, June 1965.</li> <li>Hutt, S., Private communication.</li> <li>Kay, Hector W., and Edward Peizer, <i>Studies of the upper-extremity amputee; VI. Prosthetic usefulness and wearer performance</i>, Artif. Limbs, Autumn 1958, pp. 31-87.</li> <li>Lamb, D. W., D. C. Simpson, W. H. Schutt, N. T. Spiers, G. Sunderland, and G. Baker,<i> The management of upper limb deficiencies in the thalidomide-type syndrome</i>, J. Roy. Coll. Surg. Edinb., pp. 102-108, Vol. 10, January 1965.</li> <li>McKenzie, D. S., <i>The clinical application of ex- ternally powered artificial arms</i>, J. Bone Joint Surg. (Brit.), 47B(3):399-410, August 1965.</li> <li>McLaurin, C. A., <i>External power in upper-extremity prosthetics and orthotics</i>, Inter-Clinic Information Bull., Vol. VI, No. 1, October 1966.</li> <li>MacNaughton, A., <i>The role of the occupational therapist in the training of the child arm amputee</i>, Physiotherapy, Vol. 52, No. 6, June 1966.</li> <li>Maier, W. A.,<i> Thalidomide embryopathy and limb defects</i>, Orth. Dis. Child, Vol. 40, 1965.</li> <li>Marquardt, E., <i>The Heidelberg pneumatic arm prostheses</i>, J. Bone Joint Surg. (Brit.), 47B(3):425-434, August 1965.</li> <li>Mendez, M. A., <i>Survey by the O.T. staff of the Children's Prosthetic Unit of Queen Mary's Hospital, Roehampton</i>, Occup. Therapy, Vol. 30, No. 5, May 1967.</li> <li>Motloch, W. M., and Jane Elliott,<i> Fitting and training children with swivel walkers</i>, Artif. Limbs, Autumn 1966, pp. 27-38.</li> <li>Nichols, P. J. R., <i>The development of powered limbs, Special Education</i>, Vol. 44, Winter Issue 1965.</li> <li>Nichols, P. J. R., E. H. Hollings, and M. C. Clarke, <i>Aids to daily living for children with severe multiple congenital limb deformities</i>, in preparation, 1968.</li> <li>Nickel, V. L., and Worden Waring, <i>Future develop- ments in externally powered orthotic and prosthetic devices</i>, J. Bone Joint Surg. (Brit.), 47B(3):469-471, August 1965.</li> <li>Pearson, F. A., and B. W. Spiers, <i>Teamwork in the management of dysmelic children</i>, Physiotherapy, Vol. 52, No. 6, June 1966.</li> <li>Proceedings of a Symposium on Powered Prostheses held at the Limb Fitting Centre, Roehampton, on October 29, 1965.</li> <li>Scott, Stevenson M., <i>Providing for their education</i>, Special Education, Vol. 44, Winter Issue 1965.</li> <li>Sheridan, M., <i>The developmental progress of infants and young children</i>, Ministry of Health Report No. 102, 1960.</li> <li>Siller, Jerome, and Sydelle Silverman, <i>Studies of the upper-extremity amputee; VII. Psychological factor</i>s, Artif. Limbs, Autumn 1958, pp. 88-116.</li> <li>Simpson, D. C, and D. W. Lamb,<i> A system of powered prostheses for severe bilateral upper limb deficiency</i>, J. Bone Joint Surg. (Brit.), 47B(3): 442-447, August 1965.</li> <li>Spock, B., and M. O. Lerrigo, <i>Caring for your handicapped child</i>, Macmillan Co., New York, 1965.</li> <li>Stamp, W. G., S. Mahon, and H. C. Morgan, <i>Problems of management of the child with multiple amputations</i>, Arch. Phys. Med., Vol. 46, May 1965.</li> <li>Swanson, A. B., <i>The Krukenberg procedure in the juvenile amputee</i>, J. Bone Joint Surg. (Amer.), 46A(7):1540-1548, October 1964.</li> <li>Swanson, A. B., <i>Phocomelia and congenital limb malformations; reconstruction and prosthetic limb replacement</i>, Amer. J. Surg., 109, March 1965.</li> <li>Swanson, A. B., <i>Classification of limb malformations on the basis of embryological failures</i>, Inter-Clinic Information Bull., Vol. VI, No. 3, December 1966.</li> <li>Taussig, Helen B., <i>The thalidomide syndrome</i>, Sci. Amer., Vol. 207, No. 2, August 1962.</li> <li>University of California at Los Angeles Staff, <i>Cosmesis: can it be defined?</i> Inter-Clinic Information Bull., Vol. V, No. 10, July 1966.</li> <li>Weiss, S. A., <i>Integrating the handicapped child into the community center</i>, Inter-Clinic Information Bull., Vol. V, No. 8, May 1966.</li> <li>Willert, H. G, <i>Eine Klassifikation Angeborener Armfehbildungen mit Rohrenknoch-endefkten</i>, 17 Tagung der Gesellschaft fur Orthopadie in der D.D.R., Postam-Babelsberg, 1968.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, Part 1, Artif. Limbs, Spring 1964, pp. 28-43.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, Part 1, Artif. Limbs, Spring 1964, pp. 28-43.</td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">University of California at Los Angeles Staff, Cosmesis: can it be defined? Inter-Clinic Information Bull., Vol. V, No. 10, July 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Simpson, D. C, and D. W. Lamb, A system of powered prostheses for severe bilateral upper limb deficiency, J. Bone Joint Surg. (Brit.), 47B(3): 442-447, August 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Scott, Stevenson M., Providing for their education, Special Education, Vol. 44, Winter Issue 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Weiss, S. A., Integrating the handicapped child into the community center, Inter-Clinic Information Bull., Vol. V, No. 8, May 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Brooks, M. B., and J. Shaperman, Infant prosthetic fitting, Amer. J. Occup. Ther., 19:6, November and December 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">McLaurin, C. A., External power in upper-extremity prosthetics and orthotics, Inter-Clinic Information Bull., Vol. VI, No. 1, October 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Brooks, M. B., and J. Shaperman, Infant prosthetic fitting, Amer. J. Occup. Ther., 19:6, November and December 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Fishman, Sidney, Amputee needs, frustration and behavior, Rehab. Lit., Vol. 20, 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Gouin-Decarie, T., The mental and emotional devel- opment of the thalidomide children and the psychological reactions of the mothers, Inter-Clinic Information Bull., Vol. VII, No. 4, January 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Campbell, E. I., and J. C. Bansavage, The psychological and social factors related to successful prosthetic training in juvenile amputees; a preliminary study, Inter-Clinic Information Bull., Vol. III, No. 12, October 1964.</td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Siller, Jerome, and Sydelle Silverman, Studies of the upper-extremity amputee; VII. Psychological factors, Artif. Limbs, Autumn 1958, pp. 88-116.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, Part 1, Artif. Limbs, Spring 1964, pp. 28-43.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>24.</b> </td><td class="clsTextSmall">Hutt, S., Private communication.</td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Proceedings of a Symposium on Powered Prostheses held at the Limb Fitting Centre, Roehampton, on October 29, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Kay, Hector W., and Edward Peizer, Studies of the upper-extremity amputee; VI. Prosthetic usefulness and wearer performance, Artif. Limbs, Autumn 1958, pp. 31-87.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Maier, W. A., Thalidomide embryopathy and limb defects, Orth. Dis. Child, Vol. 40, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Friedmann, L., Special equipment and aids for the young bilateral upper-extremity amputee, Inter-Clinic Information Bull., Vol. IV, No. 6, April 1965.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Hall, C. B., Corrective surgery for infant hands, Inter-Clinic Information Bull., Vol. IV, No. 8, June 1965.</td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Nichols, P. J. R., E. H. Hollings, and M. C. Clarke, Aids to daily living for children with severe multiple congenital limb deformities, in preparation, 1968.</td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Swanson, A. B., The Krukenberg procedure in the juvenile amputee, J. Bone Joint Surg. (Amer.), 46A(7):1540-1548, October 1964.</td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Swanson, A. B., Phocomelia and congenital limb malformations; reconstruction and prosthetic limb replacement, Amer. J. Surg., 109, March 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Gesell, Arnold L., et al., Infant and child in the culture of today; the guidance of development in home and nursery school, Harper, New York, 1943.</td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Sheridan, M., The developmental progress of infants and young children, Ministry of Health Report No. 102, 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Brooks, M. B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Information Bull., Vol. IV, No. 11, September 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">MacNaughton, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy, Vol. 52, No. 6, June 1966.</td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Pearson, F. A., and B. W. Spiers, Teamwork in the management of dysmelic children, Physiotherapy, Vol. 52, No. 6, June 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Buttrup, E., Parents of child amputees, Prosthetics International, Vol. 2, No. 1, 1964.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Haslam, E. T., Joan Hayden, and Jean Dutro, The habituation of a congenital quadruple amputee, Inter-Clinic Information Bull., Vol. VI, No. 9, June-July 1967.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">McKenzie, D. S., The clinical application of ex- ternally powered artificial arms, J. Bone Joint Surg. (Brit.), 47B(3):399-410, August 1965.</td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Nickel, V. L., and Worden Waring, Future develop- ments in externally powered orthotic and prosthetic devices, J. Bone Joint Surg. (Brit.), 47B(3):469-471, August 1965.</td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Stamp, W. G., S. Mahon, and H. C. Morgan, Problems of management of the child with multiple amputations, Arch. Phys. Med., Vol. 46, May 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Goldner, J. L., and Bert R. Titus, An experience with externally powered prostheses for children, Inter-Clinic Information Bull., Vol. VII, No. 2, November 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Buttrup, E., Parents of child amputees, Prosthetics International, Vol. 2, No. 1, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Brooks, M. B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Information Bull., Vol. IV, No. 11, September 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Fishman, Sidney, Studies of the upper-extremity amputee; VIII. Research implications, Artif. Limbs, Autumn 1958, pp. 117-127.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Motloch, W. M., and Jane Elliott, Fitting and training children with swivel walkers, Artif. Limbs, Autumn 1966, pp. 27-38.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Mendez, M. A., Survey by the O.T. staff of the Children's Prosthetic Unit of Queen Mary's Hospital, Roehampton, Occup. Therapy, Vol. 30, No. 5, May 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Her Majesty's Stationery Office Publication, Deformities caused by thalidomide, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Nichols, P. J. R., The development of powered limbs, Special Education, Vol. 44, Winter Issue 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Marquardt, E., The Heidelberg pneumatic arm prostheses, J. Bone Joint Surg. (Brit.), 47B(3):425-434, August 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Her Majesty's Stationery Office Publication, Deformities caused by thalidomide, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Burtch, R. L., A study of congenital skeletal limb deficiencies, Inter-Clinic Information Bull., Vol. II, No. 7, May 1963.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Frantz, C. H., and R. O'Rahilly, Congenital skeletal limb deficiencies, J. Bone Joint Surg. (Amer.), 43:1202-1224, December 1961.</td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Hall, C. B., M. B. Brooks, and M. F. Dennis, Congenital skeletal deficiencies of the extremities, J.A.M.A., 181:590 599, August 1962.</td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Maier, W. A., Thalidomide embryopathy and limb defects, Orth. Dis. Child, Vol. 40, 1965.</td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Swanson, A. B., Classification of limb malformations on the basis of embryological failures, Inter-Clinic Information Bull., Vol. VI, No. 3, December 1966.</td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Willert, H. G, Eine Klassifikation Angeborener Armfehbildungen mit Rohrenknoch-endefkten, 17 Tagung der Gesellschaft fur Orthopadie in der D.D.R., Postam-Babelsberg, 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Henkel, L., Das Fehlbildungsmuster der Dysmelie, 17 Tagung der Gesellschaft fur Orthopadie in der D.D.R., Postam-Babelsberg, 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Gouin-Decarie, T., The mental and emotional devel- opment of the thalidomide children and the psychological reactions of the mothers, Inter-Clinic Information Bull., Vol. VII, No. 4, January 1968.</td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Hebert, B., The psychologist and congenital physical anomalies, Inter-Clinic Information Bull., Vol. VI, No. 4, January 1967.</td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Spock, B., and M. O. Lerrigo, Caring for your handicapped child, Macmillan Co., New York, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, G. T., and C. H. Frantz, Management of the child amputee, Instructional Course Lecture, Amer. Acad, of Orthopaedic Surgeons, 17:246-295, 1960.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Gillis, Leon, Thalidomide babies; management of limb defects, Brit. Med. J., September 8, 1962.</td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Hall, C. B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs, Spring 1966, pp. 36-51.</td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Hunter, J. M., David Subin, and A. J. Plank, Some observations on upper extremity prosthesis applications, Inter-Clinic Information Bull., Vol. IV, No. 8, June 1965.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Lamb, D. W., D. C. Simpson, W. H. Schutt, N. T. Spiers, G. Sunderland, and G. Baker, The management of upper limb deficiencies in the thalidomide-type syndrome, J. Roy. Coll. Surg. Edinb., pp. 102-108, Vol. 10, January 1965.</td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Nickel, V. L., and Worden Waring, Future develop- ments in externally powered orthotic and prosthetic devices, J. Bone Joint Surg. (Brit.), 47B(3):469-471, August 1965.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Scott, Stevenson M., Providing for their education, Special Education, Vol. 44, Winter Issue 1965.</td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Simpson, D. C, and D. W. Lamb, A system of powered prostheses for severe bilateral upper limb deficiency, J. Bone Joint Surg. (Brit.), 47B(3): 442-447, August 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Her Majesty's Stationery Office Publication, Deformities caused by thalidomide, 1964.</td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Taussig, Helen B., The thalidomide syndrome, Sci. Amer., Vol. 207, No. 2, August 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>W. G. Stamp, M.D. </b></td></tr><tr><td class="clsTextSmall">Chairman, Department of Orthopaedics, University of Virginia School of Medicine, Charlottesville, Va. 22901; Visiting Professor to the Nuffield Department of Orthopaedic Surgery, University of Oxford, Oxford, England.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>M. S. Clark, M.A.O.T. </b></td></tr><tr><td class="clsTextSmall">Mary Marlborough Lodge, Disabled Living Research Unit, Nuffield Orthopaedic Centre, Oxford, England.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>E. E. Rogers, M.A.O.T. </b></td></tr><tr><td class="clsTextSmall">Research Assistant, Department of Engineering Science, University of Oxford, Oxford, England.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>P. J. R. Nichols M.A., D.M. (Oxon), D.Phys.Med. </b></td></tr><tr><td class="clsTextSmall">Director, Mary Marlborough Lodge, Disabled Living Research Unit, Nuffield Orthopaedic Centre, Oxford, England.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-18.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Acceptance and Rejection of Prostheses by Children With Multiple Congenital Limb Deformities Creator An entity primarily responsible for making the resource P. J. R. Nichols M.A., D.M. (Oxon), D.Phys.Med. * E. E. Rogers, M.A.O.T. * M. S. Clark, M.A.O.T. * W. G. Stamp, M.D. * https://staging.drfop.org/files/original/e1690cf1890c573375cb787032399988.pdf 87ee8a5abed800c76c98156dc2200899 https://staging.drfop.org/files/original/eabe930fc32847ec7e0d92434e7bc45f.jpeg b3f9edfdc10e1b362dba27c588c54d35 https://staging.drfop.org/files/original/4c55a6f8fb1adae4dd686d30f0e72e98.jpg 7ea898f965eb05a136608fe7f0fa85db https://staging.drfop.org/files/original/972fd80c1ddfa050d6812e2062ddeca8.jpg 3019cc6d45434da220cde813c997c009 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_03_010.pdf Text Any textual data included in the document <h2>Technical Note: A Cervical Orthosis Modification</h2> <h5>Paul Trautman, CPO&nbsp;<a style="text-decoration: none;">*</a><br />George Varghese, MD&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Recommending or prescribing the best possible cervical orthosis for a patient whose cervical vertebrae require support is a difficult task for an orthotist or physician.</p> <p>In recent years the plastazote® (Philadelphia) cervical orthosis has become a highly prescribed device for several reasons (<a href="/files/original/eabe930fc32847ec7e0d92434e7bc45f.jpeg"><b>Fig. 1</b></a>). Most importantly, the orthosis limits flexion and extension of the cervical spine as well as rotation between C-3 and C-7 and patients find it reasonably comfortable and accept wearing it. This is due, to some extent, to the fact that the low temperature, and easily moldable plastazote® conforms in time to the patient's contours. The better distribution of pressure and comfort for the patient may provide more relaxation of the para-cervical spinal <br /><br />Secondly, the Philadelphia cervical orthosis is relatively inexpensive compared to more rigid appliances. Thus, it is less costly to replace when it becomes contaminated or spoiled beyond cleansing.</p> <p>A third important feature is the ease of selecting and donning the device. Only two measurements, the length of the neck and the circumference of the neck are required. The orthotist is able to provide the item to the patient readily, and it is not necessary to maintain a large, costly inventory.</p> <p>In the Neurosurgery Intensive Care Unit of the University of Kansas' Bell Memorial Hospital, this cervical orthosis has become the orthosis of choice for treating head trauma patients. The posterior half of the collar can be slipped behind the patient's supported head and neck with a minimal amount of need to move the patient. The anterior half is easily put into place to complete the fitting.</p> <p>Since a number of ICU patients have required a tracheotomy it became necessary to modify the Philadelphia cervical orthosis. The design modification created by staff orthotist Wallace Whitney, CO is seen in <a href="/files/original/4c55a6f8fb1adae4dd686d30f0e72e98.jpg"><b>Fig. 2</b></a> and <b><a href="/files/original/972fd80c1ddfa050d6812e2062ddeca8.jpg">Fig. 3</a>.</b></p> <p>Since we do this modification fairly regularily we have made a plaster cast to preform the low temperature plastic (K-splint® or Orthoplast®) reinforcement piece. The original anterior strap is cut in the center, folded over and riveted to the plastic reinforcement piece and the collar. A hole (1 1/4 inch) for the tracheotomy tube is cut through the collar. A side effect is that the collar is made slightly more rigid which is often desirable for those patients.<br /><br /><em><b>*George Varghese, MD </b>Associate Professor, Department of Rehabilitation Medicine University of Kansas College of Health Sciences and Hospital Kansas City, Kansas</em></p> <p><em><b>*Paul Trautman, CPO </b>Director of Orthotics/Prosthetics University of Kansas College of Health Sciences and Hospital Kansas City, Kansas</em></p> <p><em>&nbsp;</em></p> <div style="width: 400px;"></div> Page Number(s) 10 - 11 Year 1983 Volume 7 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1983_03_010/1983_03_010-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1983_03_010/1983_03_010-2.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/1983_03_010/1983_03_010-3.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 Technical Note: A Cervical Orthosis Modification Creator An entity primarily responsible for making the resource Paul Trautman, CPO * George Varghese, MD * https://staging.drfop.org/files/original/f337a6d889d558b56f7603ac06e96231.pdf 26d6f3d8f69e84504a368e09c8b5db43 https://staging.drfop.org/files/original/4ba0e022e7651bf5a36b045a6168ac98.jpg 3ea9aebc91de4e8671fcea172dc4c9b2 https://staging.drfop.org/files/original/7b7fb17dbc1e54bd9317ab53fa1a6774.jpg f4b077a22c5f9973c9752101b7b664f0 https://staging.drfop.org/files/original/54f4c998ff0b12d9f2b0955afd658381.jpg 87e1bbb874cd86bc4295bc4da00c4375 https://staging.drfop.org/files/original/c87f8df1446c1a57754c6d380e1dc234.jpg e79dfcfb718efa0a42348f42453abbdd https://staging.drfop.org/files/original/aa356de1c97d7c797ba7399a8a358c73.jpg 9192c26c713613fe5afd6e6fcd9afb73 https://staging.drfop.org/files/original/4a16949b838f44f4b7bbfc854e44bbed.jpeg 84e45ae056e862a3d5e367fe7f109bbd https://staging.drfop.org/files/original/84863942578d92ee15a89ac6adee6168.jpeg dfae59cb8ee78783906dee0e5a97b696 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1982_01_005.pdf Text Any textual data included in the document <h2>Management and Construction Procedure of Bilateral Split-Bucket Type Hip Disarticulation Prosthesis</h2> <h5>Peter A. Ockenfels, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><i>Abstracted from an article that originally appeared in the June, 1968 issue of Orthotics and Prosthetics.</i></p> <p>The patient, a 37-year-old white male, received traumatic injuries while involved in an auto accident in October 1965. Both limbs were severely crushed, and very high amputations were necessary. The physical appearance of the patient resembled that of a bilateral hip disarticulation amputee; however, closer examination and X-rays of the patient revealed that femoral neck and head were present bilaterally. The remaining skeletal structures of the femurs are approximately 3" on the left and 4" on the right side (<a href="/files/original/4ba0e022e7651bf5a36b045a6168ac98.jpg"><b>Fig. 1</b></a>).</p> <p>The patient was first hospitalized at the Allentown Hospital in Allentown, Pennsylvania, and then became a patient at the St. Vincent's Rehabilitation Center in Erie, Pa. There he received initial rehabilitation training and became ADL independent.</p> <p>On September 29, 1967 a prosthetic prescription for a definitive prosthetic unit was written.</p> <p>"Modified bilateral hip disarticulation prosthesis with modified plastic split hip disarticulation buckets for bilateral use, Northwestern stride control hip joints, single axis knee units with positive locks and SACH feet."</p> <p>The split bilateral hip disarticulation socket was prescribed with the hope that the patient would be able to advance one foot in front of the other and, consequently, walk with a semi-normal gait (taking full advantage of the remaining femurs). The stride control hip locks and positive knee locks were to give him stability during walking and stance.</p> <h3>Taking of the Cast</h3> <p>The negative mold of the patient's body was obtained by utilizing the Northwestern Type Four Point Suspension Technique. The patient was freely suspended approximately 3 feet off the floor in a double layer of 10" nylon stockinette and the body stocking conformed snugly to the patient's body (<a href="/files/original/7b7fb17dbc1e54bd9317ab53fa1a6774.jpg"><b>Fig. 2</b></a>).</p> <p>The outlines of the prosthetic socket and all bony protuberances, such as the remaining femurs, the anterior superior iliac spines, the iliac crests, and the ischial tuberosities, were carefully marked with indelible pencil. Four inch fast setting plaster-of-Paris bandages were used for the cast. A rope of plaster-of-Paris bandage was pulled in deeply proximal to the iliac crests to supply suspension of the socket.</p> <p>After the plaster bandage was applied, the patient was lowered onto a stool until the ischial tuberosities were bearing moderate pressure and the patient's position was stable. Plumb lines on the anterior, posterior, and lateral midlines were drawn. The cast was then split anteriorly and posteriorly and removed from the patient's body (<a href="/files/original/54f4c998ff0b12d9f2b0955afd658381.jpg"><b>Fig. 3</b></a>).</p> <h3>Filling of the Negative</h3> <p>The anterior and posterior openings were sealed and the negative was positioned on a table and all four vertical reference lines were aligned with a level. A 3/4" pipe was positioned and aligned with the four reference lines using a special holding device. The filling of the negative proceeded in the usual manner.</p> <p>After hardening of the plaster, the reference lines were punctured with an awl and marked on the top surface of the cast. The lateral reference lines were used to establish fictitious trochanters bilaterally.</p> <p>These trochanters were located 1 1/2" proximal from the distal end of the cast. A 45° triangle was cut from 1" thick plywood. The lines for positioning of the hip joints were marked by locating the plywood triangle exactly on the previously marked trochanters with the lower point anterior. The plaster-of-Paris bandage was then removed from the male mold.</p> <h3>Modification of the Male Mold</h3> <p>All reference lines punched with the awl were connected and retained. All marked bony protuberances were built up with plaster of Paris to approximately 3/8" to 1/2". Trimlines of the socket were drawn. These consisted of a proximal brim approximately 3/4" below the rib cage and anterior and posterior teardrop openings, 4" by 5", connected to each other distally by a channel 1 inch wide. The cast was then smoothed and the trimlines built up and molded to a flare of approximately 3/4" radius. This was for the patient's comfort.</p> <p>The mold was then allowed to dry in an oven for 24 hours at a temperature of 115°F. Then it was positioned in a vise exactly 45°, using a specially milled 45° steel positioning block so that the trochanteric reference lines were vertical. The alignment of both lines was checked with a plumb line. Two cardboard cylinders, 4" in circumference and 3" high, were taped to the cast, keeping the hip joint reference lines exactly centered. Both cylinders were covered on top, and only a hole the size of a quarter was left open on each cylinder through which the liquid foam was poured.</p> <h3>Hip Joint Mounting</h3> <p>The top of each block was cut square and level with the ground and as close to the mold as possible. The hip joint mounting reference lines were marked on the blocks, and both hip joints positioned. The outline of the base plates was marked, and the foam blocks were shaped to blend in with the entire cast. The base plates were attached with plaster of Paris, and the entire foam build-ups sealed with plaster of Paris. An extra build-up of plaster of Paris of approximately 3/4" thickness was provided over the entire seat area, which would later give space for a foam (silastic) seat pad. The cast was now air dried.</p> <h3>Fabrication of the Socket</h3> <p>The model was prepared for vacuum lamination, smoothed, lacquered, and a PVA sleeve applied. The first lamination consisted of four layers of 8" nylon stockinette and polyester resin (90% 4110 - 10% 4134). After this lamination was completed, the entire surface was roughened with coarse sandpaper and a reinforcement of nine feathered layers of fiber glass cloth and epoxy resin (C-8) applied over each hip joint attachment area. A final layer of three layers of stockinette and polyester resin completed the lamination process.</p> <p>The completed socket was removed from the model, cut to the trimlines, and all edges were smoothed. The foam blocks and plaster of Paris build-ups were carefully removed, and the entire cast smoothed, lacquered, and greased. The interior hip joint mounting plates were attached with two screws, leaving one screw hole and a 3/8" center hole open for injection of the silastic. The two half sockets were repositioned on the model and the silastic, 25% 385 and 75% 386, was injected into each side. After curing of the silastic the two halves were removed and the hip joints and thigh block installed.</p> <h3>Alignment and Fitting</h3> <p>The prosthetic feet were set up so that a reference line from the hip joints through the knee bolts would fall 2 1/2" posterior to the heel of the shoes. Subsequently during dynamic alignment this was increased to 3 inches.</p> <p>The height of the knee centers was set so that the patient would be able to sit in a normal chair with both feet flat on the floor (<a href="/files/original/c87f8df1446c1a57754c6d380e1dc234.jpg"><b>Fig. 4</b></a>). Two cork seat blocks had to be added to the seat of the sockets to bring the patient up to a normal and level sitting position.</p> <p>A prelaminated flexible plastic tongue provided a closure of the anterior opening of the socket. Buckles and Dacron-reinforced leather straps were used instead of Velcro straps as the Velcro straps would be too inconsistent. The posterior opening of the socket was closed with a 4" by 6" by 1/8" Ortholene flexible hinge, so that the patient could walk with his semi-normal gait (<a href="/files/original/aa356de1c97d7c797ba7399a8a358c73.jpg"><b>Fig. 5</b></a>).</p> <p>From the knee units, cables complete with housing and retainers were brought up laterally within easy reach of the patient's hands. For unlocking they hook onto small stainless steel hooks. The stride control hip locks were to lock automatically when the patient stood up. The patient is indeed able to ambulate, advancing consecutively one foot after the other. Ascending and descending stairs is accomplished by the patient hoisting himself on the banisters (<a href="/files/original/4a16949b838f44f4b7bbfc854e44bbed.jpeg"><b>Fig. 6</b></a>, <a href="/files/original/84863942578d92ee15a89ac6adee6168.jpeg"><b>Fig. 7</b></a>). After the patient became more skilled in ambulating, and due to the extreme stability, the hip stride control locks were removed and stride length control straps substituted, giving the patient a somewhat longer step.</p> <p>The patient was followed by the author for approximately two years, during which time he was wearing his prosthesis extensively.</p> <p>After one year he was fitted with a bucket-type prosthesis which was distally closed and not used as a split socket prosthesis. A platform was attached to this socket, and carpet rollers were used so that the patient could perform some mechanic's activities closer to the floor. He propelled himself with his hands, and used padded leather gloves for that purpose.</p> <b>*<em>Peter A. Ockenfels, C.P.O. </em></b><em> American Orthotic &amp;Prosthetic Laboratory, Inc., Columbus, OH<br /><br /><br /></em> Page Number(s) 5 - 8 Year 1982 Volume 5 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1982_01_005/1982_01_005-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1982_01_005/1982_01_005-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1982_01_005/1982_01_005-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1982_01_005/1982_01_005-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1982_01_005/1982_01_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/1982_01_005/1982_01_005-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1982_01_005/1982_01_005-7.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 Management and Construction Procedure of Bilateral Split-Bucket Type Hip Disarticulation Prosthesis Creator An entity primarily responsible for making the resource Peter A. Ockenfels, C.P.O. * https://staging.drfop.org/files/original/4e183acf56bb242b877abe71bad0c82c.pdf 2d5fb2193aba4c56fe7e72e3aa738711 https://staging.drfop.org/files/original/f35dbf1ec5058164a5372c266853ed58.jpeg b93e3a485fb5fa30970f58cb3c3f97b4 https://staging.drfop.org/files/original/84f9510431f05aafdee61cf4a63a6e60.jpg 815e14879134606d06e3dec6ad49473c https://staging.drfop.org/files/original/2bf778e75bd7f9b6cdd9a04374f57fee.jpg 0ce17c62d2456956432115616f913c64 https://staging.drfop.org/files/original/bf19e271aafb1c9ff9bb542af0b93338.jpg d3e8c2de5e80c1498f33a82414e7bcb3 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_01_011.pdf Text Any textual data included in the document <h2>A Modified Hemipelvectomy Socket</h2> <h5>Peter A. Ockenfels, CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>This paper is to demonstrate a modified design for a hemipelvectomy type of prosthetic socket, which was designed for an endoskeletal system prosthesis.</p> <p>The patient, a 28-year old white male, while involved in the operation of heavy equipment in May of 1978, experienced severe crushing type injuries. The injuries required a hemipelvectomy amputation on the right side, and due to peroneal nerve injuries, the function of the left lower limb was limited. For the purpose of this paper, however, only the hemipelvectomy socket design, which is different and special due to the presence of a colostomy, which needed to be fitted into the prosthetic receptacle, will be discussed.</p> <p>The patient's first prosthesis was designed in the usual fashion with the colostomy inside the prosthetic socket. This restricted drainage into the colostomy device. The patient needed to remove his prosthetic socket during the day in order to relieve pressure and dispose of the accumulated waste.</p> <p>In considering the design of a new prosthesis, it was felt that an anterior or a lateral opening on the opposite side was inadequate and non-functional since the colostomy opening could not be maintained in one particular area at all times. Thus, a lateral opening was provided on the amputated side. A flexible tongue allows the socket to expand as the patient dons his prosthesis (<a href="/files/original/f35dbf1ec5058164a5372c266853ed58.jpeg"><b>Fig. 1</b></a>). A single Velcro strap (<a href="/files/original/84f9510431f05aafdee61cf4a63a6e60.jpg"><b>Fig. 2</b></a>) secures the prosthesis, and the colostomy opening is maintained in a permanent position while standing (<a href="/files/original/2bf778e75bd7f9b6cdd9a04374f57fee.jpg"><b>Fig. 3</b></a>), as well as sitting (<a href="/files/original/bf19e271aafb1c9ff9bb542af0b93338.jpg"><b>Fig. 4</b></a>).<br /><br /><em><b>*Peter A. Ockenfels, CPO </b> American Orthotic &amp;Prosthetic Laboratory, Inc., Columbus, OH</em></p> Page Number(s) 11 - 11 Year 1983 Volume 7 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1983_01_011/1983_01_011-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1983_01_011/1983_01_011-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1983_01_011/1983_01_011-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 4 http://www.oandplibrary.org/cpo/images/1983_01_011/1983_01_011-4.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 Modified Hemipelvectomy Socket Creator An entity primarily responsible for making the resource Peter A. Ockenfels, CPO * https://staging.drfop.org/files/original/cafa9b743d894ef8ac329dd049105439.pdf c5c3c6f8570f5611fb7f6c5a42f9907f https://staging.drfop.org/files/original/da8d8abfb620ef2e663567dd50bcc654.jpeg 1a03a7488c0c4c3a9df9bdbc0366fc44 https://staging.drfop.org/files/original/3f58c60474774ff9e63168d5ae29a02e.jpg 815138367afbe230364d1322051cddfe https://staging.drfop.org/files/original/3144aa6cc1e6fdbd0b6a2114007d029c.jpg 5b636b99ef116d0e221fdb299ac85bb1 https://staging.drfop.org/files/original/5d13bc560af79f59d4201f44574589b8.jpg c266285611b6774216497b8f21a83e26 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_03_008.pdf Text Any textual data included in the document <h2>Technical Note: Wrist Flexion Unit Modification</h2> <h5>Peter A. Ockenfels, CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Several years back we learned that a wrist flexion unit, be it the Homser FM 500, 300, 200, or the Pope Easy Flexion Wrist PW 4-6, has little value for bilateral above elbow or bilateral shoulder disarticulation amputees. The patient involved, a right true shoulder disarticulation and left humeral neck amputee, had been successfully fitted with bilateral prostheses. The term "successful" can only be used in terms that the patient felt comfortable, was able to flex his elbows to 90 degrees and 135 degrees, and able to open the terminal device with extended elbow 100 percent of full opening elbow flexion of 90 degrees, 80 percent, and at elbow flexion of 135 degrees, 50 percent. Both prostheses were harnessed with leg loops and the usual elbow lock controls. Wrist units were prescribed and incorporated into both forearms, but proved to be quite useless due to the fact that the patient was unable to activate the wrist units.</p> <p>To rectify the situation, the following modification was constructed. The trigger bar that activates the wrist flexion units is located medially on either wrist unit; therefore, an activating lever was designed and incorporated into the forearm (<a href="/files/original/da8d8abfb620ef2e663567dd50bcc654.jpeg"><b>Fig. 1</b></a>), so that the patient can trigger wrist flexion by pushing against a chair, his leg, or any other object (<a href="/files/original/3f58c60474774ff9e63168d5ae29a02e.jpg"><b>Fig. 2</b></a>). Extension of the wrist unit is achieved using the legs (<a href="/files/original/3144aa6cc1e6fdbd0b6a2114007d029c.jpg"><b>Fig. 3</b></a>). The trigger lever (<a href="/files/original/5d13bc560af79f59d4201f44574589b8.jpg"><b>Fig. 4</b></a>) is made of 1/8" aluminum and pivots on a 3/16 half-threaded rod, mounted in the sides (ant. and post.) of the forearm wall. The patient no longer uses his right SD prosthesis and has been converted to a special chest harness. The wrist flexion trigger mechanism has proven to be very successful, and the patient would not be able to accomplish many tasks of daily care without it.</p> <em><b><b>*Peter A. Ockenfels, CPO </b></b>American Orthotic &amp; Prosthetic Laboratory, Inc. Columbus, Ohio</em><b><b><br /><br /></b></b> Page Number(s) 8 - 8 Year 1983 Volume 7 Issue 3 Figure 2 http://www.oandplibrary.org/cpo/images/1983_03_008/1983_03_008-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1983_03_008/1983_03_008-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 4 http://www.oandplibrary.org/cpo/images/1983_03_008/1983_03_008-4.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1983_03_008/1983_03_008-1.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 Technical Note: Wrist Flexion Unit Modification Creator An entity primarily responsible for making the resource Peter A. Ockenfels, CPO * https://staging.drfop.org/files/original/730cd988b459c0470f09d2a2b1c901c0.pdf c64b39002b638752f02a6481b5256f6c https://staging.drfop.org/files/original/f5b53660057bef0aa5062375e0944618.jpg 71c691b1acd762609be7aef78e31a615 https://staging.drfop.org/files/original/507f8e598d697564a8825ef436c9831f.jpg 8c2dab42f1da4a77dd5b8083f04dce69 https://staging.drfop.org/files/original/541b427a8b6b0e194b041e8cc2c59da1.jpg 6919d95465a51c86db5c65678cb30502 https://staging.drfop.org/files/original/3d90295042f79f041d671c5d41f0392d.jpg 7d59e48c5e8c4047578f190b6e516375 https://staging.drfop.org/files/original/71925d0bb446f6b649060c3ce4462e59.jpg 9b323c95c211ec10d01e7feee755cd18 https://staging.drfop.org/files/original/3396fe9730b14b2e8657689fe74865b5.jpg 643294f08d5a592e58d3ea194294785d https://staging.drfop.org/files/original/b9a09fc152979d703b46c792aed66798.jpg a101cb269531ad4c2ddca3abe3c64fb3 https://staging.drfop.org/files/original/a310a604046c1382bc0c3548b947c299.jpg 0c5f822f77e1f2a66fd8f148fb0fb1b0 https://staging.drfop.org/files/original/2a80303457c8a42d0517fa0e01a299e9.jpg 44668a6d1b6a2b3675ba14074520a508 https://staging.drfop.org/files/original/3df94aa6ab1f93ff4d20a470503069ef.jpg f0c64be6e5bbae5c7b28834975248ee8 https://staging.drfop.org/files/original/3afb84d3903ae00d345a76156822ebc2.jpg c8495b91e25a321f39294efe21e110ad Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_03_109.pdf Text Any textual data included in the document <h2>The Hip Disarticulation Prosthesis as Developed by the O.I.M. Noord Nederland</h2> <h5>Peter Tuil&nbsp;<a style="text-decoration: none;">*</a></h5> <p>What characterizes the hip disarticulation prosthesis of the O.I.M. Noord Nederland is the use of a four-bar Otto Bock knee joint as a hip joint. O.I.M. Noord Nederland has used this variation with much success over the last five years. At first, it was questionable whether the joint would be strong enough, but this has proven not to be an issue. There have been some problems with the 3R21, but only when it is used as a knee joint. These complications have been due to extreme flexion, lamination sections that were too thick and caused the joint to tear apart during flexion, or too much external rotation.</p> <p>There are two advantages in the use of the four-bar hip joint. First, the patient walks with a lower energy expenditure because the prosthesis shortens the swing phase. In contrast to patients who have worn older style hip disarticulation prostheses (for years patients used to be fitted with a tilting-table prosthesis or later with a wooden "Canadian hip" prosthesis), the patients with the new style prosthesis walk more and have indicated that they use less energy. Second, there is hardly any strain on the cosmetic cover, so much less damage is done.</p> <p>An additional advantage of the four-bar joint is that the construction can be less critical. Besides, the whole prosthesis can be readily adjusted.</p> <h3>Description of the Fabrication Method</h3> <p>To make the plaster impression, two wooden blocks are mounted on a table or casting stand. (Editorial note: Presumably this stand is adjustable in height.)</p> <p>These wooden blocks have sloped planes so that a wedge-formed gap is created between them (<b>Fig. 1</b>). In the back, the sloped side forms a 60° angle. In the front, the sloped side is divided into two different angles (<b>Fig. 2</b>). Both blocks can rotate around their vertical axles with regard to the table to which they are attached. They can also be shifted with regard to each other in the sagittal plane by means of a spindle (worm gear mechanism). The blocks are primarily meant to provide a good fitting of the residual limb and pressure relief in the places where that is necessary.</p> <strong><a href="/files/original/f5b53660057bef0aa5062375e0944618.jpg">Figure 1</a>. Apparatus used for casting.</strong><br /><br /><strong><a href="/files/original/507f8e598d697564a8825ef436c9831f.jpg">Figure 2</a>. Side view of the wooden blocks.</strong><br /> <p>The four-bar joint is attached to the socket by means of a specially manufactured adaptor (<b>Fig. 3</b> and <b>Fig. 4</b>). The adaptor, which will later be incorporated into the socket, mimics the wedged shape of the wooden blocks (<b>Fig. 5</b>).</p> <strong><a href="/files/original/541b427a8b6b0e194b041e8cc2c59da1.jpg">Figure 3.</a> The adaptor.</strong><br /><br /><strong><a href="/files/original/3d90295042f79f041d671c5d41f0392d.jpg">Figure 4</a>. Shows how the adaptor, which will later be laminated into the socket, relates to the wedged form of the wooden blocks.</strong><br /><br /><strong><a href="/files/original/71925d0bb446f6b649060c3ce4462e59.jpg">Figure 5.</a> The apparatus forms a good plane of reference.</strong><br /> <p>Finally, the impression of the wooden table provides a good plane of reference for the plaster model (<b>Fig. 6</b>).</p> <strong><a href="/files/original/3396fe9730b14b2e8657689fe74865b5.jpg">Figure 6</a>. Position of the adaptor as related to the pelvic socket.</strong><br /> <p>This impression of the horizontal plane must remain horizontal during the construction process. During plaster modification, one should maintain unchanged the medial of the plaster model in the transverse plane, so that the impression of this edge will always indicate the line of progression of the plaster model.</p> <p>The socket is laminated in three layers. First though, a layer of Pe-Lite™ is put on the plaster model, followed by a layer of stockinette, and finally a layer of P.V.A. foil. The layer of stockinette is always applied under the first layer of foil. This will provide better suction, absorb some moisture, and the plaster model need not be as smooth.</p> <p>The first layer is laminated from flexible resin with two layers of Perlon stockinette, which is elastic in two directions. Subsequently the adaptor is located as shown in <b>Fig. 7</b>.</p> <strong><a href="/files/original/b9a09fc152979d703b46c792aed66798.jpg">Figure 7</a>. Reinforcement of the socket.</strong><br /> <p>The space between the adaptor and the plaster model is filled with "leichtspatel" (filler). The base of the plaster model must stand horizontally. The adaptor is placed approximately 4 to 5cm lateral of the groin. The maxim is to get the adaptor directly underneath the ischial tuberosity. However, this is influenced by the needs of the cosmetic cover.</p> <p>The adaptor is then covered with two layers of stockinette and a reinforcing layer of carbon fiber matting to prevent the adaptor breaking loose from the forces generated at heel strike. A strip of carbon fiber is put in the front to prevent the pelvis socket from curling inward. A reinforcing band of glass fiber is placed diagonally as shown in <b>Fig. 8</b>. Over this, two layers of stockinette are placed. First, rigid lamination resin is applied on those areas where the socket must be rigid. The rest is laminated with flexible resin. An adjustable "jig" is necessary in order to be able to turn the model around in the bench-vice quickly. The final layer is done with flexible resin and two layers of stockinette.</p> <strong><a href="/files/original/a310a604046c1382bc0c3548b947c299.jpg">Figure 8</a>. Alignment is first considered with the patient seated.</strong><br /> <p>A layer of stockinette and P. V. A. foil are put on the socket. Then, the little cap needed to finish the cosmetic cover is laminated with three or four layers of stockinette and one layer of carbon fiber. The extra time needed to form this cap will later save a lot of time during the finishing of the cosmetic cover.</p> <p>The prosthesis is completed with a four-bar knee joint (3R21), a single axis ankle joint foot, and a rotation adaptor.</p> <p>The alignment of the prosthesis is first considered in the sitting position. One must take into account the symmetry in comparison to the healthy limb (<b>Fig. 9</b> and <b>Fig. 10</b>). The definitive alignment is settled upon during stance and walking exercises (<b>Fig. 1</b>0). The adjustment of the 3R21 knee joint is very important. Mistakes in alignment can cause malfunctions of the knee joint. Many adjustments are possible with regard to rotation in the hip joint itself. The lack of facility to adjust abduction has never been a problem.</p> <strong><a href="/files/original/2a80303457c8a42d0517fa0e01a299e9.jpg">Figure 9</a>. Side view of the patient sitting and wearing the prosthesis.</strong><br /><br /><strong><a href="/files/original/3df94aa6ab1f93ff4d20a470503069ef.jpg">Figure 10</a>. The realization of definitive alignment.</strong><br /> <p>The freedom of movement when seated is considerable (<b>Figs. 11 and 12</b>).</p> <strong><a href="/files/original/3afb84d3903ae00d345a76156822ebc2.jpg">Figure 11 and 12.</a> Freedom of movement when seated.</strong><br /> <p>The cosmetic cover is shaped in the hip area, as well as in the knee area, so that less tension will be induced in the cover during flexion and when seated. Finally, a long elastic strip is glued to the inner anterior wall of the cover. This is done to protect the foam-cover.</p> <p>The construction process for a prosthesis for a hemipelvectomy is similar.</p> <em><b>*Peter Tuil </b> Peter Tuil can be contacted at Stitchting Orthopedische Instrumentmakerij, Noord-Nederland Dilgtweg 5, 9751 ND Haren (Gn), The Netherlands.<br /><br /><br /></em> Page Number(s) 109 - 113 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-10.jpg Figure 11 FIGURE 11 & 12 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-11.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Hip Disarticulation Prosthesis as Developed by the O.I.M. Noord Nederland Creator An entity primarily responsible for making the resource Peter Tuil * https://staging.drfop.org/files/original/d88a16b9a8be8084709e5e3adb48845a.pdf 3bf668620dc8e9ac8dec0a9782f54663 https://staging.drfop.org/files/original/9821ea432dcfb99e529e07004a2d4b03.jpg 5d9aa8667c4ce230ed99756df8364395 https://staging.drfop.org/files/original/eb06fba52df94637c4b6d85035154ac4.jpg 9af7d40a114f591e59157a8d4bd39d7b https://staging.drfop.org/files/original/71125124f8bf550f9e1870dc7b82f83d.jpg c3f5f019e6bcd04d9fb4bfd8a7ea136b https://staging.drfop.org/files/original/c83141350daa6a9dced25ae8109cb4cb.jpg 0deaeb30af7098bb4cefd892cadccc9c https://staging.drfop.org/files/original/625a51addd8c1771d0fbfb9ff3446faf.jpg 5b7f229a85f9f81fb36df03e125eb95f https://staging.drfop.org/files/original/a65a9477cbb2256a4c408da06fd4df7c.jpg f1fb749d8eb5ae7fdb7aceb732bfd3cc https://staging.drfop.org/files/original/7a19ba2de351fc879c98037e9c7956ca.jpg 0972d0503197bd6c97a29eca33d9dfc3 https://staging.drfop.org/files/original/925e37100e40101885b0398c2f037f9d.jpg 00861f5944bcf0f34911969c8b80d7f8 https://staging.drfop.org/files/original/ae805c38cc6d026abdb67d5c360765fc.jpg 3e1feb6503597f324afdbd0f0eb66669 https://staging.drfop.org/files/original/b73662bf43c27c8c8d15f5062cc7888b.jpg 77cd871c4f3f6062588f8e31b5524165 https://staging.drfop.org/files/original/2815dcc928454d295136ea43e0f41512.jpg 2f18a1dc1f8aad3b6c99e9c30f158861 https://staging.drfop.org/files/original/bc5ce764af992800cce13e2e42da079d.jpg cb14265891e5a2032db169a588dc6af6 https://staging.drfop.org/files/original/216ecc082ecea7c002317a5eb27d1d67.jpg 021d3e3f8d4f67bcbfbc942c5e2fc0f2 https://staging.drfop.org/files/original/33d9ce6aa7d9acddadfc6e4d2e456e03.jpg 8f1a796e02e25b804a1655808e51b6fa https://staging.drfop.org/files/original/be22f04f3641e4eb9b1cef97a00dc965.jpg bd502110b239db19d048a8790d45337b https://staging.drfop.org/files/original/144ae762beee458ea85db2c14acf2563.jpg 896f7b63820817cc7194620990fddbbc https://staging.drfop.org/files/original/a3349004a023470f77a69f0db5586cf6.jpg c41f81120bd300258ce7f60145120ffe https://staging.drfop.org/files/original/3346562c362c352c74f3c5f15478deb2.jpg 7a688ef6fc33cfb6d1e84f5824c83923 https://staging.drfop.org/files/original/fc6361c99f7ba00662630eaca378f5a4.jpg de3ee67c2d6483c25e1eb10f66991303 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1961_01_004.pdf Year 1961 Volume 6 Issue 1 Page Number(s) 4 - 43 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1961_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1961_01_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>The History and Development of Syme's Amputation</h2> <h5>R. I. Harris <a style="text-decoration:none;">*</a><br /></h5> <p>James Syme (1799-1870), the last and greatest of the pre-Listerian surgeons (<b>Fig. 1.</b>), was renowned in his day as the most eminent surgeon in the English-speaking world. Well informed and well trained by study and travel, he developed in practice the experience, courage, sagacity, and dexterity that enabled him to obtain improved results in the surgical treatment of disease at a time when anaesthesia and antisepsis were unknown. During his occupancy of the Chair of Clinical Surgery at the University of Edinburgh (1833-1869), he developed and perfected many new surgical procedures. Time has outmoded them all save one-his disarticulation amputation through the ankle joint with preservation of the heel flap to permit weight-bearing on the end of the stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. James Syme (1799-1870), Professor of Clinical Surgery, University of Edinburgh, 1833-1869. Holl's engraving from George Richmond's drawing of him "in the prime of life." Probably this was Syme's likeness at age 43 when he performed his first amputation at the ankle. From Paterson. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the days before antisepsis, the surgeon's efforts to cure his patients frequently ended in disaster. Compound fractures and operation wounds were almost invariably complicated by one or other of the "hospital diseases"<a></a>: erysipelas, septicaemia, pyaemia, hospital gangrene. The patient was fortunate if he escaped death. On rare occasions his wound might heal by "first intention" or "under a scab." Otherwise the wound became "inflamed." If it discharged "laudable pus," it might heal by "second intention," and if so the outlook was reasonably good. But if the discharge was "thin, watery, sanious, acrid," the future for the patient was ominous. Death too frequently supervened. We know now that these complications were the manifestation of virulent infections. But in 1843, when Syme wrote his first paper <i>On Amputation at the Ankle Joint<a></a>, </i>Pasteur's work on fermentation<a></a> which first revealed to us the world of microorganisms, was still more than a decade in the future (1856), and Lister, the founder of antiseptic surgery, was at age 16 finishing his preliminary education with a view toward entering University College, London. Twenty-four years were to elapse before Lister first wrote on his success in treating compound fractures with carbolic acid (1867). Till then the surgeon resigned himself, as had his predecessors from the dawn of history, to the possibility that his most skillful efforts and even the most simple of his operations would be followed too often by dangerous or even fatal reactions. Writing of this period, Volkmann<a></a> said in flowery simile:</p> <blockquote><p>The surgeon is like the husbandman, who having sown his field, waits with resignation for what the harvest may bring, and reaps it, fully conscious of his own impotence against the elemental powers, which may pour down on him rain, hurricane and hail storm.</p> </blockquote> <p>There is a vivid and moving picture of the surgery of the preanaesthetic and preanti-septic era in the story <i>Rab and His Friends.</i><a></a> The author, John Brown, was Syme's pupil and later his colleague and friend, and he admired him profoundly. In the memorial he wrote after Syme's death, he stated<a></a>:</p> <blockquote><p>He was my master-my apprentice fee bought him his first carriage; a gig, and I got the first ride in it, and he was my friend. He was I believe the greatest surgeon Scotland ever produced; and I cannot conceive of a greater clinical teacher.</p> </blockquote> <p>In the account of Ailie's operation, in <i>Rab and His Friends, </i>Syme is the surgeon, and John Brown is the house surgeon who tells the story. In spite of Syme's skill in removing Ailie's breast for cancer, she develops septicaemia and dies. The agony of her death from this frequent complication of the surgery of those days is so graphically depicted that it brings home to us with dramatic force the immense risks which beset the individual who sustained a compound fracture or was compelled to submit to surgical treatment-all the more impressive because it is told to us by a participant in the tragedy.</p> <p>In the case of open fractures, the complications were so likely to be fatal that the most radical measures were deemed necessary to forestall the spread of "putrefaction." Immediate amputation through the thigh was the standard procedure for compound fractures of the tibia and fibula, amputation at the site of election (a hand's breadth below the tibial tubercle) for caries and compound injuries of the foot <a></a>. Though the mortality from these amputations was 25 percent in the hands of the best surgeons and 50 percent in hospitals less carefully managed<a></a>, the results were better than those to be had from any other form of treatment. The result of conservative treatment was much worse. Mortality from compound fractures of the femur so treated was 80 percent<a></a>, from compound fractures of the tibia 50 percent<a></a>, and from compound dislocation of the astragalus 87 percent<a></a>. Whether patients were treated conservatively or by amputation, the mortality from compound injuries of the foot was shockingly great. Of those who survived compound dislocation of the astragalus without amputation, Syme said<a></a>:</p> <blockquote><p>. . . the foot generally remains in such a state of stiffness, weakness and sensibility to external impressions as to be rather an encumbrance than a support to the patient.</p> </blockquote> <p>For those who survived after amputation of the leg, the disability from loss of the limb also was great. In the words of Syme <a></a>:</p> <blockquote><p>So long as the only alternatives were an attempt to preserve the limb and amputation of the leg, there was a strong inducement to abstain from operating. But if the patient's safety and speedy recovery may be ensured by taking away merely that part of the limb, which in the circumstances can be of little value either to use or ornament, while at the same time a stump is produced in all respects preferable to a shattered, stiff, irritable foot, I think there should be little hesitation in resorting to amputation at the ankle joint under the circumstances in question.</p> </blockquote> <p>During a period of study in Europe (probably in 1822 in Paris, where he attended Lisfranc's course of surgical operations on human cadavers and Dupuytren's lectures and clinical demonstrations), Syme learned the technique of Chopart's amputation for removal of part of a foot damaged or diseased. He introduced the procedure in Edinburgh in 1829, and the results he obtained convinced him of its merit.</p> <p>Chopart's amputation (disarticulation at the mid-tarsal joint, long plantar flap) was seldom complicated by the hospital diseases that made amputations through the leg so dangerous, and it left the patient with a partial foot capable of weight-bearing and with a movable ankle joint above it. We now know that the success of Chopart's amputation was a demonstration of the principle that, in the presence of sepsis, disarticulation is a much safer procedure than is amputation through muscle masses and the open medullary cavities of long bones. Articular cartilage left on the end of a bone, or the subarticular cortical plate and the network of cancellous bone deep to it, serve as barriers to the spread of infection, whereas the intermuscular and interfascial planes of an amputation stump provide easy pathways for invasion by microorganisms. Syme could not know the true reason for the life-saving merit of Chopart's amputation because knowledge of bacteria and of wound infections was still in the future. His conviction of its value was founded on empirical experience.</p> <p>Syme commented upon the merits of Chopart's amputation as follows:</p> <blockquote><p>The operation of Chopart, which leaves only the astragalus and os calcis, is the most valuable of all partial amputations as it commands the largest portion of the foot requiring removal for disease or injury, and at the same time preserves a support for the patient not less useful than that which is afforded by the whole of the tarsus. Its introduction was long opposed on the ground that the extensor muscles of the ankle, acting through the tendo achillis, when no longer antagonized, would draw up the heel and point the cicatrix to the ground. I performed this operation in 1829, so far as I know for the first time in Edinburgh (Great Britain?) and have frequently done so since with the most satisfactory result, no inconvenience having been experienced from the source just mentioned, as the cut ends of the tendons on the forepart of the joint speedily acquired new attachments enabling them to counteract the extensive power.</p> </blockquote> <p>Syme's favourable impression of the merit of Chopart's disarticulation at the mid-tarsal joint led him to apply the same principle to the ankle joint when caries or compound injury involved the astragalus or calcaneus, problems for which Chopart's amputation was inadequate. He performed his first disarticulation at the ankle joint in 1842, thirteen years after his first Chopart amputation. The long delay in applying to the ankle joint the principle which was so successful at the mid-tarsal joint arose from the problem of how to make the long stump bear weight satisfactorily. Disarticulation at the ankle joint might prove as effective as Chopart's amputation in saving the patient's life, but the long stump would prove an intolerable nuisance unless the patient could walk upon it. In Chopart's amputation, walking upon the stump presented no problem since the whole of the posterior half of the sole of the foot remained intact, and upon this the patient walked almost as easily as upon a normal foot. Amputation at a higher level (a hand's breadth below the tibial tubercle) permitted weight-bearing by applying the flexed knee to the padded cleft in the upper end of a crude prosthesis. This was "amputation at the site of election," a useful operation if the patient survived, but the mortality rate was 50 percent.</p> <p>To make disarticulation at the ankle joint a functional success, some procedure was needed which would permit all the body weight to be borne upon the end of the stump in a manner similar to Chopart's stump. Other surgeons had attempted to solve this problem without success. Syme's solution was to detach from the underlying tarsal bones the whole thickness of the posterior half of the sole of the foot, disarticulate the astragalus from the mortise of the ankle joint, remove the malleoli, and then reapply the heel flap to the lower ends of the tibia and fibula. This proved to be the technique necessary for a satisfactory end-bearing stump at the level of the ankle joint for it provided a thick and bulky covering for the end of the stump composed of tissue adapted to weight-bearing.</p> <p>Syme's account of the development of his new operation is interesting<a></a>:</p> <blockquote><p>The idea of amputating at the ankle joint is not new, the operation having been performed on the Continent by different surgeons before I thought of it; and it would probably ere now have become generally adopted but for the doubt that was entertained as to the ends of the bones being sufficiently covered to afford the patient a comfortable and useful support for the limb. For my own part when I read of dissecting flaps of skin from the instep, or sides of the foot, I felt so much distrust in the protection that could thus be effected against the injurious effects of pressure on a part so exposed to it, that I had no desire to try the experiment. But it occurred to me, that by performing the operation in a different way all such objections might be obviated. This was to save a flap from the sole of the foot and the thick integuments of the heel, by making a transverse incision, and dissecting these parts from the os calcis, so that the dense structures provided by nature for supporting the weight of the body, might still be employed for the same purpose. Two trials of this operation having proved satisfactory, I communicated them to the profession, and am glad to find that not only my colleagues in the hospital here, but also practitioners in other planes have already acted upon this recommendation. The additional experience of my own practice now enables me to suggest some improvements in the mode of procedure-point out an error to be avoided [this was cutting the posterior tibial artery before division into the median and lateral plantar branches]-and verify the expectation formerly expressed as to amputation of the leg being hardly ever required.</p> </blockquote> <p>Since Syme does not say why it took him so long to evolve this successful technique, we can only speculate upon the reasons. It may be that the principle of raising a skin flap and then replacing it in a new position was sufficiently radical to make him hesitate. This is a possibility for it was known that amputations with flaps were more prone to postoperative troubles than circular amputations. Or it may be that he was so immersed in the many other new surgical procedures he introduced that time elapsed before he gave thought to disarticulation at the ankle joint. Or it may be that it required thirteen years of experience with Chopart's amputation to convince him that disarticulation was so much more safe than amputation that he would be justified in applying the principle to the ankle joint. Probably this last supposition is important. In the era of "hospital diseases" it was of immense value to know that disarticulations could with certainty be relied upon to heal without the complications which after amputations endangered life and marred the healing of the stump.</p> <p>Syme's first patient <a></a>was a 16-year-old boy who suffered from caries of the tarsal bones, almost certainly tuberculosis. Syme described the problem, the operation, and the result in his first published paper on the subject:<a></a></p> <blockquote><p>John Wood, aged 16, was admitted to the Royal Infirmary on the 8th of September, 1842, suffering from disease of the foot which had suppurated and ulcerated in consequence of a twist he had given to it in walking about twelve months before. The instep was swollen and there were two openings discharging pus. A probe entered the sinuses freely into the substance of the tarsal bones, more particularly the astragalus and os calcis.... As the disease had extended beyond the limits of Chopart's amputation it would have been necessary in accordance with ordinary practice to remove the leg below the knee, but as the ankle joint seemed sound I resolved to perform a disarticulation there. With this in view, I cut across the instep in a curved direction with the convexity towards the toes, and then across the sole of the foot so that the incisions were nearly opposite one another. The flaps thus formed were next separated from their subjacent connexions which was easily effected except at the heel where the firmness of texture caused a little difficulty. The disarticulation being readily completed, the malleolar projections were removed by means of cutting pliers.</p> </blockquote> <p>Although a small slough separated from the edge of the lower flap, in which a counter-opening had to be made for the drainage of matter, the patient recovered with little reaction and left the hospital in three months. Five months after the operation:</p> <blockquote><p>. . . the wounds were soundly healed, and any degree of pressure can be born by the stump which has a round form, well suited for the adaptation of a boot or artificial foot, and is strongly protected from external injury by its thick integument.</p> </blockquote> <p>The success of his first case led Syme to the following conclusion:</p> <blockquote><p>It thus appears that compound dislocation of the astragalus and caries of this bone and the surrounding articular surfaces are the principal cases for amputation of the leg. This amputation can usually be superseded by amputation at the ankle joint. . . . The advantages promised by amputation at the ankle joint instead of operation near the knee are: 1st, That the risk to life will be smaller: 2nd, That a more comfortable stump will be afforded and 3rd, That the limb will be more seemly and useful for progressive motion. ... On these grounds I think amputation at the ankle joint may be advantageously introduced into the practice of surgery. I regret having cut off many limbs that might have been saved by it, and shall be glad if what has been said in its favour encourages others to its performance.</p> </blockquote> <p>Between 1843 and 1846 Syme wrote four more papers on amputation at the ankle joint<a></a>,and he reprinted them with a summary in <i>Contributions to the Pathology and Practice of Surgery.</i><a></a> Therein he states:</p> <blockquote><p>I have operated in more nearly two than one dozen of cases with perfect success.</p> </blockquote> <p>Years later (1857) he wrote again to attest to the satisfactory results obtained by his amputation at the ankle joint.<a></a> He had been aroused by a review in <i>Lancet</i><a></a> of the then new (4th) edition of Fergusson's <i>System of Practical Surgery, </i>in which appeared the following sentence: "Mr. Fergusson states, in relation to removal of the foot at the ankle joint in the manner recommended by Mr. Syme; that he had formed from experience a most unfavourable impression against it." Syme wrote to the editor of <i>Lancet </i>to refute Fergusson's statement. He said:</p> <blockquote><p>Sir,</p> <p>Fifteen years ago I proposed a mode of affording relief from diseases that had been held to require amputation of the leg, by removal of the foot at the ankle-joint. This proposal was favourably received, and has long since been adopted by intelligent surgeons at home and abroad as the established procedure in cases proper for its performance. It is easily executed, and proves in the highest degree satisfactory, if done in accordance with certain principles which have been carefully explained, but is difficult and disastrous if performed incorrectly.</p> </blockquote> <p>He then included letters from three patients upon whom he had performed his amputation at the ankle joint, respectively 10, 14, and 15 years earlier. One of them was his first case. All were well-with useful, painless stumps on which they could walk without difficulty and without a prosthesis if necessary.</p> <p>Before Syme died in 1870, the problem of hospital diseases was in the process of solution as the result of the clinical studies of his son-in-law, Joseph Lister. Today, more than a century since Syme first wrote on amputation at the ankle joint, we have accumulated an immense fund of knowledge on the problem of infection in surgery, and we have at our command effective measures for its control. The technique of aseptic surgery and the rigid standards of cleanliness and hygiene in operating rooms and hospitals have to a large degree enabled us to eliminate infection from our surgical procedures. When infection does occur, we can now do more to control it with antiseptic and bacteriostatic and antibiotic agents than has ever before been possible. Today, therefore, the merit of Syme's amputation lies not chiefly in the circumstance that "the risk to life will be smaller." On the other hand, it still remains the most useful of all amputations of the lower extremity "because a more comfortable stump is provided, and the limb is more seemly and useful for support and progressive motion."</p> <p>Of historical interest in demonstrating Syme's conviction of the merit of end-bearing stumps in the lower extremity is the record of his attempt to devise, at the level of the knee, an end-bearing stump embodying the principles which had proved so successful at the ankle. Two years after his first account on amputation at the ankle joint he reported the results of his attempt on two patients to remove the lower extremity at the knee and to close the wound with a skin flap so that weight could be borne on the end of the stump.<a></a>Both patients seem to have been suffering from tuberculosis of the knee joint. In both, the femur was transected through the condyles just above the carious articular surface, and the end of the stump was covered with a long posterior flap of skin derived from the calf. Both wounds healed without complication, though they took a long time to do so.</p> <p>It seems evident from Syme's presentation of these two cases that he was concerned chiefly with devising an operation safer than amputation through the shaft of the femur and that he believed that transection through cancellous bone just above the articular surface would involve less risk from hospital diseases than would amputation at a higher level. Since he did not cover the end of the stump with skin accustomed to weight-bearing, he evidently believed that the achievement of a healed stump without sepsis and without serious risk to the life of the patient was the prime objective and that good function and even end-bearing would follow good healing.</p> <p>Twenty-one years later<a></a> he wrote again about transcondylar amputation of the femur. His interest had been renewed by Carden's report<a></a> of a method of amputating through the knee or through any part of the lower end of the femur using to cover the end of the bone a single, long, anterior flap composed of skin and subcutaneous tissue only. The muscles were divided at the level of transection of the bone and thus were excluded from the flap as was also the patella. Carden's purpose was to avoid the thin, sensitive, adherent cicatrix ("retreating muscles and obtrusive bone"), which so frequently resulted when equal flaps were used, and to cover the end of the femur with a broad cap of skin and subcutaneous tissue accustomed to bearing the weight of the body in kneeling (<b>Fig. 2.</b>). Syme warmly commended Carden's amputation, which he said could be performed with little risk to the patient and had the additional advantage<a></a> that:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Carden's operation by single flap, <i>a, </i>The line of the skin incision; <i>b, </i>closure of the wound; <i>c, </i>ankylosis of the knee in extreme flexion deformity following fractured patella; <i>d, </i>the end-bearing stump obtained by Carden's operation on the limb illustrated in <i>c. </i>From Carden.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <blockquote><p>. . . the stump proved eminently serviceable since the skin over the bone, instead of becoming thinner, acquired additional thickness so that patients could rest upon it just as they do after amputation at the ankle.</p> </blockquote> <p>In the same publication, Syme acknowledged that his earlier attempt to perfect the technique of transcondylar amputation had failed and that the method had fallen into disuse because the skin flap derived from the calf of the leg "proved very inconvenient." Syme, therefore, nearly achieved success in devising an end-bearing stump at the transcondylar level. He failed because his attention was focused upon the avoidance of sepsis and because he did not appreciate the importance of covering the end of the stump with skin naturally adapted to weight-bearing-a strange circumstance since he seems to have been well aware of the value of "the thick integuments of the heel" in the ankle-joint cases.</p> <h4>DEVELOPMENT OF SYME'S AMPUTATION</h4> <p>Shortly after Syme's first publication on amputation at the ankle joint,<a></a> the operation began to be adopted in England and Scotland, generally with satisfactory results. In subsequent publications Syme stressed details of technique he had found essential for success (i.e., avoidance of damage to the posterior tibial artery, separation of the heel flap by dissection close to the calcaneus, drainage of the dead space, etc.). By 1846 he had perfected the technique of the operation, and from then on he accumulated experience in the application of the procedure to various problems. But he wrote nothing more on the operation except the letter to the editor of <i>Lancet </i>in 1857.<a></a></p> <h4>BAUDENS' TIBIOTARSAL AMPUTATION</h4> <p>On the Continent, and especially in France, there was less ready acceptance of Syme's amputation, partly because a somewhat similar amputation<a></a> had been reported by Baudens (<b>Fig. 3.</b>) in 1842, a year before Syme's first publication. Described as a "tibiotarsal amputation," it involved a procedure in which the foot was removed by disarticulation at the ankle joint accompanied by removal of the malleoli and the posterior half of the inferior articular surface of the tibia by a single saw cut. The end of the stump was covered with a flap from the dorsum of the foot which included in its thickness all the structures from the skin to the tarsal bones and intertarsal ligaments (skin, subcutaneous tissue, tendons, nerves, and blood vessels). Baudens' concern was to secure good healing by a flap which would drape itself over the end of the stump as the patient lay supine in bed and when healed would provide a long stump on the end of which the patient could walk (<b>Fig. 4.</b>, <b>Fig. 5.</b>, and <b>Fig. 6.</b>). When reports of Syme's operation reached France, there was renewed appraisal of Baudens' cases, and the columns of <i>Les Annates de Therapeutique </i>for 1845-1847 contain several references to the problem. The following editorial comment<a></a> is typical:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. J. B. L. Baudens, the French military surgeon who published in 1842 the account of his tibiotarsal disarticulation. <i>Courtesy National Library of Medicine, Washington, D. C.</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. Baudens' tibiotarsal amputation. Appearance of the stump after removal of the foot. The malleoli have been removed with the posterior margin of the articular surface of the tibia. The long dorsal flap is held up. Left to itself, it fell naturally over the cut ends of the bones and required the minimum amount of fixation. From Baudens.<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. 5. Baudens' tibiotarsal amputation. Appearance of the foot after its amputation. The denuded area on the dorsum of the foot indicates the extent of the flap and shows that it included in its thickness all the tissues from the skin to the tarsal bones and inter-tarsal ligaments. From Baudens.<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. 6. Baudens' tibiotarsal amputation, <i>a, </i>End of the stump when completely healed; <i>b, </i>appearance of the stump when bearing weight; <i>c, </i>simple prosthesis fitted into a boot with a high, laced top. From Baudens.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <blockquote><p>Our readers already know the tibiotarsal amputation of the foot which Doctor Baudens performed several years ago on a young soldier at the Gros-Caillou Hospital. We followed the patient in this hospital and then at the Val-de-Grace to which he had been transferred and we were happy one year later to see him walk well with the aid of an ordinary dancing shoe supported by two small metallic splints. This soldier took long walks without fatigue, went upstairs and went down slowly, danced and jumped with agility. His peg leg made him an excellent support and all without even a limp. We were extremely satisfied with this result in spite of the fact that one or two other patients who had had this operation performed upon them by Doctor Baudens had succumbed from gangrene of the flaps. Doctor Baudens' patient was admitted subsequently to l'Hotel des Invalides. Soon we found him again admitted to the Infirmary of the Hotel and for several months he has continued there. His stump has become excessively painful. The cicatrix has re-opened and has ulcerated at several points. Doctor Hutin, the surgeon-in-chief, has been obliged to open two small new abscesses which had formed in the tissue of the scar and it is probable that the underlying bones are affected. The patient complains of acute suffering and he demands with earnest insistence an amputation near the knee. M. Hutin will probably be obliged to come to that. This fact raises questions which demand an explanation. Let us first remark that the indifference with which our surgeons, civil and military, have received the remarkable memoir of M. Baudens is not a proof that the operation is without value for it has been practised in Edinburgh by M. Syme half a score of times with complete success. (We say indifference for the reason that no French surgeon to this day has himself performed or even recommended M. Baudens' valuable operation.) It is true, however, that M. Syme had generally operated only upon children and that he had published only the immediate results of the operation. Now the question is what are the remote effects (of the operation) since the scar in M. Baudens' patient was not inflamed or ulcerated and did not re-open for more than a year after the operation. It is all the more important, therefore, to know the actual state of M. Syme's patients for this knowledge could decide whether in the patient at Les Invalides, the evil in the scar derives from morbid constitutional conditions as we have presumed or to inherent conditions in the form of the flaps or in the stump. We should recall that in M. Baudens' operation the top of the ankle is sawed off after the disarticulation, while M. Syme <i>preserved the ankle intact. </i>Let us say finally that until new facts come to enlighten the above questions and in spite of the very great aversion the civil and military surgeons show to adopting the tibiotarsal amputation, we persist in believing it beneficial in most cases which we have from time to time indicated. Amputation at the wrist is satisfactory; why then hesitate to operate at the same level in the inferior member? We know the reasons of those who oppose. Time and new facts will be the best judges.</p> <p>We should not terminate this article without stating that there prevails in military practice a sort of aversion for all those operations which one could perhaps call <i>de luxe </i>such as partial amputation of the foot, supramalleolar amputation, etc. For several reasons orders have been to adopt the same treatment for all cases. It is otherwise in civil hospitals. We have already discussed the diverse questions connected with these declarations.</p> </blockquote> <p>This editorial was reproduced in the Monthly Journal of Medical Science, where it came to Syme's attention.<a></a> Certain inaccuracies demanded correction, and there was the implication that perhaps Syme's results were not as good as they were said to be or that, if they were, the reason should be found so that Baudens' operation could be modified and made acceptable on its merits.</p> <p>Syme therefore wrote to the editor of the <i>Monthly Journal of Medical Science</i><a></a> to clarify the points in confusion. The gist of his reply was as follows:</p> <ol> <li>He had operated upon a considerable number of patients (more nearly two than one dozen of cases) with complete success.</li><li>Most of his patients were adults (not children as stated by the editor of <i>Les Annates de Therapeutique</i>).</li><li>In one case only did he leave the malleoli intact and that was the case of an infant five months of age with an erectile tumour of the foot.</li><li>His results were satisfactory, in evidence of which he quoted from letters received from his first three patients, each of whom stated that the stump was satisfactory and was scarcely any handicap.</li><li>His mode of performing the operation was to obtain a heel flap of sufficient length by cutting from the tip of one malleolus to the tip of the other. By this the risk of sloughing was lessened if not entirely prevented.</li></ol> <p>The fact is that there was an essential difference between Baudens' tibiotarsal amputation and Syme's amputation at the ankle joint. Both surgeons were striving to devise, for treatment of disease of the foot beyond the scope of Chopart's amputation, an operation which would replace amputation below the knee. They desired to diminish the risks to the patient's life and to leave him with a long, well-covered, unscarred stump capable of total end-bearing. Both surgeons disarticulated the foot at the ankle and removed the malleoli, with or without a thin flake from the lower end of the tibia. The essential difference lay in the nature of the flap used to cover the end of the stump. Baudens used a long flap from the dorsum of the foot because it would drape itself naturally over the end of the stump while the patient lay supine in bed. It required the minimum of fixation and permitted free drainage in the immediate postoperative period. Syme used a plantar flap in order that he might cover the end of the stump with the thick integument of the heel.</p> <p>Syme's amputation at the ankle joint proved superior to Baudens' tibiotarsal amputation even in the days before antisepsis. Today, with infection eliminated as an operative risk, Syme's operation has even more to recommend it as the best operation of the lower extremity.</p> <p>In addition to Baudens' tibiotarsal amputation and Syme's amputation at the ankle joint, several other amputations of the foot in the region of the ankle were devised in the latter half of the nineteenth century with the purpose of avoiding the grave complications of amputation through the leg and to provide an end-bearing stump. Though none of these proved to have the value of Syme's amputation, they are of historic interest.</p> <h4>ROUX'S AMPUTATION</h4> <p>Roux's amputation (1845) was a supramalleolar amputation<a></a> with a medial flap to cover the ends of the tibia and fibula (<b>Fig. 7.</b>). The tibia and fibula were divided transversely above the articular cartilage, and the medial flap included all the skin on the medial side of the foot as far forward as the talonavicular joint and as far inferior as the inner margin of the sole of the foot. The advantages claimed were that the flap had an assured blood supply from the posterior tibial artery and that a weight-bearing stump could be salvaged from a foot with a heel flap damaged too extensively to permit a formal Syme's amputation. The disadvantage proved to be the inadequacy of the flap, which was too thin to withstand the stresses of weight-bearing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Roux's supramalleolar amputation with medial flap, <i>a, </i>Medial view; <i>b, </i>lateral view. Redrawn from Jacobson.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is interesting to record that Roux came to recognize the superiority of Syme's amputation. In 1846, after performing his first disarticulation of the ankle joint by Syme's method, he said:<a></a></p> <blockquote><p>It appears to me that by this operation art modifies without changing the language of nature; in fact, the malleoli being removed, the lower extremity of the leg affords a base of support which transversely exceeds that of the os calcis.</p> </blockquote> <h4>GUYON'S AMPUTATION</h4> <p>Guyon's elliptical supramalleolar amputation with posterior flap (1868) was performed<a></a> by a single elliptical incision which encircled the heel and the front of the ankle joint (<b>Fig. 8.</b>). Only a finger's breadth of skin from the plantar surface of the foot in front of the heel was retained. A flake of the os calcis was removed at the insertion of the tendo achillis and retained with the heel flap, and the tibia and fibula were transected above the articular surface of the tibia. The heel flap, with its flake from the posterior end of the os calcis, was applied to the cut surfaces of the tibia and fibula, and the skin margins were sutured. The weakness of Guyon's amputation lay in the inadequate heel flap, which did not stand up under the stress of weight-bearing, and the small tapered end of the stump, which provided too small an area of support.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Guyon's elliptical supramalleolar amputation with posterior flap. Redrawn from Farabeuf.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>pirogoff's amputation</h4> <p>In 1854, Pirogoff (<b>Fig. 9.</b>), the greatest Russian surgeon of his day, published the account of his new operation at the ankle joint,<a></a> which he intended as an improvement upon Syme's amputation. In 1847, at the Clinic of Professor Chelius at Heidelberg, Pirogoff had seen two patients upon whom Syme's amputation had been performed, and he was impressed with the results. In 1848 and 1849 he performed Syme's amputation on four patients, all of whom died (one of pulmonary tuberculosis, one of scurvy, and two of sepsis, one of whom had gangrene of the heel flap). In a fifth case, an attempt to perform Syme's amputation failed because of gross damage to the heel flap incurred in separating it from the calcaneus. Nevertheless, Pirogoff, in his attempt to deal with compound injuries and caries of the astragalus and calcaneus by some method better than amputation below the knee, continued to use Syme's amputation at the ankle joint as well as Baudens' tibiotarsal amputation and Roux's supramalleolar amputation with a medial flap. From his experience he came to the following conclusions:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Nicolai Ivanovitch Pirogoff (1810-1881), who devised his amputation at the ankle to overcome certain features of Syme's amputation that he regarded as detrimental. From <i>Pirogoff: Collected Works, </i>Vol. 1, State Publications Medical Literature, Moscow-Leningrad, U.S.S.R., 1959. Print obtained through the courtesy of Dr. W. G. Bigelow and the Russian Ambassador to Canada, His Excellency A. A. Aroutunian. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The most difficult part of Syme's amputation is the separation of the heel bone from the skin. Only with great care can the tightly adherent skin be separated without injuring the flap or making it too thin.</li><li>In Syme's operation, the skin over the tendo achillis forms the base of the flap and is much thinner than the apex of the flap. If care is not taken, it may be cut too thin and the flap may become gangrenous.</li><li>A considerable depression remains in the heel flap of Syme's amputation after the os calcis is shelled out. It may form a pocket for the collection of pus.</li><li>In the method of Baudens, the skin over the lower surface of the os calcis is removed. In this operation the creation of a foundation for the stump is not accomplished as it is in Syme's method, where the thick skin of the sole of the heel forms a sturdy covering.</li><li>In Roux's method, the formation of the posteromedial flap is certainly easier than in Syme's method. The base is wider, and necrosis occurs less often because the posterior tibial artery is cut below its division. However, the base of the flap is thinner than the summit. The depression in the flap is just as deep as in Syme's method, and, finally, the Achilles tendon is completely cut at its attachment to the os calcis as in the two previous cases.</li></ol> <p>In order to avoid these inconveniences, Pirogoff devised a new procedure (<b>Fig. 10.</b>, <b>Fig. 11.</b>, <b>Fig. 12.</b>, and <b>Fig. 13.</b>). The skin incisions resembled those of Syme. The skin, soft tissues, and tendons were divided down to the bone, and the ankle joint was entered from in front by dividing the capsule anteriorly. The lateral ligaments were detached from the malleoli and the astragalus displaced downwards. The capsule was then opened posteriorly and the superior surface of the calcaneus exposed. A saw placed through the two vertical limbs of the plantar incision and across the superior surface of the calcaneus behind the body of the astragalus and in front of the tendo achillis divided the calcaneus obliquely from above downwards at the junction of the middle with the posterior third of that bone. The posterior third of the calcaneus and the tendo achillis retained their normal attachments and formed an integral part of the heel flap. The malleoli were divided at their base and removed level with the articular surface of the lower end of the tibia. The inferior articular surface of the tibia was not removed unless it was diseased. When the vessels had been ligated, the heel flap was turned up and secured to the margin of the anterior flap by two or three sutures.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Pirogoffs amputation. Redrawn from Pirogoff<a></a> and Elmslie.<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. 11. Pirogoff's amputation. Dividing the calcaneus. From Farabeuf.<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. 12. Pirogoffs amputation. Appearance of the stump after removal of the foot by disarticulation at the ankle. <i>A, </i>Tibia; B, fibula, <i>C, </i>os calcis "sawn behind <i>lig. sustentacula e" </i>Redrawn from Pirogoff.<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. 13. PirogofFs amputation. Appearance of the healed stump. Redrawn from Pirogoff.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The operation was ingenious and had certain merits. If the wound healed satisfactorily and the calcaneal fragment fused to the tibia, an end-bearing stump resulted, longer than a Syme's stump, so that no prosthesis was necessary to compensate for the shortening. The patient walked without much "dipping" (limp). Also the heel flap was firmly fixed in place by fusion of the calcaneal fragment to the tibia. But there were risks which could mar the success of the operation. If the calcaneal fragment failed to unite to the tibia, an unstable and painful stump end resulted. If the wound became infected, chronic osteomyelitis with persistently discharging sinuses was prone to establish itself in the calcaneal fragment or in the lower end of the tibia. Weight was borne ultimately upon the skin over the back of the heel, an area not as well suited to weight-bearing as is the plantar surface of the foot. For success, the calcaneus had to be free of disease and the heel flap not seriously damaged by trauma. In an age when the nature and management of infection was unknown, it was an operation technically difficult and uncertain in its results. Pirogoff's first three cases were all complicated by serious sepsis, and many months elapsed before they could walk on their stumps. Even then they still had discharging sinuses. Syme's operation was easier to perform and more certain of a good result, and these advantages still prevail.</p> <h4>SUBASTRAGALAR AMPUTATION</h4> <p>Subastragalar disarticulation was first mentioned by Velpeau in a single small paragraph in his <i>New Elements of Operative Surgery.</i><a></a> He stated that it had been proposed to him by des Lingerolles, who seems not to have been a surgeon. At the time Velpeau had not performed the operation. He merely mentioned it as a promising procedure in selected cases of disease or injury of the foot. Farabeuf<a></a> perfected the operative technique and described it with excellent engravings in his <i>Precis de Manuel Operatoire.</i><a></a> He also discussed its merits and limitations. There is also a paper by Hutchinson,<a></a> which contains a good description of the operation as well as a report upon the end result obtained in six cases. Five of his cases, operated upon by the technique described by Farabeuf, were gratifyingly successful, while the sixth, in which the flap was formed by a technique similar to that of Syme, was imperfect because the heel flap could not cover the head of the astragalus without undue tension.</p> <p>Subastragalar amputation is of value in a limited number of cases, the best technique being that described by Farabeuf.<a></a> A large internal and plantar flap extends to the outer margin of the heel and as far forward as the base of the fifth metatarsal <b>Fig. 14.</b>. The subastragalar and astragaloscaphoid joints are opened from the lateral side, and the heel is inverted until the medial side of the os calcis can be reached. The os calcis is then freed from the heel flap beginning at the medial surface and is removed with the foot. Care must be taken to avoid injury to the posterior tibial artery. The advantages over Syme's amputation, as stated by Hutchinson, are:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Subastragalar amputation of de Lingerolles and Velpeau giving large plantar flap. Redrawn from Farabeuf<a></a> . Dotted line is the plane of subastragalar disarticulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The stump is some 2 in. longer than a Syme's stump.</li><li>It gives a broader base of support.</li><li>The elasticity due to ankle movement is of marked advantage in walking.</li><li>The pad at the end of the stump is much thicker.</li><li>The arterial supply is better and runs less risk during the operation.</li><li>The artificial foot can be better fitted to the stump.</li></ol> <p>Hutchinson states that between 1891 and 1900 Syme's amputation was performed under antiseptic surgery on 27 patients at the London Hospital. The outcome: complete failure, 3 (one died); suppuration and sloughing of flap, 12; good result, 12. Several factors other than imperfection in technique (e.g., difficulty in sterilizing the skin of the heel flap, delay in operating because of patient's "obstinacy," operation in unpromising cases) contributed to the poor results. Even with the advantages of anaesthesia and antisepsis, the results at the London Hospital were inferior to those of Syme. In his meagre accounts of long-term results, Syme makes no mention of a fatality, and the functional results were good. For best results from Syme's amputation, the cases must be selected carefully, and the operation has to be timed wisely and performed skillfully.</p> <p>In Hutchinson's paper also is an informative note, quoted from Clinton Dent,<a></a> on the amputations in the South African War. The following is a summary:</p> <blockquote><p>Syme's amputation was performed in a small number of cases, but the resulting stumps were not entirely satisfactory. Damage of the foot from trauma is perhaps not as good an indication for Syme's amputation as is tuberculosis, because of damage to the skin. Sloughing of the flap sometimes occurred. Syme's amputation depends more than any other upon very careful attention to the details of the technique.... In Syme's amputation it is really impossible to depart from the lines laid down by Syme in the fashioning of the flaps. [It will be remembered that Syme emphasized this in almost the same words in his letter to the editor of <i>Lancet </i><a></a> already quoted.] There may be merit in the subastragalar amputation. English surgeons are too limited in their methods of operating upon the foot and have a good deal to learn from their French colleagues.</p> </blockquote> <p>The variety of ankle amputations introduced in the latter half of the nineteenth century is an indication of a common purpose on the part of the surgeons of that era. They were attempting to replace the dangerous operation through the upper end of the tibia with the safer disarticulation at the ankle and at the same time to provide for the end of the stump a covering which would withstand the period of postoperative sepsis without undue damage and which could ultimately permit weight to be borne upon the end of the stump. When we recall that, in its early years, Syme's amputation was performed without the benefit of anaesthesia, it is not surprising that sometimes it was executed imperfectly. Time has proved that success in Syme's amputation is dependent upon precise adherence to a particular technique. Even in today's era of advanced surgery, it still is necessary, if we are to avoid imperfect results, to use a technique which differs in no essential detail from that used by Syme.</p> <p>In Syme's day, the chief difficulty that hampered the general acceptance of his procedure was the frequent occurrence of necrosis of the heel flap, and we can appreciate from Hutchinson's account that it was still a problem even in 1900 with benefit of antiseptic surgery. According to Dent also,<a></a> necrosis of the heel flap was a complication of Syme's amputation performed on soldiers in the South African War. The chief cause of necrosis of the heel flap was injury to the posterior tibial artery. Syme himself learned, in the hard school of experience, the necessity for preserving this vessel.<a></a> His account is as follows:</p> <blockquote><p>In describing the operation, I have said that care must be taken to avoid cutting the posterior tibial artery before it divides into the plantar branches and I may now explain more particularly the ground on which this advice is founded.</p> <p>Elizabeth Wilson, aged seven, was admitted on the 19th of February on account of disease in her left ankle. . . . The foot was much enlarged, stiff and shapeless; and two sinuses allowed a probe to pass into carious bone.</p> <p>On the 21st I proceeded to amputate at the ankle joint, but finding that anchylosis had taken place between the articular surfaces, I exposed the extremities of the tibia and fibula, and sawed them through without previously removing the foot as usual. In tying the vessels, it appeared that the posterior tibial artery had been divided before its division into the plantar branches, so that one ligature sufficed in place of two.</p> <p>The stump looked remarkably well and the result of the operation was expected to prove very favourable. It was, therefore, with much surprise, and no small disappointment, that in the course of a few days I saw the flap had sloughed through fully half its extent. Recovery was consequently delayed much beyond the ordinary period. . . .</p> <p>I attributed the sloughing in this case to the undue pressure of the bandage; and having occasion soon afterwards to perform the operation on a patient in Minto House, intentionally divided the posterior tibial before its division, in order to obtain the same facility in tying the vessel as on the last occasion. To my surprise and concern, the flap again sloughed to the same extent as in the case just related, and as great attention had been paid to the dressing of the stump, I could not refer this effect to the cause formerly supposed. But as on both occasions the artery had been cut before its division, while in all other cases it had been left entire, and as the flap, being deprived of nourishment from most of its ordinary sources, must be supplied with blood only through the successive anastomoses of small vessels, I concluded that this deviation from usual practice had led to the mischief in question, and I resolved to avoid it for the future.</p> </blockquote> <p>A further cause of poor result from Syme's amputation was damage inflicted on the skin over the heel while the flap was being separated from the calcaneus or while the tendo achillis was being detached from its insertion. Unless the plane of dissection hugged the calcaneus, and unless the dissection was performed with precision and delicacy, the skin was apt to be buttonholed. It was this problem especially that led Pirogoff to introduce his operation and Guyon to devise his elliptical supramalleolar amputation at the ankle joint. Syme's amputation, then and now, is an operation which must conform rigidly to an exact technique. If it is not performed properly when first attempted, many of its advantages will be lost irretrievably. It is interesting that the technique necessary for success is almost exactly that which Syme himself ultimately evolved. As we shall see later in the section on technique, the only addition of proven value is subperiosteal separation of the calcaneus from the heel flap. All other attempts at improvement have failed to achieve the success which follows the use of Syme's original technique.</p> <p>The 1914-1918 war, with its innumerable casualties, renewed interest in amputations. One outcome was the publication of an English translation of the small volume, <i>Artificial Limbs</i><a></a>, written by the French surgeons Broca and Ducroquet. In discussing end-bearing stumps, this monograph makes no mention of Syme's amputation. It lists only supramalleolar amputation, disarticulation at the ankle joint, subastragaloid amputation, and osteoplastic amputation through the ankle joint. An editor's footnote with respect to supramalleolar amputation states, "In England, of course, this is always called a Syme's amputation." This statement is not strictly accurate since an important detail of Syme's amputation contributory to its success is the large area of support provided for the heel pad when the lower end of the tibia is left intact or virtually so. Syme's operation is not a supramalleolar amputation; it is a slightly modified disarticulation. French surgeons, particularly Farabeuf,<a></a> were meticulous in distinguishing between disarticulations (in which group Syme's amputation was included) and amputations (e.g.,the supramalleolar operations of Roux and Guyon). It is true that Syme himself always referred to his operation as "amputation at the ankle joint," but in doing so he evidently used the term "amputation" in a general sense and not in the exact sense of Farabeuf. It is certain from Syme's description of his operations, and from the derivation of his operation from the disarticulation of Chopart, that Syme's operation was in fact disarticulation of the foot at the ankle joint with removal of the malleoli. Had Syme emphasized this as precisely as did Farabeuf, he might have prevented the innumerable supramalleolar Syme amputations which have been performed because of imperfect knowledge of Syme's technique or in the hope of obtaining an improved stump. These are the cases which have cast doubt on the value of Syme's operation, for the resulting stumps are functionally imperfect and may be complete failures.</p> <p>E. C. Elmslie, who translated and edited the English edition of Broca and Ducroquet,<a></a> formed a high opinion of Syme's amputation. In a footnote to the paragraph on low leg amputations allowing walking with end-bearing only, he says, after brief discussion of Pirogoff's amputation, subastragaloid amputation, and disarticulation at the ankle joint: "In fact, in this region there is Syme's amputation and a number of other far inferior amputations which should never be considered when a Syme amputation is possible." In 1924, in the section on amputations which he contributed to Carson's <i>Modern Operative Surgery</i><a></a> Elmslie states with reference to Syme's amputation:</p> <p>When successful it yields an excellent stump which is capable of complete end bearing. It can be fitted with a simple and cheap stump boot known as an elephant boot. Upon such a boot a patient with a Syme's amputation can often walk ten or twelve miles. In fact, Syme's amputation is so satisfactory that it may be said that all other amputations of the foot at a lower level are obsolete except amputation of the toes or parts of the toes.</p> <p>Despite the high regard in which he held Syme's amputation, Elmslie does not appear to have understood how essential for success is exact adherence to the precise details of Syme's technique. For reasons which probably were related to limbfitting problems, Elmslie felt it necessary to secure an improved Syme stump, and for that purpose he devised a modified Syme amputation which is described in his chapter on amputations in Carson's <i>Modern Operative Surgery.</i><a></a> It is the only procedure for Syme's amputation that is described and illustrated there. Syme's original technique is not mentioned. Elmslie does not state clearly why he felt it necessary to revise Syme's technique. However, he does state that the Syme stump was too long and the end too bulky. Almost certainly these represent criticisms by the limbfitters of Elmslie's day, who certainly had difficulties in designing, manufacturing, and fitting a satisfactory prosthesis for a Syme stump.</p> <h4>ELMSLIE'S MODIFIED SYME'S AMPUTATION</h4> <p>Elmslie's modified Syme's amputation<a></a> differed from the classical Syme's amputation in three essential particulars:</p> <ol> <li>The heel flap was smaller.</li><li>The dissection was carried out from the dorsal to the plantar surface.</li><li>The tibia and fibula were transected at a level well above the ankle joint.</li></ol> <p>Apparently the purpose of these changes was twofold: to provide a small, neat, tapered end to the stump and thus avoid the bulge in the prosthesis necessary to accommodate a bulbous-ended stump; and to accommodate more easily the ankle-joint mechanism by high transection of the tibia and fibula.</p> <p>Elmslie was not the first person to advocate high transection of the tibia and fibula to facilitate the introduction of an ankle joint mechanism in the artificial limb for a Syme amputation in the space between the end of the stump and the level of the ground. Henry Thompson,<a></a> at a meeting of the Pathological Society of London on April 21, 1863, shared in the presentation of seven patients with Syme's amputation and two patients with Pirogoff's amputation. As reported in <i>Lancet, </i>Thompson's remarks were as follows:</p> <blockquote><p>He [Thompson] would not enter upon the various points of comparison between Syme's amputation and that modification of it in which a portion of the os calcis is left in the flap, but would only refer to the different results which remained after the two operations [i.e., Syme and Pirogoff] as regards the kind of artificial limb which is applicable afterwards. He thought it very important for the surgeon and the mechanician to act in concert in most amputations of the lower extremity and he therefore showed also two artificial limbs to illustrate the advantage in relation to this matter which the proceeding of Syme offered over that of Pirogoff. In the former the patient enjoyed the advantage of complete ankle joint movement of the limb; while in the other, the stump being so close to the ground, there was no room for it and the best substitute that could be applied was by iron hinges outside of the limb. . . . Mr. Thompson wished to point out the necessity of taking off a sufficient slice of bone, including the two malleoli instead of merely removing the lower portion of the latter, so as to avoid extreme width and a bulbous stump which was more difficult to fit with a well made artificial limb than a stump which tapered gradually from the calf downwards. . . . Mr. Thompson said that the objection to the bulbous form of the stump did not materially apply if the common circular shoe which is laced around the lower part of the leg was worn [elephant boot], but it did to the artificial leg.</p> </blockquote> <p>In Elmslie's operation the skin incision was an ellipse (<b>Fig. 15.</b>) which commenced on the plantar surface of the foot 3/4 in. in front of the point of the heel. Therefrom it extended obliquely upward and forward over either malleolus to a point on the anterior surface of the ankle 1 in. above the joint line. The ankle joint was entered, the foot depressed, and the medial and lateral ligaments of the joint divided from within the joint. The astragalus was then dislocated from the mortise of the ankle joint by depressing the foot still farther. Doing so exposed the tendo achillis, which was then divided at its insertion. The calcaneus was then separated from the heel flap by dissection close to the bone from above downward. The tibia and fibula were transected 3/4 in. to 1 in. above the highest level of the ankle joint, and the heel flap was then closed over the ends of the tibia and fibula.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Elmslie's modified Syme's amputation. Redrawn from Elmslie.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Though Elmslie intended his modified Syme's amputation to be an improvement over Syme's original procedure, the result has not lived up to his expectations, and for three reasons: the small heel flap deprived the stump of an adequate covering of skin and subcutaneous tissue adapted to weight-bearing; the high transection of the tibia and fibula diminished the cross-sectional area of their cut surfaces and impaired their support for weight-bearing; the end of the stump was no longer bulbous but was tapered, a feature that permitted the artificial limb to slip up and down during walking. He succeeded in simplifying the limbfitters' problem, and he succeeded in making the stump neat and tidy, but in so doing he sacrificed the qualities of Syme's amputation essential for success- namely, a bulbous stump end to ensure that the grasp of the prosthesis would be secure and a wide area of bony support covered by a large, thick, heel pad adapted to weight-bearing.</p> <p>Elmslie's modified Syme's amputation thus closely resembled Guyon's elliptical supramalleolar operation with posterior flap.<a></a> It seems probable that in modifying Syme's operation Elmslie adopted Guyon's technique, for the only difference between Guyon's elliptical supramalleolar amputation and Elmslie's modified Syme's amputation was that in the former, unlike the latter, a flake from the posterior end of the calcaneus was removed along with the insertion of the tendo achillis and that later the flake was applied to the cut surface of the tibia when the heel flap was sutured into place. Elmslie's modified Syme's amputation was widely used in England (but not in Scotland) during the period following the 1914-1918 war, probably because of the confidence with which he advanced it as an improvement over Syme's technique and probably also because he made no mention of Syme's technique.<a></a> It is likely that this adoption of his modified Syme amputation in England led to the dissatisfaction with Syme's amputation expressed by Langdale-Kelham and Perkins of Queen Mary's Hospital at Roehampton.<a></a> They said ". . . this type of operation does not stand weight bearing on the average longer than eight years. ... It is to be hoped that the modified Syme's amputation will soon be as obsolete as the original Syme's." The handbook of the British Ministry of Pensions, <i>Artificial Limbs and their Relation to Amputations</i><a></a> also speaks with faint praise of Syme's amputation. In Scotland, in contrast to England, a rigid adherence to the precise details of Syme's original technique resulted in satisfactory end-bearing stumps. In Canada, for a similar reason, experience has also been satisfactory. The favorable results with Syme's amputation in Scotland and Canada as contrasted with the dissatisfaction with Syme's amputation in England is evidence that a wide area of bony support covered by a large, thick, heel pad is essential for a satisfactory Syme's stump. Syme's original operation provided these indispensable features, and consequently his stumps bore weight on the end satisfactorily and more or less indefinitely. Attempts to improve upon Syme's amputation (e.g., the modifications of Roux and of Elmslie), chiefly in the matters of making the end of the stump neat and of providing the limbmaker with more space for the ankle joint of the prosthesis, proved unsatisfactory in the long run because the area of support was too small and because the covering over the end of the stump would not stand up under long-continued end-bearing.</p> <p>Syme was blessed by good fortune as well as good sense. His sound judgment brought him to the conclusion that disarticulation at the ankle joint and removal of the malleoli would constitute a safe and effective means for the removal of a damaged or carious foot. The idea of preserving the heel flap to cover the end of the stump and to provide end-bearing could have come only from profound insight. His courage, boldness, and skill enabled him to devise a simple technique by which these things could be accomplished. It was his good fortune that the operation he planned and the technique he devised have both proved to be of continuing value. He knew nothing of the minutiae which concern us today, and he ill understood the grave complications which often discounted the surgeon's efforts. But he was far-sighted enough and bold enough to embark upon a radically new approach to an old problem, to build upon his first successes, and to eliminate such defects as were present in his first efforts (e.g., to preserve the integrity of the posterior tibial artery).</p> <h4>FUNDAMENTAL PRINCIPLES OF END-BEARING AMPUTATIONS OF THE LOWER EXTREMITY</h4> <p>The essential functions of the normal lower extremity are weight-bearing and locomotion, and amputation stumps in the lower extremity must be designed accordingly. The more perfectly they bear the body weight and transmit the forces of locomotion the more efficiently will they utilize prosthetic appliances. For purposes of weight-bearing, nothing is as satisfactory as a stump which can bear weight upon its end. Propulsion is best accomplished by a leg stump of the greatest possible residual length and with as many normally functioning nerves, muscles, and joints as can be preserved. Only two levels in the lower extremity can be adapted to provide end-bearing stumps-the lower end of the femur with a covering of prepatellar skin, and the expanded lower ends of the tibia and fibula covered by the heel pad.</p> <p>To secure an end-bearing stump in lowerextremity amputations, certain requirements must be met:</p> <ol> <li>In order to provide a broad area of support, the bone must be divided where its cross-sectional area is as great as possible.</li><li>The whole of the cut surface of the bone must be capable of bearing weight. This requirement can be achieved by a strong meshwork of cancellous bone across the whole area, or, in the case of the ankle joint, by retention of the subarticular cortical bone at the lower end of the tibia. The tubular cross-section of the shaft of the tibia at higher levels is unsuited to weight-bearing.</li><li>The skin and subcutaneous tissue covering the end of the stump must be appropriate for weight-bearing.</li><li>The weight-bearing skin must be properly centered upon the area of support and firmly attached to it.</li><li>The end of the stump must be bulbous, thus ensuring that the prosthesis will not slide off the stump or rotate upon it.</li></ol> <p>Syme's operation, properly performed, meets all these requirements. For conditions which require amputation in the vicinity of the ankle joint, it provides a stump superior to all others. But the initial operation provides the sole opportunity for securing a Syme stump satisfactory in all respects. Even minor deviations from detail are prone to result in a stump imperfect in one way or another, and such imperfections usually cannot be corrected by secondary operations. If the imperfection is not great, the stump may function reasonably well, for some time at any rate, but it may not stand up indefinitely, as has proved to be the case with Elmslie's modified Syme's amputation.</p> <p>Because preservation of the unique structure of the heel pad is essential for attaining a perfect Syme stump, it is appropriate now to describe its specialized nature. In the human heel, as in other parts of the body adapted to weight-bearing (finger tips, thenar and hypothenar eminences, ischial tuberosities, and prepatellar pads), the ability to withstand the stresses imposed by the weight of the body and by body movements derives in part from the thickness of the skin and in part from a special elastic adipose tissue beneath the skin. Of the two, the latter is the more important, for without the buffering action of this elastic adipose tissue not even a thick layer of skin can provide satisfactory protection against the stresses of weight-bearing.</p> <p>Kuhns<a></a> has reviewed our knowledge of elastic adipose tissue and has brought to our attention the detailed studies of Tietze<a></a> and Blechschmidt.<a></a> Kuhns shows that the stress-absorbing qualities of the subcutaneous layer in areas adapted to weight-bearing are due to its structure and to the elastic qualities of its connective tissues. In these areas the subcutaneous tissue consists of dense septa of elastic connective tissue which completely enclose spaces rilled with fat cells. Each such loculus is separate from its neighbour, and the fat cells within it are isolated from the surrounding loculi. In the heel pad, the fibrous septa extend from the dermis below and are attached above to the calcaneus posteriorly and to the plantar aponeurosis anteriorly. The flasklike spaces are filled with fat cells, and their walls are reinforced by oblique and spiral bands. These compartments, bounded by sheets of elastic fibrous tissue and filled with semifluid fat, act as hydraulic buffers. Under pressure they change form but not contents. When pressure is released, they resume their normal size and shape owing to the elasticity of the walls. A lateral radiograph of the heel, if not overexposed, often will reveal this fundamental structure of the subcutaneous tissue. The vertical septa of the relatively dense, elastic, connective tissue are readily seen extending upwards from the skin below to be attached above to the calcaneus posteriorly and to the plantar aponeurosis anteriorly (<b>Fig. 16.</b>, <b>Fig. 17.</b>, <b>Fig. 18.</b>, <b>Fig. 19.</b>, <b>Fig. 20.</b>, <b>Fig. 21.</b>, and <b>Fig. 22.</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Structure of the heel pad as revealed by radiograph. Top, without weight-bearing, bottom, patient standing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Structure of the heel pad, diagrammatic representation reproduced from radiographs. Top, without weight-bearing; bottom, patient standing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Anatomy of the field of Syme's amputation. Insert shows the plane of the section. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Structure of the heel pad in Syme's amputation. Coronal section enlarged from Figure 18. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Longitudinal section of foot to show structure of heel pad. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Horizontal section through heel pad to show structure. This specimen is a slice of the heel pad cut parallel to the sole of the foot and midway between the skin and the inferior surface of the calcaneus. The skin surface is on the back and either side of the heel. Insert shows plane of section. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Vertical section through heel flap, approximately 8X. <i>a, </i>Bellies of short muscles of foot; <i>b, </i>plantar aponeurosis; <i>c, </i>specialized elastic adipose tissue; <i>d, </i>skin. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is important to preserve intact this specialized subcutaneous tissue in the heel flap of a Syme stump; otherwise the weight-bearing qualities will be impaired. To do so necessitates removal of the periosteum and the plantar aponeurosis with the heel flap, since these elements form the superior attachment of the septa. If the heel flap is dissected through the layer of subcutaneous tissue (i.e., between the periosteum and the plantar aponeurosis above and the dermis below), the septa will be divided and the loculi opened, thus allowing the fat cells to leak out. In such circumstances, the distinctive structure and function of the elastic adipose tissue is lost, for then the tissue no longer consists of separate, elastic-walled spaces enclosing fat under tension. Once the elastic adipose tissue has been damaged, its stress-resistant properties cannot be restored.</p> <h4>THE TECHNIQUE OF SYME'S AMPUTATION</h4> <p>In the five papers Syme wrote between 1843 and 1846 there is no complete and formal description of the technique of his operation, and there is only one inadequate illustration (<b>Fig. 23.</b>). Scattered throughout the papers, however, are comments on various points in the procedure, and when the articles were gathered together and republished in the volume <i>Contributions to the Pathology and Practice of Surgery</i><a></a> there was included an addendum concerned chiefly with certain details of the operation, particularly the technique for separation of the heel flap from the calcaneus. Therein, after emphasizing the desirability of "preserving entire the thick integuments of the heel to form a cushion for the stump," and after ascribing the known failures either to lack of skill in removing the flap from the calcaneus or to the use of flaps of skin other than that from the heel, Syme describes his technique as follows:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. The only illustration included by Syme in any of his publications on amputation at the ankle joint. It appeared in the <i>London and Edinburgh Monthly Journal of Medical Science</i><a></a> with the following comment in the text: "The stump has the shape here represented, conical in form on the inferior surface and having for its apex, or central point of pressure, the thick integument which covered the heel." This illustration was not included when the five papers<a></a> on <i>Amputation of the Ankle Joint </i>were reproduced in <i>Contributions to the Pathology and Practice of Surgery.</i><a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <blockquote><p>The foot being placed at a right angle to the leg, a line drawn from the centre of one malleolus to that of the other, directly across the sole of the foot will show the proper extent of the posterior flap. The knife should be entered close up to the fibular malleolus and carried to a point to the same level on the opposite side, which will be a little below the tibial malleolus. The anterior incision should join the two points just mentioned at an angle of 45° to the sole of the foot and the long axis of the leg. In dissecting the posterior flap, the operator should place the fingers of his left hand upon the heel, while the thumb rests upon the edge of the integuments, and then cut between the nail of the thumb and the tuberosity of the os calcis so as to avoid lacerating the soft parts which he, at the same time, gently but steadily presses back until he exposes and divides the tendo achillis. The foot should be disarticulated before the malleolar projections are removed, which it is always proper to do, and which may be most easily effected by passing a knife around the exposed extremities of the bones and then sawing off a thin slice of tibia, connecting the two processes.</p> </blockquote> <p>Scattered throughout the five papers are some other details worth noting. Syme found it important to avoid division of the posterior tibial artery above its branching into the median and lateral plantar arteries; otherwise there was risk that the flap would slough. Separation of the heel flap, while not easy, could be accomplished satisfactorily by keeping close to the bone. The heel flap was not to be unduly large lest its circulation be impaired. Though Syme freed the heel flap before he dislocated the talus from the ankle joint, it was not long before surgeons were freeing the ankle joint first and dissecting the calcaneus from the heel flap downward from above, and this approach is part of our present procedure.<a></a></p> <p>Today, when the problem of infection is not paramount, the purpose of the operation is, first, to remove the foot by disarticulation at the ankle joint and without damage to the specialized structure of the heel flap; second, to remove the malleoli and trim the lower ends of the tibia and fibula so as to provide a broad support for weight-bearing; third, to fashion from the heel a flap with unimpaired blood supply and with its weight-bearing mechanism undamaged; and, last, to secure this heel flap firmly and accurately to the lower ends of the tibia and fibula. The resulting stump should have a bulbous end to facilitate maintenance of the prosthesis on the stump. To meet these requirements, the skin incisions should be so designed as to give a heel flap of generous size but not so large that its blood supply will be impaired. This shape and size may be obtained by tilting the plantar incision slightly forward. Syme advocated a smaller heel flap because he feared necrosis from impaired circulation. Today, with the risk of infection removed, the larger heel flap, if carefully separated from the calcaneus, need not suffer from impaired circulation, and when sutured in place it has the advantage of overlapping and protecting the anterior margin of the lower end of the tibia. The lower ends of the tibia and fibula are fashioned with a saw cut which removes the medial and lateral malleoli and shaves off the articular surface of the tibia. The plane of this saw cut must be parallel to the ground when the patient stands (<b>Fig. 24.</b>). That is to say, in all cases the tibia must be transected to suit the individual case and not necessarily in the same plane as the articular surface of the tibia or at right angles to the long axis of its shaft. The transection of the tibia and fibula must be as low as possible to ensure that an area of support as broad as possible is obtained. With the modern type of Syme prosthesis, the resulting long stump presents no problem in fitting.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Proper saw line for Syme's amputation, when tibia is abnormal or deformed. The plane of section of the lower ends of tibia and fibula is not necessarily that of the inferior articular surface of the tibia but must in all cases be parallel to the ground when the patient stands erect. When for example the tibia is bowed, as represented here, the plane of section is horizontal and not at 90 degrees to the long axis of the bone. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The fashioning of the heel flap and its proper attachment to the lower ends of the tibia and fibula are important steps in the operation. Preservation of the specialized fibroelastic subcutaneous tissue and the posterior tibial artery can best be assured by subperiosteal separation of the heel flap from the calcaneus. While this is a procedure somewhat more precise than that recommended by Syme (who advised that the flap be separated from the calcaneus by dissection with a sharp knife in a plane close to the bone), today with modern techniques and instruments it is easy to accomplish the desired result. The only step likely to give any difficulty is the detachment of the tendo achillis from the calcaneus, since in this situation there is no plane of cleavage. The tendon must therefore be divided carefully at its insertion close to the bone in order to avoid damage to the skin close behind it.</p> <p>Subperiosteal dissection of the calcaneus from the heel flap has one advantage not envisioned by Syme. Besides preserving the posterior tibial artery and the weight-bearing structure of the heel, it leaves a heel flap lined with periosteum, which more readily and more firmly adheres to the cut surfaces of the tibia and fibula. Henry Thompson<a></a> must have had something of this nature in mind when he advocated leaving a flake of the os calcis in the heel flap. As can be seen in radiographs (<b>Fig. 25.</b> and <b>Fig. 26.</b>), new bone sometimes forms from the periosteal lining of the heel flap, in which case there is very firm fixation of the heel flap to the tibia and fibula. In this connection, it is interesting to note an observation of Jacobson.<a></a> In discussing Syme's amputation, he describes the technique of removal of the calcaneus from the heel flap by an approach from above:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. A flake of new bone laid down in the heel flap of a Syme stump, the result of subperiosteal separation of the heel flap from the calcaneus. Firm fixation of the heel flap to the cut surfaces of the tibia and fibula is thus ensured. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. A large mass of bone laid down in the heel flap of a Syme stump. <i>A, </i>four months after operation; <i>B, </i>one year after operation. This unusually large cloud of new bone resulted from the stimulation of the periosteum by the inflammatory reaction to tuberculosis of the tarsus, the reason for the amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The foot being still more pressed (i.e., downward to dislocate the talus from the ankle joint), the upper nonarticular surface of the os calcis comes into view and then the tendo achillis. This is severed and the heel flap next dissected off the os calcis from above downwards, special care being taken to cut this flap as thick as possible, not to score or puncture it, but rather to peel it off the bone with the left thumb nail kept in front of the knife aided by touches of this.</p> <p>Thereto is appended a footnote:</p> <blockquote><p>If, in a young subject, the epiphysis comes away in the heel flap, it may remain there if the parts are healthy. <i>The same course may be followed with the periosteum if it is found loose and peels away. </i>Mr. Johnston Smith, when amputating both feet for frostbite, left the periosteum on one side; on the other no attempt was made to save it. The first stump was much larger than the other, harder and more rounded, more like that of Pirogoff's amputation.</p> </blockquote> <p>Published in 1889, this comment preceded introduction of the roentgen ray. In all respects, save the radiographic proof, it indicates clearly that subperiosteal separation of the heel flap results in more firm attachment of flap to the tibia and fibula than is the case when the periosteum is not preserved.</p> <p>When stresses come upon a heel flap not firmly attached to the cut surfaces of the tibia and fibula, it wobbles and thus loses some of its functional value. Moreover, the tendo achillis and the peroneal tendons buried therein drag the heel flap this way or that when they contract (<b>Fig. 27.</b> and <b>Fig. 28.</b>). Both of these problems can be eliminated by subperiosteal separation of the calcaneus from the heel flap, for doing so ensures firm fixation of the flap to the cut ends of the tibia and fibula.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Misplaced and unstable ("wobbly") heel flap, the result of tidying up the heel flap by removal of the stumps of the short plantar muscles and with them the plantar aponeurosis and the periosteum of the calcaneus. The result is a heel flap imperfectly fused to the end of the tibia and in bad position. Left, muscles at rest and heel pad held as nearly as possible under the tibia by elastic traction; right, contraction of peroneal muscles drags the unstable heel flap toward the lateral side of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Radiograph of the imperfect Syme stump shown in <b>Fig. 27.</b>. In addition to the unstable and misplaced heel flap, the high level of transection of the tibia and fibula limits the area available for support. In spite of these defects, the stump has functioned reasonably well for 12 years. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A heel flap which has been formed by subperiosteal dissection from off the calcaneus is clumsy and untidy in appearance. It is a deep, cup-shaped structure covered with thick skin and rendered bulky at its anterior end by the inclusion of the bellies of origin of the short plantar muscles. The instinct of every meticulous surgeon is to tidy it by removal of these bulky muscle stumps, but it is best to leave them in place. They do no harm, and any attempt to remove them may damage the specialized, weight-bearing, subcutaneous tissue by removing with them the plantar aponeurosis, from which the fibrous septa originate.</p> <p>The detailed steps (<b>Fig. 29.</b>, <b>Fig. 30.</b>, <b>Fig. 31.</b>, and <b>Fig. 32.</b>) in the operation as at present performed are as follows:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Technique of the Syme amputation. <i>A, </i>Skin incisions from the medial side; <i>B, </i>skin incisions from the lateral side; C, division of the collateral ligaments from within the joint; <i>D, </i>dislocation of the talus downward from the mortise of the ankle joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Technique of the Syme amputation, continued. The talus has been dislocated from the ankle joint. The calcaneus has been separated almost completely from the heel flap by subperiosteal dissection. The tendo achillis is about to be divided at its insertion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Technique of the Syme amputation, continued. Left, the anatomy of the field of operation after the tarsus has been removed from the heel flap; right, closure of the wound with drainage. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Technique of the Syme amputation, continued. The method of strapping the heel flap to the leg to ensure that its position in relation to the cut ends of the tibia and fibula is exactly correct and will remain so. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>Apply an air-pressure tourniquet to the thigh.</li><li>With the foot at a right angle to the tibia, make two incisions: First, from the tip of the lateral malleolus, across the sole of the foot to a point just below the tip of the medial malleolus, the cut being made through all the soft tissues directly down to the tarsal bones. At its center, this plantar incision should be curved slightly forward from the tips of the malleoli, rather than the reverse, so that the center of the flap will be elongated to facilitate covering the anterior margin of the cut surface of the tibia when the wound is closed. Second, a dorsal incision joining the upper ends of the plantar incision and running upward and forward at an angle of 45 deg. from the line of the tibia and from the plantar surface of the foot. It bisects the angle between the tibia and the foot. Through it the ankle joint is entered.</li><li>With the ankle joint open, plantar flex the foot and divide the tibial and fibular collateral ligaments of the ankle from within the joint. On the medial side, be careful to avoid the posterior tibial artery.</li><li>Dislocate the talus downward from the mortise of the ankle joint, open the posterior part of the capsule of the ankle joint from within, and expose the posterosuperior nonarticular surface of the calcaneus and the anterior surface of the tendo achillis just above its insertion.</li><li>With a periosteal elevator (Bristow raspatory), enter the subperiosteal plane on the medial and lateral sides of the calcaneus and extend this subperiosteal dissection to the inferior surface of the bone. Tilt the foot first into inversion and then into eversion and continue the subperiosteal freeing of the calcaneus on its inferior surface. Then work forward in the subperiosteal plane on the medial, lateral, and inferior surfaces of the calcaneus. Detach the origin of the long plantar ligament from the tuberosity of the calcaneus, and continue in the subperiosteal plane until the plantar skin incision is reached and the anterior end of the bone is free. Work backward in the subperiosteal plane until the whole of the calcaneus is free except at the insertion of the tendo achillis. With a knife, carefully divide the tendo achillis working downward from above. Stay close to the bone and avoid damaging the skin flap behind the tendo achillis. Remove the talus and calcaneus together with the damaged portion of the foot. If this step is accomplished successfully, the posterior tibial artery will be unharmed. Only its plantar branches will have been cut by the primary plantar incision. Do nothing to the posterior tibial nerve, which also will have been cut by the primary plantar incision.</li><li>Carefully turn the heel flap backward and upward, and free the malleoli and the lowest 1/4 in. of the tibia. Remove the malleoli and a thin slice of the lower end of the tibia by a saw cut. Be certain that the saw cut will be parallel to the ground when the patient is standing. The amount of tibia removed should be the thinnest possible shaving from its lower end, the sub-articular cortical plate being conserved if possible. In any case, be certain that the largest possible cross-sectional area of the tibia and fibula is obtained to ensure a broad area of support (<b>Fig. 33.</b>).</li><li>Remove the tourniquet and secure perfect haemastasis. Do not trim the heel flap, much as you may desire to make it tidy.</li><li>With interrupted sutures of chromic catgut #0 for the subcutaneous layer and interrupted everting mattress sutures of braided nylon for the skin margins, suture the margin of the heel flap to the margin of the anterior incision across the front of the ankle joint. Suture nothing but the subcutaneous layer and the skin. To drain the dead space, enclose across the wound a section of Penrose tubing and allow the ends to come out at either corner of the wound. The line of suture should be slightly above the anterior margin of the cut surface of the tibia so that cut ends of the bones fit into the cup of the heel flap.</li><li>In closing the wound, pay no attention to the disparity in size, shape, and thickness between the heel flap and the skin margin to which it will be sutured. Center the hollow of the heel flap beneath the cut ends of the tibia and fibula as accurately as possible, and begin the suture line in the center anteriorly and work to either end. Do nothing to the "dog ears" of skin which project at the corners of the approximated skin margins. In time they will shrink and disappear. To trim them invites impairment of circulation.</li><li>The heel flap thus sutured is attached only at its margin and is not yet fixed firmly to the cut surfaces of the tibia and fibula, and accordingly it can be moved about in relation to them. It needs to be secured and maintained in a proper position. To do so, hold the heel flap accurately centered beneath the cut surfaces of the tibia and fibula and secure it in this position by two strips of adhesive tape fastened U-shaped across the end of the stump in the anteroposterior and medio-lateral directions (<b>Fig. 32.</b>). Adhesive tape is better than pins transfixing the heel pad to the tibia, as has sometimes been advocated. Do not apply the adhesive strips too tightly.</li><li>Dress the wound with two layers of surgical pads smoothly applied and held in place by a mildly compressive bandage. Flannelette cut on the bias is ideal, although cotton-crepe bandage (without elastic) will do if not applied tightly.</li><li><i>Important.</i> Open the dressing 24 hours after the operation and every second day thereafter, and inspect the position of the heel flap in relation to the lower ends of the tibia and fibula. Adjust or renew the adhesive strips if necessary to maintain the correct position of the heel flap. If the operative dressing is left unchanged, the heel flap may unite asymmetrically. The stump must be inspected frequently in the postoperative period, and adjustments of the position of the heel flap must be made when necessary. Remove the Penrose tube about the sixth day.</li><li>Maintain a firm dressing until the wound is healed and the stitches are removed (about two weeks). Support the stump thereafter with a cotton-crepe elastic bandage until the first limb is fitted. At the end of four weeks, the patient may begin to put weight on the end of the stump. A prosthesis may be fitted at the end of two months, though it will require a new socket within a year, when shrinkage of the calf muscles is complete.</li></ol> <h3>IMPERFECTIONS WHICH IMPAIR THE FUNCTION OF THE SYME STUMP-HOW TO AVOID OR CORRECT THEM</h3> <p>Not all Syme stumps are perfect, but nearly all imperfections can be avoided by meticulous attention to the details of the operation. Too much emphasis cannot be placed upon a proper understanding of the principles of the amputation and upon its proper performance. Although some imperfections can be compensated for in the fitting of the prosthesis or in the manner of its use, and although some can be eliminated by revision operations, others cannot be overcome at all, usually because of faulty performance of the initial operation.</p> <h4>DAMAGE TO THE WEIGHT-BEARING STRUCTURE OF THE HEEL FLAP</h4> <p>A serious imperfection, which cannot be corrected by further operation, is damage to the weight-bearing structure of the heel flap. This is almost always due to the manner in which the operation is performed. Care must be taken to preserve intact the specialized subcutaneous fibroelastic tissue of the heel pad. As previously indicated, this can be accomplished most certainly by attention to two details in the operation: subperiosteal separation of the heel flap from the calcaneus and avoidance of any attempt to tidy the clumsy flap by removing the stumps of origin of the small muscles of the foot. If these steps in the operation are properly performed, the specialized subcutaneous tissue will remain intact and its function will be unimpaired. On the other hand, if the plane of the subcutaneous tissue is entered during the operation, there will be more or less impairment of its structure and function. This is the prime example of the necessity to perform Syme's amputation by a technique which adheres rigidly to the basic principles of anatomy. There is only one opportunity to fashion a Syme stump of the best quality and that is the occasion of the primary operation. If this is performed skillfully and with due regard for basic principles, it will produce a good end-bearing stump. If the basic principles are disregarded, or if the operation is performed carelessly, the weight-bearing qualities of the flap are likely to be impaired, and they cannot be restored by any subsequent operation.</p> <p>While a defective Syme stump deprives the patient of the comfort and good function he would enjoy with a perfect stump, it may still be sufficiently useful to make it worth while retaining. Reamputation at a higher level is not always inevitable.<a></a> Even an imperfect Syme stump may be more useful than a below-knee amputation. Therefore re-amputation at a higher level because of an imperfect Syme stump should be undertaken only after the most careful consideration of every aspect of the problem.</p> <p>Besides damage to the heel flap, and consequent impairment of the weight-bearing qualities of the stump, a number of other faults can impair the functional value of a Syme amputation.</p> <h4>MISPLACED HEEL FLAP</h4> <p>Care must be taken to secure the heel flap beneath the tibia in such a manner that the plantar surface of the flap is exactly beneath the center of the lower end of the tibia. To keep it there necessitates painstaking care and supervision during the immediate postoperative period. The heel flap being a large, cup-shaped structure, loosely attached to the leg, it must be secured in its proper position by adhesive strips and maintained so until healing has fixed it to the lower end of the tibia (<b>Fig. 32.</b>). If postoperative inspection is neglected, the heel flap may be pushed out of place by the dressing and may unite to the tibia displaced to one side or the other or backward. Its end-bearing capability is then impaired. Fortunately, if the specialized fibroelastic adipose tissue has not been damaged, malposition of the heel flap can be corrected by detaching it and replacing it in its proper position.</p> <h4>SLOPING SURFACE OF LOWER END OF TIBIA</h4> <p>If the cut surface of the lower end of the tibia is not parallel to the ground when the patient stands, the heel flap tends to be pushed to the high side of the slope (<b>Fig. 33.</b>) The plane of transection must therefore be parallel to the ground when the patient stands no matter what its geometric relationship to the long axis of the tibia. If there is any bowing or other deformity of the tibia, the proper plane of transection may actually be oblique to the long axis (<b>Fig. 24.</b>). The particular circumstances in the individual case must be assessed at the time of the primary operation to make certain not only that the plane of section of the lower surface of the tibia is parallel to the ground but also that the maximum area of bony support for the heel flap is secured (<b>Fig. 34.</b>). Any operation to revise an improper bearing surface must necessarily be at a higher level where the cross-sectional area for support is smaller (<b>Fig. 24.</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Oblique transection of lower end of tibia results in displacement of heel pad to high side. <i>A, </i>The stump when no weight is upon it; the heel pad is displaced medially. <i>B, </i>Radiograph of stump; tibia transected obliquely, higher on the medial than on the lateral side. <i>C, </i>The stump bearing weight; the heel pad is markedly displaced to medial side. The function of this heel flap (which already is unstable and misplaced) is impaired still more by the displacement which occurs when weight is borne upon it. This is the result of oblique section of lower end of tibia. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. The proper level for transection of the tibia and fibula in Syme's amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>"WOBBLY," OR UNSTABLE, HEEL FLAP</h4> <p>If the heel flap is loosely attached to the lower end of the tibia, it is easily displaced, and pressure while walking or standing may wipe it to one side or the other or backward. Similarly (<b>Fig. 27.</b> and <b>Fig. 28.</b>), it may be pulled out of place by the stumps of the tendons that are embedded in it, the tendo achillis and the peroneal tendons being the chief offenders. Because the thrust of weight-bearing cannot be maintained through the center of the flap, even when the prosthesis is snugly fitted, an unstable heel flap does not bear weight satisfactorily. The anterior margin of the lower end of the tibia presses through the scar of the anterior suture line, and the patient stands insecurely upon the shifting end of his stump. A flaccid, loose, heel flap occurs when the plane of separation is through the subcutaneous elastic adipose tissue. It can be prevented by subperiosteal dissection of the heel flap. The deep surface of the flap then attaches itself firmly to the cut surface of the bone, and the intact pad of weight-bearing subcutaneous tissue resists changes in shape. An unstable heel flap can be avoided only by proper operative technique. Once it exists it cannot be corrected by further operation though its shortcomings may be minimized by modifying the fit of the prosthesis.</p> <h4>NEUROMA ON POSTERIOR TIBIAL NERVE</h4> <p>In the surgery of the Syme amputation, no attempt should be made to free the posterior tibial nerve and divide it at a high level lest so doing lead to damage of the adjacent posterior tibial artery and consequent impairment of the blood supply to the heel flap. Although a neuroma inevitably develops at the cut end of the nerve, it seldom gives trouble. In the rare case in which the neuroma is sensitive, a cure can be effected by late transection of the nerve at a level well above the ankle joint but without removal of the distal segment of the nerve.</p> <h4>MARGINAL GANGRENE OF THE HEEL FLAP</h4> <p>Except in cases of peripheral vascular disease, marginal gangrene of the heel flap is nearly always due to faulty operative technique. Either the blood supply to the flap is impaired by injury to the posterior tibial artery, or the dressings are put on too tightly, or swelling occurs beneath the adhesive strips and they are not loosened soon enough. With care in operating, there is little danger of necrosis of the flap. Should necrosis occur, the stump is not necessarily ruined unless the loss of tissue is very great (<b>Fig. 35.</b>, <b>Fig. 36.</b>, and <b>Fig. 37.</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Salvage of a Syme stump in spite of marginal gangrene of the flap. This 38-year-old man suffered ischemic necrosis of the muscles of his leg as a complication of fracture of the femur when he was eight years old. He slowly developed a grossly deformed, insensitive foot with trophic ulceration. When the Syme amputation was performed, the posterior tibial artery was inadvertently divided. The result was marginal gangrene of the flap. Separation of the gangrenous margin occurred slowly over a period of eight months. During that time the flap was held in place by adhesive strapping and carefully applied dressings. Wearing an "elephant prosthesis" (<b>Fig. 36.</b>), he first walked five months after his operation. The scar is depressed at the line of suture as the result of the separation of the gangrenous margin of the heel flap. Left, appearance of stump; right, radiograph of stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. The temporary "elephant prosthesis" used on the patient shown in <b>Fig. 35.</b>. It enabled him to walk during the long period of wound-healing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. The final prosthesis provided the patient shown in <b>Fig. 35.</b>. See pages 52-75. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>VASCULAR INSUFFICIENCY IN THE HEEL FLAP</h4> <p>It has been said that the great length of a Syme stump results in vascular insufficiency manifested by a cold, blue, painful stump end, symptoms which are greatly accentuated in cold weather. There has been no such experience in Canada, where, in winter, many of the patients are exposed to very low temperatures. Experience leads to the conclusion that vascular stasis from exposure to cold is not a problem of any importance in the Syme amputation.</p> <h4>TENDER HEEL FLAP WITH CALLUSES</h4> <p>A calloused and tender heel flap is almost always due to failure to preserve the specialized fibroelastic adipose tissue. It is accentuated if the area of transection of the tibia and fibula is small or if there are projecting bone spurs. The problem can be prevented by proper fashioning of the heel flap and by division of the tibia and fibula low enough to provide a broad area of support. If bony spurs are present, they should be removed, but neither a damaged heel flap nor an inadequate area of support can be corrected by any subsequent operation.</p> <h4>IMPERFECT SKIN COVERING OF THE STUMP</h4> <p>In an occasional Syme stump the end is covered with skin ill adapted to weight-bearing. Usually in such cases the extent of the original trauma was such as to leave very little material from which to fashion an adequate heel flap. Sometimes the heel flap is scarred by wounds or infection. Some of the heel flap may have been lost by vascular damage, or the original covering of the stump may have been skin from a site other than the heel. Though little can be done to improve such stumps by further operation, modification of the prosthesis so as to distribute the weight between the end of the stump and the upper end of the socket, as in a below-knee prosthesis, offers promise of improvement. Despite the great importance of covering the end of the stump with skin and subcutaneous tissue accustomed to weight-bearing, there is reason to believe that, when the cut surfaces of the tibia and fibula are as broad as possible, the stresses of weight-bearing are distributed so widely that even ordinary skin and subcutaneous tissue can sometimes function satisfactorily (<b>Fig. 38.</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. A modified Syme amputation in which, because of an injury that completely destroyed the heel flap and the calcaneus, the transected ends of the tibia and fibula were covered with a flap from the dorsum of the foot. Photo shows stump 10 years after amputation, never any trouble; insert is a radiograph showing broad area of support, which probably accounts for the success of this stump despite lack of covering with normal heel pad. Similar to Baudens' supramalleolar amputation.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>INDICATIONS FOR SYME'S AMPUTATION</h4> <p>With a technique that ensures a satisfactory end-bearing stump, Syme's amputation is indicated for all destructive, infective, or other disabling lesions of the foot that cannot be dealt with by a transmetatarsal amputation. The skin over the heel must be intact. Syme's amputation should replace Lisfranc's and Chopart's whenever these amputations are apt to be unsatisfactory, as is often the case. The following are the principal conditions for which Syme's amputation is most frequently performed.</p> <h4>SEVERE INJURIES OF THE FOOT</h4> <p>Compound and comminuted fractures of the tarsus and metatarsus and crushing injuries of the foot are usually best treated by Syme's amputation. If damage to the skeleton of the foot is severe, it is often impossible to salvage a useful and painless foot. As soon as this circumstance becomes apparent, or if from the beginning it is obvious that much of the foot must be lost by reason of the injury or that the foot will ultimately become deformed, rigid, and painful, a Syme's amputation is indicated. It should be performed as soon as the risk of infection can be eliminated. With antibiotics available, the amputation can sometimes be performed as a primary measure. More frequently it will be wise to perform it as a secondary procedure after infection has been brought under control and the wound has healed or nearly healed. In dealing with injuries to the foot, especially war injuries, the advantages of the Syme amputation should be borne in mind so that, instead of immediate resort to a mid-tibial amputation, a two-stage operation can be planned, the primary stage being to remove the shattered and infected distal portions of the foot while preserving the heel flap, the second to effect a formal Syme amputation after the wound has healed or after infection is under adequate control.</p> <h4>INTRACTABLE INFECTIONS OF THE BONES AND JOINTS OF THE FOOT</h4> <p>Today infection is less often an indication for Syme's amputation than it was formerly. Antibiotics give us such control over infections (including tuberculosis) that amputation is seldom necessary as a life-saving measure. It still has a place in the eradication of persistent, chronic infection and in the management of a few unusual infections, such as blastomycosis. Syme's first operation was for tuberculous infection of the talus and calcaneus. It is a tribute to the operator that in a day of uncontrolled infection the result was completely successful.</p> <h4>DEFORMITIES OF THE FOOT</h4> <p>Foot deformities that cause serious disablement from rigidity and localized pressure and that are incapable of correction are indications for Syme's amputation. Although the chief cause of such deformities is previous trauma or infection, conditions such as old clubfoot with intractable deformity can also be well treated by Syme's amputation.</p> <h4>WAR INJURIES</h4> <p>Because battle wounds commonly cause gross damage to tissues, and because they must often be treated hastily, in large numbers, and usually under conditions less than ideal, the merits of Syme's amputation must be emphasized lest the soldier be deprived of its advantages. Every war injury of the foot should be regarded as a condition that might ultimately best be treated by Syme's amputation. Even in questionable cases, consideration should be given to a two-stage procedure: first, removal of the damaged parts with concomitant control of infection; second, a formal Syme amputation when healing of the first wound is well along.</p> <h4>FROSTBITE AND IMMERSION FOOT</h4> <p>Extreme cold causes thrombosis of the smaller vessels of the foot, especially of the distal portions, so that gangrene of the toes develops in severe cases. Foot damage from frostbite, if of considerable extent, is well treated by Syme's amputation. Less severe cases may recover without amputation, or escape with amputation of the toes, or with transmetatarsal amputation.</p> <h4>SELECTED CASES OF OBLITERATIVE VASCULAR DISEASE</h4> <p>Contrary to expectation, it has proved possible to deal with certain cases of Buerger's disease and of arteriosclerotic vascular disease by Syme's amputation. Buerger's disease is more often suitable for Syme's amputation than is arteriosclerotic vascular disease. The most suitable case is a young or middle-aged man suffering from obliterative disease with gangrene of the toes and neighboring parts and a favourable response to lumbar sympathetic block. In such cases, a lumbar sympathectomy, followed by Syme's amputation, will often provide a useful stump that will last for years. Dr. Gordon M. Dale<a></a>, who has had considerable experience with the Syme amputation for obliterative vascular disease (page 44), has had success in 50 percent of his cases. The Syme stump has provided much better function than would have been possible with amputation at a higher level, a matter of special importance since these patients constantly face the possible loss of the other leg at a later date for the same disease.<a></a></p> <h4>CERTAIN NEUROLOGICAL LESIONS</h4> <p>Neurological diseases occasionally produce in the foot changes which impair its usefulness and which may transform it into an encumbrance. If infection supervenes, the patient's life may be endangered.</p> <p>Neuropathic joints in the foot can develop from tabes dorsalis, syringomyelia, or Charcot-Marie-Tooth neuromyopathy. If the disability and deformity from these problems is severe, a Syme amputation is a valuable procedure. It removes the damaged joints and provides the patient with a useful end-bearing stump.</p> <p>The sensory loss which accompanies irreparable sciatic-nerve lesion or spina bifida is prone to result in trophic lesions of the skin of the sole of the foot. These skin lesions occur most frequently in the anterior portion of the foot, where the metatarsal heads press unduly upon the skin which underlies them. When ulceration of the skin develops, infection follows. It must be quickly and completely eradicated. The skin beneath the heel is less often involved because of the thickness of the heel pad. The ulcers beneath the metatarsal heads are so situated that a transmetatarsal amputation is seldom possible because the skin available is inadequate to cover the end of the foot without tension. Such cases are well treated by Syme's amputation.</p> <h4>SYME'S AMPUTATION IN CHILDREN</h4> <p>Syme's amputation can be utilized in children as successfully as in adults, especially in the treatment of destructive foot injuries and of certain congenital foot deficiencies and deformities. Indeed, if properly performed it has in children two special advantages not applicable to adults. Provided the lower epiphyseal line of the tibia is preserved intact, the growth in length of the tibia is but little diminished. Secondly, progressive growth does not project the lower ends of the bones through the skin, as happens all too frequently when amputation through the shaft of the tibia is performed in early childhood.</p> <p>The chief indications for the operation in children are trauma that results in irreparable damage to distal parts of the foot, vascular accidents that terminate in ischemic necrosis or gangrene of the toes and associated parts, and congenital deficiencies and deformities that result in a foot so imperfect as to be an encumbrance. It is of importance that the lower epiphyseal line of the tibia be undamaged and that an area of support as broad as possible be obtained. In children, accordingly, little more should be done to the bones than to remove the malleoli. The lower articular surface of the tibia is left untouched, while the calcaneus is removed from the heel flap by subperiosteal dissection.</p> <p>The Syme amputation can be performed in children as early as the second or third year, with great benefit to the patient. Even if it does nothing more than postpone a formal, mid-tibial amputation until growth has ceased, it is worth performing<a></a> since it ensures a shank of more or less normal length (<b>Fig. 39.</b> and <b>Fig. 40.</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. The Syme amputation in children. This 18-year-old boy suffered embolism or thrombosis at the bifurcation of the aorta as a complication of septicaemia at the age of seven years. Gangrene of his right toes and of the left foot occurred. A Syme amputation was performed on the left foot in May of 1948. He has had a perfectly satisfactory stump for 11 years. Left, the stump (in 1958) shows a large heel pad which moves rather loosely on the ends of the bones; right, radiograph of the stump showing that the transection was rather high. The left tibia is 2 1/8 in. shorter than the right. There is no projection of the bone ends through the end of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. Lower extremities of a 70-year-old man whose Syme amputation was performed 65 years ago for deformed foot resulting from a severe injury at the age of two. Left, appearance of the stump; right, radiographs of the stump. The heel flap is large and soft, moves rather freely on the ends of the bones, and can be moved voluntarily by contraction of the tendo achillis. There is very little shortening of the tibia. Patient has led a very active life (squash-rackets champion at one time) and has had no trouble with his stump. He wears a Marks prothesis (wooden bucket closed with leather flaps over a tongue, solid ankle, and sponge-rubber foot). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is interesting to record that among Syme's earliest cases were three children,<a></a> ages respectively 11 years, 10 years, and 5 <i>months. </i>In all three a good result was obtained.</p> <h4>MALIGNANT DISEASE OF THE FOOT</h4> <p>Malignant disease of some part of the foot, for example malignant melanoma, is an occasional indication for Syme's amputation. Under appropriate circumstances, tumours of the tarsus, such as osteoclastoma, may be well treated by Syme's amputation. As already noted, one of Syme's outstanding successes was an amputation at the ankle joint performed for "an erectile tumour of the foot" (probably a haemangioma). In general, it may be said that any tumour of the foot which can be completely removed without sacrificing any of the principles of the amputation should be regarded as a problem suitable for treatment by Syme's amputation.</p> <h3>RESULTS AND CONCLUSIONS</h3> <p>It is difficult to discuss the results of Syme's amputation because success or failure is so much dependent upon the manner in which the operation has been performed. No matter how many Syme's stumps may be examined to ascertain the end results, the conclusions will be misleading unless the technique of the operation is known for each case. If the basic principles have been observed, and if the operation has been performed properly, the result is an assured success. If any of the fundamental principles have been disregarded, the result may be unsatisfactory, and it may not be possible to improve it. The four basic principles are simple and clear-cut: 1. to remove the damaged foot by disarticulation at the ankle joint; 2. in doing so to preserve the heel flap with its blood supply and weight-bearing qualities unimpaired; 3. to remove the malleoli and the articular cartilage on the lower end of the tibia leaving a surface of support as broad as possible; and 4. to secure the heel flap to the ends of the tibia and fibula in the best position for weight-bearing. When these principles have been followed and the operation has been performed properly, the result almost invariably is a satisfactory end-bearing stump (<b>Fig. 41.</b> and <b>Fig. 42.</b>). But the less perfect the operation the less perfect the result. If some of the principles have been imperfectly applied or some of the details of the operation neglected, the result will not be an ideal Syme's stump, though it may serve the patient's needs with reasonable satisfaction for some period of time. If the principles have been completely neglected and the operation performed without regard to the precise details of technique, the resulting stump will be unsatisfactory and beyond improvement by any subsequent operation limited to the stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. A good functional Syme stump. The heel flap is large and firmly fixed to the lower end of the tibia in good position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Radiograph of the Syme stump shown in <b>Fig. 41.</b>. The area of support is as broad as possible. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Where, in the past, tradition has given rise to a somewhat blind but devoted adherence to Syme's perfected technique, the result has usually been a firm conviction that Syme's amputation is a good amputation. Where attempts have been made to improve upon the operation, usually in an attempt to simplify the limbmaker's problem or to provide a smaller and neater stump, the results have been indifferent or poor, and the operation has been condemned on inadequate grounds. This paper is the first since Syme's day to explore the reasons for the success of Syme's amputation in his hands and in the hands of those who followed him and for the failure of otherwise able surgeons to achieve equal success when they neglected or modified Syme's technique. The first merit which Syme claimed for his new procedure was "that the risk to life will be smaller." That indeed was the case in his day, when it spared the patient the dangerous amputation at the upper end of the tibia. Today this argument in favour of Syme's operation is no longer valid, since we now know the nature of infection and have solved the problem of its control. Though the environment of surgery has changed fundamentally from the preantiseptic era of Syme to the aseptic, bacteriostatic, and antibiotic era of today, his amputation at the ankle joint still has the other merits he claimed for it-"a more comfortable stump, more seemly and useful for support and progressive motion." When circumstances permit it to be performed, Syme's amputation provides indeed the most useful of all amputation stumps of the lower extremity.</p> <p>The history of Syme's amputation during the years since Syme first performed it shows that it has been used widely throughout Europe and North America with variable results. Syme's early cases had the good fortune to escape the complications due to sepsis, such as marred Pirogoff's early experience with the operation. Syme built on the experience he gained in his early successes and gradually perfected a technique which gave a good stump. In Syme's papers on the subject there is no record of a failure or a death, a circumstance extraordinary in view of the sepsis which to some degree complicated every surgical procedure of that day and also in view of the fact that many of his amputations were undertaken for tuberculous caries of the ankle joint or subastragalar joint. The explanation may lie in the fact that in Syme's day operations in the home and in small private hospitals were much less likely to be complicated by "hospital diseases" than were those performed in public hospitals. From 1829 to 1833, all of Syme's operations were performed in the private hospital he established in Minto House. Even after his appointment to the Chair of Clinical Surgery in the University of Edinburgh in 1833, he continued for another 15 years to act as the consulting and operating surgeon of Minto House Hospital and Dispensary, though wards in the Edinburgh Royal Infirmary were assigned to his official position. Syme was well aware that hospital diseases were in some way related to the overcrowding and filth that were universal in public hospitals of that day. The Minto Surgical Hospital, which he founded and controlled, was much less troubled with these complications because he was able there to avoid overcrowding, to ensure adequate ventilation and sanitation, and to segregate ailing patients from those in good health. In discussing compound dislocation of the astragalus, for example, he makes the following reference<a></a> to this aspect of the surgery of his day:</p> <blockquote><p>Compound dislocation of the astragalus with or without that curious displacement of the astragalus, which results from falling with great force on the heel, was formerly held to require amputation of the leg. The authority of Sir A. Cooper's experience encouraged attempts to preserve the limb in such cases; and in private practice both forms of injury are now frequently conducted to a successful issue, though in general through a protracted period of recovery. But it must be admitted that many lives have been lost, especially in hospitals, from trying to retain the limb. In the Royal Infirmary I find that of thirteen patients who had suffered compound dislocation of the ankle, and were not subjected to amputation, only two recovered.</p> </blockquote> <p>When Syme assumed charge of wards in the Edinburgh Royal Infirmary, he bent all his energy toward improving sanitation by providing adequate space between beds, by better ventilation, and by more cleanliness. An interesting outcome of this activity was his insistence that the Governors establish a separate hospital for the treatment of burns. The story is well told by Simpson and Wallace.<a></a> Syme's purpose was not so much to improve the treatment of burns as to remove the unfortunate burn victims, with their offensive wounds and filthy dressings, from his surgical wards to avoid contamination of his operative cases. Pirogoff's experience with his first four cases of Syme's amputation, all of whom died (of scurvy, tuberculosis, and sepsis), must surely be an indication that the surgical wards of Russian hospitals provided an environment much less favourable to surgical operations than did Syme's private hospital at Minto House or his surgical wards at the Edinburgh Royal Infirmary.</p> <p>It is said of Syme that he never wasted a drop of blood, never wasted a drop of ink, and never wasted a word. His publications on the subject of his amputation at the ankle joint were limited to the five papers<a></a> finally gathered together in <i>Contributions to the Pathology and Practice of Surgery</i><a></a> and to his letter to the editor of <i>Lancet.</i><a></a> Having developed a new operation and perfected it to his satisfaction, he published the account of its value. He indicated how the complications and imperfections could be avoided and then left it to stand on its own merit. It must be said also that in Edinburgh his operation has always been held in high repute and that his technique for the procedure has been taught without change to successive generations of students. From the present survey it seems clear that when Syme's operation is condemned because of a poor stump it is almost always because of some obvious failure to follow Syme's technique. As time goes on, more and more evidence accumulates to demonstrate that Syme's operation, properly performed, will provide a good stump. Imperfections are almost invariably the result of failure to follow strictly the details of technique.<a></a> </p> <p>It is strange that over the years there has been such imperfect appreciation of the principles of Syme's amputation. In Syme's own day, Guyon, Roux, and Pirogoff modified Syme's procedure in the hope that they might avoid certain complications. After the 1914- 1918 war, Elmslie introduced his modification, which he confidently believed to be an improvement upon Syme's original technique. Even during the 1939-1945 war, and in subsequent years, the basic principles of Syme's operation were imperfectly understood. <b>Fig. 43.</b> and <b>Fig. 44.</b>, taken from standard texts of that era,<a></a> advocate such a high transection of the tibia and fibula that the result would certainly be an imperfect stump. None of these changes in Syme's procedure has improved the results.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Drawings from Kirk<a></a> showing misconception of the principle of Syme's amputation as late as the year 1942. The indicated level of division of the tibia and fibula is too high; description of Syme's amputation as a "supramalleolar amputation" is incorrect; the skin incision shown is that of Elmslie's modification of Syme's operation, not that used by Syme himself. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Drawing of Syme's amputation showing division of tibia and fibula at a level much too high for a satisfactory stump. From Vasconcelos.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Such misunderstandings must be due to several factors. For one thing, Syme himself wrote about his amputation at the ankle joint in a limited way only, in a style always terse and often obscure, and he published nothing on the subject after 1846. In his publications there is only one inadequate illustration (<b>Fig. 23.</b>). For another, in Syme's day the matter of prime importance was to remove the patient's damaged or infected foot with minimum risk to life. That accomplished, perfection of the stump and fit of the prosthesis were secondary considerations, important but not vital. When infection disappeared as a major problem, the new mastery of surgery, derived from anaesthesia and antisepsis (later asepsis), led surgeons to think that their new freedom in operating should make it possible to refine the procedure and thus to produce a more tidy, more elegant, and more useful stump. Besides this, the demands of the limbmakers led them to believe that high transection of the tibia and fibula would ensure that the patient could more readily be fitted with a satisfactory prosthesis. Whereas in the preanaesthetic and preantiseptic days, the emphasis in operating was upon speed, dexterity, and the control of haemorrhage, in the new freedom of painless and aseptic surgery there was a widespread impulse to devise more sophisticated operations. While the functional value of Syme's amputation derived chiefly from the resulting weight-bearing properties, the stump seemed bulky, clumsy, and unsightly to the new generation of surgeons. Their success in other fields of operative procedure naturally led them to the opinion that Syme's amputation, already good, could be made still better by refining the details of the technique, and the entry into the picture of highly skilled limbfitters encouraged a belief in the necessity for certain modifications to facilitate limb-fitting.</p> <p>Today, fortunately, the perfection of a new type of Syme prosthesis (page 52) has eliminated the ankle-joint problem and minimized the bulbous appearance of the perfect Syme stump. Seldom in the history of surgery has it been necessary to adhere rigidly to the technique of an operation developed and perfected in preantiseptic days. Yet such is the case with Syme's amputation. The simple technique devised by Syme to spare his patients the risks of amputation at the site of election and to give them an end-bearing stump still provides the best end-bearing stump of the lower extremity.</p> <p>Finally, and in summary, the conclusions to be drawn from this examination of the history and development of Syme's operation are as follows:</p> <ol> <li>The stump resulting from a Syme operation has great merit. It bears all the weight of the body on its end and withstands the stresses of locomotion without difficulty and for an unlimited time. It is the most satisfactory amputation of the lower extremity and should be utilized whenever circumstances permit.</li><li>A satisfactory Syme stump can be assured if the principles underlying the operation are understood and if the technique of the operation is followed strictly.</li><li>Deviation from the basic principles or from the details of the technique of the operation will impair the perfection of the stump, and imperfections thus incurred cannot be corrected by subsequent operation.Though imperfect, a Syme stump may still be useful, but sometimes it is ruined irreparably.</li><li>All surgeons who have occasion to deal with trauma or disease of the foot which may require amputation should be familiar with the merits of Syme's amputation and should be prepared to utilize it when the occasion arises. They must be familiar with the principles of the procedure, and they must perform the operation with meticulous adherence to the technique which has proven successful. Interestingly enough, that is the technique which Syme himself perfected.</li></ol> <p>This account of the history and development of Syme's amputation cannot end better than with Syme's own summary of the operative problem, which has been quoted earlier:</p> <blockquote><p>THE AMPUTATION IS EASILY EXECUTED AND PROVES IN THE HIGHEST DEGREE SATISFACTORY IF DONE IN ACCORDANCE WITH CERTAIN PRINCIPLES WHICH HAVE BEEN CAREFULLY EXPLAINED, BUT IS DIFFICULT AND DISASTROUS IF PERFORMED INCORRECTLY.</p> </blockquote> <h3>ACKNOWLEDGMENTS</h3> <p>My thanks are due to many colleagues who have permitted me to see their patients and to reproduce in this paper their photographs and radiographs. Dr. Robert Salter, of the Hospital for Sick Children, Toronto, brought in the patient illustrated in <b>Fig. 37.</b>. Dr. Donald E. Starr, of Vancouver, sent me the photographs and radiograph shown in <b>Fig. 38.</b>. Miss Patterson and her staff at the Library of the Academy of Medicine, Toronto, have rendered me invaluable service in securing from the most distant sources journals of a hundred years ago. Without their assistance, it would have been impossible to compile these historical notes. I am indebted also to the Librarian of the Royal College of Surgeons of Edinburgh for much assistance. I am particularly indebted to Miss Alexandra Birinkova for the translation of Pirogoff's paper,<a></a> to Mrs. Hannah Parnas for the translation of Volkmann's address,<a></a> and to Beatrice Harris for the translation of relevant material from the publications of Baudens,<a></a> Farabeuf,<a></a> and Velpeau,<a></a> and from <i>Les Annates des Therapeutique.</i><a></a> My secretary, Miss Florence Spencer, has spent untold hours of unstinted labour in preparing the manuscript from my notes. I am deeply grateful to her for her devoted work on my behalf.</p> <p>Both the editor and the publisher of the British Edition of the <i>Journal of Bone and Joint Surgery </i>have kindly permitted me to utilize certain illustrations which appeared in a previous publication of mine on Syme's amputation.<a></a>. Their courtesy has enabled me to use material not available elsewhere.</p> <p>-R.I</p> <p><b>References:</b></p> <ol> <li><i>Artificial limbs and their relation to amputations,</i> British Ministry of Pensions, His Majesty's Stationery Office, London, 1939. P. 55.</li> <li>Baudens, J. B. L., <i>Nouvelle methode des amputations,</i> Premiere Memoire, <i>Amputation Tibio-tarsienne, </i>Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</li> <li>Blechschmidt, E., <i>Die Architektur des Fersenpolsters,</i> Morphol. Jahrb., 72:20-68 (1933).</li> <li>Broca, A., and C. Ducroquet, <i>Artificial Limbs,</i> Military Medical Manuals, English ed., Sir Alfred Keogh and R. C. Elmslie, eds., 1918. Pp. 77 and 78.</li> <li>Brown, Dennis, personal communication, 1955.</li> <li>Brown, John, <i>Horae subsecivae, </i>new ed. in 3 vols., Adam and Charles Black, London, 1897. Second series, p. 363. See also Everymans Library, <i>Rob and his friends and other papers, </i>by John Brown, J. M. Dent and Sons, London, 1906.</li> <li>Brown, John, <i>Horae subsecivae, </i>new ed. in 3 vols., Adam and Charles Black, London, 1897. First series, p. 360.</li> <li>Carden, H. D., <i>On amputation by single flap, </i>Brit. Med. J., 1:416 (1864).</li> <li>Dale, G. M., personal communication, 1960.</li> <li>Dent, Clinton T., <i>Surgical notes from the military hospitals of South Africa, </i>Brit. Med. J., 1:1313 (1900).</li> <li>Elmslie, R. C, in Carson's <i>Modern operative surgery, </i>1st ed., Cassel &amp; Co., London, 1924. Vol. 1, section on amputations, p. 132.</li> <li>Farabeuf, L. H., <i>Precis de manuel operatoire (ligatures, amputations), </i>G. Masson, Editeur, Paris, 1881. P. 473.</li> <li>Fergusson, <i>System of practical surgery, </i>4th ed., review in Lancet, Vol. II, p. 394 (1857).</li> <li>Godlee, Sir Rickman, <i>Life of Lord Lister, </i>3rd ed., Clarendon Press, Oxford, 1924. Chapter X.</li> <li>Guyon, F., <i>Gazette des hopitaux, </i>p. 514 (1868), quoted from Farabeuf, <i>Precis de manuel operatoire (ligatures, amputations) </i>G. Masson, Editeur, Paris, 1881. P. 543.</li> <li>Hancock, Henry, <i>On operative surgery of the foot and ankle joint </i>(1873).</li> <li>Harris, R. I., <i>Syme's amputation, </i>J. Bone &amp; Joint Surg., 38B:614 (1956).</li> <li>Hutchinson, J., Jr., <i>On the substitution (when practicable) of subastragalar for Syme's amputation, </i>Brit. Med. J., 2:1169 (1900).</li> <li>Jacobson, W. H. A., <i>The operations of surgery, </i>First American ed., Blakiston, Philadelphia, 1889. Pp. 939-943.</li> <li>Kirk, N. T., <i>Amputations, </i>W. F. Prior Co., Inc., Hagerstown, Md., 1942.</li> <li>Kuhns, J. G., <i>Changes in elastic adipose tissue, </i>J. Bone &amp; Joint Surg., 31A:541 (1949).</li> <li>Kuhns, J., and P. D. Wilson, <i>Major amputations-analysis and study of end results in 428 cases, </i>Arch. Surg., 16:887 (1928).</li> <li>Langdale-Kelham, R. D., and G. Perkins, <i>Amputations and artificial limbs, </i>Oxford, London, 1942. P. 3.</li> <li>LeMesurier, A. B., personal communication, 1952.</li> <li>Paterson, R., <i>Memorials of the life of James Syme,</i> Edmonston and Douglas, Edinburgh, 1874.</li> <li>Pirogoff, N. L, <i>Osteoplastic elongation of the bones of the lower leg in conjunction with release of the foot from the ankle joint, </i>J. Military Med., St. Peters-berg, 63:83 (1854). See also Farabeuf,<a></a> <i>Precis de manuel operatoire (ligatures, amputations), </i>G. Masson, Editeur, Paris, 1881. P. 527.</li> <li>Roux, J., <i>Annales de Therapeutique, </i>Paris, 1846, quoted from Farabeuf, <i>Precis de manuel operatoire (ligatures, amputations), </i>G. Masson, Editeur, Paris, 1881. Pp. 500-515.</li> <li>Shellswell, J. H., <i>Svme's amputation, </i>Lancet, Vol. II, p. 1296(1954).</li> <li>Simpson, D. C, and A. B. Wallace, <i>Edinburgh's first burn hospital, </i>J. Roy. Col. Surg. Edinburgh, 2:134 (1956).</li> <li>Syme, J., <i>On amputation at the ankle joint, </i>London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</li> <li>Syme, J., <i>Amputation at the ankle joint, </i>London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVIII, April 1843, p. 274.</li> <li>Syme, J., <i>Amputation at the ankle joint, </i>London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</li> <li>Syme, J., <i>Amputation at the ankle joint, </i>London and Edinburgh Monthly Journal of Medical Science, Vol. 5, No. LIII, May 1845, p. 341.</li> <li>Syme, J., <i>On amputation at the knee, </i>Monthly Journal of Medical Science, Vol. 5, No. LIII, p. 337, 1845.</li> <li>Syme, J., <i>Amputation at the ankle, </i>Monthly Journal of Medical Science, Vol. 6, No. LXVII, Aug. 1846, p. 81.</li> <li>Syme, J., <i>Contributions to the pathology and practice of surgery, </i>Murray &amp; Gibb., Edinburgh, 1848. Pp. 114-147.</li> <li>Syme, J., <i>Mr. Syme on amputation at the ankle joint,</i> Letter to the Editor, Lancet, Vol. II, p. 394 and 480 (1857).</li> <li>Syme, J., <i>On amputation at the knee, </i>Edinburgh Medical Journal, Vol. XI, p. 871 (1866).</li> <li>Thompson, Henry, Reported in the account of the meeting of the Pathological Society of London for April 21, 1863, and published in Lancet, Vol. I, p. 525 (1863).</li> <li>Tietze, A., <i>Uber den Architektonischen Aufbau des Bindegewebes in der Menschlichen Fussohle, </i>Beitrage zur Klin. Chir., No. 123, p. 493 (1921).</li> <li>Valery-Radot, R., <i>Life of Pasteur, </i>Doubleday, Page &amp; Co., New York, 1919. Chapter IV.</li> <li>Vasconcelos, E., <i>Modern methods of amputation,</i> Department of War Medicine, The Philosophical Library, New York, 1945.</li> <li>Velpeau, A. A. L. M., <i>New elements of operative surgerv, </i>First American Ed., Samuel and William Wood, New York, 1847. P. 595.</li> <li>Volkmann, Richard, <i>Sammlung klinischer Vortrage,</i> Vol. III, #221, (Surg. 70), p. 1878, Die Moderne Chirurgie (1882).</li> <li>Warren, R., I. Thayer, H. Achenbach, and L. Kendall, <i>The Syme amputation in peripheral vascular disease, </i>Surgery, Vol. 37, p. 156 (1955).</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>12.</b> </td><td class="clsTextSmall">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Harris, R. I., Syme's amputation, J. Bone &amp;Joint Surg., 38B:614 (1956).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Velpeau, A. A. L. M., New elements of operative surgerv, First American Ed., Samuel and William Wood, New York, 1847. P. 595.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Volkmann, Richard, Sammlung klinischer Vortrage, Vol. III, #221, (Surg. 70), p. 1878, Die Moderne Chirurgie (1882).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Pirogoff, N. L, Osteoplastic elongation of the bones of the lower leg in conjunction with release of the foot from the ankle joint, J. Military Med., St. Peters-berg, 63:83 (1854). See also Farabeuf,12 Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 527.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Vasconcelos, E., Modern methods of amputation, Department of War Medicine, The 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>20.</b> </td><td class="clsTextSmall">Kirk, N. T., Amputations, W. F. Prior Co., Inc., Hagerstown, Md., 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Kirk, N. T., Amputations, W. F. Prior Co., Inc., Hagerstown, Md., 1942.</td></tr><tr><td class="clsTextSmall"><b> 42.</b> </td><td class="clsTextSmall">Vasconcelos, E., Modern methods of amputation, Department of War Medicine, The 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>22.</b> </td><td class="clsTextSmall">Kuhns, J., and P. D. Wilson, Major amputations-analysis and study of end results in 428 cases, Arch. Surg., 16:887 (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>37.</b> </td><td class="clsTextSmall">Syme, J., Mr. Syme on amputation at the ankle joint, Letter to the Editor, Lancet, Vol. II, p. 394 and 480 (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>36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>30.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr><tr><td class="clsTextSmall"><b> 31.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVIII, April 1843, p. 274.</td></tr><tr><td class="clsTextSmall"><b> 32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 33.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 5, No. LIII, May 1845, p. 341.</td></tr><tr><td class="clsTextSmall"><b> 35.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle, Monthly Journal of Medical Science, Vol. 6, No. LXVII, Aug. 1846, p. 81.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Simpson, D. C, and A. B. Wallace, Edinburgh's first burn hospital, J. Roy. Col. Surg. Edinburgh, 2:134 (1956).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 33.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 5, No. LIII, May 1845, p. 341.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Brown, Dennis, personal communication, 1955.</td></tr><tr><td class="clsTextSmall"><b> 24.</b> </td><td class="clsTextSmall">LeMesurier, A. B., personal communication, 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>45.</b> </td><td class="clsTextSmall">Warren, R., I. Thayer, H. Achenbach, and L. Kendall, The Syme amputation in peripheral vascular disease, Surgery, Vol. 37, p. 156 (1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Dale, G. M., personal communication, 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Shellswell, J. H., Svme's amputation, Lancet, Vol. II, p. 1296(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>19.</b> </td><td class="clsTextSmall">Jacobson, W. H. A., The operations of surgery, First American ed., Blakiston, Philadelphia, 1889. Pp. 939-943.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Thompson, Henry, Reported in the account of the meeting of the Pathological Society of London for April 21, 1863, and published in Lancet, Vol. I, p. 525 (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">Jacobson, W. H. A., The operations of surgery, First American ed., Blakiston, Philadelphia, 1889. Pp. 939-943.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>30.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr><tr><td class="clsTextSmall"><b> 31.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVIII, April 1843, p. 274.</td></tr><tr><td class="clsTextSmall"><b> 32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 33.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 5, No. LIII, May 1845, p. 341.</td></tr><tr><td class="clsTextSmall"><b> 35.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle, Monthly Journal of Medical Science, Vol. 6, No. LXVII, Aug. 1846, p. 81.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Blechschmidt, E., Die Architektur des Fersenpolsters, Morphol. Jahrb., 72:20-68 (1933).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Tietze, A., Uber den Architektonischen Aufbau des Bindegewebes in der Menschlichen Fussohle, Beitrage zur Klin. Chir., No. 123, p. 493 (1921).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Kuhns, J. G., Changes in elastic adipose tissue, J. Bone &amp;Joint Surg., 31A:541 (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>1.</b> </td><td class="clsTextSmall">Artificial limbs and their relation to amputations, British Ministry of Pensions, His Majesty's Stationery Office, London, 1939. P. 55.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Langdale-Kelham, R. D., and G. Perkins, Amputations and artificial limbs, Oxford, London, 1942. P. 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>11.</b> </td><td class="clsTextSmall">Elmslie, R. C, in Carson's Modern operative surgery, 1st ed., Cassel &amp;Co., London, 1924. Vol. 1, section on amputations, p. 132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Broca, A., and C. Ducroquet, Artificial Limbs, Military Medical Manuals, English ed., Sir Alfred Keogh and R. C. Elmslie, eds., 1918. Pp. 77 and 78.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Guyon, F., Gazette des hopitaux, p. 514 (1868), quoted from Farabeuf, Precis de manuel operatoire (ligatures, amputations) G. Masson, Editeur, Paris, 1881. P. 543.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Elmslie, R. C, in Carson's Modern operative surgery, 1st ed., Cassel &amp;Co., London, 1924. Vol. 1, section on amputations, p. 132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Thompson, Henry, Reported in the account of the meeting of the Pathological Society of London for April 21, 1863, and published in Lancet, Vol. I, p. 525 (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>11.</b> </td><td class="clsTextSmall">Elmslie, R. C, in Carson's Modern operative surgery, 1st ed., Cassel &amp;Co., London, 1924. Vol. 1, section on amputations, p. 132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Elmslie, R. C, in Carson's Modern operative surgery, 1st ed., Cassel &amp;Co., London, 1924. Vol. 1, section on amputations, p. 132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Elmslie, R. C, in Carson's Modern operative surgery, 1st ed., Cassel &amp;Co., London, 1924. Vol. 1, section on amputations, p. 132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Broca, A., and C. Ducroquet, Artificial Limbs, Military Medical Manuals, English ed., Sir Alfred Keogh and R. C. Elmslie, eds., 1918. Pp. 77 and 78.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Broca, A., and C. Ducroquet, Artificial Limbs, Military Medical Manuals, English ed., Sir Alfred Keogh and R. C. Elmslie, eds., 1918. Pp. 77 and 78.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Dent, Clinton T., Surgical notes from the military hospitals of South Africa, Brit. Med. J., 1:1313 (1900).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Syme, J., Mr. Syme on amputation at the ankle joint, Letter to the Editor, Lancet, Vol. II, p. 394 and 480 (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>10.</b> </td><td class="clsTextSmall">Dent, Clinton T., Surgical notes from the military hospitals of South Africa, Brit. Med. J., 1:1313 (1900).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Hutchinson, J., Jr., On the substitution (when practicable) of subastragalar for Syme's amputation, Brit. Med. J., 2:1169 (1900).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Velpeau, A. A. L. M., New elements of operative surgerv, First American Ed., Samuel and William Wood, New York, 1847. P. 595.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Pirogoff, N. L, Osteoplastic elongation of the bones of the lower leg in conjunction with release of the foot from the ankle joint, J. Military Med., St. Peters-berg, 63:83 (1854). See also Farabeuf,12 Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 527.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Pirogoff, N. L, Osteoplastic elongation of the bones of the lower leg in conjunction with release of the foot from the ankle joint, J. Military Med., St. Peters-berg, 63:83 (1854). See also Farabeuf,12 Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 527.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Elmslie, R. C, in Carson's Modern operative surgery, 1st ed., Cassel &amp;Co., London, 1924. Vol. 1, section on amputations, p. 132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Pirogoff, N. L, Osteoplastic elongation of the bones of the lower leg in conjunction with release of the foot from the ankle joint, J. Military Med., St. Peters-berg, 63:83 (1854). See also Farabeuf,12 Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 527.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Pirogoff, N. L, Osteoplastic elongation of the bones of the lower leg in conjunction with release of the foot from the ankle joint, J. Military Med., St. Peters-berg, 63:83 (1854). See also Farabeuf,12 Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 527.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Guyon, F., Gazette des hopitaux, p. 514 (1868), quoted from Farabeuf, Precis de manuel operatoire (ligatures, amputations) G. Masson, Editeur, Paris, 1881. P. 543.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Hancock, Henry, On operative surgery of the foot and ankle joint (1873).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Jacobson, W. H. A., The operations of surgery, First American ed., Blakiston, Philadelphia, 1889. Pp. 939-943.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Jacobson, W. H. A., The operations of surgery, First American ed., Blakiston, Philadelphia, 1889. Pp. 939-943.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Roux, J., Annales de Therapeutique, Paris, 1846, quoted from Farabeuf, Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. Pp. 500-515.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Syme, J., Amputation at the ankle, Monthly Journal of Medical Science, Vol. 6, No. LXVII, Aug. 1846, p. 81.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Syme, J., Mr. Syme on amputation at the ankle joint, Letter to the Editor, Lancet, Vol. II, p. 394 and 480 (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>30.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Carden, H. D., On amputation by single flap, Brit. Med. J., 1:416 (1864).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the knee, Edinburgh Medical Journal, Vol. XI, p. 871 (1866).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Carden, H. D., On amputation by single flap, Brit. Med. J., 1:416 (1864).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the knee, Edinburgh Medical Journal, Vol. XI, p. 871 (1866).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Syme, J., On amputation at the knee, Monthly Journal of Medical Science, Vol. 5, No. LIII, p. 337, 1845.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Fergusson, System of practical surgery, 4th ed., review in Lancet, Vol. II, p. 394 (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>37.</b> </td><td class="clsTextSmall">Syme, J., Mr. Syme on amputation at the ankle joint, Letter to the Editor, Lancet, Vol. II, p. 394 and 480 (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>36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>31.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVIII, April 1843, p. 274.</td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 5, No. LIII, May 1845, p. 341.</td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle, Monthly Journal of Medical Science, Vol. 6, No. LXVII, Aug. 1846, p. 81.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>30.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr><tr><td class="clsTextSmall"><b> 37.</b> </td><td class="clsTextSmall">Syme, J., Mr. Syme on amputation at the ankle joint, Letter to the Editor, Lancet, Vol. II, p. 394 and 480 (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>References</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Godlee, Sir Rickman, Life of Lord Lister, 3rd ed., Clarendon Press, Oxford, 1924. Chapter X.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Godlee, Sir Rickman, Life of Lord Lister, 3rd ed., Clarendon Press, Oxford, 1924. Chapter X.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Godlee, Sir Rickman, Life of Lord Lister, 3rd ed., Clarendon Press, Oxford, 1924. Chapter X.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>30.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr><tr><td class="clsTextSmall"><b> 31.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVIII, April 1843, p. 274.</td></tr><tr><td class="clsTextSmall"><b> 32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 33.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 5, No. LIII, May 1845, p. 341.</td></tr><tr><td class="clsTextSmall"><b> 35.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle, Monthly Journal of Medical Science, Vol. 6, No. LXVII, Aug. 1846, p. 81.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Brown, John, Horae subsecivae, new ed. in 3 vols., Adam and Charles Black, London, 1897. First series, p. 360.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Brown, John, Horae subsecivae, new ed. in 3 vols., Adam and Charles Black, London, 1897. Second series, p. 363. See also Everymans Library, Rob and his friends and other papers, by John Brown, J. M. Dent and Sons, London, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Godlee, Sir Rickman, Life of Lord Lister, 3rd ed., Clarendon Press, Oxford, 1924. Chapter X.</td></tr><tr><td class="clsTextSmall"><b> 44.</b> </td><td class="clsTextSmall">Volkmann, Richard, Sammlung klinischer Vortrage, Vol. III, #221, (Surg. 70), p. 1878, Die Moderne Chirurgie (1882).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Valery-Radot, R., Life of Pasteur, Doubleday, Page &amp;Co., New York, 1919. Chapter IV.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Godlee, Sir Rickman, Life of Lord Lister, 3rd ed., Clarendon Press, Oxford, 1924. Chapter X.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Paterson, R., Memorials of the life of James Syme, Edmonston and Douglas, Edinburgh, 1874.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>R. I. Harris </b></td></tr><tr><td class="clsTextSmall">M.C., M.B., F.R.C.S. Can., F.R.C.S. Eng. (Hon.), F.R.A.C.S. (Hon.), F.R.C.S. Edin. (Hon.), Lecturer in Surgery, University of Toronto, Toronto, Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1961_01_004/a001.jpg Figure 2 http://www.oandplibrary.org/al/images/1961_01_004/a002.jpg Figure 3 http://www.oandplibrary.org/al/images/1961_01_004/a003.jpg Figure 4 http://www.oandplibrary.org/al/images/1961_01_004/a004.jpg Figure 5 http://www.oandplibrary.org/al/images/1961_01_004/a005.jpg Figure 6 http://www.oandplibrary.org/al/images/1961_01_004/a006.jpg Figure 7 http://www.oandplibrary.org/al/images/1961_01_004/a007.jpg Figure 8 http://www.oandplibrary.org/al/images/1961_01_004/a008.jpg Figure 9 http://www.oandplibrary.org/al/images/1961_01_004/a009.jpg Figure 10 http://www.oandplibrary.org/al/images/1961_01_004/a010.jpg Figure 11 http://www.oandplibrary.org/al/images/1961_01_004/a011.jpg Figure 12 http://www.oandplibrary.org/al/images/1961_01_004/a012.jpg Figure 13 http://www.oandplibrary.org/al/images/1961_01_004/a013.jpg Figure 14 http://www.oandplibrary.org/al/images/1961_01_004/a014.jpg Figure 15 http://www.oandplibrary.org/al/images/1961_01_004/a015.jpg Figure 16 http://www.oandplibrary.org/al/images/1961_01_004/a016.jpg Figure 17 http://www.oandplibrary.org/al/images/1961_01_004/a017.jpg Figure 18 http://www.oandplibrary.org/al/images/1961_01_004/a018.jpg Figure 19 http://www.oandplibrary.org/al/images/1961_01_004/a019.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 History and Development of Syme's Amputation Creator An entity primarily responsible for making the resource R. I. Harris * https://staging.drfop.org/files/original/09ae6273b7efa1eca6cc0322ff308dd3.pdf c37e010a6efb7da15ebc3041aebdd09c https://staging.drfop.org/files/original/0e3e1220253af6aa4b191462f1226ca4.jpg b0082ad957d997d1c0132891b476d3b6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_02_044.pdf Year 1965 Volume 9 Issue 2 Page Number(s) 44 - 45 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_02_044.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_02_044.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>L'Attelle Monotubulaire, a Review</h2> <h5>Ralph Lusskin, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>L'Attelle Monotubulaire is the second fascicle, or increment, of the Atlas d'Appareillage Prothetique et Orthopedique (Atlas of Prosthetic and Orthopaedic Appliances) being published under the direction of Professor Louis Pierquin of the Faculty of Medicine of Nancy {Artificial Limbs, Spring 1964). L'Attelle Monotubulaire describes a lower-extremity brace of novel design and function-the monotubular brace. This interesting departure in French orthotics utilizes a single straight tubular upright to provide lightness and strength. The conventional medial upright is eliminated.</p> <p>Additional departures include a round caliper shoe attachment placed anterior to the ankle joint as well as below it. Geometry is accommodated during ankle movement and spring action is added to the joint by the use of a telescoping lower leg piece which inserts into an upper tube below the calf band. Stops and additional springs can be attached to the stirrup piece.</p> <p>Thus there has been developed a brace that uses a straight upright anterior to the axis of the leg, which has a moderate posterior offset of the knee joint, which varies in length with ankle motion and is easily adjusted to the torsional alignment of the leg. Patellar-tendonbearing-type leg bands and quadrilateral sockets can be utilized in place of narrow leg and thigh bands. Wide, contoured plastic bands are attached by metal bands soldered to the brace.</p> <p>To evaluate such a novel device, one must determine whether construction would present significant problems, whether fitting and alignment procedures can be standardized, and whether utilization corroborates the claimed attributes. Unfortunately, the publication does not provide sufficiently detailed information to answer these questions. This work is presented in broad terms for the general information of the physician-therapist-orthotist team. It does introduce the device but does not describe the metals used or the fabrication methods. Alignment procedures are not discussed, although two errors-improper depth of the thigh and leg bands and improper rotational alignment due to faulty positioning of the shoe piece-are demonstrated. No analysis of failure rates or comparison of the effectiveness of this brace versus that of standard braces is given. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. "When viewed laterally, the monotubular brace is traight; it does not show even the slightest curve at the level of the knee. It rests on a forward pin; that is, on a pin located in front of the axis of the limb." From L'Attelle Monotubulaire </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Considerable thought and work have obviously been expended to bring this device to its present state. Thus it is unfortunate that one can only speculate concerning possible limitations or advantages that might be inherent in its design.</p> <h4>Possible Limitations</h4> <p>Difficulties in using this brace might be encountered if deformities of the knee in the frontal plane, for example, genu valgum or genu varum, are present. In addition, the management of any flexion contracture of the knee would apparently be most difficult.</p> <p>Ankle instability would not be controlled by this device. While drop foot could be managed, varus and valgus deformities, both fixed and functional, might exceed the capacities of the brace. It is not apparent whether or not a calcaneal deformity could be adequately stabilized.</p> <p>The report notes the critical nature of the depth of the leg band, indicating that proper alignment and fit are vital factors in the application of this orthosis and that careful supervision by the physician would be required.</p> <h4>Possible Advantages</h4> <p>Certain advantages of the monotubular brace are apparent. The simplicity of the single-bar fabrication, the lightness of the device, and its potential for control of bilateral disorder without clearance problems are all positive values.</p> <h4>Conclusions</h4> <p>Since the monotubular brace appears to have potential value and its limitations can be only assumed, the device should be the subject of a controlled evaluation to identify problem areas and to demonstrate the usefulness of the device. This evaluation should include the training of others in fabrication, alignment, and fitting of the brace, and its utilization by a representative group of patients under controlled conditions.</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>Ralph Lusskin, M.D. </b></td></tr><tr><td class="clsTextSmall">Associate Clinical Professor of Orthopaedic Surgery, School of Medicine and Post-Graduate Medical School, New York University, 550 First Ave., New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_02_044/1965_02_044.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 L'Attelle Monotubulaire, a Review Creator An entity primarily responsible for making the resource Ralph Lusskin, M.D. * https://staging.drfop.org/files/original/1a6a1f184c2cd633f78c0e51e7fd583d.pdf 888106633767347702e5270333805508 https://staging.drfop.org/files/original/8171860100ffe17960ae92f1c1b7a8d0.jpg 0c7928d738cf860db28f518883959e4d https://staging.drfop.org/files/original/8a08a028e48debbdf4ee986f98699a5c.jpg 4a00b22dd3dfd62390f8ba4f63b18825 https://staging.drfop.org/files/original/08ca4555f259d231e98499d7c73c6745.jpg bed855e369a3efebf3dbb45a39dc26d3 https://staging.drfop.org/files/original/5d9726a0d70d25e282e5ce3cb6acc7c3.jpg 84b68d902457336b3a79c6063c74c0ee https://staging.drfop.org/files/original/561c6de9e48cf18c7f2151422e231efe.jpg d97ac2700c75061656d8e1361d5ead59 https://staging.drfop.org/files/original/3877690c34824efa8115956d3b0a2228.jpg ca94e33e0cc3b346a85cae372f9efa31 https://staging.drfop.org/files/original/214655cdfbc70a1417706fd03bf6a90c.jpg c097b37a2e6e301bf9f8d22a385ac217 https://staging.drfop.org/files/original/d43be2a407eb388121e5a356fea5944f.jpg 9f50cc9d64f58612267042301517bfb0 https://staging.drfop.org/files/original/12b1d25199058a29e26176c2409e0d03.jpg 4950e3238e3bba891356e29d6431a8cb https://staging.drfop.org/files/original/3394cf2dce7b6e4720919e2650d7edfc.jpg 28bddd80061034f8d909eee6b3640a40 https://staging.drfop.org/files/original/e058338cad5520af44befe2f6a5065b2.jpg 07c48836d80a04cfe671b99f8b536819 https://staging.drfop.org/files/original/08d3f28bce0cc2b654faee759fbf43df.jpg 092fc66c6603e929370979286f089b62 https://staging.drfop.org/files/original/5f840ffc2fa022f39d93f212174b17d0.jpg 31e3d1cd5d444f17ff180e1a8d0f4ddf https://staging.drfop.org/files/original/16c6c01bce1b985df06b3717a4a4ea62.jpg 24c528bc31b56db4151f81170510c7ee https://staging.drfop.org/files/original/4030c50d9472b0af3537174082a6c112.jpg 6858cd0a306c0b542ec75507d11cd306 https://staging.drfop.org/files/original/4a43c2820bac145818f45fcb14291807.jpg 511c75d1f2c73f882f969ad6ee91b696 https://staging.drfop.org/files/original/14cff0d7ef503eb8545491831195dc8b.jpg c86204cca3a3d38e040653e3c6af86ee https://staging.drfop.org/files/original/a8e82dc65e5d99d52bd3f5ee18dc4085.jpg 92e551a7865e62369eedec664217bdd1 https://staging.drfop.org/files/original/0740cc4fe2fb2fc64ac5b4869573d026.jpg d0e7bf7ba9a78049c80e1b8560127ec3 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1972_01_001.pdf Year 1972 Volume 16 Issue 1 Page Number(s) 1 - 19 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1972_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1972_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>Body Segment Parameters, Part II</h2> <h5>Renato Contini <a style="text-decoration:none;">*</a><br /></h5> <p>The performance of human (animal) activity requires the expenditure of energy. During the contraction of the muscles involved in this activity, chemical energy is converted first into mechanical energy, then into work and heat. Some of this chemical energy is required for maintenance of body functions. In movement, however, much of the mechanical energy is required to overcome friction and tissue displacement at the joints, gravity, inertial forces, air and water resistance—all of which oppose the action desired.</p> <p>Biomechanics is the science that is concerned with such effects. In order to understand better the biomechanics of movement, it is necessary to know certain characteristics of the segments involved. Among these characteristics are the mass of the segments, their centers of mass, and their mass moments of inertia. The characteristics (body parameters) themselves are not readily obtained on living subjects.</p> <p>It was the purpose of two studies conducted at the New York University School of Engineering and Science to obtain some of these body parameters. The first of these studies, <a></a> completed in 1966, was conducted on normal, healthy American males in the age range of 20-40 years. The second study, <a></a> completed in 1970, was conducted on a random selection of adults, young males and females 20-30 years of age, some females in the 40-50 age bracket, and a number of amputees and hemiplegics, male and female, in all age ranges.</p> <p>A history, survey of measurement techniques, and data developed over the years was given in "Body Segment Parameters: A Survey of Measurement Techniques," which appeared in <i>Artificial Limbs, </i>Spring 1964. <a></a> Also, a condensation of four of the most important monographs in this field ("Center of Gravity of the Human Body" by W. Braune and O. Fischer; "Theoretical Fundamentals for a Mechanics of Living Bodies" by O. Fischer; "The Human Motor" by J. Amar; and "Space Requirements of the Seated Operator" by W. T. Dempster) has been prepared by Krogman and Johnston <a></a> under the sponsorship of the United States Air Force.</p> <h3>Methods</h3> <p>Most studies undertaken previously used cadavers, but in a few studies, including those at New York University, living subjects were used. Although some available measuring techniques for compiling the data are similar for live subjects and for cadavers, other techniques must obviously differ. In general, the techniques covered here are for living subjects; thus, all techniques used on dissected cadavers are not included. When living subjects are used, particularly the elderly and those suffering with some affliction or disability, any technique utilized must be at the convenience of the subject. Some subjects cannot comfortably assume the necessary postures during the measurement processes, while for some others the procedures are physically impossible. As a result, not all measurements can be taken on all subjects, but, because of the various techniques available, most of the desired data can be obtained.</p> <p>The techniques are only briefly presented here because more adequate descriptions are available in other references.</p> <h4>Volume Determination</h4> <p>The body and all of its segments are irregular solids. The volume of an irregular solid may be obtained or approximated in a number of ways: by mensuration, immersion, or photogrammetry. Only the first two were used in both studies.</p> <p><i>Mensuration</i></p> <p>A relatively good approximation of body-segment volume can be obtained by using circumferential measurements at certain selected stations on the segment and the linear dimensions between any two consecutive circumferential measurements. If all these measurements are known for the full length of the segment, then an approximate volume can be determined. Accuracy will increase with the increased number of such measurements. This technique assumes that any two successive cross sections of the member are parallel and essentially similar geometrically. In that event, the volume contained within the two cross sections may be expressed as: <b>Equation 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is obviously impossible to obtain cross-sectional areas on the body segments of living subjects. If it is assumed, however, that the cross sections of the limbs are elliptical, it is possible to establish a relationship between the cross-sectional area and the perimeter at any chosen level. For any segmental portion between two levels, the volume may now be expressed as: <b>Equation 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For a total limb divided into n segments, each <i>h </i>distance apart: <b>Equation 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The derivation of this equation is given in reference. <a></a></p> <p><i>Immersion</i></p> <p>In this method, the segment whose volume is to be determined is immersed in water. Incremental volumes are taken of the segment whose total volume then is the sum of these increments. For these studies, four tanks were specially designed: an arm tank, a hand tank, a leg tank, and a foot tank. Each tank was constructed of Plexiglas, the first three cylindrical in cross section, and the last, rectangular.</p> <p>The limb or body segment was completely immersed in the tank. Water was permitted to drain off in controlled increments, each representing a known change in cylinder height. Drained water was collected and measured. The difference in volume between that collected and that obtainable without the body segment in place (the actual volume of the tank for that increment) represents the volume of the body segment contained within the height increment. Whenever possible, these increments were 2.0 cm apart, but, if subjects with limited physical tolerance had minimal cross-sectional variation, the increments were increased to every 4.0 cm apart.</p> <p><i>Photogrammetry</i></p> <p>Two types of photogrammetric techniques are available-mono and stereo. In the former, lines or colored shadows are projected on the subject in such fashion as to produce a contour map on the particular segment of interest. The areas contained within these contours may be measured with a planimeter, and the same general equation for determining the volume as given previously may be used. Again, the sum of all the incremental volumes of the segment represents its total volume.</p> <p>In stereophotogrammetry, two cameras are used side by side to create an illusion of depth when the two photographs are juxtaposed. The resulting picture is treated as an aerial photograph of terrain upon which contour levels are applied. These then are treated as in monophoto-grammetry.</p> <h4>Density Determination</h4> <p>To obtain the overall body density of living subjects is extremely difficult. To obtain the density of individual segments on living subjects is virtually impossible. There are ways, however, to obtain fairly accurate values. The problems involved will not be discussed here; some of them are described in the two referenced reports. <a></a></p> <p><i>Empirical (Whole Body)</i></p> <p>Whole-body volume may be approximated in several ways. The mass may be obtained by weighing accurately. The density is the ratio of mass to volume. For lean bodies, the density is higher than for fat bodies. One provisional formula for determining density, developed by Dupertuis in 1950, <a></a> makes use of Sheldon's somatotyping system <a></a> and introduces the first component (x) of the system into the equation:<br /><i>d(ensity) =</i> 1.094 - 0.0119x</p> <p>A second equation developed by the Biomechanics Group at NYU, using data developed by Behnke, <a></a> is based on the height <i>(H) </i>in inches, and weight <i>(W) </i>in pounds of the individual (<b>Fig. 1</b> and <b>Fig. 2</b>): <b>Equation 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Anthropometric (Whole Body)</i></p> <p>Many studies have established the reasonably close relationship between body fat and certain skin-fold thicknesses. <a></a> The equations used for the NYU study were those developed by Pascale. <a></a></p> <p>The first depends on the measurement of the skin-fold thickness at the triceps:</p> <p><i>d(ensity) </i>= 1.0923 - 0.0202(S_t) x 10^-1</p> <p>The second depends on the measurement of the skin-fold thickness at the scapula:</p> <p><i>d</i> = 1.0896 - 0.0179(S_s) x 10^-1</p> <p><i>Mensuration (Whole Body)</i></p> <p>Skerlj in 1954 <i>(13) </i>developed a method for determining whole-body volume. He measured 10 circumferential dimensions and 6 linear dimensions (<b>Fig. 3</b>). From these he developed a formula that gives an approximate value for whole-body volume.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Linear measurements: measurements for body-volume determination (after Skerlj). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The NYU group presented <a></a> a modified equation using the Skerlj notation and included some correction factors derived by applying the equation to five subjects for whom the volume of the various body segments was known. The modified formula is: <b>Equation 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the volume so determined, the mass may be obtained by direct weighing and the overall (whole body) density may be obtained: <i>d(ensity) = M(ass) /V(olume)</i></p> <p><i>Empirical (Body Segments)</i></p> <p>Until recently, very little work has been done to establish segment densities. Harless <a></a> conducted some studies with cadavers, as did Dempster. <a></a> At NYU, in the first of the two studies, the mass of certain body segments was established by the reaction-board method, which is described below.</p> <p>Based on these studies, two graphs were developed that relate whole-body density to body-segment density (<b>Fig. 4</b> and <b>Fig. 5</b>). These are approximations only, since no exact data are available.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Mass Determination</h4> <p>In studies conducted with cadavers, weight and eventually mass are obtained directly by accurate weighing techniques applied to the total segment or to its increments. In studies with live subjects, this cannot be done. The reaction-board method may be used.</p> <p><i>Reaction-Board Method</i></p> <p>This method is dependent on the validity of two assumptions. The first is that the center of mass can be established if the center of volume is known. This is true only if the density of the segment is constant along its entire length. The studies conducted by the Aerospace Medical Research Laboratory showed that the density is not constant along the segment and the variation in density is not the same for all segments.</p> <p>The second assumption is that the rotation of a segment occurs about a single axis. If this were so, in the movement of a segment the centers of mass of all other body segments would remain fixed relative to the center of rotation. Since no body joint is uniaxial, and since the muscle masses shift in the course of any movement, this also is not quite correct.</p> <p>Nonetheless, the method has been used (<b>Fig. 6</b>). For the purpose, a board or platform is supported on two knife edges- one on a fixed base, the other on the platform of a weighing scale. The subject is. placed on the board in a position that can be maintained or reproduced if necessary. A reading is taken on the scale. The subject is then asked to flex the segment of interest (forearm, arm, etc.) through a given angle-usually 45 deg., 90 deg., or 135 deg. A new reading is taken. The mass of the segment can then be determined substituting the appropriate readings in the formula: <b>Equation 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Determination of the arm mass (reaction-board method). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Empirical</i></p> <p>For body segments the mass may be determined if the volume and density have been established. The mass, of course, is the product of the volume of the segment and the density of the segment. <i>M_s = V_sd_s</i></p> <h4>Center-of-mass Determination</h4> <p>The center of mass of the whole body may be determined readily by several methods since the mass is readily obtainable. The center of mass of a body segment on a live individual is not easily obtained, but may be approximated by one of several techniques.</p> <p><i>Volumetric Approximation</i></p> <p>A number of researchers, the NYU group included, have assumed that the density along the segment is constant and thus have concluded that the center of mass is coincident with the center of volume. Under this assumption, the center of volume, hence the center of mass, is found in the following way:</p> <p>A base line is established, usually the proximal joint of the segment. This segment is divided into a number of increments for which the volume is obtained by one of several methods (<i>V1, V2, V3</i>,..., <i>Vn). </i>The distance to the center of volume is measured from the base line (<i>d1, d2, d3, . . ., dn</i>).</p> <p>The center of volume is determined by dividing the sum of the products of each volume times its distance from the base line, by the sum of the volumes. <b>Equation 7</b>, <b>Equation 8</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Reaction-Board Method</i></p> <p>With cadavers, segments, or with plaster models of body segments, the center of mass may be obtained by use of the reaction board, previously described.</p> <p>Of these techniques, the one using the cadaver segment and the reaction board is the most accurate; the true center will vary in this technique only by the change that has occurred in the body tissues after death. Use of the plaster-of-paris cast creates the same error as that obtained by use of the volumetric technique; i.e., the error is introduced because it is assumed that the density along the segment is constant, whereas the density in any segment usually increases from the proximal to the distal end. This occurs because the ratio of bone to muscle and fat increases distally.</p> <h4>Segment Mass Moment Of Inertia</h4> <p>The motions of body segments are essentially rotatory, and linear movement is the result of a number of coordinated rotatory motions. The motion is assumed to occur about a fixed axis that is perpendicular to the plane in which the motion occurs. It is assumed that frictional and inertial forces occur in the plane of rotation. Rotation can be caused by a force at some distance from the axis of rotation, or by a force couple. In rotation, an inertial force resists angular acceleration which acts at the center of mass resulting in an inertial moment. This mass moment of inertia depends on the size, shape, and mass distribution of the body.</p> <p>The mass moment of inertia may be determined in several ways.</p> <p><i>Empirical</i></p> <p>The mass moment of inertia of a body with respect to a given axis of rotation is the sum of the products of the mass increments <i>mi </i>(into which the total mass may be divided) by the square of their respective distances from the particular axis of rotation: <b>Equation 9</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Quick Release</i></p> <p>If a force <i>(F) </i>is applied to a segment at some distance <i>(d) </i>from the axis of rotation of the segment, it will be imparted at an angular acceleration (a) in accordance with the equation: <i>Fd = Ia</i></p> <p>Because of this relationship, it is possible to determine the mass moment of inertia (<i>I</i>) experimentally by this quick-release method.</p> <p>In this method, the body segment of interest is arranged so that it may be free to swing about the proximal joint, which in turn is restrained from motion. At some distance (<i>d</i>) from the axis of rotation, a cable is attached to the segment such that it will prevent rotation in one direction. The other end of the cable is attached to a spring restraint, which in turn is attached to a force-measuring device. The subject is instructed to pull against the spring with a force <i>(F), </i>which is recorded. The cable is cut suddenly and the segment accelerates with an acceleration <i>(a) </i>that is appropriately recorded. By substitution of the known values <i>F, d, a, </i>the mass moment of inertia <i>(I) </i>can be obtained. <i>I</i> = Fd/<i>a</i></p> <p><i>Pendulum</i></p> <p>The period of a pendulum is related to the mass moment of inertia of the pendulum. For a simple pendulum, i.e., one where the mass is concentrated at some distance from the center of oscillation, the relationship is expressed by the equation: <b>Equation 10</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 10. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This method utilizes plaster casts of body segments or the severed cadaver segments. The segment or its counterpart is suspended at one point near the end of the segment. It is permitted to swing through an arc of limited magnitude. The period of oscillation is obtained by some appropriate instrumentation. The values that are obtained are substituted in the above equation.</p> <h3>Results</h3> <p>Results are given for tests conducted both in the first and second series of experiments. In the first series of tests, data were collected on 12 male subjects in the age range of 20-40 years. In the second series of tests, data were collected on 9 male subjects in the age range of 20-30 years, 5 female subjects ages 17-20 years, and 3 female subjects ages 40-50 years, all without disabilities. Data were also recorded on 19 additional subjects with either hemiplegia or an amputation. In the second series of tests, not all data were recorded for every subject. The following tables contain the most valid data acquired.</p> <h4>VOLUMES</h4> <p><b>Table 1</b> contains the volume of body segments recorded during the first series of tests. There is only one major difference between the two series on males. In the first series, the value for volume of the upper arm—and hence the value for the whole arm—included the shoulder cap, i.e., the volume from the axilla to the acromion process. In the second series (<b>Table 2</b>), the values of volumes for the upper and whole arm are only up to the axilla. On the basis of the mean values for the upper arm in the two series, the volume of the shoulder cap is approximately 36% of the whole upper arm.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the second series of tests, a limited number of shoulder caps were cut off from the plaster-of-paris arms at the level of the axilla. Their dimensions, circumference at the axilla (c), and height to the acromion process <i>(h) </i>were taken. The volumes were obtained by immersion.</p> <p>An approximate equation for determining the volume of the shoulder cap was then established: <i>Volume </i>(shoulder cap) = 0.0526 <i>hc</i>²</p> <p>This equation is approximate to + 20% of the true value.</p> <p>In all other respects, the two series of tests give comparable results. The differences in mean values are of the order of 1%-10%. Considering the limited numbers of subjects, 12 and 8 in the respective samples, the differences are not serious, and the mean values are useful in general computations. Of interest in the second series of tests is the close relationship between mean values for right-hand and left-hand volumes. The variation between means in most instances is less than the variation between the volume of right and left segments in any subject.</p> <p><b>Table 3</b> indicates similar values for female subjects. There was greater inter-subject variation in this population than in that for the males. In view of this, and because there was such a limited number of subjects both in the younger and older age groups, the values for the two groups were combined. Even so, these mean values may be less accurate than those for the male population. They are presented, however, because few other similar data are available.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The body-segment volume may be expressed as a ratio or percentage of the whole-body volume. If it is desired to estimate body-segment volume, it is better to do so on the basis of the segment volume as a percentage of whole-body volume. This probably will give a more accurate result than using an average value for the volume of body segment.</p> <p><b>Table 4</b> gives such values for the first series of males. <b>Table 5</b> gives similar values for the second series of males, and <b>Table 6</b> gives these values for females.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Densities</h4> <p>As mentioned previously, it is very difficult to determine densities accurately. In <b>Table 7</b>, the densities have been determined by the equations shown in the section III-B for males first series. The densities for both males and females, second series, have been determined by dividing the mass (weight) by the volumes derived by using the NYU and Skerlj formulas and by using Pascale's equations A and B and skin-fold thicknesses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Center Of Volume</h4> <p>In the absence of satisfactory techniques for determining the center of mass, it has been assumed to be coincident with the center of volume. <b>Table 8</b> shows the location of mass centers (volume centers) obtained by various researchers. Some studies conducted on cadavers are probably more truly mass centers. Others, conducted on live subjects, are probably the centers of volume.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 9</b> has been prepared to provide information as to the location of the center of volume of the various body segments, measured from the proximal joint. Again, it should be noted that the values for the upper arm are measured from the axilla. In both <b>Table 8</b> and <b>Table 9</b>, the value indicated is in percent of the segment length.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A study was conducted on seven above-knee amputees. There was considerable variation in the length and contour of the stumps, although all of them could be described as modified truncated cones. The average distance from the crotch, measured downward and expressed as a percentage of the total stump length, was 32.1%, with an upper limit of 44.0% and a lower limit of 23.0%. The standard deviation was + 6.4%.</p> <h4>Radius Of Gyration</h4> <p>The radius of gyration (p) is a distance measured from the true center of mass to a point within the mass at which, if all the mass were concentrated, its effect in rotatory movements would be similar to the effect of the mass as it is actually distributed. For geometrically similar shapes, the radius of gyration along a particular axis may be expressed as a percentage of the length of that shape along that axis.</p> <p>It has been assumed that every body segment-arm, leg, upper arm, forearm- for one subject is geometrically similar to that of any other subject. If it were so, then the radius of gyration expressed in percentage of the length <i>(p/L) </i>should be relatively constant. It was found to be so, with minor variations. The values of <i>p/L </i>for the various body segments obtained by previous researchers and in the first NYU study are given in <b>Table 10</b>. Values for the second NYU study are given in <b>Table 11</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 10. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 11. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 12</b> has been included as a guide against which the computed values of <i>p </i>may be compared. This table indicates the average values of <i>p </i>(the radius of gyration) for the populations included in the second series of NYU studies; not all values were determined for each category, and the table reflects this. The results were computed on the basis of tests and measurements were made as previously described.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 12. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Discussion</h3> <p>The data may be used in a number of ways. Consideration must be given to the nature of the problem for which a solution is sought and the accuracy desired. If a situation exists where a prosthesis or orthosis is desired for a specified individual, it would be best to obtain data directly on the individual. In such a case, judgment should be made as to which of the various techniques available would be adapted best to the set of conditions present, i.e., the condition of the subject, the skills of available personnel, and the facilities available.</p> <p>When extreme accuracy is not required, or in cases when the problem is confined to a class of individuals, or the solution may have a general application, the data may be used in various ways, with differing degrees of accuracy. In successively decreasing order of accuracy, the following maybe done:</p> <ol> <li>Obtain the weight and height of the subject and length and circumferences of the segments under consideration; use tables and graphs judiciously and, where several sets of data are available, use the most appropriate.</li><li>Obtain weight and height of the subject only and use tables as suggested.</li><li>Obtain weight and height of subject and use average data only. Data may be used for determining the length of a segment, its volume, mass, center of volume, center of mass, radius of gyration, and moment of inertia.</li></ol> <h4>Sample Computation</h4> <p>To determine the mass moment of inertia of the upper arm, forearm, and hand for a male patient (possibly for application of an externally powered orthosis), only the height and weight of the subject need be known.</p> <p><i>Procedure</i></p> <p>If the subject weights 190 pounds and is 73 inches in height:</p> <ol> <li>On graph (<b>Fig. 1</b>), join the weight in pounds (190) to the height in inches (73) by a straight line. At the intercept of this line with line c a value for c, approximately 12.8, is obtained.</li><li>On graph (<b>Fig. 2</b>), locate c = 12.8, proceed vertically upward to intersect solid black line, then proceed horizontally from this point to determine the value of whole-body density <i>d: d = </i>66.8 pounds per cubic foot</li><li>On graph (<b>Fig. 4</b>), proceed as in, <a></a> from <i>d = </i>66.8 vertically downward to intersect lines of segment densities:<br /><i>d, </i>upper arm = 68.1 lb/ft^3<br /><i>d, </i>forearm = 70.7 lb/ft³<br /><i>d, </i>hand = 72.2 lb/ft³</li><li>Given the weight of 190 pounds and whole-body density of 66.8 pounds per cubic foot, we may compute whole-body volume: 190/66.8 = 2.85 cubic feet</li><li><b>Table 4</b> gives values of volume for body segments in percentage of whole-body volume:<br />volume, upper arm = 3.495 x 0.01 x 2.85 = 0.0995 ft^3<br />volume, forearm = 1.70 x 0.01 x 2.85 = 0.0485 ft³ volume, hand = 0.566 x 0.01 x 2.85 = 0.0161 ft³</li><li>Multiplying the volumes of the segments by their respective densities, the mass (or weights) of the segments are obtained:<br /><i>m (w), </i>upper arm = 0.0995 x 68.1 = 6.78 lb<br /><i>m (w), </i>forearm = 0.0485 x 70.7 = 3.43<br />lb <i>m (w), </i>hand = 0.0161 x 72.2 = 1.16 lb</li><li>To obtain the approximate lengths of the body segments when they have not been measured, <b>Fig. 7</b> and <b>Fig. 8</b> may be used. The mean lengths expressed in terms of body height are 0.189<i>H</i>, 0.145<i>H</i> and 0.128<i>H</i> for the upper arm, forearm, and hand respectively. The lengths then are:<br /><i>Lv </i>= 0.189 x 73 = 13.8 in.<br />L<i>f </i>= 0.145 x 73 = 10.6 in.<br />L<i>h</i> = 0.128 x 73 = 9.35 in.</li><li>Having obtained the lengths of the segments, the location of the center of volume (mass) can be determined using values given in <b>Table 8</b> and <b>Table 9</b>: <br />c, upper arm = 0.461 x 13.8 = 6.37 in.<br />c, forearm and hand = 0.420 (10.6 + 9.35) = 8.38 in.</li><li>The radius of gyration (p) for the segments may be obtained using the values in <b>Table 10</b> or <b>Table 11</b>:<br /><i>p, </i>upper arm = 0.268 x 13.8 = 3.70 in.<br /><i>p, </i>forearm and hand - 0.263 x (10.6 + 9.35) = 5.25 in.</li><li>The moment of inertia about its proximal axis of rotation is expressed by the equation: Ij = m(p^2 + c^2)</li></ol> <p><b>Fig. 7</b> and <b>Fig. 8</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The moment of inertia of the upper arm about the shoulder: <b>Equation 11</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 11. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The moment of inertia of the forearm about the elbow: <b>Equation 12</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 12. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the moment of inertia of the forearm and hand about the shoulder joint is desired, then the equation is: <b>Equation 13</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Equation 13. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 9</b>, <b>Fig. 10</b>, <b>Fig. 11</b>, <b>Fig. 12</b>, and <b>Fig. 13</b> have been included to facilitate any computations, to ease conversion from metric to British systems of measurement, and for graphically determining the moments of inertia.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Acknowledgment</h3> <p>Appreciation is expressed to Dr. Rudolfs Drillis and Messrs. Darrell Hill, Howard Gage, Maurice Bluestein, Albert Yatkauskas, and George Vadell for their contributions to this research project, and to Mrs. Mary Klaus for the preparation of the reports.</p> <p><b>References:</b></p> <ol> <li>Behnke, A. R., Jr., B. G. Feen, and W. C. Welham, The specific gravity of healthy men; body weight devided by volume as index of obesity, J.A.M.A. 118:495-498, Feb. 14, 1942.</li> <li>Brozek, J., J. K. Kihlberg, H. L. Taylor, et al., Skinfold distributions in middle-aged American men: a contribution to norms of leanness-fatness, Ann. N.Y. Acad. Sci. 110:492-502, Sept. 26, 1963.</li> <li>Contini, Renato, Body Segment Parameters (Pathological), Tech. Rept. 1584.03, New York Univ. School of Engineering and Science, June 1970.</li> <li>Dempster, W. T., Space Requirements of the Seated Operator, U.S. Air Force WADC Tech. Rept. 55-159, Wright-Patterson Air Force Base, Ohio, July 1955.</li> <li>Dempster, W. T, The anthropometry of body action, Ann. N.Y. Acad. Sci. 63:559-585, 1956.</li> <li>Drillis, Rudolfs, and Renato Contini, Body Segment Parameters, Tech. Rept. 116.03, New York Univ. School of Engineering and Science, Sept. 1966.</li> <li>Drillis, Rudolfs, Renato Contini, and Maurice Bluestein, Body segment parameters-a survey of measurement techniques, Artif. Limbs 8:1: 44-66, Spring 1964.</li> <li>Dupertuis, C. W., and J. M. Tanner, The pose of the subject for photogrammetric anthropometry, with especial reference to somatotyping, Amer. J. Phys. Anthrop. 8:1:27-47, March 1950.</li> <li>Harless, E., The static moments of human limbs, Treatises of the Math.-Phys. Class of the Royal Academy of Science of Bavaria 8:69-96, 257-294, 1860.</li> <li>Krogman, Wilton Marion, and Francis E. Johnston, Human Mechanics: Four Monographs Abridged, U.S. Air Force Systems Command Tech. Rept. AMRL-TDR-63-123, Univ. Pennsylvania Graduate School of Medicine, Philadelphia, December 1963.</li> <li>Pascale, L. R., M. I. Grossman, H. S. Sloane, and T. Frankel, Correlations between thickness of skinfolds and body density in 88 soldiers, Hum. Biol. 28:165-176, May 1956.</li> <li>Sheldon, W. H., C. W. Dupertuis, and C. McDermott, Atlas of Men: A Guide for Somatotyping the Adult Male at All Ages, Harper, New York, 1954.</li> <li>Skerlj, B., Volume, density and mass distribution of the human body by means of simple an-thropometrical means, Bulletin Scient., Conseil Acad. RPFV, hub. 2:11, 1954.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Brozek, J., J. K. Kihlberg, H. L. Taylor, et al., Skinfold distributions in middle-aged American men: a contribution to norms of leanness-fatness, Ann. N.Y. Acad. Sci. 110:492-502, Sept. 26, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Dempster, W. T., Space Requirements of the Seated Operator, U.S. Air Force WADC Tech. Rept. 55-159, Wright-Patterson Air Force Base, Ohio, July 1955.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Dempster, W. T, The anthropometry of body action, Ann. N.Y. Acad. Sci. 63:559-585, 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Harless, E., The static moments of human limbs, Treatises of the Math.-Phys. Class of the Royal Academy of Science of Bavaria 8:69-96, 257-294, 1860.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Contini, Renato, Body Segment Parameters (Pathological), Tech. Rept. 1584.03, New York Univ. School of Engineering and Science, June 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Pascale, L. R., M. I. Grossman, H. S. Sloane, and T. Frankel, Correlations between thickness of skinfolds and body density in 88 soldiers, Hum. Biol. 28:165-176, May 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Brozek, J., J. K. Kihlberg, H. L. Taylor, et al., Skinfold distributions in middle-aged American men: a contribution to norms of leanness-fatness, Ann. N.Y. Acad. Sci. 110:492-502, Sept. 26, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Behnke, A. R., Jr., B. G. Feen, and W. C. Welham, The specific gravity of healthy men; body weight devided by volume as index of obesity, J.A.M.A. 118:495-498, Feb. 14, 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Sheldon, W. H., C. W. Dupertuis, and C. McDermott, Atlas of Men: A Guide for Somatotyping the Adult Male at All Ages, Harper, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Dupertuis, C. W., and J. M. Tanner, The pose of the subject for photogrammetric anthropometry, with especial reference to somatotyping, Amer. J. Phys. Anthrop. 8:1:27-47, 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">Contini, Renato, Body Segment Parameters (Pathological), Tech. Rept. 1584.03, New York Univ. School of Engineering and Science, June 1970.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Drillis, Rudolfs, and Renato Contini, Body Segment Parameters, Tech. Rept. 116.03, New York Univ. School of Engineering and Science, Sept. 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Contini, Renato, Body Segment Parameters (Pathological), Tech. Rept. 1584.03, New York Univ. School of Engineering and Science, June 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Krogman, Wilton Marion, and Francis E. Johnston, Human Mechanics: Four Monographs Abridged, U.S. Air Force Systems Command Tech. Rept. AMRL-TDR-63-123, Univ. Pennsylvania Graduate School of Medicine, Philadelphia, December 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Drillis, Rudolfs, Renato Contini, and Maurice Bluestein, Body segment parameters-a survey of measurement techniques, Artif. Limbs 8:1: 44-66, Spring 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Contini, Renato, Body Segment Parameters (Pathological), Tech. Rept. 1584.03, New York Univ. School of Engineering and Science, June 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Drillis, Rudolfs, and Renato Contini, Body Segment Parameters, Tech. Rept. 116.03, New York Univ. School of Engineering and Science, Sept. 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Renato Contini </b></td></tr><tr><td class="clsTextSmall">Prosthetic-Orthotic Education Program, UCLA, Los Angeles, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-05.jpg Figure 5 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-06.jpg Figure 6 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-04.jpg Figure 7 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-08.jpg Figure 8 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-07.jpg Figure 9 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-10.jpg Figure 10 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-11.jpg Figure 11 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-14.jpg Figure 12 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-09.jpg Figure 13 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-12.jpg Figure 14 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-13.jpg Figure 15 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1972_01_001/1972_01_001-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Body Segment Parameters, Part II Creator An entity primarily responsible for making the resource Renato Contini * 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. Pinot, Paris, 1917.</li> <li>Bechtol, Charles O., <i>The prosthetics clinic team, </i>Artificial Limbs, January 1954. p. 9.</li> <li>Bernshtein, N., <i>Die Kymocyclographische Methode der Bewegungsunlersuchungen, </i>in <i>Hndb. d. biol. Arbeitsmethoden, </i>Lief. 263., Urban und Schwar-zenberg, Wien, 1928.</li> <li>Bernshtein, N., <i>et al., Investigations on biodynamics of locomotion, </i>Vols. 1 and 2, Moscow, 1935 and 1940. In Russian.</li> <li>Borchardt, M., <i>et al., </i>eds., <i>Ersatzglieder und Arbeit-</i><i>shilfen, </i>Springer, Berlin, 1919.</li> <li>Borelli, Giovanni A., <i>De motu animalium, </i>Romae,1679. Two volumes. To be found in <i>Pathologie de chirurgie, </i>Vol. 2 of 3 vols., by Jean Baptiste Ver-duc, Paris, 1727.</li> <li>Carlyle, Lester, <i>Fitting the artificial arm, </i>Chapter 19in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</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 U.S. Veterans Administration] covering the period from 1 April 1945 through 30 June 1947.</li> <li>Contini, R., and R. Drillis, <i>Biomechanics, </i>Appl.Mech. Rev., 7:49 (1954).</li> <li>Drillis, R., <i>Chronocyclographische Arbeitsstudien, </i>in<i>Psychophysiologische Arbeiten, </i>1A, Riga, 1930.</li> <li>Drillis, R., <i>Investigation on axe and woodcutting,</i>Latvijas Lauksaimnieks, Riga, 1935. In Latvian.</li> <li>Drillis, R., <i>Investigations on stability, </i>unpublishedreport, Prosthetic Devices Study, New York University, 1954.</li> <li>Eberhart, H. D., and V. T. Inman, <i>An evaluation of experimental procedures used in a fundamental study of human locomotion, </i>Ann. N. Y. Acad. Sci., 51:1213(1951).</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>Elftman, H, <i>The measurement of the external force in walking, </i>Science, 88:152(1938).</li> <li>Elftman, H., <i>The force exerted by the ground in walking, </i>Arbeitsphysiol., 10:485 (1939).</li> <li>Elftman, H., <i>The basic pattern of human locomotion,</i> Ann. N. Y. Acad. Sci., 51:1207(1951).</li> <li>Faries, John Culbert, <i>Limbs for the limbless, </i>Institute for the Crippled and Disabled, New York, 1934.</li> <li>Fick, R., <i>Handbuch der Anatomic und Mechanik der Gelenke unter Berucksichtigung der bewegenden Muskeln, </i>G. Fischer, Jena, 1904-1911. Three volumes.</li> <li>Fischer, O., <i>Theoretische Grundlagen fur eine Mechanik der lebenden Korper, mit speziellen Andwendungen auf den Menschen, </i>B. G. Teubner, Leipzig and Berlin, 1906.</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.</li> <li>Fletcher, Maurice J., and A. Bennett Wilson, Jr.,<i>New developments in artificial arms, </i>Chapter 10 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Frank, Wallace E., and Robert J. Gibson, <i>New pressure sensing instrument, </i>J. Franklin Inst., in press 1954.</li> <li>Gilbreth, Frank B., and Lillian M. Gilbreth, <i>Motion study for the handicapped, </i>G. Routledge and Sons, Ltd., London, 1920.</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. p. 29.</li> <li>Henschke, Ulrich K., and Hans A. Mauch, <i>The improvement of leg prostheses, </i>The Military Surgeon, 103(2) :135 (1948).</li> <li>Hettinger, Th., and E. Muller, <i>Der Einfluss des Schuhgewichtes auf den Energieumsatz beim Gehen und Lastenlragen, </i>Arbeitsphysiol., 15:33 (1953).</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>Kaplan, S., <i>Determination of dynamic loads and strains in below-knee artificial limbs, </i>unpublished report, Prosthetic Devices Study, New York University, 1954.</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>Leonardo da Vinci, <i>On the human body, </i>C. D.O'Malley and J. B. DeC. M. Saunders, eds. Schuman, New York, 1952.</li> <li>Marey, E., <i>Mouvement, </i>G. Masson, Paris, 1894.</li> <li>Marey, E.-J., and G. Demeny, <i>Eludes experimentales de la locomotion humaine, </i>Compt. rend. Acad. d. sc, 106:544 (1887).</li> <li>Martin, Florent, <i>Artificial limbs, </i>International Labour Office, Geneva, 1925.</li> <li>Muybridge, Eadweard, <i>The human figure in motion,</i>Chapman &amp; Hall, London, 1901.</li> <li>New York University, College of Engineering,Research Division, [Report to the] Special Devices Center, Office of Naval Research (Contract No. N6onr-279), <i>Investigations with respect to the design, construction, and evaluation of prosthetic devices, </i>June 1, 1949. Two volumes.</li> <li>New York University, Prosthetic Devices Study,(report to the) Advisory Committee on Artificial Limbs, National Research Council, <i>The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, </i>March 1953.</li> <li>Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A report on prosthesis development, </i>1947.</li> <li>Parmelee, Dubois D., U.S. Patent 37,637, February10, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</li> <li>Public Law 729, Eightieth Congress, Second Session,Approved June 19, 1948.</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. p. 20.</li> <li>Schede, Franz, <i>Theoretische Grundlagen fur den Bau von Kunstbeinen; Insbesondere fur den Ober-schenkelamputierten, </i>Ztschr. f. orthopad. 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. *